14 20 371 https://staging.drfop.org/files/original/d386a411367e3ccde8de539fc4a1242f.pdf 4ed3a9095b43b4bd7f3819c9eb8dfa7a https://staging.drfop.org/files/original/7a5e8868268876fcf1e3856884e6c69c.jpg fd74970347d887a411311884e1262354 https://staging.drfop.org/files/original/caec0103bc664a9d5e8457d1901a9e15.jpg 6b145520feb78ecf54f8c9a9684c4a26 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_029.pdf Text Any textual data included in the document <h2>The Total Contact Partial Foot Prosthesis</h2> <h5>Richard LaTorre, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The purpose of this paper is to present a prosthetic fitting procedure for a "Partial Foot" level amputation. The "Transmetatarsal," "Lisfranc," "Chopart," and "Pirogoff" type amputations are all treated with this procedure with some modification, mainly in length of forefoot. The partial foot as a category presents more anxiety among physicians and prosthetists and clinics, than is generally realized. For the avascular patient, a "toe filler" is not adequate, no matter how cosmetic it appears. Classically, patients who are diabetics and have been given toe filler type prostheses tend to develop eversion, a tightening of the Achilles tendon, and are usually doomed to perforating ulcers on the distal plantar anterior or distal anterior portion of the residual foot.</p> <p>The solution presented here is an ultra-lightweight prosthesis, one that removes stress (caused by torque on the leg), protects the extremity from shock at heel strike and toe off, controls plantar and dorsi-flexion, controls eversion, controls edema, and still is cosmetically acceptable. This style prosthesis has been in use since March, 1974. By 1977, 62 prostheses of this type had been successfully delivered. The largest group of patients was between 45 and 65 years of age and almost equally divided between males and females. The next largest group was geriatrics (over 65) and only four patients were in the 20 to 45 age group. Only one patient went on to further amputation.</p> <p>As a result of wearing this type of prosthesis, the residual limb is usually warm, free of ulcers, callosities, and edema. When compared to the contra-indicated extremity, it appears to be generally healthier and most patients state "it feels better than my other leg."</p> <p>By 1984, this type of prosthesis was being fabricated at the rate of one every three weeks. At present, the average is one every two weeks.</p> <p>"Lower Profile" partial foot prostheses are also fitted, but only after the patient has successfully worn this two piece design for at least six months. This insures, if trouble starts with a Low Profile prosthesis, there is no "down time" for the patient; they simply go back to "old faithful."</p> <p>Incidentally, we have also developed three different styles of the Low Profile partial foot prosthesis (that we have not described in the literature), but have never been able to develop a series of four or more successes for each design.</p> <h3>Evaluation and Casting</h3> <p>Prior to casting, a prosthetic evaluation is made to determine joint limitations, noting mainly inversion/eversion and degree of plantar flexion/dorsi-flexion. Old scars are noted, as is the condition of skin over bony prominences and any possible weeping of draining areas. The patient's weight, height, and occupation are included in the evaluation before casting. Determination of material, usually polypropylene, thickness of material selected, and length of the prosthesis to be fitted is made at this time. The negative cast is usually taken with the patient in the sitting position. Any scab or draining area is covered with Saran Wrap® or its equal. Stockinette is then applied to the extremity from the toe to the supracondylar area. With indelible pencil the malleoli, anterior crest of the tibia, head of the fibula, old scars, and any extremely sensitive-to-touch areas, as well as those that may cause future problems, are marked.</p> <p>Casting is a two step procedure. The residual foot should be barely touching the floor and the foot to tibia relationship should be 90°. Splints of plaster of Paris are laid on the anterior tibia from a point approximately 2 cm. distal of the level of the tibial tuberosity distally to the point of floor contact. If it has been decided to weight-relieve the ankle complex, the well known P.T.B, casting procedure is used at this point.</p> <p>The extremity is now wrapped with Coban bandage. Coban is a plastic seersucker type material that acts as a waterproof Ace bandage and will not adhere to plaster. This technique enables the practitioner to make a thin-walled cast that is easier to remove from the tender extremity. The "Coban Technique" gives an eggshell hard cast, because it compresses the plaster, thus enabling the user to use less plaster and still obtain a firm satisfactory cast.</p> <p>As soon as the extremity is wrapped, it is replaced in the original position, (i.e. foot to tibia relationship of 90°). After the cast has sufficiently hardened, the bandage is removed and rerolled for future use.</p> <p>The already cured plaster and stockinette are now coated with K-Y Jelly. Plaster strips 4" x 12" are applied vertically to the posterior and lateral aspects of the extremity, overlapping the anterior cured cast from 3/4" to 2". The extremity is wrapped once again with the Coban bandage and returned to the sitting position. The Coban bandage is removed and reference lines are horizontally laddered across the cast overlapping areas when the posterior section has hardened. The exterior cast is carefully removed, the stockinette is cut away posteriorly, and the anterior "shell" carefully removed. Both sections are quickly re-oriented to each other and sealed together.</p> <p>In the laboratory, the negative cast is rinsed with a solution of soap or detergent, the surplus is poured out, the cast is placed in a sandbox, and the positive model is poured with bulk plaster. A pipe is placed in the cast and held in place until the plaster has set.</p> <h3>Fabrication</h3> <p>When the model is hard, the negative cast is stripped away. The model is held in a bench vise, sanded smooth, and plaster is added to problem areas noted at the time of casting. The amount added is 6-7 mm. at both malleoli, fibular head, and along the tibial crest. A 3mm. buildup over any scar or weeping area is sufficient. At this point, the model is covered with a layer of stockinette.</p> <p>An appropriately cut section of sheet polypropylene is placed in an oven at 400°F for ten minutes. The material is draped over the anterior portion of the model. The material will have the consistency of taffy when removed from the oven. If any wrinkles appear, the plastic must be discarded and a new piece cut and molded. Sometimes several trials are necessary until satisfactory results are achieved.</p> <p>When cooled, the anterior portion is removed from the model, trimmed, and all edges smoothed to the touch. The plantar trimline is just anterior of the os-calcis. The medial and lateral trim lines are on the midlines viewed in the sagittal plane. The original technique has been modified so as to provide a more posterior plantar trim line that now encompasses the os-calcis. This reassembles an inverted "T" shape.</p> <p>The model, minus the anterior molded shell, is further prepared by tacking a leather inner-sole that fits the patient's shoe (or opposite foot pattern inverted) to the plantar surface of the model. One inch nails are driven into the anterior portion of the positive model to provide an anchor for the plaster to be added next.</p> <p>The cast with the innersole attached is placed on a casting board. This is usually done with the aid of a vertical alignment jig, but can be accomplished manually without a jig if great care is exercised. This aligns the model to simulate the normal contour of the shoe relative to ball and heel. Bulk plaster is now applied to the innersole and built up onto the anterior foot portion. When firm, the plaster is trimmed to the edges of the innersole.</p> <p>The model is placed back in the vise horizontally and rotated so the posterior surface faces the fabricator. Appropriate size plastic is laid out and cut, and the molding process is repeated.</p> <p>Once cooled, the posterior shell is removed from the model. The forefoot is trimmed away laterally so all that remains, from midfoot running distally, is an innersole-like projection (i.e., it resembles a molded polypropylene solid ankle-ankle-foot orthosis).</p> <p>The anterior buildup of plaster is now removed from the original model. The polypropylene anterior shell snaps back on the model and the posterior shell goes over it. A Velcro® closure is attached to the proximal portion and a filler is cemented onto the innersole portion to simulate the forefoot and fill the shoe. The material used is plastazote bonded with barge cement.</p> <p>This version was used until 1983 when a woodsman who complained that "the toes lose their spring" was encountered. This was found not to be a problem with other patients. To satisfy this patient, roughly ten modifications of the forefoot section were tried. Unsuccessful were thicker polypropylene, metal reinforcement (spring steel), "double soling" the forefoot, and many other less involved changes. All met with patient displeasure. Success came with the fabrication of a forefoot "box section."</p> <p>To fabricate one, bulk plaster is poured into a shoe box top to provide a mold. Polypropylene is molded over this. The molded plastic is cut into quarters and the four corner pieces are arranged in such a manner that the corners fit together forming a three dimensional cross shape. Place them onto the anterior "sole" of the prosthesis. Trim to fit the edges of the sole. Rivet the two anterior (left and right) sections to each other and then to the toe section of the prosthesis. Next, rivet the remaining two pieces together and place this section against the anterior shell. Trim and fit it until a 5/8" gap is formed between it and the "anterior box" section. Rivet the remaining loose box section to the sole (<a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg"><b>Fig. 1</b></a>). The 5/8" gap between the two "box" sections is filled with foam rubber (<a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg"><b>Fig. 2</b></a>). The durometer selected depends on how firm a toe break is desired. This design has provided the more agressive patient with a toe action that simulates the push-off activity of the contralateral foot.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg"><strong>Figure 1. Box sections rivetted in place. Anterior shell shown in the back ground.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg">Figure 2. Foam rubber bumper laying beside forefoot section. Anterior shell in place.</a><br /></strong><br /> <h3>Fitting</h3> <p>The prosthesis is now ready for fitting. Shoes used have usually been of the double depth type with removable innersole. This type is preferred because it gives extra depth inside the shoe for the affected extremity and allows room for, and needed balancing of, the remaining foot. Most often the patient has been fit with the extra depth shoes and they later purchase ordinary footwear and manage without incident.</p> <p>It is felt that the total contact principle that has been so beneficial to other amputees has been adopted successfully in the design of this prosthesis. By encapsulating the extremity, edamatous problems have been prevented and circulation boosted, or so the patients have reported. The skin texture is soft and warm by comparison to the contraindicated limb. In fact, many patients have remarked that the extremity had always felt cold but now the other leg feels cold by comparison. This prosthesis prevents the problem of distal end friction that can result in further amputation.</p> <p>It is not possible for a shoe to cause friction to any part of the residual limb. One patient, who is a farm machinery repairman, has also found that it prevents the problem of bruising of the shin he encountered in his occupation.</p> <p>This style prosthesis, for all its length and function, weighs little more than the toe-filler type prostheses and is certainly lighter than other versions. It is relatively more expensive than most toe-fillers, but considerably less expensive than other types of prostheses, such as a conventional Chopart.</p> <p>On heel strike, the material "puckers" slightly, cushioning the impact. On foot flat, as well as at toe-off, the action of the foresection simulates the norm. In many patients, better gait on the affected extremity than on the contra-indicated limb has been observed.</p> <p>The gaits of all patients fitted have improved dramatically and some are undetectable to the eyes of even trained personnel.</p> <h3>Conclusion</h3> <p>Experience to date is that the above described prosthesis provides superior gait, less cost, less weight, and better patient acceptance than other types of Chopart prostheses. The material will torque with the extremity and does cause friction to tissue of poor quality.</p> <p>This material was originally presented in 1974 and not submitted for publication because it was thought that it would be outdated within a year or two. Evidently, this was a wrong assumption. With an ever increasing number of surgeons doing more distal amputations, there have been more and more requests for this information.</p> <h3>Acknowledgments</h3> We thank Siegfried Paul, C.P.O., for awakening us to thermoplastics, Thorkild Engen, CO., for introducing us to polypropylene, and Dr. Richard Jacobs for being all that a great physician should be.<br /><br /><em><b>*Richard LaTorre, CO. </b> Richard LaTorre, CO., is President of LaTorre Orthopedic Laboratory, 846 State Street, Schenectady, New York 12307.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 29 - 32 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Total Contact Partial Foot Prosthesis Creator An entity primarily responsible for making the resource Richard LaTorre, CO. * https://staging.drfop.org/files/original/6212151a4fd93fa9dfd236829b610b9d.pdf 189fa090d4acf3dfea37b1693a79a780 https://staging.drfop.org/files/original/74352196c91439b746c487380d4c7d77.jpg 05c134f6b80ae4f5c032ba27b11de016 https://staging.drfop.org/files/original/10e30ded97b085e2b2892d7eea9365a3.jpg 25847e110d18fb0e9863908ef7b26efb https://staging.drfop.org/files/original/c14ca2b677fa08c269cdf300b3ac8d05.jpg 6aa3d9f3fdbb8117d775aec6125b3749 https://staging.drfop.org/files/original/56605a5d73b41e6c48d52f069c0109e4.jpg 0d4dd9bf592027776b6b43c7fb8e2dfd https://staging.drfop.org/files/original/8b2233e0b1a3db5f4e26c29029c28d52.jpg c9c9ed230bf33f6d1f48fe13e3d4c838 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_109.pdf Text Any textual data included in the document <h2>The Amputee Athlete</h2> <h5>Richard Riley, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>An increasing number of amputees in the United States are moving beyond mere ambulation into active sports and recreation activities. Estimates of the number of amputees actively involved range from 15,000 to 20,000, with over 5,000 participating in organized competitive sports.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.jpg"><strong>Figure 1. Below-knee amputee, George Lombard, member of the Fisher-Saloman Marathon Team and the U.S. Disabled Ski Team.</strong></a><br /> <p>Ten years ago, the athletic amputee was a unique phenomenon in our practice. Today few practitioners cannot count two or three among their clientele. These amputees are at the cutting edge of our field because they push us as professionals to expand our perceptions of what is possible. They also provide the positive role models that we hold out to the rest of our clients as an example of what can be done.</p> <p>The able-bodied sports world has taken some giant leaps of perception regarding the amputee athlete. No longer is it just "inspirational" to have a disabled person competing in sports. Today there are amputees that compete in world class events alongside the able-bodied. The skiing world has demonstrated this by naming below-knee amputee George Lombard to the Fischer-Saloman Marathon cross country ski team and awarding above-knee amputee Diana Golden with the U.S. Ski Writers Award for Outstanding Alpine Competitor.</p> <p>Not only are there more elite amputee athletes today, there is a much larger body of rec-reationally oriented amputees. The days are gone when the prosthetist and rehabilitation team could be satisfied with being able to get the amputee to just walk. Expectations of our clients have changed. Not only the younger amputee, but also the active geriatric expects to be able to ride a bicycle, play golf, tennis, or jog around the block.<a></a> Our challenge is to meet these expectations.</p> <h3>Psychology of the Amputee Athlete</h3> <p>What causes one amputee to become an elite cross country skier (one of the most demanding physical sports in the world) and another with the same level of disability to be unable to even return to gainful employment? Part of the answer lies in the individual's ability to handle the stress and trauma of amputation. These are factors that we have little control over. The other part of the answer lies with environmental issues and can be addressed.</p> <p>Most amputee athletes are highly motivated individuals with a strong desire to overcompen-sate for their disability. A percentage of these people will rehabilitate themselves with practically no help at all and go on to accomplish great things in their personal lives as well as in sports. Others need the influence of role models to show them that their limitations are what they place upon themselves. One of the most positive experiences for any new amputee is when they meet another amputee with a positive attitude.<a></a> This positive motivation is best facilitated by a support structure of family, friends, and the rehabilitation team. If any one of these aspects is continually placing limits on the amputee, eventually the amputee will accept these limitations. There are physical limitations for the amputee, but these should be discovered not imposed. There are ways around most physical limitations by keeping an open mind and being willing to innovate.</p> <p>Pain is an aspect of amputation that in many cases is initially the greatest barrier to overcome. All athletes know pain through training and the physical exertion of competition. People who are athletic prior to becoming an amputee will generally be able to deal with pain more easily due to their previous development of strategies to perform while enduring levels of pain. The successful amputee will develop ways of minimizing discomfort, either through increasing the conscious tolerance for pain or seeking a lifestyle that reduces trauma to the residual limb.</p> <p>The amputee athlete not only has the pain of general physical exertion to deal with, but also the added trauma of torques and stresses far beyond normal to the skin and bone structure of the residual limb. Most of these athletes have developed very high pain tolerances and their body readily reacts to pain stimuli by releasing endorphines<a></a> (the body's natural pain medication) into the body. These factors enable the amputee athlete to achieve great physical accomplishments. It also sets up potential for serious damage to the residual limb tissue because of overactivity. Pain is the body's message to the brain that something is wrong and many amputees have developed ways to short-circuit this signal. This is a fact we must all be aware of in caring for and guiding the amputee athlete.</p> <h3>Prosthetic Care</h3> <p>For the prosthetic professional, the active amputee can be either a great source of pride and stimulation or a perpetual problem fraught with frustration. Nevertheless, this group of our clientele will continue to occupy a greater share of our patient load and we must develop strategies to successfully accommodate their needs.</p> <p>As important to the success of the athletic amputee as the prosthesis is his knowledge of how it works. Of equal importance are the limitations of the prosthesis and problem solving strategies for residual limb breakdown. The time spent in educating the amputee about his prosthesis and ways to deal with skin problems is always well spent.</p> <p>Regardless of how well fitting a prostheses is, there is a potential for skin breakdown of the residual limb due to overactivity.<a></a> Athletes will continually push themselves to their limits and beyond. If they are armed with methods to deal with skin breakdown, they will benefit greatly.</p> <p>Advances in sports medicine for runners was bound to spill over into prosthetics. Of particular use is a skin protection material called "2nd Skin™" (<b>Table 1</b>). It is a 1/16" thick piece of gel that is applied directly onto the skin. It prevents friction between the skin and any moving surface. It does not stick to normal skin, yet because of its viscosity, will stay where it is placed. It is perforated so as to let the wound breathe as well as being sterile to prevent infection. 2nd Skin™ absorbs secretions, feels cool, alleviates itching, and can relieve pain.</p> <p>2nd Skin™ comes with plastic on both sides of the gel material. Before the plastic is removed, cut a piece one third larger than the area to be covered. This allows coverage of the affected area despite migration. The directions recommend removing the plastic from one side or from both sides. Personal experience has shown that removing the plastic from both sides prevents most migration.</p> <p>Because 2nd Skin™ is so thin, it does not increase pressure on blisters or abrasions. It prevents most friction and can actually promote healing even during heavy usage. 2nd Skin™ comes in a variety of sheet sizes which can be cut to the size needed and has to be kept in the zip-lock container provided. Unfortunately, it can be used only once and has to be cleaned off the sock after use. It works very well on below-knee amputees, especially when used beneath a sheath. In above-knee amputees, only suction wearers will experience difficulty in usage due to excessive migration from pulling into the socket. Second Skin™ is an inert material made from 96 percent water and four percent polyethylene oxide.</p> <p>Another product which provides excellent friction reduction and is also reusable is "Spenco® Skin Care Pad" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg"><b>Table 1</b></a>). This product comes in three thicknesses, 1/2", 3/16", and 1/8". The 1/8" thickness produces the least amount of pressure inside the socket. Spenco® Skin Care Pad acts like a second layer of fat to protect the skin from friction or abrasion. It adheres to the skin without sticking due to its viscosity. Made from a reticulated closed cell elastomer, it can be gas sterilized or washed in soap and warm water. It should also be stored in the zip-lock bag and has a shelf life of two</p> <p>years. It is best used as a preventative measure in circumstances where skin breakdown is a danger.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg"><strong>Figure 2. Applying 2nd Skin™ to a residual limb abrasion.</strong></a><br /> <p>One of the problems with most skin protection materials is that suction socket wearers cannot utilize them. When the amputee pulls into the suction socket, "2nd Skin™" or "Spenco® Skin Care Pads" become displaced and usually do not cover the areas intended. A product that can be of use to suction socket wearers, or any amputee for that matter, comes with a variety of names. It is a transparent dressing with one adhesive side that is paper thin and porous both to air and water. The trade names are "Op-Site," "Bioclusive," "Tega-derm," and "Acuderm" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg"><b>Table 1</b></a>). This material can be applied directly to the skin and acts as another layer of protection, while still allowing normal dermal respiration and perspiration to occur. It can be left on the skin for four to five days before it needs to be removed. If left on much longer, the epidermis does not get an opportunity to slough off properly.<a></a></p> <p>These products work well to prevent friction, but do not provide any relief for pressure problems. The transparency of these materials allow for continual evaluation of the healing process. There is a problem that the adhesive is quite strong and oftentimes pulls hairs out upon removal. Different brands utilize different ad-hesives, but in general it is recommended that some soaking of the covered area in warm water will help remove the covering with minimal discomfort. Careful attention should be paid to the application instructions so as to avoid getting it adhered to itself when applying it. Most brands come with a paper backing and application method that allows it to be cut to the desired size.</p> <p>Until the time when skin abrasions and adherent scars become a thing of the past, we will have the need for skin protection materials. These products can give relief to thousands of prosthetic wearers as well as prevent much discomfort for active amputees. They should become a standard part of the amputee's "survival kit."</p> <h3>Sports Organizations for Amputees</h3> <p>The perceptions that amputees have of their capabilities has risen dramatically in the last decade. Paralleling the growth of competitive sports for amputees has been the organizations that provide the forum for these activities (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg"><b>Table 2</b></a>). Prior to these organizations bringing together amputees from around the nation and the world, there was little opportunity for exchange of ideas on the consumer level.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg"><strong>Figure 3. The United States Disabled Ski Team.</strong></a><br /> <p>Organizations such as the "National Handicapped Sports and Recreation Association," sponsor and provide for competitive sports activities. Competition is based on ability and level of amputation with competitive levels ranging from local races to world class and a parallel Olympic structure.</p> <p>The impact of these organizations on the field of prosthetics has been enormous. All of us have fielded questions concerning amputee athletes and their various prostheses. This direction from the people whom we serve has been healthy for prosthetics for many reasons. First, we have had to expand our horizons and adapt technologies and techniques to accommodate these athletic amputees. Secondly, it has created a demand and thus a market for new components to accommodate extra-ambulatory activities. Third, there now exists a forum for amputees to exchange ideas, compare techniques, and services, as well as push each other to greater accomplishments. Another important contribution is the role model aspect of these athletic amputees. They provide inspiration to all of our clientele to continue to expand their perceptions of what is possible.</p> <p>All of these factors have changed prosthetics. Because of publicity surrounding some of the more astounding accomplishments, not only has the field gained more public recognition, but there is a growing acceptance of us as professionals. These organizations will continue to provide and promote sports and recreation as a normal part of the amputees lifestyle. Not only is it our responsibility and challenge to continue to adapt prosthetics to these activities, but it will play a major role in the future of our profession.<a></a></p> <h3>Conclusion</h3> <p>As leisure time in our society increases, the need to accommodate sports and recreation in our society becomes essential. The perception of the amputee's lifestyle parallels this societal shift. Prosthetics must be able to accommodate this change in our patients' attitudes toward activity. This can best be accomplished through education and communication, as well as further development of componentry geared to the athletically inclined.<a></a></p> <p>The amputee athlete has given rise to a new specialty in our field. The sports prosthetist is now a viable specialist that as professionals we should recognize and refer our patients to. We will continue to provide state-of-the-art prostheses for our active amputees, and armed with information about proper care, they will be among the best athletes in the world.</p> <p><b>References:</b></p> <ol> <li>Riley, Richard, "The Amputee Athlete," <i>Sports Medicine</i>, Volume 4, October, 1984, pp. 31-32.</li> <li>Kegel, Bernice, "Recreational Activities of Lower Extremity Amputees: A Survey," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 61, June, 1980, pp. 258-264.</li> <li>Foort, James, "How Amputees Feel About Amputation," <i>Orthotics and Prosthetics</i>, Volume 28, March, 1974, pp. 21-27.</li> <li>Gaylor, Michael, M.D., personal communication, April, 1987. Presently Professor, Dartmouth College, Specialty in Sports Medicine.</li> <li><a href="poi/1980_01_037.asp">Levy, W. S., "Skin Problems of the Leg Amputee," <i>Prosthetic and Orthotic International</i>, Volume 4, 1980, pp. 37-44.</a></li> <li>Riley, Richard, "Skin Protection Materials," lecture given at American Academy of Orthotists and Prosthetics Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "Sports Organizations for the Disabled and Their Impact on Prosthetics," lecture given at American Academy of Orthotists and Prosthetists Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "A Survey of Active Below-Knee Amputees," study undertaken at Northwestern Orthotic and Prosthetic Research Center, Chicago, Illinois, December, 1980.</li> <li>Kegel, Bernice, <i>Sports for the Leg Amputee</i>, 1986.</li> </ol> <em><b>*Richard Riley, CP. </b> Richard Riley, CP., specializes in sports prosthetics and has a private practice with SportsMedicine Portsmouth, in Portsmouth, New Hampshire. Also a below-knee amputee, Riley is a member of the U.S. Disabled Nordic Ski Team and the Vice President of the National Handicapped Sports and Recreation Association.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 109 - 113 Year 1987 Volume 11 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg Figure 3 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg Figure 4 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 TABLE 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Amputee Athlete Creator An entity primarily responsible for making the resource Richard Riley, CP. * https://staging.drfop.org/files/original/30b4b4710a8911bc0aea77a638feabd8.pdf d94353f2854ff602c0f9346f778e7e3d https://staging.drfop.org/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg fafe36c6b4d258417e6f680dddb9b70e https://staging.drfop.org/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg 293e8f412cb4574591640035f63316e5 https://staging.drfop.org/files/original/6cf829e905f2e447ba594e3384850a62.jpg 4550835e4a6000c414e01462ccfa5217 https://staging.drfop.org/files/original/add90ab6d50a34714b20dca5c661b095.jpg f6b8c5082ce320e83340172ce97d6143 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_01_001.pdf Text Any textual data included in the document <h2>Instep Strap</h2> <h5>Richard Rosenberger&nbsp;<a style="text-decoration: none;">*</a><br />Charles H. Pritham <a style="text-decoration: none;">*</a></h5> <p>Ankle-foot orthoses are prescribed for a variety of reasons, but chief among them is the control of undesirable positions of deformities, the most common being equino-varus. Gravity alone will cause the ankle-foot complex to adopt the equino varus position, but spasticity or contracture of the triceps surae can only complicate the situation.</p> <p>A conventional metal ankle-foot orthosis, with either a single or double uprights, can be effective in combating this deforming position, but success depends on proper construction and application of the orthosis. While in most instances the shoe is strong enough, in the presence of severe spasticity it is necessary to reinforce the shank of the shoe lest it break down at the anterior edge of the tongue and thus allow the shoe and foot to adopt a position of equinus. To properly control the foot the shoe should fit snugly when laced up. This latter point can be difficult to achieve and it is not uncommon to find that the heel has ridden up in the shoe. It may be necessary to prescribe a high-top surgical boot with undesirable economic and cosmetic side effects that weigh against use of the orthosis, as does the stipulation, when necessary, that the orthosis be worn at night. It is unconventional, uncomfortable, inconvenient, and unsanitary to wear shoes to bed.</p> <p>The situation with unmodified plastic ankle-foot orthoses is much the same, although it is somewhat easier to apply the orthosis properly than is the case with the shoe. For this reason it has proven popular to modify the basic orthosis by the addition of straps in various configurations. The attraction of this course of action should be obvious. First it makes it possible to don the orthosis and maintain the desired position without a shoe, and thus eliminates the need for expensive high-top surgical boots and it is practical to wear the orthosis in bed. The clear view afforded by these orthoses (as well as the translucency of polypropylene when used) and the strap makes it easy to secure the foot in the proper position before donning the shoe, which obscures the view. Moreover, the use of an instep strap makes the selection of a proper shoe even less critical than it is with the unmodified ankle-foot orthosis. While selection of proper heel height is unaffected, the instep strap allows the use of loose floppy shoes and slippers. This can be important for people who must get up at night or who desire to use the orthosis at poolside.</p> <p>In the hospital the use of an orthosis modified by an instep strap allows ambulation to proceed with an ordinary bedroom slipper while a proper shoe is being obtained. Frequently, delays can be encountered in obtaining shoes, with needless extension of the hospital stay.</p> <p>What is less clearly appreciated is the proper positioning of the strap. For our purposes in this instance the shin-foot complex can be considered as two arms, the tibia and the foot, set at right angles to each other and articulating at the ankle. In combating equinus the orthosis imposes two anteriorly directed forces, one at the top edge of the orthosis, and the other at the metatarsal heads. If unopposed by an anterior third point the leg will ride up in the orthosis, pivoting about these two points with the ankle moving forward. In effect, the leg bowstrings about the two most extreme points. To be maximally effective and comfortable the third force should be as far as possible from the two end points so as to develop the maximum resistance with the minimum force and thus minimum pressure under the strap. In the ordinary course of events this third force is provided by the lace closure of the shoe over the oblique instep of the foot. Since this surface is oblique the force provided normal to this surface can be resolved into two right-angle forces, each of which opposes one of the two anteriorly directed forces of the orthosis. If an accessory strap is added in this bony area it is likely to prove uncomfortable owing to the relatively small area underneath it and the fact that it is positioned too far distally to oppose the anterior motion of the tibia with minimum force. Moreover, if a shoe is worn over it the additional bulk in the shoe is likely to prove undesirable. Conversely, if the strap is added proximal to the malleoli it will be in good position to control the tibia but inadequate to affect the foot.</p> <p>Unless opposed by a second strap or the shoe, equinus is likely to occur and since anterior motion of the tibia is prevented all the motion is likely to occur in a proximal direction with the malleoli riding up and shear taking place under the strap.</p> <p>Following the foregoing analysis then, it seems logical to locate the strap at the deepest point of the radius connecting the oblique dorsal surface of the foot and the vertical tibia, roughly equidistant to the ankle mortice and the subtalar joint. In this position the instep strap is as far as possible from each of the two end points, well positioned to control motion in each segment, and free of the lace area of the standard low-quarter shoe. Instep straps have been used in this configuration a number of years now and, contrary to expectations, irritation under the strap in this relatively unpadded area has not been a problem. This can be attributed, in part, to the fact that the strap is well placed to develop maximum torque with minimum pressure. It is, of course, possible to pad the strap if so desired.</p> <h3>Method</h3> <p>Two methods of adding the strap have proven successful. In one the strap and a narrow loop are riveted to the orthosis on either side along the intended line of force. In the second two slots are cut in the material of the orthosis if the orthosis extends far enough anteriorly to permit it. One end of a Velcro strap is passed through one of the slots and sewn back on to itself. The free end of the strap can then be passed through the other slot and placed back on itself to secure the orthosis. In each case a flexible tape measure can be used to measure the proper length of strap and to plan the proper points of attachment (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). This procedure can be done either over the positive model or the involved extremity itself and a strap can be added at any time.<br /><br /><strong><a href="/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg">Fig. 1</a>. A tape measure is used to locate the position of the rivet hole for attaching the Velcro strap. This can be done on the patient or around the positive model.</strong></p> <strong><a href="/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg">Fig. 2</a>. Similarly, a tape measure is used to plan the location of the slots to be cut in the orthosis.</strong><br /><br /><strong><a href="/files/original/6cf829e905f2e447ba594e3384850a62.jpg">Fig. 3</a>. Appearance of the Velcro strap and metal loop once they are riveted to the orthosis. Normally, of course, the patient would be wearing a stocking. The metal loop should be located further posterior so as not to impinge on flesh.<br /><br /><a href="/files/original/add90ab6d50a34714b20dca5c661b095.jpg">Fig. 4</a>. The Velcro strap attached to an orthosis through slots cut in the orthosis. Excess material has been cut away from around the slots to present a neat and finished trimline.<br /></strong><br /> <h3>Summary</h3> <p>A rationale for the use of an accessory strap to control equino-varus in an orthosis without the shoe is given. Some thoughts about its placement and descriptions of two methods of attachment are also given.<br /><em><b><br />Charles H. Pritham&nbsp;<br /></b></em><em>Director, Orthotics and Prosthetics Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, Pennsylvania<b><br /><br />Richard Rosenberger <br /></b>Director, Prosthetics and Orthotics Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia<b><br /></b><br /></em></p> Page Number(s) 1 - 3 Year 1979 Volume 3 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Instep Strap Creator An entity primarily responsible for making the resource Richard Rosenberger * Charles H. Pritham * https://staging.drfop.org/files/original/5482be4ae060a01e68f831179c03541a.pdf c4183c71a23a893c1ee48207ff643511 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_005.pdf Text Any textual data included in the document <h2>Editorial: Orthotics For Spinal Deformity - 1980 View</h2> <h5>Robert B. Winter, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Thirty-three years ago the Milwaukee brace made its first appearance, originally designed as a postoperative immobilizing and corrective device. Soon thereafter, it began to be used as a non-operative treatment method for both scoliosis and kyphosis. Between 1950 and 1970, the brace was gradually improved and the system of non-operative treatment became more refined, with more knowledge of the indications and contraindications.</p> <p>In Europe in the 1960's and in North America in the 1970's, a wave of new braces appeared, all attempting to control spinal curvatures without surgery. The corset Lyonnaise, the Riviera brace, the Pasadena brace, and finally the Boston brace and the Wilmington jacket were all basically "underarm" orthoses, although most could be extended up to a neck ring for special circumstances.</p> <p>The "underarm" orthoses were, of course, more aesthetically&nbsp;pleasing to the child, but there was considerable controversy as to whether they could achieve the same quality of curve control as was achieved by the Milwaukee brace.</p> <p>About this time, i.e. 1975, relatively long-term studies of the Milwaukee brace experience began to appear, not just what the curve was at the time of brace stoppage, but what was happening to those curves five and ten years later. It became increasingly apparent that there was a wide spectrum of brace results, even when ideal circumstances of brace manufacture, curve selection, and patient cooperation existed. The average result was a curve the same at the end as at the beginning.</p> <p>Why then use an orthosis if there is to be no correction? The answer is obvious: to prevent progression. We have learned through experience that orthoses are not designed to make large curves permanently into small curves. Orthoses <em>are</em> designed to keep small curves small.</p> <p>Should all small curves, therefore, be braced? The answer is "no," since many small curves are nonprogressive and do not need treatment of any kind. An 18° thoracic idiopathic scoliosis in a pre-menstrual 13 year-old girl has a 63 percent chance of being nonprogressive without treatment and a 4 percent chance of spontaneously improving without treatment. There is only a 33 percent chance of her curve progressing, and therefore she needs treatment only if progression is well-documented.</p> <p>What kind of a brace is best? It depends on multiple factors as to which brace is best for which patient. All too often, proponents of a particular design will claim that their design is best and will solve all problems. As in all phases of medicine, there is a spectrum of diseases and a spectrum of solutions. The pendulum of enthusiasm swings first one way (the Milwaukee brace only), and then the other (underarm orthoses only), and finally settles in the middle.</p> <p>The current "middle ground" of orthotic management is best expressed by that sophisticated program in which the orthotist and orthopaedic surgeon work together to design an orthosis for the specific child's curvature problem. For a lumbar or thoracolumbar curve, they will use an orthosis that exerts correctional and stabilizing forces on the curve, but does not extend up to the neck, i.e., some type of underarm orthosis. If there is a decompensation problem, a trochanteric extension will be employed.</p> <p>If the curvature is in the thoracic spine, i.e., the apex is at T7, an orthosis is needed which will give a maximal effect at that area. The best orthosis is still the Milwaukee brace, regardless of whether the curve problem is a kyphosis or a scoliosis.</p> <p>Why is a Milwaukee brace best for such thoracic curves? It is best because it is designed to apply its forces in that area without negative effects on other areas. Those who suggest that an underarm orthosis can achieve the same result are looking only at the roentgenogram, not at the patient. It is of no benefit to create a "good looking" roentgenogram, if at the same time the patient has decreased lung function, permanent alteration of rib cage dimensions, skin sores, digestion problems, or any of the other secondary effects which improper bracing can create.</p> <p>In summary, we have reached a point of professional advancement in which children with progressive curvatures are being detected early enough to permit non-operative control (not "correction") by orthoses. We are sophisticated enough not to overtreat small curves, nor to attempt to orthotically treat curves needing surgery. We now have a wide selection of orthotic devices from which to choose for the individual patient and her or his specific curve problem. We must stop looking just at an anteroposterior roentgenogram and begin to look at the patient as a three dimensional individual. Finally, we must recognize defeat - sometimes the orthosis just doesn't work and the patient needs surgery.</p> <em><strong><b>*Robert B. Winter, M.D. </b></strong>Professor of Orthopedic Surgery University of Minnesota</em><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 5 Year 1981 Volume 5 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Orthotics For Spinal Deformity - 1980 View Creator An entity primarily responsible for making the resource Robert B. Winter, M.D. * https://staging.drfop.org/files/original/34801932f31180cf39fb42463e18ca64.pdf b4ff1b0359d2a02dba24114047c1044d https://staging.drfop.org/files/original/6809b2f2afa3773a2820029b18b49a0b.jpg b8e4c1286250c652a53ec2b688db1acb https://staging.drfop.org/files/original/57e50e2a54f0ed529988256cbb6dd943.jpg aaac9f8f9b8b2b5bf8bab18389269d28 https://staging.drfop.org/files/original/69330701385993f53424c16d9fd378d8.jpg 53eb4adca9de07365f0faacc7c1b2bfa https://staging.drfop.org/files/original/f4181d44fd6538734307d9ea8b28ee4d.jpg e62d56cac139627fc1c316f26e860671 https://staging.drfop.org/files/original/d486cbde489421e053211e9332e2c877.jpg 79345ea5bfda40249c1da95de22377db https://staging.drfop.org/files/original/e6f7827c015798b9284c3ad7bce99e38.jpg ff99b290faf944d9eebd1823beba3dee https://staging.drfop.org/files/original/5155ade9bfc40b5ca7f8f0ffd21b75b7.jpg 63ded18f1ee6bf58ba96d15ebbbd68a0 https://staging.drfop.org/files/original/c14fa38126fa67950a300f4f17a45399.jpg 03b0ad5b1d067e9071f0fa40d0d0fd4c https://staging.drfop.org/files/original/23b23cf47b748b0346de8afd3db7a6c1.jpg 50ec8dabc7e88784dc0fc29ba58bfb93 https://staging.drfop.org/files/original/5d0a16bddb915f4ed3e31d89b05da45e.jpg abb09ce6db620b6606f9e0aac650b94e https://staging.drfop.org/files/original/5ac7ebb70decd31ce91601a4ac4da9a3.jpg 04eb1f4faa9d34d5281ad3d69e9e9810 https://staging.drfop.org/files/original/3677c02db76680b30ae38c40228c41b5.jpg 75c09a73c1870f3807933653b49680d3 https://staging.drfop.org/files/original/07dd115ef89f6e6ef005fb07d990dd9a.jpg 7a6534119ecd4981b5a7fb1b7cf37739 https://staging.drfop.org/files/original/0a4c66d644160de8fd4f209c4af5be31.jpg c243901ecf8305a715c919c7ee9e9ca8 https://staging.drfop.org/files/original/284b966aa49d3e57ea60dffeb209a3f4.jpg 34a52cafac6420239a7e937c337dda16 https://staging.drfop.org/files/original/7a18444d44b13d13f4e58b5f7788a592.jpg 7a7490de4b0d6b9ce087c838b433bea6 https://staging.drfop.org/files/original/535a6901340cdd81ec7457c80224e031.jpg c5033dc23af49069a08349ed2d3ef192 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_035.pdf Text Any textual data included in the document <h2>New Concepts in Post-Operative Scoliosis Management</h2> <h5>Robert D. Fitch, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Carrie Louise Beets, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>As improved surgical techniques and stronger spinal instrumentation are developed, the need for external stabilization post-operatively and the design of post-operative orthotics have also evolved. The purpose of this article is to review the many recent advances in the surgical technique and spinal instrumentation, and the early results of a new management protocol (both surgical and orthotic) in the treatment of selected spinal deformities.</p> <h3>Evolution Of Spinal Stabilization</h3> <p>The goal in the surgical treatment of scoliosis is to correct the deformity and maintain correction until fusion of the spine occurs. It is the surgical technique of fusion that provides long term spinal stability. Until the fusion mass matures, we must rely on stability provided through surgical instrumentation (internal support) and casts or orthoses (external support). If the spine is not stabilized sufficiently internally and externally, then a non-union of the spine will occur similar to that which occurs with inadequate immobilization of long bone fractures. Once a non-union develops, the deformity may gradually recur.</p> <p>Prior to the advent of the Harrington rod, correction of the spinal deformity was obtained through complicated casting techniques. Risser described the turnbuckle in 1927<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg"><b>Fig. 1</b></a>). Later he developed the localizer cast.<a></a> A cast technique similar to this was perfected by Dr. Cotrel of France<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg"><b>Fig. 3</b></a>). These casting techniques allowed correction of the deformity in the cast. The spine was then operated upon in the corrected position through the cast and the patient was maintained in a cast postoperatively for a period of nine to 12 months. With this form of treatment, there was a high incidence of failure, primarily due to the development of cast complications, or pseudoarthroses.<a></a> Many surgeons advocated routine exploration of the fusion mass six months postoperatively to identify any areas of non-union.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg"><strong>Figure 1. Turnbuckle cast as devised by Risser. Patient had to remain in bed for six months. (Photo reproduced with permission from Scoliosis by J.I.P. James, Williams &amp; Wilkins Publishers, 1967.)</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg"><strong>Figure 2. Localizer cast which extends up over the occiput and mandible. (Photo reproduced with permission from Scoliosis, ibid.)</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg"><strong>Figure 3. Posterior view of localizer cast showing window through which surgery was performed. (Photo reproduced with permission from Scoliosis, ibid.)</strong></a><br /> <p>In 1960, Paul Harrington reported on the use of a stainless steel distraction rod for the correction and stabilization of spinal deformities.<a></a> The Harrington device has since become the mainstay of surgical treatment for scoliosis. It has shown to be of great benefit in experienced hands and has shortened hospitalization time, avoided the need for preoperative correction with casting, permitted early mobilization of the patient in a well-fitted cast or orthosis, and has markedly decreased the pseudoarthrosis rate following fusion. What it has not accomplished, however, is the ability to provide sufficient internal stabilization to allow the abandonment of external support either by cast or orthosis.</p> <p>There are many instances in which external immobilization is undesirable. These include patients with insensitive skin, spasticity, or respiratory compromise. During the early 1970's, Edwardo Luque, M.D. from Mexico City was faced with many complex spinal deformities similar to those just mentioned. This led him to develop a new form of spinal instrumentation called segmental spinal instrumentation.<a></a> Unlike the Harrington rod, which uses distraction forces and is fixed to the spine at the top and bottom so that all the forces are concentrated at the bone-hook interface superiorly and inferiorly, segmental instrumentation provides corrective forces in a transverse manner at each spinal segment and, therefore, the distribution of forces is spread out over the whole length of the instrumentation. This has been shown to be much stronger biomechanically than the Harrington system and is extremely stable<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg"><b>Fig. 4</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg"><strong>Figure 4. X-ray showing Harrington rod system.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg"><strong>Figure 5. X-ray showing Luque rod instrumentation.</strong></a><br /> <p>Segmental spinal instrumentation has become the preferred method of treatment of complex spinal deformities, especially those associated with neuromuscular conditions such as muscular dystrophy, myelodysplasia and cerebral palsy. However, it has not replaced the Harrington rod for the management of idiopathic scoliosis. This is primarily because of the added neurologic risk that is involved when performing segmental spinal instrumentation. Wires must be passed sublaminarly within the spinal canal at every level to perform this technique. The potential for neurologic complications is related to invasion of the spinal canal with these wires and the potential for vascular compromise to the cord by correction of the deformity, which leads to elongation of the spinal canal and vascular stretch.</p> <p>It must be kept in mind that segmental spinal instrumentation does not take the place of a meticulous fusion, and if fusion does not occur, then instrumentation failure in inevitable. In general, patients who have been treated with segmental spinal instrumentation are not placed in any cast or orthosis post-operatively. This is based on the assumption that the Luque instrumentation is so strong that no external support is needed. However, recently some surgeons have questioned the requirement for external support even with Luque instrumentation. Although the early instrumentation failures have been solved with segmental spine instrumentation, some surgeons have found increased loss of correction over the first few months in patients not treated with orthoses, compared to those who have been treated with orthoses postoperatively. Also, the question of late pseudoarthroses must yet be resolved; and if there is a significant incidence of pseudoarthroses with Luque instrumentation, would post-operative orthotic support decrease this incidence?</p> <p>Because of the added neurologic risk, we have opted not to use segmental instrumentation in dealing with most idiopathic spinal deformities. Rather, we continue to use the Harrington rod with some recent modifications. The modified Harrington rod provides enough internal stability to allow us to use a post-operative orthosis that is comfortable, convenient, and cosmetic. Added stability to the Harrington system has been achieved by a simple modification of the Harrington hooks. This was devised by Dr. Bobechko of Toronto. The new hook has a cam placed inside a slot which allows two hooks, rather than one hook, to be utilized at the upper level. Since most of the early instrumentation failures with Harrington rods have been with the cut-out of the upper hook, two hooks allow the forces to be distributed over a larger surface area, and when the technique is properly performed, corrects that problem. At the bottom end, a specially designed hook with a longer shoe is used to prevent dislodgement of the hook in this area, which can occur when the patient flexes forward.</p> <p>With the degree of stability provided by this method, post-operative cast immobilization is unnecessary. In addition, currently available orthoses such as the Greenville spinal orthosis, the SOS modular orthosis, or the Milwaukee brace also provide more external support than we feel is necessary. This has led us to adopt the use of a posterior plastic shell with corset front and shoulder straps.</p> <h3>Current Management Protocol</h3> <p>This post-operative orthosis is used in two situations: (1) in the patient with idiopathic scoliosis who has undergone Harrington rod instrumentation with modified hooks as described above, and (2) in patients with more complex spinal deformities who have had segmental instrumentation and are at risk for loss of correction or late pseudoarthrosis.</p> <p>Our post-operative regimen consists of taking a mold at the time of surgery. The patient is then mobilized quickly beginning on the first post-operative day. The patient is allowed to stand at the bedside twice a day until the orthosis is ready and applied, usually on the third post-operative day. At that point, the patient is allowed to begin ambulation and sit with the orthosis on. Following discharge, the patient is allowed to doff the orthosis at night and once a day for showering. The orthosis is worn for four months post-operatively.</p> <h3>Orthosis Design</h3> <p>The posterior shell orthosis used at Duke University Medical Center is based on an orthosis design that was originally used at the Texas Scottish Rite Hospital for Crippled Children in Dallas, Texas. At the Scottish Rite Hospital a Surlyn® posterior shell, with a special order Camp corset front riveted to the shell, is used. It is cast and delivered post-operatively, or sometimes on an outpatient basis.</p> <p>At Duke, the design was modified by the addition of shoulder straps for provision of an anti-rotatory movement reminder. The shoulder straps and the corset front are removable for easy laundering. The Duke protocol is for its use as an immediate post-operative orthotic device.</p> <h3>Casting</h3> <p>The Department of Prosthetics and Orthotics at Duke University Medical Center has the advantage of being located on site. This permits close coordination with the physician and his operating room schedule. The dates for which an orthotist is needed in the operating room are known in advance, as well as the time and estimated length of surgery. The surgeon notifies the orthotist as the surgical team prepares to close the case. The orthotist arrives in the operating room while the case is being closed. Adequate time is available to set up splints and water, inspect operative x-rays, and confirm the length of the instrumentation (helpful in determining proximal trimline of orthosis).</p> <p>Following closure of the surgical site, a small temporary sterile dressing is placed over the suture line for protection. The orthotist places a split piece of cotton stockingette over the patient's back and buttocks. Using an indelible pencil, the axillary and proximal trimlines are marked, C-7 is marked for reference, the waist and the gluteal fold and a horizontal line across the top of the gluteal fold are also marked (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg"><b>Fig. 6</b></a>). Six inch wide plaster splints, three layers thick, are applied lengthwise starting with the center back and overlapping towards both sides. Attention is paid to apply the plaster splints as far anteriorly on the patient as possible to make sure the cast impression has been taken to midline or just beyond. If a patient appears large busted or overweight, the sides of the impression can be compressed while the plaster is setting up (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg"><b>Fig. 7</b></a>). This will afford a truer M-L measurement for the patient when standing and sitting. The cast impression is removed (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg"><b>Fig. 8</b></a>) and the post-operative bandages are applied.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg"><strong>Figure 6. With the patient still on the operating room table, a split piece of stockinette is placed over the patient's back and landmarks and trimlines are marked.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg"><strong>Figure 7. If a patient is large busted, the sides of the cast impression can be compressed while the plaster is setting, allowing a truer M-L dimension for when the patient will be sitting and standing.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg"><strong>Figure 8. Cast impression simply lifts off. Operating room nurses replace temporary bandage, protecting the suture site with a regular post-op dressing.</strong></a><br /> <h3>Fabrication</h3> <p>Any number of thermoplastics can be used to fabricate this orthosis, however, we have found Surlyn® to be sufficiently rigid and cosmetic. The advantage of fabricating with Surlyn® is that the standard practice of pouring, stripping, and modifying a positive model can be completely eliminated.</p> <p>In the fabrication lab, the cast impression is allowed to dry 30 minutes to an hour. The stockinette is then powdered. The impression is placed into an adjustable support to prevent any M-L spreading during the plastic molding. A piece of 3/16" thick Suryln®, large enough to cover the inside of the impression, is placed in the oven and allowed to heat just until it is pliable (about five minutes). The heated plastic is placed in the impression and pressed into the contours of the cast impression (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg"><b>Fig. 9</b></a>). The plastic is then rapidly cooled by a wet towel or air (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg"><b>Fig. 10</b></a>). When completely cooled, the plastic shell is lifted off the cast impression and the stockinette is stripped, exposing trimlines and reference marks made at the time of casting. The plastic shell is set back on top of the cast impression and the trimlines are transferred to the shell (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg"><b>Fig. 11</b></a>). The shell is trimmed and the edges finished (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-12.jpg"><strong>Fig. 12</strong></a><b> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-13.jpg">and 13</a></b>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg"><strong>Figure 9. Surlyn®, heated just until pliable, is pressed into the contours of the cast impression.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg"><strong>Figure 10. Surlyn® is rapidly cooled with a wet towel.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg"><strong>Figure 11. Trimlines are transferred from the cast impression to the Surlyn® shell.</strong></a><br /><br /><strong>Figures 12 and 13. Drape forming the Surlyn® to the cast impression without pouring a positive mold gives excellent contour detail to the resulting posterior shell.</strong><br /> <p>The posterior shell is ready for the attachment of the corset front and shoulder straps. We use a standard corset front available from Truform in either a 9", 10", or 12" abdominal length, depending on the patient's stature. Holes corresponding to the corset eyelets are drilled in the lateral edges of the posterior shell and the corset front is laced onto the posterior shell (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg"><b>Fig. 14</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg"><strong>Figure 14. Finished posterior shell with corset front laced in place and shoulder straps also removable for laundering.</strong></a><br /> <p>The shoulder straps, which are also removable for laundering, are attached to the posterior shell via Velcro® on the ends which double back on themselves after slipping through loops permanently riveted to the posterior shell. The shoulder straps are attached to the shell just proximal to the interscapular level. They cross the shoulders and attach laterally several inches distal to the axillae via a standard corset style hook. Placement of the lateral hooks midway between the axillae and the waistline prevents binding in the axillae when the straps are tightened. Total fabrication time from casting to initial fit is approximately four hours.</p> <h3>Fitting</h3> <p>Though the fabrication of the posterior shell orthosis is fast enough to permit fitting the same day as the cast impression is taken, the orthosis is usually delivered on the third post-operative day. This is done to allow post-operative illeus with accompanying abdominal distention to resolve. If the orthosis is fit too soon, the corset front invariably needs to be altered or the size of the front changed altogether. By the third day, the patient is alert and tolerant of being log-rolled, and the majority of abdominal distention has subsided. The posterior shell is tried for initial fit in bed and the patient is measured for the corset front with the shell in place. The accuracy of the trimlines is noted and the shell is marked if any adjustments are needed.</p> <p>After the corset front is attached, the orthosis is delivered to the patient, along with two pieces of stockinette to serve as in-hospital t-shirts and a written information/instruction sheet which covers care of the orthosis and basic "do's and don'ts."</p> <p>When providing this orthosis for community physicians at nearby hospitals, rather than trying to coordinate with their operating room schedule since travel time is involved, we cast the patient several days post-operatively. The patient is log-rolled in bed to a prone position and the plaster impression is taken the same way as in the operating room. If thick bandages are still over the patient's surgical area, the impression will be slightly deeper than the final product. Trimlines must be adjusted accordingly. The community hospital patient is measured for the corset front at the same time as casting since he can be log-rolled back to a supine position for measuring. The M-L measurement for the corset front is taken midline to midline. The shell is then delivered in 24-48 hours. By either method, the patient is up and walking in the orthosis at four days postoperative and is usually discharged at 6-7 days post-operative.</p> <h3>Summary</h3> <p>As of this writing, the protocol described above had been utilized in 44 patients over a period of 18 months. Diagnoses include adolescent idiopathic scoliosis, myelodysplasia, adult scoliosis, and adult spinal tumor. There has been one occurrence of instrumentation failure in a patient with adolescent scoliosis who had dislodgement of the upper hooks as a result of improper hook placement at the time of surgery.</p> <p>We feel that with the increased internal support provided by the Bobechko hooks in the Harrington rod instrumentation that the modified bracing provided by the posterior shell (versus Milwaukee or Greenville orthosis) has provided satisfactory restriction of gross motions which might endanger the success of surgery. Forward bending and twisting are restricted and the shoulder straps add an upper torso anti-rotatory reminder for the patient. We have had no problems with lack of compliance in brace wearing, even though both the shoulder straps and the corset front are removable.</p> <p>The orthosis has been well received by the patients. It is cooler and more comfortable than many of its counterparts. It is also cosmetically acceptable and is easily donned and doffed. Hygienic maintenance requires minimal time and effort. Finally, it has been well received by both adolescent and adult patients (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-15.jpg"><b>Fig. 15</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-16.jpg"><b>Fig. 16</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-17.jpg"><b>Fig. 17</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-18.jpg"><b>Fig. 18</b></a>).</p> <strong>Figures 15(above) and 16(below). The orthosis is easily donned by the patient.</strong><br /><br /><strong>Figures 17(above) and 18(below). Posterior shell orthosis is very cosmetic.</strong><br /><br /><em><b>*Carrie Louise Beets, CO. </b> Carrie L. Beets, CO., is formerly of the Department of Prosthetics &amp;Orthotics, Duke University Medical Center. She is presently with the University of Virginia, Department of Prosthetics and Orthotics, 1224 W. Main Street, Charlottesville, Virginia 22908.</em><br /><br /><em><b>*Robert D. Fitch, M.D. </b> Robert D. Fitch, M.D., is Assistant Professor at the Division of Orthopaedic Surgery, Duke University Medical Center.</em><br /><br /><br /> <p><b>References:</b></p> <ol> <li>Cotrel, Y., "Le corset de platic E.D.F. dass le treatment de la scoliose idiopathegirel," <i>Med. Hyg.</i>, 28:1032, 1970.</li> <li>Harrington, P.R., "Correction and internai fixation by spine instrumentation," <i>J. Bone Joint Surg.</i>, 42A:1448, 1960.</li> <li>Luque, E.R., "The anatomic basis and development of segmental spinal instrumentation," <i>Spine</i>, 7:256-259, 1982.</li> <li>Ponseti, E.V. and Friedman, B., "Changes in the scoliotic spine after fusion," <i>J. Bone Joint Surg.</i>, 32A:751-766, 1950.</li> <li>Risser, J.C., "The application of body casts for the correction scoliosis," Am. Acad. Orthop. Surg., Instructional Course Lect., 12:255-259, 1955.</li> <li>Risser, J.C.; Lauder, CH.; Norquist, D.M.; and Craig, W.A., "Three types of body casts," Am. Acad. Orthop. Surg., Instructional Course Lect., 10:131-142, 1953.</li> <li>Wenger, D.R.; Eurollo, J.J.; Wilkerson, J.A.; Wau-ters, K.; and Herring, J.A., "Laboratory testing of segmental spine instrumentation versus traditional Harrington instrumentation for scoliosis treatment," <i>Spine</i>, 7:265-269, 1982.</li> </ol> Page Number(s) 35 - 42 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New Concepts in Post-Operative Scoliosis Management Creator An entity primarily responsible for making the resource Robert D. Fitch, M.D. * Carrie Louise Beets, CO. * https://staging.drfop.org/files/original/1bc3249b9871bf77d6deaebeec0f9573.pdf 062b6087654766cc1458acca6e7a8016 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/cpo/pdf/1984_04_028.pdf Text Any textual data included in the document <h2>Technical Note: Rigid A.F.O. - Another Choice</h2> <h5>Robert E. Doran, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>When an orthotic prescription calls for an ankle/foot orthosis to provide rigid ankle/foot stabilization, the two basic choices have been (1) a double bar metal orthosis or (2) a thick and/or reinforced thermoplastic orthosis. We are all familiar with the advantages and disadvantages each has to offer.</p> <p>It was this author's goal to design a rigid A.F.O. that would combine the advantages of both. The features of such an orthosis should include light-weight construction; provide rigid ankle stabilization; provide adjustable plantar and dorsiflexion in order to dynamically align the orthosis; fit inside the shoe; be cosmetically acceptable; be easily donned; and maintain alignment while changing heel heights.</p> <p>With the above in mind, the following orthosis was designed. The orthosis consists of "pre-preg" (the resin is impregnated in the matrix in an uncatalyzed form prior to lay-up, generally at the factory. Once the desired lay-up is achieved, the structure is exposed to a catalyzing agent so that it hardens), carbon-fiber and fiberglass fabric. Epoxy and polyester resin have been used as bonding agents and the orthosis is formed over a plaster model of the patient's leg. Such pressure applying agents as vacuum bags and pressure wraps have been used. The carbon fiber and fiberglass fabric are properly oriented to resist the stresses imposed upon the orthosis and comprise a structure that provides a high strength to weight ratio.</p> <p>The orthosis has a foot section which begins on the plantar aspect of the foot and extends proximally on the medial and lateral sides of the leg. The "uprights" are connected by adjustable velcro-closing calf straps. Plantar and dorsiflexion adjustments are independently achieved by adjusting the anterior and posterior velcro-closing calf straps.</p> <p>In some cases, donning is simplified by removing the posterior strap, thus allowing for a posterior entry of the foot and leg into the orthosis and shoe.</p> <p>Over the past eighteen months, nine patients with diagnoses that include low level paraplegic, C.V.A., and neuromuscular disease have been fitted with the graphite composite A.F.O. as a successful alternative to "traditional" orthoses.</p> <p>Orthotists now have another choice when designing a rigid ankle foot orthosis for their patients. The graphite composite A.F.O. combines some of the advantages of the standard metal and thermoplastic constructed A.F.O.</p> <b>Robert E. Doran, C.P.O. </b> Thousand Oaks Prosthetic Orthotics, 253 Lombard Street, Suite C, Thousand Oaks, California 91360.<br /><br /><br /> <div style="width: 400px;"></div> Page Number(s) 28 - 28 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Rigid A.F.O. - Another Choice Creator An entity primarily responsible for making the resource Robert E. Doran, C.P.O. * https://staging.drfop.org/files/original/bb5505172d6f91d3b4c1078c76732cdd.pdf 5f258ce3f8db62c96aded278f4214167 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_001.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation Revalued</h2> <h5>Robert E. Stewart, D.D.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In any sound program of research and development, whatever the intended goal, there must inevitably come a time when extensive evaluation of the product is indicated. Less than fifty years ago, systematic tests of new concepts were performed more or less routinely by private inventors dedicated to proper self-appraisal as occasion warranted. In a period less sophisticated technologically, this fashion in science served its purpose adequately and well. But with the growth in a more modern era of the large and vastly more complicated system of scientific inquiry, such as we know it today in government and industry alike, the requirement for periodic assessment of experimental results has led to the development of the independent testing laboratory, either as a part of the basic organization or as a separate contracting institution. So indispensable has this phase of technical investigation become that now large sums of money are spent annually in support of evaluation groups who themselves commonly engage at least in part in research aimed at improving their own methods and techniques.</p> <p>With respect to these matters, the Artificial Limb Program has exhibited ostensibly no basic deviation from the general pattern now characteristic of other broad exploratory projects involving the cooperation of various specialists in otherwise distinct disciplines. But because of the peculiar nature of the amputee problem, the particular state of the art of limb prosthetics, especially in the upper extremity, and the demands of rather unusual external influences of one kind or another, the approach to systematic evaluation has in this case evolved out of a unique history and has, consequently, given rise to some valuable results in research and education of which the influence was not fully anticipated in the beginning.</p> <p>Although in that portion of ALP devoted to the upper extremity much of the initial investigation was directed toward all-purpose, or "ideal," prostheses for selected levels of arm amputation, it was soon recognized that the desired objectives would be served more effectively were a variety of components made available for assembly into various combinations the better to provide for the particular needs of the individual patient. As these components were developed, prototypes and, later, production units were subjected to systematic testing by the Prosthetic Devices Study, an organization established for this specific purpose within the Research Division of the College of Engineering of New York University.</p> <p>At this point, evaluation generally furnished much needed data concerning the usefulness and reliability of individual units in direct comparison with previous similar parts but without regard for the influence of socket fit, type of harness and harness adjustment, type and extent of training, individual amputee preference, and other factors. Because methods suitable for the evaluation of techniques had yet to be introduced, early evaluations of components brought with them the subtle dangers of misinterpretation owing to the indirect effects of pre-existing errors in socket or harness, to say nothing of the possibility of the influence of one component upon the performance of another used in conjunction. In these circumstances, a great deal was left to be desired in reference to the over-all problem of upper-extremity prosthetics.</p> <p>To fill the gap, there was initiated in 1950, in the Department of Engineering at the University of California at Los Angeles, the so-called "Case Study," with the purpose of bringing together all available information, of viewing systematically the results obtained by use of various combinations of devices and techniques, and thus of developing a set of general principles of management for the upper-extremity amputee. As the Case Study progressed, there arose an increasing awareness of the necessity for teamwork in the proper application of such knowledge as there was, and by 1952 the Prosthetic Devices Study was called upon to conduct an evaluation of the results of the UCLA Case Study.</p> <p>It was obvious that, if such an evaluation were to be conclusive, large numbers of cases under varying geographical conditions would be needed for observation and that therefore the services of a number of clinic teams throughout the country would be required. Although the Prosthetic and Sensory Aids Service of the Veterans Administration, long the chief sponsor of the Artificial Limb Program, had already established some thirty prosthetic clinic teams, and although these groups were readily available for participation, it was patently mandatory that they be trained in the latest methods before any reliable program of evaluation could be initiated. Accordingly, short-term courses for clinic team members physicians, therapists, and prosthetists were organized and conducted at UCLA beginning in 1953. The formation of new clinic teams outside the VA framework was encouraged, and these, along with a few private clinic teams already in existence, were invited to participate.</p> <p>The education program leading to the Upper-Extremity Field Studies, the name applied to this part of the NYU evaluation work, proved to be a pioneering effort in its own right. While results of research were being made available to clinic teams for general use in a remarkably short time after the initiation of laboratory work, the continued association of clinic personnel with the research program through participation in the Field Studies had a definite impact on those responsible for amputee care. Thus the Field Studies came to be a series of complex investigations designed not only to evaluate the usefulness of available upper-extremity prostheses but also to determine the effectiveness of the management procedures elucidated by the UCLA Case Study. Simultaneously, and almost unavoidably, the process of accumulating voluminous clinical data on one segment of the population led to a general upgrading of industry practices in amputee service and furnished the basis for further research into the needs, physical and mental, of the armless.</p> <p>Because the NYU Field Studies represent the first, and thus far the only, attempt in the United States to appraise the status of upper-extremity prosthetics directly and on such a broad scale, and because the results present such a wealth of information not available elsewhere, this and the following issue of Artificial Limbs are given over to presentation of a series of summary articles divided into two parts the first (this number) concerned with the educative aspects of the work, the second (Autumn 1958, Vol. 5, No. 2) with the research implications. For those who would undertake further study and interpretation in the interest of scholarship, the original data, far too detailed for thorough analysis by other than biostatisticians, are available in the College of Engineering of New York University, New York City.</p> <p>In reviewing the material offered here, it is appropriate to keep in mind that the Field Studies constituted a new voyage into an area in which both subject matter and method of approach were uncharted and unexplored. Understandably beset by all the problems of design, organization, and execution typical of adventures into the unknown, they now reveal certain deficiencies most readily viewed with benefit of hindsight. In all probability, the true value of the Field Studies remains to be had in the further application of the principles not only in the field of limb prosthetics but in other, more general areas of physical handicap as well.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert E. Stewart, D.D.S. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic and Sensory Aids Service, U. S. Veterans Administration, Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation Revalued Creator An entity primarily responsible for making the resource Robert E. Stewart, D.D.S. * https://staging.drfop.org/files/original/a16c64d7ccf859685483448cdaa30655.pdf 030e2ddd7f33ca508ab0109a9cb77990 https://staging.drfop.org/files/original/20971c1df6a94f651c41c24f4b2fa35b.jpg 2531dc6b54ab731bd857b99ad1648727 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_001.pdf Text Any textual data included in the document <h2>Up-Date on Immediate Post Surgical Fittings</h2> <h5>Robert F. Hayes, CP.&nbsp;</h5> <p>I would like to express some thoughts regarding the use of the technique of immediate post-surgical fittings of prostheses for below-knee amputees.</p> <p>Nearly all of us certainly agree that there are definite advantages to the patient in the use of prosthesis immediately after amputation, especially in the case of the BK amputee. However, the I.P.S.F. technique is not being used as standard practice in many areas. Perhaps one of the reasons is the lack of continuing education courses dealing with immediate postsurgical procedures.</p> <p>When the concept of immediate postsurgical fitting was first introduced approximately fifteen years ago there was a heavy concentration to the point of saturation on the application of prostheses in the operating room. This was good, because it gave us all an opportunity to be educated in such a revolutionary technique of treatment. However, today, there are many people entering the field involving amputation and amputee care every year, surgeons and prosthetists and in most cases they have only a limited knowledge of the I.P.S.F. techniques.</p> <p>Obviously, and for good reason, most surgeons are reluctant to use a technique with which they themselves are not familiar. It then becomes the role of the prosthetist to educate and encourage the use of I.P.S.F. and, ideally, apply the concept himself.</p> <p>Another reason for lack of use of I.P.S.F. is the inconvenience created by scheduling between doctor, prosthetist, and operating room. Often hours of valuable time are wasted when things are not proceeding on schedule, which is the norm rather than the exception.</p> <p>Another reason why I.P.S.F. techniques are abandoned is that when a surgeon and prosthetist first attempt this technique, they sometimes use a patient whose probability of healing is marginal under the best of circumstances. And sometimes ambulation is attempted too early, causing stump breakdown. The result is a surgeon convinced that this technique is not for his patients.</p> <p>Still another factor that discourages use of the I.P.S.F. concept is the application of a poorly fitting weight-bearing cast by individuals not fully trained. There have been individuals who, after reading an article or hearing a thirty-minute lecture on I.P.S.F., attempted to apply a weightbearing cast. Some of the more skilled are able to do this, but most have problems. If a cast is intended to bear weight, it must fit well, have proper relief areas and distal padding to provide relief if the patient should atrophy and settle in the socket.</p> <p>It is my opinion that no weight-bearing cast at all is better than a poor application of one that is supposed to bear weight. Please note, I said "weightbearing cast" and not a rigid dressing, which is and should be more readily applied immediately after the operation and does not require the same precision as does the weight-bearing cast. This will be taken up later.</p> <p>Now that we have discussed some of the problems that may have discouraged the utilization of I.P.S.F.- and I'm sure there are many more- let's constructively consider a couple of approaches that seem to work well.</p> <p>Since the inception of I.P.S.F., most of us have changed our thinking for some very solid reasons. One of the primary problems arose in the attempt to have the patient weightbearing and often ambulating within forty-eight hours postoperatively. We have learned that, in most cases, this concept is a disadvantage rather than an advantage and can be the cause of stump breakdown. If we agree that early ambulation is not intended, we may apply an immediate rigid dressing with the appropriate snugfitting sterile stump sock.</p> <p><b><a href="/files/original/20971c1df6a94f651c41c24f4b2fa35b.jpg">Fig 1:</a> Schematic lateral view of method first recommended in the U.S. for immediate past surgical fitting of below-knee prostheses. From "<i>Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees</i>, Ernest M. Burgess, Joseph E. Traub, and A. Bennett Wilson, Jr., Veterans Administration, TR 10-5, April 1967.</b></p> <p>When the rigid dressing is not intended for weightbearing, most surgeons will make the application since they need not be concerned about felt pads for relief over pressure areas. The initial rigid dressing can be left on for approximately two weeks. During this time we have:</p> <ol> <li> <p>Protected the wound by</p> <ol> <li> <p>Keeping external contaminates out</p> </li> <li> <p>Preventing injury to the stump</p> </li> <li> <p>Protecting the posterior flap from undue pressure</p> </li> </ol> </li> <li> <p>Maintained the size of the stump, preventing edema, which alleviates pain</p> </li> <li> <p>Made the patient more comfortable and able to move about without fear of injury to the stump</p> </li> <li> <p>Prevented knee flextion contracture</p> </li> <li> <p>Greatly reduced complaints of phantom limb</p> </li> </ol> <p>After two weeks the initial rigid dressing is removed; or, in some cases, the surgeon will remove the sutures and wait for an additional week or two. At the end of the two-week postoperative period, the prosthetist is called in to apply an early post-surgical prosthesis usually with a plaster socket and a pylon with a SACH foot.</p> <p>In the fabrication of our plaster sockets, we strive to keep the plaster high up over the condyles to the mid thigh area. We find this is beneficial in eliminating knee flexion contractures and, most importantly, eliminating piston action within the socket, a very hazardous condition, especially in the early stages of fitting.</p> <p>I know attempts are made to trim plaster to a P.T.B, level for increased knee motion. The advantages of enclosing the knee offset the short time needed for patients to regain knee motion. I also use a waist belt and fork strap for added suspension. This temporary prosthesis is worn for approximately six weeks.</p> <p>The very thin patient may not need a cast change before the end of six weeks, but more muscular and fatty tissue will require cast changes according to the amount of atrophy.</p> <p>After the patient has been ambulating for approximately six weeks, the plaster socket is bi-valved and a negative mold is taken for the definitive prosthesis. The plaster socket is then put back on the patient and closed with plaster or tape. The plaster socket and pylon stay on the patient until delivery of the definitive prosthesis and removed as needed for fittings. When minor changes in stump size occur, stump socks may be added while using the plaster pylon prosthesis.</p> <p>To reduce some expense to the patient, the hospital can inventory several pylon assemblies suitable for temporary use. We also supply various sizes of used SACH feet that can be used temporarily. The patient is then charged only for the professional services of the prosthetist, thus saving the considerable expense of components.</p> <p>I hope that some of my comments may be of assistance to others who would like to employ more immediate postsurgical prosthetic care for patients, and hopefully stimulate others to respond with other approaches so that we may all benefit.</p> <p>I would like to acknowledge Dr. Elmer Franseen, from whom I have used references many times in this paper. Dr. Franseen is an Orthopedic Surgeon at Baystate Medical Center, Springfield, Mass. I am sad to say that Dr. Franseen is retiring this month, and I will miss working with this truly professional man. In the past fifteen years of working with Dr. Franseen, I have witnessed him employing I.P.S.F. on all of his B.K. amputees and only on rare occasions was a revision necessary.</p> Page Number(s) 1 - 3 Year 1978 Volume 2 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1978_04_001/1978_04_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Up-Date on Immediate Post Surgical Fittings Creator An entity primarily responsible for making the resource Robert F. Hayes, CP.  https://staging.drfop.org/files/original/3c4ac589e8903780aa0da08c35aaeb58.pdf c97b050714fb3e489b9de161df583e40 https://staging.drfop.org/files/original/e764f2e58593ada37005d3d671580fcc.jpg e1b3b3b57afea255233eea6635c36111 https://staging.drfop.org/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg 6fcb2c844c796a0566c819a3ec665430 https://staging.drfop.org/files/original/3f65a33756d243d9afabd2712fe9240b.jpg 7e2a8536aa8f9635302e070c9e7f99ca https://staging.drfop.org/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg 95b1799693489eae13885500343e64d2 https://staging.drfop.org/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg c17a38b68b4a2e9a28ba4bfc88b46ab0 https://staging.drfop.org/files/original/a9f74838bb3d260e38168c79e38c620a.jpg c910911d2c29aac18ef5344138533538 https://staging.drfop.org/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg 29990018762f14ec45b71e8106effaaf https://staging.drfop.org/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg f505f6705bbc9e93d3772e72f9a5b118 https://staging.drfop.org/files/original/f88f0a978929d9669ad1e8001308498d.jpg 2ed82df089dc35c181a50d43ec37a98e https://staging.drfop.org/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg 560f2db154b03d37f12eb9b6d864e7d2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_013.pdf Text Any textual data included in the document <h2>A Below-Knee Weight-Bearing Pressure-Formed Socket Technique</h2> <h5>Robert F. Hayes, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>I'm pleased that the Academy has requested that I update and rewrite the Below-Knee Weight-Bearing, Pressure-Formed Socket Technique article I originally wrote in 1975. It's hard to believe that ten years have passed since the original publication of this paper.</p> <p>I haven't made any significant changes regarding the principles or application of this procedure, but let's go back to some of the reasons this concept was developed.</p> <p><strong><a href="/files/original/e764f2e58593ada37005d3d671580fcc.jpg">Fig. 1.</a> Place a sheet of plastic wrap, such as Saran, over the patient's stump to keep it clean and to ease removal of the cast.</strong></p> <p>As I explained in the original article, my son was being fitted for ski boots and it occurred to me that we might make use of some of the techniques used by ski boot designers. The ski boot had an inflatable inner bladder. With the foot under weight-bearing, a conforming material similar to certain silicone compounds was injected into the bladder to give a perfect form-fitting in the attitude of weight-bearing. The incentive to apply this technique to limb prosthetics was reinforced while I was casting a below-knee patient who was a dentist. We exchanged thoughts on molds and changes when pressures are applied. Dentists take one mold for a cast which is filled with dental impression cream (similar to alginate). This is applied to the patient under pressure to give a more accurate impression, and then this is filled to form the definitive positive mold.</p> <p>The standard method of fitting a below-knee amputee involves taking a negative cast in a non-weight-bearing condition, forming a positive model, modifying it in size to present dimensions by removing material to create pressure, and applying material to relieve pressure on the stump as appropriate. A socket is then molded over this model with the hope that, with small adjustments, it will fit the patient.</p> <p>Wouldn't it be wiser to develop a socket under pressure that will adjust to and fit the patient, rather than fit the patient to the socket? In trying to answer this question, the procedure described here was developed.</p> <p><strong><a href="/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg">Fig. 2</a>. Apply cast sock and felt relief pads.</strong><br /><br /><strong><a href="/files/original/3f65a33756d243d9afabd2712fe9240b.jpg">Fig. 3.</a> Using Plaster-of-Paris, wrap the residual limb in the usual manner.</strong><br /><br /><strong><a href="/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg">Fig. 4</a>. Remove the tube gauze and felt buildup from the negative cast.</strong><br /><br /><strong><a href="/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg">Fig. 5.</a> Pour and modify the positive model.</strong><b><br /><br /></b><strong><a href="/files/original/a9f74838bb3d260e38168c79e38c620a.jpg">Fig. 6</a>. Build up the distal end of the positive model at least 1".</strong></p> <h3>The Procedure</h3> <p>Measure the patient in the usual manner. Place a sheet of plastic wrap material, such as Saran, over the patient's stump to keep it clean of indelible pencil, and to make removal of the cast easy. If a wool sock is to be used, apply it, and then apply the plastic wrap. Apply a cast sock or tube gauze over the stump. Bond 1/4" felt over all pressure-sensitive areas: the crest of the tibia and the head of the fibula.</p> <p>Keep in mind that all areas being built up will be filled with alginate to give contact, yet minimizing pressure. There are some prosthetists who have adopted this technique and claim they apply direct pressure over the crest of the tibia. My experiences do not agree with that. In particular, since many of our patients are diabetic with very thin skin, extra caution should be taken to reduce pressure and especially friction over all bony prominences.</p> <p>Using elastic Plaster-of-Paris bandage 4" wide, wrap the stump in the usual manner, and reinforce with 3" or 4" wide regular plaster bandage. Remove the cast and remove the tube gauze and felt buildup from the negative cast.</p> <p>Pour the positive model, remove the negative cast, and modify in the usual manner, but do not touch areas that were covered with felt. Build up the distal end of the positive model at least 1".</p> <p><strong><a href="/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg">Fig. 7.</a> Set up the transparent check socket for dynamic alignment.</strong><br /><br /><strong><a href="/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg">Fig. 8.</a> Pour the alginate and let it escape through the distal holes until the patient is lowered into the socket to the proper level at which time the holes are blocked. The alginate will then escape along the proximal brim of the socket.</strong></p> <p>Make a check socket. This is a perfect application for vacuum-forming. Plaster bandages or laminates can, of course, be used. Drill two holes 1/4" in diameter in the distal end and rough up the inside surface of the socket. For the first fitting, apply the stump sock of choice, and place plastic "wrap" over the stump sock to act as a separator. An invaginated balloon will not work because it adheres to the alginate that is to be used later.</p> <p>Some prosthetists apply the check socket to the patient's bare stump (no socks) for visual inspection. It bothers me to think what happens to the fit of this socket when the prosthesis is finished from this exact mold and the patient applies the usual stump sock of 3-ply or 5-ply. When the check socket is applied on new patients, I recommend using a thin-fitting sock in anticipation of stump atrophy. On seasoned, well-shaped stumps, I use the same sock that the patient usually wears. When using inserts that tend to compress, i.e. Pelite®, you may use a 3-ply and, after several weeks of prosthetic use, the socket should accommodate a 5-ply sock. Of course, there are many factors to be considered, and this is the area where the prosthetist's knowledge and experience will play the major role as to how well his or her patient does.</p> <p>Mix about 1/2 pint of dental impression cream or alginate (which is more economical). Pour about 1/3 of the total amount in the distal part of the socket and, with a spatula, spread the rest around the remaining surface of the socket. It is necessary to work quickly at this point.</p> <p>Place the socket on a fitting stool adjusted for height. Use some sort of pad to prevent slipping and cover the drilled holes in the socket with your thumb and forefinger. Have the patient place his stump in the socket. Let the alginate escape through the distal holes until the patient is lowered into the socket to the proper level, at which time the holes are blocked. Alginate will now escape along the proximal brim of the socket.</p> <p><strong><a href="/files/original/f88f0a978929d9669ad1e8001308498d.jpg">Fig. 9.</a>&nbsp;The completed socket.</strong><br /><br /><strong><a href="/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg">Fig. 10</a>. The completed socket.</strong></p> <p>As soon as the alginate has set up, remove the stump from the socket and immediately fill the socket with plaster. The rigid socket and alginate are removed by using a cast cutter. The mold resulting is a perfectly smooth, pressure-formed, positive mold that can be used in any method of fabrication desired.</p> <p>When this technique is used, patients can be fit with sockets without soft liners.</p> <p>Only a minimal amount of additional time is required. I feel that the technique allows better fitting of "problem" stumps and that it may be used as a routine procedure to advantage, especially in central fabrication systems. Vacuum-forming procedures recently introduced make this approach to fitting even more attractive. We have since switched to clear plastic check sockets for the obvious advantage of visual inspection and also the ability to adjust check socket pressure areas with a heat gun on some plastics. We also now fit the check socket on the adjustable leg, rather than the fitting stool. This better simulates the pressures exerted on the stump by the definitive prosthesis, since we all agree that socket alignment greatly affects the application of pressure.</p> <p>I know that this procedure has been used by many prosthetists in various parts of the country, and I have received many favorable comments about the benefits to the patient. This pleases me because this is the goal of the process. I'm sure that in the future new devices and innovations will continue to add to and improve this concept to even greater benefit of the patient.</p> <strong>*<em><b>Robert F. Hayes, CP.</b></em></strong><em>President of Hayes Prosthetics, Inc., 1309 Riverdale Street, West Springfield, Massachusetts 01089.<br /><br /><br /></em> Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Below-Knee Weight-Bearing Pressure-Formed Socket Technique Creator An entity primarily responsible for making the resource Robert F. Hayes, CP. * https://staging.drfop.org/files/original/d30d90150edc24e748bab158375cb723.pdf aa70fbf64b2b0a120d496af8fc3055be https://staging.drfop.org/files/original/225dc1b21aefe0852c68ef5b2e996348.jpg 8ab20befafe25dde5db91d3b298002e9 https://staging.drfop.org/files/original/0b2de6b395b114394842205a02afef18.jpg a63b96cb4a0c54917747fb79a032b485 https://staging.drfop.org/files/original/64306830b9afd89a7374bd95f3a753b8.jpg 9158f03044f9ae6c9d51e47bd761513d https://staging.drfop.org/files/original/3a0c484f58ba18c2b9bf3063e1455320.jpg affb00b0c04bff688f65f72440927ee4 https://staging.drfop.org/files/original/0b4a9ac4b93a10eaf842a3baf263266b.jpg d882b9048a91bfd682ad26c6e302954f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_041.pdf Text Any textual data included in the document <h2>Technical Note: Fabrication of the Syme Prosthesis</h2> <h5>Robert Gilley, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>I first became familiar with this method of fabricating a Syme prosthesis in 1981, when I was transferred to Snell's of Memphis from Nashville. The technique had been in widespread use there and in the Memphis area for sometime, with every evidence of satisfactory service. I am describing the procedure here for it has proven to be not only durable, but a most practical and simple method of fabrication.</p> <p>A Syme socket is set in a foot block (Kingsley catalog, #K1910) slightly behind the anterior-posterior centerpoint (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg"><b>Fig. 1</b></a>). Care should be taken to set it in the proper angle of flexion and adduction.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg"><strong>Figure 1. Socket set in block.</strong></a><br /> <p>An ordinary Kingsley Syme SACH foot (Catalog #K07) is taken and sectioned horizontally below the level of the proximal surface of the keel (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg"><b>Fig. 2</b></a>). This leaves the distal portion with a flat proximal surface.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg"><strong>Figure 2. Cross sectional diagram of Syme SACH foot, showing cut line.</strong></a><br /> <p>The foot and socket are then positioned together in the proper bench alignment. The height is checked and corrected by removing material from the socket block. Bench alignment is reestablished and the position of the bolt hole is marked on the distal surface of the socket block. The bolt hole is drilled and a recess for the adapter nut is counterbored in the distal end of the socket. This is done with an improvised counterbore made from a 3/8"-16 bolt and adapter nut. The adapter nut is set in place, and thickened resin is used to secure it there and smooth the surface. The foot and socket are assembled and excess material is removed from the socket block (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg"><b>Fig. 3</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg"><b>Fig. 4</b></a>), leaving some to allow for any adjustments in toe-out. The foot bolt should be cut to length.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg"><strong>Figure 3. Foot and socket unassembled.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg"><strong>Figure 4. Foot and socket assembled.</strong></a><br /> <p>Following completion of dynamic alignment, the prosthesis is laminated and finished in a manner identical with that employed to finish the shin of any below-knee or above-knee prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg"><strong>Figure 5. The finished prosthesis.</strong></a><br /> <p>To recapitulate, the technique offers the prosthetist an efficient and expeditious method of fabricating a Syme prosthesis with good cosmetic results. It has the added advantage that foot replacement, should it become necessary, is facilitated.</p> <em><b>*Robert Gilley, CP. </b> Robert Gilley, C.P.O., is Supervisor of Prosthetics Central Fabrication Services for Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406.<br /><br /><br /></em> Page Number(s) 41 - 43 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Fabrication of the Syme Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. * https://staging.drfop.org/files/original/666cfa2a8d900d4b2efb1a009252fa73.pdf f59717a74400ff0ab5095ddffea74b4f https://staging.drfop.org/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg b63ddbe760c50ee253d76f42eca4d956 https://staging.drfop.org/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg 748745d3b330d67f707679ee011a6836 https://staging.drfop.org/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg 5402ccb72158719c003f664b4fd179c5 https://staging.drfop.org/files/original/8ee7cd25050f94773cb45ef98356241f.jpg 126d19241c60416ec37fa343f5b67a70 https://staging.drfop.org/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg d56eb7f7a83a1e97e40b5c0d1717d804 https://staging.drfop.org/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg 2c05e9d4f88546fe77cdbf7e84fd5833 https://staging.drfop.org/files/original/65a023e3490a43a115438d29c1640630.jpg 3b5b83d904e8f0092b48ac81539603f6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_123.pdf Text Any textual data included in the document <h2>Technical Note: Cosmesis and the Knee Disarticulation Prosthesis</h2> <h5>Robert Gilley, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>One central problem confronts the prosthetist when fabricating a knee disarticulation prosthesis with side joints, regardless of the socket style (laminated, molded, leather, or flexible frame) used. As the knee flexes, the space anterioraly between the thigh section and the inner edge of the shin increases in width (<b>Fig. 1</b>). The result is cosmetically unacceptable. The gap develops because the radial distance from the knee joint center to the periphery of the socket gradually decreases from anterior to posterior (<b>Fig. 2</b>). Resolution of the problem may be achieved by building up the distal end of the socket so as to maintain a constant spherical shape through the full range of motion (<b>Fig. 3</b>). Observation over the years has led me to conclude that many younger prosthetists are not as familiar with the process as perhaps they should be. Therefore, these few notes are offered in hopes of redressing the situation.</p> <strong><a href="/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg" target="_blank" rel="noopener">Figure 1.</a> As the knee flexes, the gap anterioraly increases.</strong><br /><br /><strong><a href="/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg" target="_blank" rel="noopener">Figure 2.</a> This problem results from the fact that the radial distance from the knee joint center to the periphery of the thigh decreases from anterior to posterior.</strong><br /><br /><strong><a href="/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg" target="_blank" rel="noopener">Figure 3</a>. The distal end of the thigh has been built up so that the space between the thigh and shin is constant throughout the range of motion.</strong><br /> <p>Fabrication of the prosthesis begins by mounting the proximal portion of both joints to the thigh, and similarly, mounting the distal portions in a suitably sized block of wood. Obviously, every effort should be made to maintain the narrowest possible medial-lateral diameter at the knee joint center and to keep the joints square. Wood is removed from between the distal joint sections to permit proper mating of the shin block to the thigh and full range of motion. The interior inner edge of the shin block should fit closely to the thigh in the fully extended position while allowing sufficient space distal to the edge for the material to be added to the thigh during finishing.</p> <p>The distal end of the thigh is then built-up with rigid urethane foam. The convex shape of the anterior socket from medial to lateral, and at the level of the proximal anterior edge of the shin block, is repeated radially about the knee joint axis from anterior to posterior. This can be accomplished, rather laboriously, by first removing enough extra material from the thigh to permit it to be assembled with the shin block in the fully extended position. Then, as the knee is gradually flexed through the full range of motion, the anterior edge of the shin is used as a guide to judge how much material to remove at each successive position of flexion. Sufficient material is removed to permit full range of flexion. Care must be taken to maintain a smooth, even surface from medial to lateral and to not remove too much material. Nonetheless, it will doubtlessly be necessary to add material.</p> <p>The posterior surface of the distal thigh is finished off flat from medial to lateral, so as to fill most of the posterior knee opening. It should not rise above the anterior rim of the shin in the fully flexed position, and at the same time, should not protrude too far posteriorly when in the fully extended position.</p> <p>The process can be greatly expedited if the following simple apparatus is used. Two aluminum plates are modified so that a piece of stiff paper or cardboard can be clamped between them (<b>Fig. 4</b> and <b>Fig. 5</b>). The plates are cut away on one edge so as to span the largest socket. At the leading edge of the cut away side, two threaded rods with tapered points are mounted on a common axis (<b>Fig. 6</b>). These two rods permit the device to be mounted on the proximal knee joints and swung around the distal end of the thigh section (<b>Fig. 7</b>). The stiff paper clamped between the two plates of the device is cut to match the shape of the anterior surface of the thigh at the requisite level. The resulting template is then used to duplicate the shape through the full range of motion. (Some prosthetists will of course identify the device as a simple adaptation of the templates that were formerly used when shaping the ball of the knee of a handmade knee-shin set-up for an above-knee prosthesis.) The device described has been in use by us now for over a year. It greatly speeds up the process of finishing a knee disarticulation prosthesis.</p> <strong><a href="/files/original/8ee7cd25050f94773cb45ef98356241f.jpg" target="_blank" rel="noopener">Figure 4</a>. Knee spanning template holder. Six inch rule included in photograph to give a sense of scale.</strong><br /><br /><strong><a href="/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg" target="_blank" rel="noopener">Figure 5</a>. Template holder with stiff cardboard template clamped between the two plates of the holder.</strong><br /> <p><strong><a href="/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg" target="_blank" rel="noopener">Figure 6.</a> Exploded parts view of template holder and template.</strong></p> <p><strong><a href="/files/original/65a023e3490a43a115438d29c1640630.jpg" target="_blank" rel="noopener">Figure 7</a>. Template holder in place mounted on the knee bolt of a conventional above-knee prosthesis (for illustrative purposes only, a knee disarticulation prosthesis was not available at the time this article was prepared).</strong></p> <p>In conclusion, it is hoped that these comments on the matter will aid a prosthetist confronted for the first time with the task of finishing a knee disarticulation prosthesis-a task that is rather infrequently confronted in the United States and not always addressed by the schools.</p> <p><em><b>*Robert Gilley, CP. </b> Robert Gilley, CP., is with Durr-Fillauer Medical, Inc., 2710 Amnicola Highway, Chattanooga, Tennessee 37406.<br /><br /><br /></em></p> Page Number(s) 123 - 127 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Cosmesis and the Knee Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. * https://staging.drfop.org/files/original/4466dc9f88049d40488d6be216fd66d6.pdf df7dcc4340714709da0ed7b7c1699d85 https://staging.drfop.org/files/original/53b5a7a21d9da4b70e22698b5a760aaa.jpg 580a52b9ef39dda90026098898a6a1ce https://staging.drfop.org/files/original/a0eb985726680bed7cd45922e2034e1d.jpg c4a800fceb94238c2677ac1353245ed1 https://staging.drfop.org/files/original/67e644fd9e00ecd25e6e49a71794f407.jpg 60eaf7d0437847d9e266dcd9fbc1c939 https://staging.drfop.org/files/original/589ba45ffbb62595ca1df05cfeb159c0.jpg 8566b117423ddacb7a5d4153e234f8a8 https://staging.drfop.org/files/original/36ba8f4a7fa3b03421d6f86028269823.jpg 1abb24b7a318ac3b59305fe354af6d54 https://staging.drfop.org/files/original/073598b3381e4a6ac1c6962280a87675.jpg 5b5ae92ad35825fadc4a43eca508978b https://staging.drfop.org/files/original/720a349f49e9cd4af439cb42bebb620b.jpg 10091d4c9cdda7e591209ada36971ae1 https://staging.drfop.org/files/original/f376141812a404af3010dfdf6dbedf29.jpg da6eec89495628a12e65102fc753e2b6 https://staging.drfop.org/files/original/206ae750fa9a0a06275a4a9cc9a4dce8.jpg 724c967272fa84216d1830d4dd4d9548 https://staging.drfop.org/files/original/73d9f7175d3a09f5fd09ba00e95cca0e.jpg 394abd72058740013c9e1f4ea0d5011f https://staging.drfop.org/files/original/a44144b9c6d5a256cd7da054cf8621d2.jpg 418b6d99ee67aedca58cceff52f4205e https://staging.drfop.org/files/original/a716afbeccd1b0841e1ff0e4c66fc23d.jpg e9abb6131a86c67ffdd79c69428ff2a8 https://staging.drfop.org/files/original/eb429fccd53602c04c0a0d04864cad6f.jpg 99826548df6f19c657326b20ba9434f3 https://staging.drfop.org/files/original/16212ba76062ab46774d405e1c0d6dbb.jpg 10231e0bc58bc0d853c27072bd4f19fd https://staging.drfop.org/files/original/8eb0c9a2760981415e2d2ac1a225b498.jpg 1078787fef23aa145c6f4ba544fa286b https://staging.drfop.org/files/original/c7712445845a41b936dc9aeb5cf902d3.jpg 18d9adab9f4fb258d754543b62f65721 https://staging.drfop.org/files/original/067afcb3523416f2f0455fb4e8973fd5.jpg 6b11e8017d8bf6ffd5e528d796afc842 https://staging.drfop.org/files/original/05def91a2bbdd073ada3f01fe3651289.jpg e36c49e73001acd8cb53a05c873baf00 https://staging.drfop.org/files/original/30f0645250433050bcfeab5015060e2d.jpg e054259f8d752d7f0859d67bd239c669 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_026.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 26 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_026.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Harness Patterns for Upper-Extremity Prostheses</h2> <h5>Robert J. Pursley, Lt., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The comparatively recent development of more functional components for artificial arms has made it necessary to analyze in greater detail the requirements of harnessing the power needed for effective operation. Just as an automobile is helpless without a well-designed and well-built engine and transmission system, so an arm prosthesis is helpless without a well-designed and well-constructed harness. To build a successful harness system requires not a knowledge of some long-lost art but, instead, a careful appraisal of the wearer, of the device to be worn, and of the available tools to be put to work. Since the modern body harness constitutes a dynamic coupling between a human being and a mechanism designed to replace a living extremity, the problem of devising it is also one of dynamics and of what some call "human engineering."</p> <p>Many illustrations of typical harness patterns are presented later in this article. But it is not enough for the harnessmaker simply to reproduce what is shown in these drawings of typical patterns or to superimpose on an individual amputee a generalized harness pattern of any particular type. He must first understand the purpose of the harness, the requirements of the particular prosthesis involved, and the body motions available, and he must then apply his own skill and judgment in making appropriate modifications to suit the individual case. It is, of course, far more important to produce a harness that will give the desired functional results than it is to produce one that looks exactly like any one of the drawings. The illustrations are therefore intended as general guides only, not as a detailed description applicable to every case of amputation at the indicated level. When planning and making any harness, the prosthe-tist should examine the location of each element to ensure proper function with the expenditure of minimum effort on the part of the particular wearer concerned.</p> <p>The first and most simple requirement of any harness is that it must hold the prosthesis securely on the stump. The second is that it must be comfortable to the amputee. Generally, suspension, as such, is easily obtained, but to suspend the prosthesis properly and at the same time to assure maximum comfort for its wearer is more difficult. If either of these requirements becomes a matter of choice, then comfort must be the more important consideration. If the harness is not comfortable, or at least tolerable, the person for whom it was intended will soon hang it politely on a suitable nail. Since almost no harness can be constructed satisfactorily without a few compromises at first, it is unwise to promise complete success on the first try.</p> <p>The third and all-important requirement of functional body harness is that it must supply a source of power for the operating components of the prosthesis. This means simply that residual body motions must be harnessed to replace lost functions of the natural member, but to provide controls that are operable in an effective and yet inconspicuous manner poses a complex problem. It requires an examination of the body motions that can be utilized by the harness without detracting from the usefulness of the remaining normal hand and without introducing unduly awkward gyrations of parts of the anatomy not ordinarily involved in arm activity. The higher the level of amputation, the greater the control requirements but the fewer the sources of control. The problem is further complicated by the need to maintain the proper balance between adequate suspension, acceptable comfort, and worthwhile function, for each of these needs is often satisfied only at the expense of the other two. A look at the background of harnessing for upper-extremity prostheses <a></a> reveals that, when devices were generally passive in nature, so was the harness. As devices have increased in function, so has the harness also. Today the development of devices has in general surpassed the art of harnessing them. With the proper approach, however, and using a common-sense analysis both of the amputee's capabilities and of the requirements of the prosthesis, an accomplished limbfitter can in almost every case turn out a very acceptable harness that will meet functional needs to a surprising degree.</p> <h4>Harnessing for the Below-Elbow Cases</h4> <p>The prosthesis for the unilateral below-elbow case is unquestionably the simplest to harness. For the reason that the below-elbow amputee retains his own elbow, and therefore usually requires replacement of prehension only, he can almost without exception be harnessed successfully. At least three feasible control motions are to be had. In order of decreasing usefulness, they are arm flexion on the amputated side, shoulder depression on the amputated side, and scapular abduction. The choice and extent of use of these three motions, singly or in combination, is largely a matter of personal preference depending on the area in which the terminal device is required to operate. With the elbow flexed to 90 deg. and with the terminal device located slightly above the level of the head, for example, arm flexion is almost completely spent. Using scapular abduction under the same circumstances, however, the below-elbow amputee can still operate the terminal device satisfactorily. Successful wearers of below-elbow prostheses develop their own individual patterns of operation and subconsciously learn to operate the device in all areas in which it is called upon.</p> <p>The problem of transmitting the force and excursion of body motions from the source to the point of use has in the past involved a wide variety of materials. Rawhide thongs and leather laces are only two of many that have been used, even as late as only a decade ago.<a></a> The flexible metal cable and wrapped-wire housing adopted from the aircraft industry is currently the most widely used and is the most satisfactory available today. It is based on the Bowden principle (<b>Fig. 1</b>), which makes it possible to transmit force and excursion from the body to the terminal device regardless of elbow angle.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The principle of the Bowden cable for transmitting tension forces applied at one end. Although point <i>C </i>is brought closer to point <i>A </i>when rotation occurs about <i>B, </i>the housing <i>D </i>prevents slack in cable <i>E </i>by preserving the <i>effective </i>path length <i>A </i>to C. A counter-force is required at the opposite end to return the flexible cable to its original position. Other types of Bowden cables are based on the torque principle, as used in speedometer cables, or the push-pull principle, as used in the temperature controls of the automobile heater. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Utilizing any or all of the three useful body motions, together with the Bowden-cable transmission system in every case, two alternate harness patterns are available for the below-elbow amputee with a stump of medium length. The first is known as the "figure-eight" harness, the second as the "chest-strap" harness. In addition, there are two special modifications, one for the very long and another for the very short below-elbow stump. These are, respectively, the "double-axilla-loop" harness and the "dual-control" harness. Finally, there is the special harnessing arrangement using the biceps cineplastic muscle tunnel to provide force and excursion.</p> <h4>The Below-Elbow Figure-Eight Harness</h4> <p><i>The Harness Pattern</i></p> <p>The figure-eight pattern, of which <b>Fig. 2</b> presents a typical example, is the harness most commonly used in the unilateral below-elbow case, the axilla on the sound side being the site of anchor for capturing the relative motion. The front view of <b>Fig. 2</b> shows the suspension portion of the harness. The front harness strap, passing over the shoulder at the pectoral interval on the amputated side, buckles to the inverted Y-strap supporting the leather triceps pad, which in turn supports the socket through the flexible elbow hinges. The back view shows the transmission system from harness to terminal device. The general path of the control cable is such that sharp bends and curves of small radius are avoided as much as possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The below-elbow figure-eight harness. A simple webbing loop passes around the sound shoulder, the front portion being used for suspension, the back for attachment of the control cable. The inverted Y-suspensor. triceps pad, and flexible elbow hinges are constructed of 4 to 6-oz. strap leather and lined with 4-oz. pearl horse-hide or equivalent. The proximal retainer on the triceps pad is of the flexible leather type to improve cable life. The three circled inserts show possible variations in individual cases. Circle <i>A </i>illustrates the leather half-cuff as used in combination with rigid elbow hinges and a single billet. Circle <i>B </i>shows a hall-cuff with two billets, again in combination with rigid elbow hinges. Circle <i>C </i>shows the inverted Y-strap as made from fabric instead of leather. Any of the combinations shown may be used as required to furnish the necessary stability depending upon occupational needs, level of amputation, and other factors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chief purpose of the control system is to transmit force and excursion to the terminal device. When, however, the amputee must pick up loads with forearm extended, the cable is expected to assist in support whenever the load is of any appreciable magnitude. This, then, is an example of what is meant by the proper balance of forces that is needed to meet amputee requirements. Both suspension and control system should be so constructed and adjusted as to be comfortable and yet be able to meet a reasonable load-support requirement without unnecessary displacement of the prosthesis. Tests for determining allowable displacements and other important factors have been set forth by Carlyle.<a></a></p> <p>As shown in <b>Fig. 2</b>, the harness is padded and protected under the axilla, and the control cable is so adjusted that it cannot come into contact with the amputee's back. For maximum excursion, the cross of the harness should be below the cervical vertebrae and not more than 1 in. toward the sound side of the vertebral spine. The control attachment strap <i>(i.e., </i>the strap attached to the flexible control cable) should lie at the midscapular level. In the course of constructing the harness, visual observations of all these details should be made while the wearer goes through the movements to be expected in normal use.</p> <p>Because of the simplicity of the figure-eight harness, minor deviations usually are not serious. Occasionally, indeed, exceptions to the normal placement of the harness cross are necessary and desirable to improve comfort. The figure-eight harness can be worn successfully by the majority of below-elbow amputees with ordinary duties, it is easy to construct and there is little chance for error, and it is functional and comfortable in most cases. Together these advantages generally represent the reason why it is so widely used. It readily adapts itself to vocations that are clerical in nature and to individuals requiring medium duty, such, for example, as the lifting that might be required of a stockroom worker.</p> <p><i>Below-Elbow Cliffs, Pads, and Hinges</i></p> <p>To furnish suspension and socket stability, three types of cuffs and pads, with and without fillers, are available, and any of several types of hinges, some flexible and some rigid, may be used. The circled inserts <i>A </i>and <i>B </i>of <b>Fig. 2</b> show some of the variations giving greater and greater stability as needed in the individual case. The choice of cuff and hinge combination is strictly a consideration for the prescription team, the rule being to provide maximum stability with the absolute minimum of harness. Prescription criteria and suitable templates for cuffs are described in considerable detail in Section 5.6 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> It should be remembered that many combinations of hinges and cuffs are available and that no one cuff must necessarily be accompanied by any particular type of hinge. Moreover, the prescription for any given amputee should take into account his own individual requirements and personal preferences.</p> <p>There are at least two ways of making cuff suspension systems, material selection being the principal distinguishing factor. The preference of the limbmaker may enter into the choice of technique largely because of the fabrication facilities that happen to be available. Leather has long been used in the limb industry, and it is readily adaptable because of its molding characteristics. Although the ability of leather to conform readily to the shape of the arm represents something of an advantage over webbing straps (circled insert <i>C </i>of <b>Fig. 2</b>), its tendency to absorb perspiration and thus to deteriorate, as well as to acquire unpleasant odors, is considered by many to be a distinct argument against its use in arm cuffs. The webbing strap, while perhaps less stable, offers the advantage of being easily washed and quickly replaced. Modern synthetic fabrics now available commercially can be laundered without undue shrinkage and may be reapplied without stretching under load.</p> <p>The below-elbow cuffs and pads usually are made of 4- to 6-oz. strap leather and are lined with horsehide or similar material. The fabrication of this component calls for the cutting, sewing, and fitting skills of the limbmaker. To make the Y-shaped leather suspension strap, a paper pattern is first cut to conform to the amputee's arm. When the template lies smoothly against the arm above the bulge of the biceps and will reach properly from the triceps pad or cuff to the webbing suspension strap passing over the shoulder at the pectoral interval, its shape is reproduced in 4- to 6-oz. strap leather or equivalent. The lower legs of the leather suspension strap are then riveted to the cuff or pad in such a position that the "V" lies smoothly against the arm and will support axial loads.</p> <p>The webbing inverted Y-suspensor is prepared by folding a piece of 1/2-in. webbing back on itself in such a way as to form a "V." The apex of the "V" is then sewed directly to the front suspensor strap of the harness at such a level as to give a smooth transition from the harness to the cuff or pad. The lower attachments to the cuff or pad are made by means of 1/2-in. buckles.</p> <p>Again, material selection is the chief factor determining technique. When leather is used, it is hard to determine the proper length of the legs of the "V" and to assure proper alignment without later adjustments. Moreover, unless leather components are coated with nylon <a></a> or similar material, the effects of perspiration will soon become apparent. Conversely, the webbing Y-suspensor offers easy adjustment of alignment and also resistance to perspiration by virtue of its washability. When fitted properly, both systems are acceptable, and hence personal preference is an influencing factor.</p> <h4>The Below-Elbow Chest-Strap Harness</h4> <p>Although the figure-eight harness is suitable for most below-elbow cases, it does not meet all vocational requirements. Heavy-duty activities, such as those of a farmer, requiring frequent lifting of loads greater than 50 lb., can best be accommodated by a below-elbow chest-strap harness. <b>Fig. 3</b> shows a typical example. By the addition of the shoulder saddle to reduce unit stresses on the shoulder and opposite axilla, the load-supporting capabilities and amputee comfort can be greatly improved, but to obtain a satisfactory result with the chest-type harness presents a greater challenge to the harnessmaker.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The below-elbow chest-strap harness The two suspensor straps running through D-rings are attached to a leather shoulder saddle Improved stability and reduced unit stresses over the shoulder offer greater ability to lift axial loads. Normally, the below-elbow chest-strap harness, used on amputees requiring heavy-duty service. is constructed in combination with half-cuff and rigid elbow hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><a></a> It has been said that some limbmakers construct the chest-strap harness simply because they do not know how to make the figure-eight design. There ap pears to be no real evidence to prove which type really is the older, but it is generally accepted that the chest strap was the forerunner of the figure-eight. Regardless of priority, both patterns are acceptable, and each offers advantages and disadvantages.</p> <p>As shown in <b>Fig. 3</b>, there are basically three elements in the below-elbow chest-strap harnessâ€"the chest strap to hold the harness on, the shoulder saddle to serve as an anchor for suspending the prosthesis, and the control attachment strap for operating the terminal device. To connect the shoulder saddle and to suspend the prosthesis, two lengths of 1/2-in. leather or webbing are used. They originate on the back of the shoulder saddle, thread through D-rings on the cuff, and then buckle to the front of the saddle. This arrangement distributes the load on four points of the saddle and two points of the cuff and offers the inherent self-equalizing effect by virtue of the D-rings.</p> <p>The control attachment strap is connected to the chest strap and utilizes arm flexion and scapular abduction on the amputated side. Since no definite anchor is involved, neither scapular abduction nor shoulder flexion on the sound side can be harnessed, so that, unlike the case with the figure-eight harness, in the chest-strap design these body motions cannot be used as a source of reserve excursion. Although this basic difference is responsible for the improved comfort of the chest-strap harness, lack of a positive anchor not only robs the amputee of a third control motion but actually permits the harness to rotate upon the chest when excessive forces are applied to the control cable.</p> <p>The indications for and advantages of the chest-strap harness lie in its improved comfort and greater lifting capacity. The chief reasons for its selection over the figure-eight arrangement are concerned with vocational considerations, relief of unavoidable discomfort in the opposite axilla, and amputee preference based on his past experience. Both the figure-eight and the chest-strap harness may be used with almost any combination of hinges and cuffs. It may not be desirable to use a triceps pad and a shoulder saddle in combination, but there is no law against this possibility. The rule, as always, is to try for maximum stability with a minimum amount of harness. This being the case, the figure-eight harness should be tried first.<a style="text-decoration:none;">*</a> If it is not satisfactory, then the more complicated chest-strap harness may be resorted to. For detailed discussions of fabrication techniques for both harnesses, reference may be had to Section 5.0 of the <i>Manual of Upper Extremity Prosthetics .</i><a></a> </p> <h4>The Double-Axilla-Loop Harness</h4> <p>The increased frequency of successfully fitted wrist-disarticulation cases has led in such instances to a departure from the typical below-elbow harness pattern. A very simple and useful harness has been reported by the Naval Prosthetics Research Laboratory<a></a> for use with transcarpometacarpal cases, and the technique is also adaptable to wrist-disarticulation cases. As shown in <b>Fig. 4</b>, a double axilla loop originates the initial body motion on the sound side and provides its own reaction point on the amputated side. A solid piece of Bowden cable extends from the proximal reaction point located on the axilla loop on the amputated side to the distal reaction point located on the arm socket. The cable housing is covered with a piece of plastic tubing to prevent pinching of flesh and pulling of hair on the subject's arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The double-axilla-loop harness for wrist disarticulations and transcarpometacarpal amputations. The loop on the amputated side serves as the reaction point, relative motion being produced when the sound shoulder is flexed. The control cable continues to the distal reaction point on the arm socket ([link5]) The auxiliary elastic strap indicated by dotted lines may or may not be needed. <i>Courtesy U S Naval Hospital, Oakland, Calif. .</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the double-axilla-loop harness is only a means of supplying terminal-device operation. Suspension must be inherent in a well-fitted socket, which usually must be split to facilitate donning, the condyles of the wrist being the principal means of retaining the socket on the stump (<b>Fig. 5</b>). Wrist disarticulations can be fitted by this technique at first. If it proves to be unsuccessful for any reason, the harness may easily be replaced with a conventional below-elbow figure-eight harness.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Wrist-disarticulation socket for use with the double-axilla-loop harness. Control cable extends to the proximal reaction point located on the axilla loop on the amputated side ([link4]). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Below-Elbow Dual-Control System</h4> <p>As opposed to the problem of fitting the wrist disarticulation and other long below-elbow stumps, there is the one involving the fitting and harnessing of the very short below-elbow slump. Use of the split-socket type of prosthesis furnishes a means of increasing the range of elbow flexion through a mechanical step-up. Thia expedient greatly improves the versatility of the below-elbow prosthesis and in the majority of cases proves to be very satisfactory when using the below-elbow figure-eight harness based on the single-control principle.</p> <p>For marginal cases with insufficient torque about the elbow to lift the prosthetic forearm, another departure has been made from the usual pattern of control. The below-elbow dual-control system, shown in <b>Fig. 6</b>, uses a forearm lever loop and a split-housing cable system. Since in this case the cable housing is in two separate pieces, the effective distance between the reaction point on the arm cuff and that constituted by the lever loop on the forearm shell is no longer independent of elbow angle, so that arm flexion produces forearm flexion. When used with the very short below-elbow stump, the dual-control system thus provides an assistive lift for forearm flexion, sometimes especially needed when forearm flexion is begun from full forearm extension. Ordinarily the short below-elbow case has enough torque about the elbow to stabilize the forearm, so that no elbow lock is required. When the forearm socket is stabilized by the stump, the force from the harness is transmitted to the terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The below-elbow dual control using the split-socket type of prosthesis for the short below-elbow case. Since the cable housing is in two pieces, arm flexion assists in lifting the prosthetic forearm. The stump is then used to stabilize the elbow for terminal-device operation, no elbow lock being needed. The design of the step-up elbow hinges has been discussed in detail by Alldredge and Murphy (<i>1</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The familiar rule of first trying the less complicated harness should be applied at this level also. If the forearm cannot be flexed by the stump without unnecessary fatigue, or if forearm flexion is painful, then the dual system is indicated. Amputees fitted with the dual control should be checked periodically to see whether the residual muscles have hy-pertrophied enough to be adequate for unassisted forearm flexion, in which event the single control may be substituted. No harm is done by using the below-elbow dual-control harness when its necessity is questionable, but again the usual desirability of simplicity of harness would suggest discard of the assist lift when adequate function can be obtained without it.</p> <h4>The Below-Elbow Biceps-Cineplasty System</h4> <p><i>The Case for Cineplasty in General</i></p> <p>Since World War II, there has been, especially in the United States, a considerable revival of cineplastic surgery <a></a> to produce muscle tunnels capable of harnessing for the operation of artificial arms. Practically all available muscles of the arm and two major muscles of the chest (the pectoralis major and minor) have been harnessed by various means to operate arm prostheses. Two basic philosophies have developed in the use of the cineplastic muscle tunnel. First established was the idea of using the muscle motor to power the terminal device. The advantages of this means of independent terminal-device operation, without relying upon body motions, were readily apparent, to say nothing of the possibility of eliminating body harness completely in some cases.</p> <p>Some authors, for example Mount and Bernberg,<a></a> discuss the advantages of an increased sense of pressure and generally improved sense of perception when a muscle motor is harnessed to a terminal device. Mount and Bernberg say "The results generally indicate that the two Ss [subjects] using cine-plastic prosthesis distinguished, compared and recognized given objects with greater skill and precision than the Ss [subjects] using prosthesis of the harness type." Although further scientific tests to support this observation have not been conducted, subjects successfully fitted with both a conventional and a cineplastic prosthesis indicate that they have a better sense of pressure or feel with the latter.</p> <p>In the second philosophy developed, the pectoral tunnel is used to operate the elbow lock in the shoulder-disarticulation case. Obviously, the advantage in this case lies in the provision of the additional source of control.</p> <p>It may be stated, without reservation, that of all the possible arrangements involving cineplasty, the greatest degree of success has been obtained using the biceps muscle tunnel to power terminal-device operation in the below-elbow case. This does not mean that the combination of other muscle tunnels and other levels of amputation may not be successful in individual cases. Spittler and Fletcher,<a></a> Kessler , <a></a> Alldredge <i>et al., </i><a></a> and Taylor<a></a> report other muscles and other levels of amputation successfully fitted with cineplastic prostheses. Because, however, the other cases have not yet been proven clinically in the general sense, the discussion of the fitting of cineplasty is here restricted to the below-elbow biceps system.</p> <p>In the below-elbow biceps case, fitting is greatly simplified because the muscle tunnel is above the first sound joint in the amputated stump. The socket may thus be made to harness residual pronation and supination, and it does not require window-type construction <a></a> since the tunnel is once removed in the upper arm.</p> <p>Because the biceps tunnel in the below-elbow case is able to avail itself of the physiological characteristics of muscle, <a></a> adequate force and excursion are to be had. Since normally muscles are contracted to produce prehension, contraction of the biceps muscle tunnel should effect closing of the terminal device. For this reason it is generally accepted that a voluntary-closing device is most desirable for use with cineplastic amputees. Of course if the improved sense of pressure is to be had, then it may be best to use the voluntary-closing terminal device. Regardless of all data presented here and elsewhere, however, many biceps tunnels have been successfully harnessed in the below-elbow case with the voluntary-opening terminal device.<a style="text-decoration:none;">*</a> This circumstance can only suggest that the prescription of the terminal device in cineplasty is largely in the same area as is the prescription of the terminal device in the conventional case using body harness.</p> <p>The back-and-forth discussion of these factors is endless. It is therefore useful to have a look at the indications for cineplasty as seen from the point of view of the amputee. Needless to say that, in the growth of prosthetics clinic teams, new amputees are seeing more and more the types of prostheses worn by other amputees. Usually when the wearer of a conventional arm prosthesis sees a cineplastic type he feels that a "Cadillac" version of an artificial arm is available for him. No doubt personal choice, or the individual desire for a cineplastic type of prosthesis, is the major consideration. Amputees who were not too favorable at the time of discussing the cineplasty procedure have not obtained the same degree of success and training as have those who indicated their preference for cineplasty from the beginning.</p> <p>Another important factor relates to vocation. If a below-elbow amputee desires to do, for example, mechanical work on an automobile, he often finds himself lying on his back on a dolly. In this position, he is quite restricted in body motions for using a shoulder-harness prosthesis. For the wearer of a conventional prosthesis to operate his terminal device in this position involves the use of many body motions other than those ordinarily involved.</p> <p>Although no real criterion has yet been developed for the selection of individuals for the cineplasty type of prosthesis, it can be stated categorically that the personal preference of the individual and the vocational considerations are of prime importance and should therefore be discussed thoroughly with the patient before reaching a decision.</p> <p><i>The Two Established Systems</i></p> <p>Prosthetic fitting and socket construction for a biceps-cineplasty below-elbow prosthesis are very similar to the conventional techniques. The socket must provide stability and a means of attaching a terminal device. Suspension of the prosthesis may be handled in various ways. Two power-transmission systems have been developed, one at the University of California at Los Angeles and the other at the Army Prosthetics Research Laboratory. A comparison of the efficiencies of the two systems has revealed that they have quite similar characteristics.<a></a></p> <p><i>The UCLA Below-Elbow Biceps-Cineplasly System. </i></p> <p>The power-transmission system of UCLA consists of a muscle-tunnel pin, a dual-cable power-transmission system, and a twin cable mounting harnessed to the terminal device. All parts of this system, shown in <b>Fig. 7</b>, have been available commercially for some time, and the arrangement has received wide use in the field. Three types of cuffs are available for suspension in the UCLA system. The epicondyle cuff (<b>Fig. 8</b> and <b>Fig. 9</b>), the epicondyle clip (<b>Fig. 10</b>), and the epicondyle strap (<b>Fig. 11</b>) may be used with any selection of either flexible or metal double- or single-axis elbow hinges. The method of installing the UCLA system is described in detail in Section 10.0 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The UCLA below-elbow biceps-cineplasty system with epicondyle cuff and rigid elbow hinges. The twin cable mounting is connected to the yoke to allow positioning for adequate operating excursion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Pattern for the UCLA epicondyle cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Alternative design of the UCLA epicondyle cuff, constructed of stainless steel and covered with horsehide, the rigid hinges being attached to the cuff before covering. The cross strap at the top helps to stabilize the cuff on the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The UCLA epicondyle clip, constructed of stainless steel and covered with horsehide. Conventional baseplates are attached to be used as the proximal retainers for the dual cable system. The clip can be used with or without the auxiliary elastic strap as needed to maintain the clip in position when the arm is flexed. The epicondyle clip has also been constructed of a semirigid plastic such as Royalite. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical pattern for the APRL epicondyle strap, reduced to exactly half the size needed to produce a strap for an arm with a circumference of 10 1/2 in. Placed as drawn on the grain side of the selected leather, this template makes a left or a right strap depending on whether the amputee prefers to have the strap buckle toward the medial or toward the lateral side of the arm. To produce a strap buckling in the reverse directions, the template is turned over and placed on the grain side of the leather. The dotted lines indicate a modification to accommodate a biceps tunnel located low on the upper arm when it is desirable to save space in the anterior fold of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The UCLA system is quite adequate and very simple to harness and provides easy pre-positioning and ready adjustment of effective cable length. It has met with a very large degree of success throughout. Compared to the APRL system,<a></a> it offers the advantage of being applicable to a wider selection of terminal devices inasmuch as the control system may be mounted either on the top or on the bottom of the arm socket (<b>Fig. 12</b>). It offers also the advantage of allowing pre-positioning of terminal devices with less friction throughout the cable system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Alternate locations of the twin cable mounting for various terminal devices in the UCLA below-elbow biceps-cineplasty system. If it is desirable to interchange between the voluntary-opening hook and the voluntary-closing hand, two snap portions of the twin cable mounting may be used, one toward the lower side and another on the top side of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The APRL Below-Elbow Biceps-Cineplasty System. </i>The APRL system, as it appears in the <i>Manual of Upper Extremity Prosthetics</i><a></a>has been revised to improve function. The principal modifications (<b>Fig. 13</b>) have been to adopt flexible leather hinges and to discard the so-called "transit elbow hinges." Since these changes,<a></a> indications have pointed to a greater degree of success when the biceps tunnel is used with a voluntary-closing terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Completed installation of the APRL below-elbow biceps-cineplasty system. The epicondyle strap is used in conjunction with flexible leather hinges, the hinges being adjustable by means of strap-type buckles placed at the points of attachment on the arm socket. The ox-bow tunnel pin, fitted with "Dot Fasteners" for joining to the sheave-type cable equalizer, is recommended for use with the APRL system. A flat cable-extensor mechanism is used to allow cable adjustment within the system and to permit interchangeability of terminal devices. Insert shows a variation in pin design that is available commercially. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although both the voluntary-closing and voluntary-opening hands and hooks are recommended routinely for use with biceps tunnels in below-elbow amputees, experience has shown that voluntary-closing devices have offered a number of special advantages. The available excursion can be increased by utilizing spring forces in the terminal device to recover excursion, thereby stretching the biceps tunnel into pre-tension beyond the rest length of the muscle.<a></a> Moreover, the improved ability to select prehensile forces at the finger tips makes it possible for amputees to handle, say, an ice-cream cone without crushing it or to wield a hammer or other heavy object without dropping it. Expressed amputee reaction seems to indicate, furthermore, that a considerable amount of pressure appreciation is realized through the use of the voluntary-closing terminal device, where the biceps is contracted for gripping an object. Of course, some pressure appreciation is lost when the voluntary-opening device is used, for then the biceps is contracted to open the device against the tension of the spring or rubber band, and the grasping force is exerted by the spring or rubber band upon relaxation of the muscle. Although no published data are available to support the claim of improved pressure appreciation with the voluntary-closing device, there are sound indications from active users that such a cue to the pressure exerted is of definite advantage.</p> <p>Since no published instructions for installing the APRL below-elbow biceps-cineplasty system are available, a simplified set is included here. The first step is to cut and check a paper template for the epicondyle strap in order to assure proper size and shape before proceeding to make the finished strap. The typical size and shape are indicated in <b>Fig. 11</b>. The pattern should be placed around the arm and examined for comfort, both with the patient's elbow extended and in maximum flexion (<b>Fig. 14</b>). If the biceps tunnel is located low on the arm, the template should be shaped as indicated by the dotted lines in <b>Fig. 11</b> to allow for maximum passive stretch. By thus lowering the front portion of the epicondyle strap, comfort, as well as excursion, is improved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Procedure for checking the paper template when making the epicondyle strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the epicondyle strap fastened in place, the normal elbow center is marked on the projecting hinge tabs. Standard baseplates are located as close to these points as possible and are held in place with a clamp on the upper edge (<b>Fig. 15</b>). They are then so aligned that the cable housings will follow smooth curves from the tunnel pin through the elbow center to the two distal retainers on the arm socket. Notation should be made of the approximate angles shown in <b>Fig. 11</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Placement of the baseplates on the epicondyle strap. They should be so positioned that the cable housings pass through gentle curves from the muscle tunnel to the distal baseplates on the arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The extending ears adjacent to the rivet holes on the two proximal baseplates should now be bent, as shown in <b>Fig. 16</b>, to follow the contour of the epicondyles, thus giving greatly improved comfort as well as added stability in supporting axial loads. The baseplates are then riveted to the epicondyle strap by means of the top rivets only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bending the ears of the proximal baseplates to conform to the contour of the epicondyles. This detail gives added stability in supporting axial loads and improves amputee comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Two pieces of 4-oz. strap leather 5/8 in. wide are now cut long enough to connect the epicondyle strap to the arm socket. A piece of nylon or vinyon strap is attached by rubber cement to the inside of the leather straps, and the whole is stitched along each side. One end of each of these two flexible hinges is then laid under one of the lower ears of the proximal baseplates and the lower rivets are driven in.</p> <p>With the epicondyle strap fastened in position, the arm socket is placed on the patient, and the proper length of the flexible hinges is determined. Finally, the positions of the distal hinge attachments are marked, and the hinges are riveted to the socket, adjustment being provided for by the two buckles.</p> <p>The arm socket and epicondyle strap are now put in place, the cable-housing retainers are attached to the baseplates on the epicondyle strap, and the cable housings are continued through the elbow center in such a way as to maintain a gentle wave to a point approximately 2 in. below the top of the arm socket (<b>Fig. 13</b>). The arm is then removed from the patient, and the baseplates are riveted in position on the socket. The male end of the cable lengthener is now attached to the terminal device, the lengthener is extended to the full-open position, and the other end of the lengthener is attached to the sheave equalizer.</p> <p>Next the cable housings are installed and adjusted to obtain maximum elbow flexion and extension without compression or stretch of the housings. The ends of the housings are trimmed so that, when the ferrules are installed, the housings will terminate flush with the rivets on the baseplates. The ferrules are then pinched slightly with a diagonal cutter.</p> <p>A female snap-on attachment is now fastened to one end of a length of cable, and the attachment is snapped to the pin. The free end of the cable is fed through one cable housing, down through and around the sheave, and back up through the other cable housing. The terminal device is opened, the muscle tunnel is pulled into passive stretch, and the cable length is measured. The cap fitting is installed according to manufacturer's instructions. Normally, the cable will be a little too long. Adjustment may be made by taking up on the cable-length adjuster.</p> <p>After a period of use of the prosthesis, the amputee may find that the adjuster can no longer remove slack from the system. This development can be expected in some cases. It is only an indication that the tunnel has stretched with use. In this event, the control cable should be detached, shortened, and reattached as in initial cable installation.</p> <p>The APRL system as described here has been used experimentally with a great deal of success, but the lack of commercial availability of components in the past has limited its use in the field. It is designed primarily to be used with the voluntary-closing type of terminal device. Furthermore, the frictional losses in pre-positioning are greater than in the UCLA system, and unless the sheave equalizer is placed on the top of the socket use is limited to voluntary-closing terminal devices. This circumstance makes interchange-ability of a voluntary-closing hand and a voluntary-opening hook quite impractical. The APRL system is primarily recommended for use with the epicondyle strap, which normally gives ample support for axial loads without appreciable displacement of the socket.</p> <p>A distinct advantage of the APRL system over that of UCLA is that the effective cable links between the equalizer and the muscle tunnel may be adjusted while at the same time maintaining equalized forces. To adjust the effective cable links between the twin cable mounting and the muscle tunnel in the UCLA system requires a turnbuckle, which in effect changes the links of the cable housing, thus increasing frictionai losses within the system.</p> <h4>Harnessing for the Above-Elbow Cases</h4> <p>Basically, two functional requirements must be met in above-elbow cases. Not only must prehension be provided for but it must be usable at various degrees of forearm flexion. Experience has shown that satisfactory prehension can best be obtained through a normal range of forearm flexion when provision is made for stabilizing the forearm at the selected level of operation. Thus, to the two basic functions there must be added the requirement of elbow lock. The body motions easily accessible and available for controlling these three functions in the above-elbow prosthesis are arm flexion, arm extension, and scapular abduction.<a style="text-decoration:none;">*</a></p> <p>At present there are three satisfactory harness patterns for the above-elbow case, two based on the so-called "dual control" and the third based on "triple control." The two dual-control systemsâ€"the above-elbow figure-eight harness and the above-elbow chest-strap harnessâ€"utilize arm flexion for forearm flexion and terminal-device operation, elbow lock being effected by arm extension. In the triple-control harness, arm flexion is used to produce forearm flexion, arm extension gives elbow lock, and terminal-device operation is obtained by shrug of the sound shoulder. Each of the three systems has its own advantages and disadvantages, and each therefore has indications and contraindications in individual cases.</p> <h4>The Above-Elbow Figure-Eight Harness</h4> <p>From the wearer's point of view, the above-elbow figure-eight harness (<b>Fig. 17</b>) constitutes the easiest way of meeting the requirements of the above-elbow case. It is simply a modified below-elbow figure-eight design with provisions for the added functional requirements. Although in the below-elbow case it is essential mechanically to maintain a constant effective distance between the proximal and distal reaction points of the terminal-device control cable (Bowden principle), in the above-elbow case two functions may be obtained from a single cable by splitting the cable housing and substituting for the distal reaction point a lift lever on the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. The above-elbow figure-eight harness. The basic structure consists of a loop about the opposite axilla, the front portion supporting the arm and the rear portion attaching to the control cable so that arm flexion gives forearm flexion and terminal-device operation. The piece of elastic inserted in the front portion provides for relative motion for elbow locking by arm extension, the elbow-lock control being attached to the nonelastic portion. Suspension is improved by the lateral support strap and indicated auxiliary straps when necessary. As in the below-elbow dual control ([link6]), the cable housing is split so that arm flexion gives forearm lift when the elbow is unlocked, the leather lift loop on the forearm shell serving as the distal reaction point. If it is difficult to start the forearm into initial flexion, two baseplates may be used on the arm socket. The length of the leather lift loop on the forearm shell should be such that, when the forearm is extended, the distance from the center of the cable to the center of the elbow is equal to the distance from the center ot the forearm to the center of the cable housing. This arrangement reduces the amount of force needed to start the forearm into initial flexion without increasing the excursion required for full forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This arrangement couples forearm flexion and terminal-device operation to produce the dual control as used in the case of the very short below-elbow stump. Motion in the control source elicits terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p>In the dual-control system, arm flexion is used as the source of control for forearm flexion and terminal-device operation, sometimes augmented by scapular abduction at large elbow angles, such as when the terminal device is near the mouth. A piece of elastic-webbing is substituted for the nonelastic front attachment strap of the below-elbow figure-eight harness. It is attached at the level of the clavicle and extends to the adjustable buckle on the arm socket, a minimum of 6 in. being desirable for easy operation of the elbow lock. The elbow-lock control cable is attached to</p> <p>the nonelastic portion of (he front attachment strap by means of a piece of 1/2-in. webbing bearing a 1/2-in. adjustment buckle. Arm extension thus produces relative motion between the elastic webbing and the nonelastic control strap in such a way as to induce elbow locking. Thereafter arm flexion controls terminal-device operation. With proper training and practice the amputee can become very adept in effecting smooth operation of all three prosthetic controls.</p> <p>Suspension is improved by adding a connecting strap, known as the "lateral support strap," above the cross on the amputee's back. It extends laterally across the shoulder to a buckle on the lateral side of the arm socket. Proper adjustment of the lateral support strap controls alignment in the abduction-adduction plane. With these modifications, the below-elbow figure-eight harness is adapted to become the figure-eight for the above-elbow case. In summary, the alterations include insertion of the elastic webbing in the front to help suspend the socket and to provide for relative motion for elbow-lock control, addition of the lateral support strap over the shoulder to contribute to socket stability, and the use of the two-piece cable housing to give forearm flexion when the elbow is unlocked.</p> <p>The two optional straps indicated in <b>Fig. 17</b> together improve suspension, increase the available excursion, and assist in maintaining the control attachment strap on the shoulder when the arm is raised. The over-the-shoulder strap forms a webbing network to support axial loads and to stabilize the lateral support strap and front attachment strap on the shoulder. The cross-back elastic strap not only gives greater excursion both in scapular abduction and in arm flexion but it helps to prevent the control attachment strap from riding over the shoulder during extreme arm flexion, such as when the amputee is working in areas over his head. But again, following the rule of simplicity whenever possible, the above-elbow figure-eight harness should be tried first without the two optional straps. If that proves unsatisfactory, then the extra straps may be added.</p> <p>For a detailed description of the technique of fabricating the above-elbow figure-eight harness, reference may be had to Section 6.7 of the <i>Manual of Upper Extremity Prosthetics </i><a></a> or to the report of the NYU Committee on Above-Elbow Harness.<a></a> It will suffice here to describe some of the common errors often leading to difficulties. Careful observation should always be made to be certain that the elastic straps are not too short and that the proximal end and distal buckle of the front suspensor strap are properly positioned. A minimum of 6 in. of elastic is required to give sufficient excursion for operation of the elbow lock and to provide adequate length for adjustment of tension in the strap.</p> <p>Placement of the proximal end of the elastic suspensor not lower than the clavicle enables the amputee to feel the elastic stretching over the deltopectoral interval during the elbow-lock operation, thus furnishing an additional cue to ensure reliable elbow function, and it permits the minimum of 6 in. of elastic to be used without bringing the attachment too far down on the socket. Normally the harness cross should lie approximately 1 in. toward the sound side of the vertebral spine. Crossing the harness at this point usually brings the control attachment strap over the lower third of the scapula, where maximum excursion may be utilized. The cross should be below the seventh cervical vertebra, thus avoiding the discomfort caused when the harness rides up. If the cross is more than 1 in. toward the sound side, the axilla loop is unduly decreased in size, with consequent increase in discomfort at the axilla.</p> <p>The control attachment strap should not fall so low as to prevent arm abduction, and the lateral support strap should not ride too high on the neck. If the cross is farther to the amputated side, the control attachment strap may ride too high. Placement of the lateral support strap 1/2 in. forward of the acromion is found to result in optimal stabilization of the prosthesis on the stump without causing rotation. Attachment of the lateral support strap should be 2 in. below the acromion. When it is attached at a lower point, the strap rolls back and forth over the shoulder, and higher attachment results in poor cosmesis because of the interference of the buckle with the shoulder pad of clothing. Placement of an adjustable buckle at the junction of the front support strap and elastic suspensor provides optimal position for adjustment of the elbow-lock control cable.</p> <p>The placement of the elastic suspensor strap markedly influences the effectiveness of the elbow-lock control motion. If excess slack is left in the elbow control cable, it must be taken up by the control motion before the lock will operate, and consequently the total excursion will then be greater than necessary. At the same time, there must be sufficient slack in the cable to permit relaxation of tension for resetting the elbow-lock mechanism.</p> <h4>The Above-Elbow Chest-Strap Harness</h4> <p>The chief advantages of the above-elbow figure-eight harness are that it is functional and simple and will satisfy the needs of most vocational activities. As in the below-elbow case, however, if there is a requirement for the harness to lift heavy loads, then another type is indicated. Again as in the below-elbow case, the chest-strap harness (<b>Fig. 18</b>) is recommended for the above-elbow amputee whose activities commonly involve heavy-duty work. By supplying a shoulder saddle and thus reducing the unit stresses over the shoulder, the above-elbow chest-strap harness provides greater comfort, and hence greater loads can be accommodated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The above-elbow chest-strap harness using for suspension a leather strap threaded through a D-ring on the lateral wall of the socket and attached to a leather shoulder saddle at two points, The strap for the control cable may be attached either to the shoulder saddle, as shown, or to the chest strap at the midspine position. As in the below-elbow case, this type of harness improves lifting ability and reduces unit stresses over the shoulder on the amputated side. The elbow-lock control cable is attached to the front of the shoulder saddle, and again a piece of elastic is used as the front suspensor between shoulder saddle and arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shoulder saddle has taken two forms, the leather type and the webbing type. The leather type is precisely like that used in the below-elbow chest-strap harness. <b>Fig. 19</b> and <b>Fig. 20</b> illustrate webbing-type shoulder saddles that furnish adequate suspension on the lateral side of the arm socket and provide for the relative motion needed for elbow lock and for dual control. The operational pattern of body motions is identical to that used with the above-elbow figure-eight pattern. Arm flexion manages dual control <i>(i.e., </i>forearm flexion and terminal-device operation), and arm extension controls the elbow lock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. The above-elbow chest-strap harness with webbing shoulder saddle. The functional arrangement is identical to that in the above-elbow chest-strap harness with leather shoulder saddle ([link18]). The leather has simply been replaced with a webbing saddle designed to give the same function. The technique is best used on individuals who perspire freely but who nevertheless need the chest-strap type of harness for heavy lifting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. An alternative construction of the webbing shoulder saddle for use with the above-elbow chest-strap harness. Beginning at the point of attachment on the front of the arm socket, the principal strap passes over the shoulder on the amputated side, continues across the amputees back, goes under the opposite arm, crosses the chest, again passes over the shoulder on the amputated side, and buckles to the rear portion of the socket. This arrangement equalizes the forces when axial loads are encountered. A Y-type construction is used to connect the control cable to the chest strap at the midspine position and at the point where the chest strap crosses the shoulder. A similar construction is used in front, the lower leg of the Y" being made of elastic to permit the relative motion needed for elbow-lock control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The above-elbow chest-strap harness has as its chief advantage the ability to lift axial loads with lower unit stresses over the shoulder. Its primary disadvantage lies in its characteristic tendency to rotate about the chest owing to lack of a positive anchor. Again as in the below-elbow case, the simpler figure-eight design should be applied to the above-elbow case whenever it can be made to serve the amputee satisfactorily. The above-elbow chest-strap harness should be adopted only when the simpler figure-eight harness proves to be inadequate in any given case.</p> <h4>The Above-Elbow Triple Ccontrol</h4> <p>In the above-elbow triple-control harness (<b>Fig. 21</b>), arm flexion produces flexion of the forearm, arm extension provides elbow-lock control, and extreme flexion of the sound shoulder (shrug) gives terminal-device operation. Although the control system is quite simple, it requires the amputee to distinguish between arm flexion on the amputated side and extreme flexion of the shoulder on the opposite side to yield two separate controls. Above-elbow amputees with long stumps can usually make this distinction readily enough; those with medium to short stumps find it very difficult.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The above-elbow triple-control harness. It differs from the dual-control pattern in that three body motions are required. The axilla loop uses shrug of the opposite shoulder to operate the terminal device, so that in this case the chest strap is separated at approximately the midspine position. Relative motion takes place between the axilla loop on the sound side and the reaction point located on the portion of the harness on the amputated side. A supporting shoulder saddle is constructed of a webbing network, and the control attachment strap for forearm flexion is attached at a point over the superior spine of the scapula on the amputated side. Arm flexion then lifts the forearm. Arm extension is harnessed as usual, a piece of elastic being used as the front suspensor strap to provide for the necessary relative motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The advantage of triple control lies in the possibility of operating the terminal device without first locking the elbow. But the complexity of fabricating the triple-control system has been a major disadvantage and has discouraged its use. It is recommended for amputees requiring versatility in the use of the prosthesis, but it should be approached cautiously by the harnessmaker.</p> <h4>Harnessing for the Shoulder-Disarticulation Cases</h4> <p>To provide adequate functional harness for the shoulder-disarticulation amputee has always been especially difficult because of the lack of the control source otherwise available from humeral motion. In the absence of an arm stump, it has been to date, for all practical purposes, impossible to provide any satisfactory voluntary motion of the prosthetic arm about the shoulder, and consequently a substitute must be sought for arm extension, the control source commonly used by the above-elbow amputee for operation of the elbow lock. The alternatives are to use manual operation of the lock by the sound hand or else to harness some residual control source ordinarily remote from arm function.</p> <p>Since in any case manual control is undesirable because it interrupts two-handed activities, the trend has been to utilize other body motions such as those of the head or shoulders. The nudge control,<a></a> with the operating button located on the shoulder cap of the prosthesis, was designed to be operated by pressure from the chin. But this system leads to such awkward appearance in use that it has since been more or less superseded by harness designs utilizing shoulder motions. The perineal strap, with function based on relative displacement between shoulders and pelvis, is disliked by most amputees and therefore has been used less and less except where special complications prohibit other arrangements. The most practical system worked out to date involves use of a waist band or equivalent. At the present time, there are four satisfactory harness patterns for the male shoulder-disarticulation case and two suitable for the female. For the male, there are three dual-control systems, all operated by scapular abduction, elbow lock being accomplished in the first case by shoulder elevation on the amputated side, in the second by flexion of the opposite shoulder, and in the third by shoulder extension on the amputated side. The fourth system for the male utilizes the triple-control principleâ€"scapular abduction to provide forearm flexion, elevation of the shoulder on the amputated side to give elbow lock, and shrug of the opposite shoulder to operate the terminal device. Since all four of these systems involve a chest strap unsuited to the female, two special arrangements have been worked out for women. Both are built around a brassiere, and both utilize dual control, in the one case operated by scapular abduction, in the other by motion of the opposite shoulder. In both cases, elbow lock is effected by elevation of the shoulder on the amputated side.</p> <h4>Harness Patterns for Men</h4> <p><i>Dual Control with Shoulder-Elevation Elbow Lock</i></p> <p>Of the four shoulder-disarticulation harness systems for males, the one most often used with the least trouble involves scapular abduction for dual control of forearm flexion and terminal-device operation, elbow lock being managed by elevation of the shoulder on the amputated side. As in all dual-control systems, excursion of the control source, in this case bilateral abduction of the scapulae, produces either terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p><b>Fig. 22</b> presents the basic details of this harness pattern. A webbing chest strap attaches to the front of the shoulder cap, passes under the axilla on the sound side, crosses the back at the midscapular level so as to utilize the maximum available excursion, and attaches to the control cable positioned on the back of the shoulder cap. An elastic suspensor strap extends from the top of the shoulder cap, diagonally across the back, and attaches to the chest strap at a point just toward the sound side of the vertebral spine. The length of the chest strap is so adjusted as to permit full terminal-device operation without bringing the cable into contact with the skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by shoulder elevation on the amputated side. After Pursley <i>, </i><a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Elbow-lock operation by shoulder elevation is provided for by linking the elbow control cable to a waist strap encircling the trunk below the thoracic cage, thus establishing an anchor to oppose shoulder elevation. Although adequate force for elbow locking is usually available, care is taken to position the cable reaction points in such a way as to eliminate as much frictional resistance as possible.</p> <p>This system offers several distinct advantages over other methods of harnessing the shoulder-disarticulation case. It involves the minimum amount of harness needed to operate the three basic controls, and it has the inherent advantage of avoiding any possibility of interference between elbow locking and the other two functions. Thus training is simplified considerably, and the success of the individual harness may be determined at the time of fitting.</p> <p><i>Dual Control with Opposite-Shoulder Elbow Lock</i></p> <p>A second shoulder-disarticulation harness system seen frequently also uses scapular abduction for dual control of forearm flexion and terminal-device operation, but elbow lock is effected by a forward rotation of the sound shoulder. The arrangement for dual control is precisely like that just described, the difference in the harness as a whole being concerned with the method of elbow locking (<b>Fig. 23</b>). In addition to the chest strap and the elastic suspensor strap, there is provided for the sound shoulder a webbing saddle, the cross-back extension being attached to the elbow control cable near the point of stabilization on the back of the shoulder cap. Again the lengths of the straps are so adjusted as to permit adequate excursion without the cables touching the flesh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by flexion of the shoulder on the sound side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appli~ ance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this system eliminates the need for the waist strap, it obviously introduces more complicated harness about the shoulders, and it offers the inherent disadvantage of the possibility of inadvertent locking or unlocking of the elbow in the course of forearm flexion or terminal-device operation. If, however, care is taken to keep the chest strap at the mid-scapular level while making the opposite-shoulder loop as high as possible, and if the amputee is thoroughly trained, the two operating body motions can usually be separated satisfactorily.</p> <p>Because in this system the elbow-lock control cable traverses a comparatively long path, and also because the associated harness moves across the entire surface of the back, the frictional forces involved are sometimes such that the alternator spring in the elbow is not strong enough to return the control cable to the relaxed position. When this is the case, an additional spring may be added on the inside of the arm section (<b>Fig. 24</b>). Since this extra spring force makes the elbow lock more difficult to operate, it has the incidental advantage of making it easier for the amputee to separate opposite-shoulder shrug from scapular abduction, thus helping to avoid inadvertent elbow action. If difficulty is still encountered, separation of controls is sometimes made easier if the opposite-shoulder loop is adjusted to require an extreme flexion of the sound shoulder before elbow locking is induced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Installation of the elbow-lock cable, showing arrangement when auxiliary spring is needed to return cable to relaxed position. The additional spring force makes it easier to separate the elbow-lock control motion from scapular abduction. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In any event, a considerable period of practice is usually required before the average amputee can manage separation of controls systematically and with the necessary confidence. Training is thus more prolonged than is the case with the shoulder-elevation elbow lock, and consequently the dual-control harness using opposite-shoulder lock offers the further disadvantage that the ultimate success in any given case is difficult to determine at the time of initial fitting.</p> <p><i>Dual Control with Shoulder-Extension Elbow Lock</i></p> <p><b>Fig. 25</b> presents the dual-control shoulder-disarticulation harness utilizing shoulder extension to lock and unlock the elbow. The lower leg of the front attachment strap contains a piece of 1-in. elastic, the front elbow-lock control being connected to the nonelastic part of the chest strap. Thus shoulder extension produces a relative motion for elbow locking.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shoulder-disarticulalion harness using scapular-abduction dual control, elbow lock being operated by extension of the shoulder on the amputated side The chest strap terminates in front in a forked arrangement for attachment to the socket. A piece of 1-in. elastic is inserted in the lower leg of the fork, and the elbow-lock control cable is attached to the base portion of the chest strap just beyond the elastic, thus providing for relative motion upon extension of the shoulder on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To operate the prosthesis starting with forearm extended, scapular abduction is used to produce forearm flexion. While maintaining enough force on the lift cable to hold the forearm in the desired position, the amputee extends his shoulder on the amputated side to lock the elbow. Thereafter scapular abduction operates the terminal device.</p> <p>Although this system may be used on any shoulder-disarticulation case, amputees retaining the humeral neck are the most successful. Patients without the humeral neck experience difficulty in coordinating the two body motions. In any event, the length of the elastic and the position of the wide attachment are both critical. Normally a piece of 1-in. elastic 1 1/2 in. long is used as a start. If the elbow is difficult to operate, the elastic portion is made longer. If the elbow operates inadvertently, the elastic is shortened so as to require more definite shoulder extension to lock and unlock. Although this type of shoulder harness is quite new, experience to date would suggest consideration of new elbow mechanisms especially designed for use with it. An obvious advantage is elimination of the waist band and opposite-shoulder loop used respectively in the other two dual-control systems.</p> <p><i>Triple Control</i></p> <p>In the triple-control system for shoulder disarticulation, as in the triple control for above-elbow cases, the three necessary functions are provided by three control sources, one for each. The usual and generally most successful pattern utilizes scapular abduction for forearm flexion, shrug of the sound shoulder for terminal-device operation, and elevation of the shoulder on the amputated side for control of the elbow lock. The basic pattern (<b>Fig. 26</b>) involves a minor modification of the chest strap seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an elastic suspensor strap also similar to that seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an opposite-shoulder loop with an extension passing over the seventh cervical vertebra or slightly below it, and a linkage between elbow control cable and waist band.<a style="text-decoration:none;">*</a>Although the triple control requires more harness than do the other three patterns for shoulder disarticulation, it offers certain advantages not to be had from dual control. Separation of terminal-device operation from forearm flexion offers improved control over prehension, since during forearm flexion no force or excursion is introduced affecting the terminal device. Likewise, as in the case of the dual control with shoulder-elevation elbow lock, the triple-control system overcomes the difficulty of separating elbow lock from the other two functions, so that inadvertent elbow locking or unlocking is avoided. The result is, again, simplified training and the possibility of determining the success of the harness at the time of initial fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Shoulder-disarticulation harness utilizing triple control. Scapular abduction provides forearm flexion; shoulder on sound side operates terminal device; elbow lock is operated by shoulder elevation on the amputated side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harness Patterns For Women</h4> <p>Since the chest strap, common to all four harness patterns for male shoulder-disarticulation cases, is unsuited for most women, harness designs for female shoulder-disarticu-lation amputees are best based on some other principle. The most satisfactory method found to date for eliminating the chest strap is to utilize as part of the harness a brassiere made of sturdy material.<a style="text-decoration:none;">*</a> As shown in <b>Fig. 27</b>, a strip of 1-in. webbing is sewed around the lower edge of the brassiere known to bra designers as the "diaphragm band." The shoulder cap is so designed as to project in front below the breast on the amputated side to provide an anchor point <i>(B) </i>to which the diaphragm band is attached. An elastic sus-pensor strap attaches to the top of the shoulder cap at <i>A</i>, passes diagonally down the back, and is sewed to the diaphragm band at <i>C </i>somewhat toward the sound side of the vertebral spine. For ease in adjustment and to provide for ready laundering, a buckle is used at <i>D, </i>a clip-type disconnect is installed at <i>E, </i>and attachments at <i>B </i>and <i>A </i>are made with snap fasteners. The arrangement for control of the elbow lock utilizes the waist band<a style="text-decoration:none;">*</a> in the same way as in the corresponding pattern for the male (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Harness for female shoulder-disarticulation cases, made integral with bra but detachable from arm socket for laundering. Scapular abduction provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side. After Pursley, <a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this harness design the diaphragm band crosses the back somewhat lower than the midscapular level desired with the chest strap, adequate excursion is usually available from biscapular abduction, which, as in the male patterns of <b>Fig. 22</b>, <b>Fig. 23</b> and <b>Fig. 25</b>, provides dual control of forearm flexion and terminal-device operation. Shoulder elevation provides control of elbow locking.</p> <p>A problem encountered with the design shown in <b>Fig. 27</b> is that in flat-chested persons or in those with comparatively small breasts it is sometimes difficult to get adequate stability, so that operation of the dual control causes the brassiere to rotate upon the chest. When such a situation prevails, use may be made of the modification shown in <b>Fig. 28</b>, where the brassiere is called upon to provide suspension only, the loop about the sound shoulder furnishing the dual control. Here, as in Figure 27, attachments <i>A, B, </i>and <i>D </i>are made with snap fasteners so that the entire harness can be removed from the arm socket for laundering, the elastic suspensor being sewed to the diaphragm band at <i>C.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Alternative harness for female shoulder-disarticulation cases in which the simpler arrangement of Figure 27 proves too unstable. Here the bra is used for suspension only. The loop over the sound shoulder provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic A ppliance Journal</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Special Cconsiderations</h4> <p>A distinguishing characteristic of the shoulder-disarticulation amputee is that the available control sources are for the most part of comparatively high force but of low excursion. Most commercially available terminal devices require an average of 1 3/4 in. of excursion for full operation, and normally 2 to 3 in. of excursion are needed to produce full forearm flexion of 135 deg. Generally, the total exceeds the excursion available from scapular abduction. This means that if, in a dual-control system with a voluntary-opening hook, where the excursions for forearm flexion and for terminal-device operation are additive, the amputee is to be able to open the hook at the mouth, some means must be found for obtaining the extra excursion. The only other alternatives are to use a voluntary-closing hook, in which case the excursion used in forearm flexion is regained for hook operation, or to use triple control, in which case forearm flexion and terminal-device operation are obtained from two separate sources. But many shoulder-disarticulation amputees do not care for voluntary-closing terminal devices, and others, for this reason or that, are not always able to manage the triple control. Since in general the force available from scapular abduction far exceeds that needed for forearm lift and prehension, some of the force may be sacrificed in the interest of obtaining an increase in excursion. The "block-and-tackle" cable system shown in <b>Fig. 29</b> and <b>Fig. 30</b> provides a two-to-one step-up in excursion at the expense of surplus force. It may be used with any of the six harness systems whenever added excursion is needed either for forearm flexion or for terminal-device operation. In <b>Fig. 23</b>, for example, it is applied to the dual control. In [link26], it is used to step up forearm flexion in the triple control. It could equally well be installed in the system of <b>Fig. 22</b>, should that prove to be necessary in any given case. Conversely, when excursion step-up is not required for the patterns of <b>Fig. 23</b> and [link26], an external cable routing may be used, as in <b>Fig. 22</b>. In any case, careful analysis of the excursion available and of that required for the terminal device prescribed forms the basis of judgment as to whether the step-up system is indicated or not.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cable system for reducing the amount of excursion needed in the shoulder-disarticula-tion dual control. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of the excursion-reducing cable system shown in Figure 29. After Pursley <a></a>, by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the six harness patterns described here represent the most generally successful designs now in common use for the shoulder-disarticulation case, no one of them provides a voluntary control source for motion of the upper arm about the shoulder. This deficiency, of course, imposes upon the shoulder-dis-articulation amputee a rather serious limitation not characteristic of the normal arm. Some provision for arm flexion-extension is possible by making the arm socket in two pieces, a humeral section and a shoulder cap, and using the so-called "sectional plates" .<a></a> But this arrangement is intended for manual pre-position only. Recently<a></a> a shoulder-disarticulation arm has been designed with a shoulder joint giving a combination of flexion and abduction to permit comfortable sitting at a table or desk, but again arm lift is manual, there being no satisfactory control source for voluntary flexion-abduction about the shoulder cap. Development of an additional voluntary control source to simulate the motion of the normal glenohumeral joint is now perhaps the most pressing need of the shoulder-disartic-ulation amputee.</p> <h4>Harnessing for Bilateral Arm Amputees</h4> <p>As compared to the unilateral case, the prosthetic requirements of bilateral arm amputees are magnified many fold. Experience shows that the unilateral subject uses his prosthesis chiefly to hold, carry, or assist in activities requiring two hands. Bilat-erals, on the contrary, are required to rely wholly on their arm substitutes for both one-handed and two-handed activities. The prescription criteria and techniques of fitting are therefore modified for the bilateral in an attempt to provide general operation in areas where the unilateral uses his normal hand. Bilateral arm amputees must, for example, have access to the pockets, both shirt pockets and side and hip trouser pockets if possible. They must be able to brush the teeth, comb the hair, use a buttonhook to manage button closures, and perform a great variety of other essential activities in the course of daily living. In general, all of these functions require action close to the body, behind the back at waist level, or at face, neck, or above the head. The prescription criteria for bilaterals therefore require special attention to personal as well as vocational needs, and consideration must be given to such special items as easily operable wrist disconnects and wrist-flexion units. Fabrication techniques are altered to provide for greater strength, and socket margins must be carefully determined in order to assure maximum socket stability for improved control.</p> <p>In below-elbow cases, residual pronation and supination is, of course, priceless. In every step of amputee care, every effort should be made to maintain forearm rotation. Attention should be paid this matter from the time of the original amputation and should continue through prescription, socket fitting, and fabrication of the harness.</p> <p>A matter of the greatest importance to the bilateral arm amputee is that of being able to get the harness and prostheses on and off without help from others. Bilateral above-elbow and shoulder-disarticulation amputees can almost always manage to get their prostheses off without help, but they sometimes require assistance in putting the arms on. Special brackets mounted on a wall in a bedroom are often needed to help amputees otherwise unable to perform independent donning. If, for example, a bilateral with short above-elbow stumps cannot control his prostheses while reaching for the harness cross on his back to remove the harness by pulling it over his head ("skinning-the-cat"), he hangs the cross over the wall hook by simply backing up to it. He then bends his knees to lift the straps over his head. Leaving the harness cross on the hook, he then removes the prostheses by holding the terminal devices, one at a time, each with the opposite foot. Thus the arms are left hanging in such position that the stumps can again be inserted into the sockets and the harness slipped back over the head.</p> <p>Control in the bilateral amputee is at best difficult. Because the number of controls required is doubled, less effective control motions must be brought into use, and independence of control becomes a problem. At present, six control functions, three for each arm, are about all that can be manipulated conveniently and efficiently. Even so, interaction between controls is noticeable.</p> <h4>The Bilateral Below-Elbow Harness</h4> <p>The easiest way to describe a bilateral below-elbow harness (<b>Fig. 31</b>) is to start by supposing that a unilateral below-elbow amputee has lost his remaining good arm below the elbow and has asked that his old figure-eight harness be used to make the new bilateral harness. The first step would be to cut the axilla loop on what was formerly the sound side. The front portion of the cut strap would then be attached to the inverted Y-suspensor of the new prosthesis. The back portion of the cut strap would be turned back upon itself and attached to a buckle. It thus would become the control attachment strap for the new prosthesis.<a style="text-decoration:none;">*</a> Arm flexion on either side then gives terminal-device operation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The bilateral below-elbow figure-eight harness. A webbing inverted Y-suspcnsor with triceps pad and flexible leather hinges is shown on the right side, while a leather inverted Y-suspensor with full cuff and rigid hinges is shown on the left. Similarly, one type of hook is shown on one side and another type on the other. In the bilateral case, prescriptions should be written independently for the two sides with a view toward providing as much utility as possible. As in the corresponding unilateral cases, the choice of cuffs, pads, hinges, terminal devices, and other details is made on the basis of the individual characteristics of the stump for which the prosthesis is intended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cross on the back may be lowered by loosening the inverted Y-straps in front and taking up the slack in the control attachment straps. The reverse procedure moves the cross up. Should the cross be too far to one side, it may be moved horizontally by loosening the inverted Y-strap and control attachment strap on that side and taking up the slack on the opposite side.</p> <p>An important consideration is the choice of materials best suited to the individual case. In <b>Fig. 31</b>, the right Y-suspensor is made of vinyon, while the left is made of leather. If the amputee finds that getting the harness on and off is a major problem, then the tendency of leather to maintain its shape makes it easier to slip the stumps through the suspensors. If excessive perspiration is a problem, then vinyon tape may be more suitable.</p> <p>Although the combination of one leather and one vinyon Y-suspensor is shown in <b>Fig. 31</b> primarily to suggest the two possibilities, it is not inconceivable to consider the arrangement for actual use. In the bilateral below-elbow cases, the choice of cuffs and hinges is made independently for each side on the basis of such factors as stump length, muscular tone, and elbow mobility. In some cases, it might be well to consider using flexible hinges on one side to encourage the use of residual pronation-supination while applying full cuff and rigid hinges on the other to provide stability. A bilateral so fitted would thus have the added versatility provided by an enhanced function of one kind in one arm and an enhanced function of a different kind in the other.</p> <p>In <b>Fig. 31</b>, a wrist-flexion unit is installed on the left prosthesis. Although in exceptional cases the bilateral fitting of wrist-flexion units might be desirable, ordinarily only one flexion device is necessary. When only one wrist-flexion unit is used, amputee preference, or simply prosthetic dominance of one extremity over the other, is probably the best criterion for determining the side to which wrist flexion should be applied.</p> <h4>The Bilateral Above-Elbow Harness</h4> <p>The unilateral below-elbow figure-eight harness has been adapted for bilateral above-elbow cases as well as for the bilateral belowelbow amputee. It is essentially the same as for the below-elbow cases but with added suspensory harness and means of operating the elbow locks. A typical pattern is illustrated in <b>Fig. 32</b>. If allowance is made for the increased need for function in the bilateral case, then fabrication of the bilateral above-elbow harness is similar to that of the unilateral above-elbow figure-eight pattern. Use is made of the same methods of harness adjustment as in adjusting the harness for the below-elbow bilateral.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. The bilateral above-elbow figure-eight harness. As in the bilateral below-elbow case, here too the choice of components for the two sides is made independently with regard for individual stump characteristics and with the intention of providing as much useful function as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before attempting the fabrication of the bilateral above-elbow harness, the harness-maker must understand the above-elbow figure-eight harness for unilaterals. He should then discuss with his patient any special vocational or personal activities requiring modification of harness design. When the harness is completed, the prosthetist should make it a point to follow up progress in training to make sure that the bilateral amputee can soon become self-sufficient in all necessary activities. If attention is paid to these few details, and if each bilateral amputee is treated as an individual problem, surprisingly good results may be obtained in practically all bilateral cases.</p> <h4>The Bilateral Shoulder-Disarticulation Harness</h4> <p>Because the bilateral shoulder disarticulation and the bilateral above-elbow/shoulder combination represent comparatively rare and highly specialized instances of upper-extremity amputation, it has thus far not been possible to establish any set harness pattern for these cases. Although in general the bilateral shoulder-disarticulation harness is a sort of combination of two shoulder-disarticulation harnesses for the unilateral, every amputee requiring such harness must have meticulous attention to details in the individual case. In any event, it is obvious that, in the bilateral shoulder-disarticulation amputee, the goal of the prosthetist is to obtain as much function as possible regardless of necessary deviations from ordinary practice. Although experience with extreme cases of this kind has to date been limited, the Case Study at the University of California at Los Angeles (page 61) has accumulated some useful information. At present, the knowledge gained at UCLA probably offers the most important guide for management of the individual bilateral shoulder-disarticulation case.</p> <h3>Conclusion</h3> <p>To the student of the art of harnessing upper-extremity prostheses, it will now have become perfectly plain that here, as in almost every other published source, the harness designs presented are principally those applicable to the comparatively young, healthy, adult male amputee. Included, furthermore, are only those systems for which there has been accumulated enough clinical evidence to prove their validity for use with presently available arm components. Noticeably missing are special patterns and fabrication techniques for the very young, for the very old, for the debilitated, for the special cases involving other complicating handicaps, and, with two exceptions, for the female.</p> <p>The reason for this situation lies in the fact that, inspired as it was by the desire to aid the veteran returning from the wars, the Artificial Limb Program, sponsored by the Veterans Administration and the Department of Defense, has quite naturally placed emphasis upon the type of amputee to be expected from the battlefield. But it is not fully appreciated by the general public that there are produced annually from disease or accidentsâ€"in the home, on the highway, in the factoryâ€"many, many more amputees than are ever produced in military campaigns. Such causes of amputation play no favorites with age or sex.</p> <p>Fortunately, the basic principles involved in the harnessing of the adult male are more or less fully applicable to the juvenile amputee. Recently, for example, an armamentarium chart defining child amputee types and offering suggestions for prescription for children of age three and a half to ten years has been prepared under the auspices of the Michigan Crippled Children Commission.<a></a> Two columns of this reference document are devoted to "harness type" and "control type" respectively. Except for the omission of the below-elbow dual control and of the above-elbow and shoul-der-disarticulation triple controls, at every level of arm amputation in the child the recommended harness and control systems are identical with those used for the corresponding level in the adult male. The only significant modifications are concerned with the use of 1/2-in. instead of 1-in. webbing, according to the size of the child, and with the twofold recommendation that the harness be worn over a T-shirt and that the younger children be provided with two harnesses, one to be worn while the other is laundered. Since in general young children do not possess harnessable forces as large as are usually to be had in the adult, the unit stresses produced by the narrower webbing are acceptable to the small child, and hence, following the rule of minimum permissible harness in all cases, it is obviously advisable to use the 1/2-in. material whenever it can serve the small fry satisfactorily. The need of children generally for a frequent change of clothing deserves no further comment here.</p> <p>In any event, it will be recalled that some twelve-year-olds are actually larger and stronger than some adults, and consequently the determining factor in any given child is his own particular size, which in turn determines whether 1/2-in. or 1-in. material will provide the more comfort. Other features of harness fabrication for children are essentially the same as for adult harnessing.</p> <p>As for the adult female, generally the harness for the adult male is applicable, with the exceptions that the chest-strap designs usually are not desirable and that commonly more emphasis is placed on cosmesis. Most women, for example, prefer to have a choice of wearing "V" necklines instead of being restricted to Peter Pan collars or other high necklines. The figure-eight harness pattern is adequate for both above- and below-elbow female amputees. In high-above-elbow cases and shoulder disarticulations, the patterns of <b>Fig. 27</b> and <b>Fig. 28</b> usually serve satisfactorily.</p> <p>Elderly amputees, amputees with multiple limb losses, and those with additional complications such as blindness or deafness all present such highly specialized problems that no single harness pattern can be more than partially satisfactory in all cases. Some evidence seems to indicate that there may even be an age limit beyond which most individuals begin to feel that bothering with an artificial arm at all is no longer worth the effort. But no really scientific evaluation has yet been made of the needs of the aged amputee. Circumstances in the individual case must therefore dictate the course to be taken. As in the case of children, some geriatric patients are healthy, strong. and dynamic; others are ailing, feeble, or lethargic. In the elderly amputee, therefore, as in all special cases, personal factors prevent the recommendation of any generalized harnessing system.</p> <p>In the two illustrations of typical harnessing for bilateral arm amputees (<b>Fig. 31</b> and <b>Fig. 32</b>), the subjects are shown as having amputations at approximately the same level on the two sides. In actual clinical practice, of course, bilateral arm cases present all possible combinations of above- and below-elbow amputations. In all such cases, the problem of devising suitable harnessing combinations presents a special challenge to the prosthetics clinic team. Similarly, in the case of amputations complicated by other mental or physical handicaps, special assessment of the individual patient must be made to determine, first of all, whether use of a prosthesis is actually feasible and, if so, what if any departures from conventional harness patterns are indicated. In all such unusual instances, the considered judgment of the clinic team is indispensable in the development of a specialized harness pattern suited to the needs and abilities of the individual concerned,</p> <p>It may now be reiterated that, even in the so-called "standard" cases, it does not suffice to supply a "standard" harness. The reference chart of <b>Table 1</b> is appended here only for the convenience of the clinic team in selecting the basic kind of harness applicable to any given case. It is, in the end, the responsibility of the prosthetist to see that the details are properly custom-matched to the wearer and that, after adequate amputee training, the harness chosen actually fulfills satisfactorily the needs of the wearer for whom it was intended. Less meticulous avenues of approach lead ultimately to failure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. (For a larger image of this table, please refer to the PDF link at the top of the page.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, cognizance should be taken of the understandable circumstance that the harness patterns presented here have all been developed specifically for use with existing mechanical devices. The above-elbow and shoulder-disarticulation systemsâ€"the dual-control figure-eight, the dual-control chest-strap, and the triple-control patternsâ€"have, for example, all been designed around existing elbows. Because heretofore the art of harnessing has lagged behind the development of arm components, it has been necessary in recent years to design the harness systems to fit the mechanical parts rather than vice versa. A more logical arrangement would have been first to analyze the available body control motions, to design the harness for maximum utilization of these motions in the least awkward way, and then to design the other parts of the prosthesis in such a manner as to be operable by control patterns best suited to amputee characteristics. Future research in harnessing can be expected to influence redesign of desirable operational characteristics of the mechanical devices now available and to encourage the development of wholly new and improved arm components.</p> <h4>Acknowledgment</h4> <p>With the exception of the photographs and of <b>Fig. 12</b>, the illustrations appearing in this article are the work of George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon, </i>Artificial Limbs, 1(3):4 (September 1954).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty,</i>, Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes. </i>McGraw-Hill, New York, 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, <i>Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, </i>21 June 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, <i>Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), </i>8 August 1955.</li> <li>Carlyle, Lester, <i>Artificial arm checkout procedures,</i>Artificial Limbs, January 1954. p. 25.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Applied Microbiology, 3(4):238 (1955).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Hitchcock, William E., <i>Abduction for shoulder disarticulation prosthesis, </i>Orthop, Pros. Appl. J., September 1955. p. 23.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary miscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Kessler, Henry H., <i>Cineplasty, </i>Charles C Thomas,Springfield, Ill., 1947.</li> <li>Langdale-Kelham, R D., and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944.</li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind Eng. Chem., 45:773 (1953).</li> <li>Marks, George E., <i>A treatise on Marks' patent artificial limbs with rubber hands and feet, </i>A. A. Marks, New York, 1889.</li> <li>Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., <i>Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years </i>(a chart), 1955.</li> <li>Mount, George E., and Raymond E. Bernberg,<i>A preliminary comparison of perception undet cineplastic and harness prostheses, </i>Am. J. Psychol., LXII(1):106(1949).</li> <li>New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, <i>The above-elbow figure-eight harness a guide to procedures and principles, </i>September 23, 1954.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial arm and leg research and development, </i>February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Pursley, Robert J., <i>Harness for shoulder disarticulation amputees, </i>Orthop. &amp; Pros. Appl. J., March 1955. p. 15.</li> <li>Spittler, August W., and Maurice J. Fletcher,<i>Technique of cineplastic surgery and prosthetic appliances for cineplasty, </i>Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, <i>Carpometacarpal {harness controlled) prosthesis, </i>September 22, 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years (a chart), 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">While this hypothetical case suffices to describe the harness, it carries the faulty implication that the bilateral harness is simply two unilateral harnesses. No such implication is justified, for, as already pointed out, the functional requirement is magnified many fold, there is the complication of effecting separation of controls, and in addition there is the problem of getting into and out of the harness.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hitchcock, William E., Abduction for shoulder disarticulation prosthesis, Orthop, Pros. Appl. J., September 1955. p. 23.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">When the waist band is disliked by the female amputee, the elbow control strap may be anchored to a girdle or pantie girdle, just as it may be anchored to the trousers in the male.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Not chiffon or lace!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Use of the waist band, as in Figure 22, is largely a matter of personal preference. Some amputees like it, some do not. When the amputee wishes to dispense with the extra waist strap, the elbow control may be anchored to an item of clothing such as a button at the top of the trousers near the fly, as in Figure 26. The control strap then passes out of the shirt between buttons, so that no special opening is needed. But of course when this arrangement is used, the prosthesis is inoperable when the wearer is unclothed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, The above-elbow figure-eight harness a guide to procedures and principles, September 23, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It may be noted that the techniques for harnessing the above-elbow amputee can be applied equally well to articulated braces for flail arms.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), 8 August 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Although common-sense logic might lead one to suppose that improvement in pressure appreciation would be obtainable only were the terminal device voluntary-closing, it turns out that considerable improvement is to be had also from muscle tunnels harnessed to voluntary-opening devices. The tests conducted by Mount and Bernberg were, for example, all made with amputees wearing voluntary-opening hooks. How does the amputee so fitted estimate the amount of force being exerted at the hook fingers? He measures holdback and subtracts it mentally from the known total force exerted by the hook when no restraint is applied. (Ed)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mount, George E., and Raymond E. Bernberg,A preliminary comparison of perception undet cineplastic and harness prostheses, Am. J. Psychol., LXII(1):106(1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Except, of course, in those cases where extremely heavy duty is a requirement from the beginning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Applied Microbiology, 3(4):238 (1955).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures,Artificial Limbs, January 1954. p. 25.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial arm and leg research and development, February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3):4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Langdale-Kelham, R D., and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Marks, George E., A treatise on Marks' patent artificial limbs with rubber hands and feet, A. A. Marks, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Pursley, Lt., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Chief, Research Limb Section, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Harness Patterns for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Robert J. Pursley, Lt., USA (MSC) * https://staging.drfop.org/files/original/64eb48831c842d569b969a8c4023b43a.pdf 23a3264fbd43cb19735d1394ea4628b9 https://staging.drfop.org/files/original/457d0569478cb47d506c23642463165c.jpg 45eb3dbafd54e0d668f2f3bfc95c21f2 https://staging.drfop.org/files/original/f273ddd8f2d9ddf2bcefdc00fecea5cd.jpg 32d7ead140275fb07cd1b5fb68f0d23c https://staging.drfop.org/files/original/926a3decfb9da45446674f936ec89f91.jpg a5f732da60ea27eaccc3b5f8030bb28a https://staging.drfop.org/files/original/1ed3a83ad57a832a54252e4a0737039f.jpg 74e042f3b878ccf644a029e6c7863bd2 https://staging.drfop.org/files/original/e646eb1d8492cc5ba623391e15c6cad5.jpg dcd12710088de3f157db636bb403595c https://staging.drfop.org/files/original/826147443b433df462696387b01d80a1.jpg a3dd7046d03c6312c1783e053e286e89 https://staging.drfop.org/files/original/6db35e73e1a625e17d758c9c372e668b.jpg 3d9d018b29c5258b24e6459783cdfe87 https://staging.drfop.org/files/original/2b3975ce6719b0edcd6b0152b38e1452.jpg 87afc6aa558904540e7d54714b7c124c https://staging.drfop.org/files/original/6f94b060664d6dee12584cfafd9dfb42.jpg e8c575c8db2e62e393094a9bf8f896e4 https://staging.drfop.org/files/original/6a71bd9c057c8ce272a912840c6bdcdb.jpg 27624130c2456841ffa292e8b25b333c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_005.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 5 - 9 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Evolution of the Georgia Warm Springs Foundation Feeder</h2> <h5>Robert L. Bennett, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Thirty years ago (March 1936) a young lady rom Crawfordsville, Ga., was fitted at the Georgia Warm Springs Foundation with what was referred to in her medical record as "an ingenious device" (<b>Fig. 1</b>). This apparatus was later called a "foot-operated feeder" because it required voluntary extension of her foot against a movable footboard on her wheelchair to bring about tilting of the seesaw cradle supporting her forearm. In this manner, she was able to feed herself. She used this device for twenty years and then returned to Warm Springs and was fitted with a far more efficient type with the imposing name "balanced forearm orthesis."<a style="text-decoration:none;">*</a> <!--Page 6--> The "ingenious device" just mentioned appears to have been the first feeder ever used at Warm Springs, and perhaps the first ever used anywhere.<a style="text-decoration:none;">*</a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "An ingenious device" supplied in 1936 to a patient at Georgia Warm Springs Foundation; also known as a "foot-operated feeder." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1936 is found what appears to be the first feeder used at Warm Springs that required shoulder depression to bring the hands toward the head, and perhaps this feeder should be thought of as the true ancestor of our present-day device. As can be seen in <b>Fig. 2</b>, the 1936 device consisted of a metal yoke bolted to the lapboard of a wheelchair but free to revolve horizontally. A metal forearm cradle fastened to the yoke by a wooden block moved vertically in a seesaw fashion. This was called a "Barker feeder," since Edward H. Barker was the first patient to use the device. Over the next few years, at least three patients were fitted with this type of feeder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the "Barker feeder" of June 1936. Perhaps the true ancestor of the present-day device, it required shoulder depression to bring the hand toward the head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Reviewing the literature to determine the first feeder and then tracing the development of the feeder at Warm Springs has been an unexpectedly difficult and time-consuming job. It has been most difficult to separate mobile supportive devices used in the treatment of the paralyzed upper extremity from the functional seesaw devices used to assist the patient with a paralyzed biceps to flex his elbow.</p> <p>Looking back over the years, one is rather amazed to find that it took so long to develop the <!--Page 7--> present-day balanced forearm orthesis. The excuse must be that the development of truly efficient orthetic devices comes only with persistent patient demands and long usage. Extensive patient demand for this type of apparatus did not come until the mid-1940's. Records indicate that perhaps as few as 20 feeders were made at Warm Springs between 1936 and 1946. It should be remembered that prior to the occurrence of large epidemics of poliomyelitis in the early 1940's there were really very few patients who survived the acute attack of poliomyelitis with massive involvement of upper extremities. As the incidence of acute poliomyelitis increased, the medical profession learned how to keep these patients alive. Rather suddenly, in the mid-1940's, Warm Springs was faced for the first time with the problem of large numbers of patients who had such weakness in their upper extremities that they could not bring their hands toward their head.</p> <p>In May 1943 the bulky base of the "Barker feeder" was replaced by a simple rod and collar, the rod passing through a hole in the lapboard of the wheelchair and held in position by a simple collar (<b>Fig. 3</b>). Several holes were placed in <!--Page 8--> the lapboard to determine the proper position for attaching the feeder. In March 1945 the feeder was placed on a simple aluminum base (<b>Fig. 4</b>). This allowed the patient to move the feeder horizontally across the lap-board by body movements for best position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The feeder of May 1943. The base of the "Barker feeder" has been replaced by a simple rod and collar. Several holes placed in the lapboard helped to determine the proper position for attaching the feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The stand feeder of March 1945. The aluminum base permitted the patient to move the feeder horizontally across the lapboard by body movements for best position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first real change in the design of feeders occurred in April 1946. The feeder was suspended from the upright of an overhead sling! Originally, it was called a "bird-cage feeder," simply because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages (<b>Fig. 5</b>). At this time, the Warm Springs treatment program dictated that no patient with severe upper-extremity involvement should use a feeder until late in the convalescent phase of care. Hence there was a natural transition from the use of overhead slings to protect the weakened shoulder girdle to the suspension feeder to develop functional capacity in the upper extremity. For the next ten years, there is record of 326 suspension feeders being fitted to a total of 197 patients. Only seven of this type were used after 1956, and none after 1961.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The "bird-cage feeder" of April 1946-so called because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was not until December 1949 that segmented feeder arms were used (<b>Fig. 6</b>). These arms were attached directly to the vertical tubing of the back of the wheelchair. Insofar as can be determined, hinged-spring control of the proximal link-seen in <b>Fig. 6</b>-was used in this instance only, and no further use of the mobile arms was made until October 1952.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Segmented-arm feeder used in December 1949. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The light and mobile C-clamp feeder that could be easily attached to the edge of a table, to the lapboard, or to a wheelchair arm rest was developed in the spring of 1950 (<b>Fig. 7</b>). Between 1950 and 1960, 61 were used on 45 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. C-clamp feeder developed in May 1950. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In October 1952 the segmented-arm feeder was again used but without the spring hinge at the attachment of the proximal link to the back of the wheelchair. The proximal link was rigidly clamped to the upright (<b>Fig. 8</b>), allowing horizontal motion only. This feeder was followed in 1953 (<b>Fig. 9</b>) by one to which ball bearings had been added to the base and to the moving joints of the arms. The base could also be <!--Page 9--> tilted to assist movement of the proximal link. This was really the first of the present-day Georgia Warm Springs Foundation feeders. Between 1952 and 1964, 786 of these feeders were applied to 427 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Segmented-arm feeder of October 1952. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Present-day Georgia Warm Springs Foundation feeder, the balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In September 1953 it was found that many patients with severe upper-extremity weakness had good musculature in the lower extremities and trunk; therefore, while they needed a feeder, they did not require a wheelchair. It was at this time that feeders were fitted directly to the trunk of the patient, either attached to a corset (<b>Fig. 10</b>) or to a belt. Between 1953 and 1961, 100 such feeders were fitted to a total of 53 individual patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Two views of a patient fitted with a corset-based feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the years 1946 through 1964, for which the record is quite detailed and complete, a total of 1,334 feeders were applied to 773 patients. Some patients had several different kinds of feeders, and so the latter number does not indicate that there were 773 different patients. In 1961 questionnaires were sent to 488 patients who had been fitted with feeders and who had returned to their homes with feeders. Two hundred nine replies were received; of this number, 139 (66.5 per cent) were still using their feeders.</p> <p>The feeder, or balanced forearm orthesis, was developed primarily for patients with paralyzed upper extremities following acute anterior poliomyelitis; however, it is being used for many neuromuscular problems that result in lack of sufficient voluntary strength to bring the hand toward the head. More recently it has been used in conjunction with externally powered orthetic devices that activate elbow, forearm, and hand.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1966_01_005/sp66-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_005/sp66-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_005/sp66-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_005/sp66-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_005/sp66-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_01_005/sp66-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_01_005/sp66-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_01_005/sp66-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_01_005/sp66-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_01_005/sp66-010.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Evolution of the Georgia Warm Springs Foundation Feeder Creator An entity primarily responsible for making the resource Robert L. Bennett, M.D. * https://staging.drfop.org/files/original/57984a195780837231c3d47547393acc.pdf 11789779a85e2b709280689bf0e71309 https://staging.drfop.org/files/original/229e5d0143847fe4a628fb14ddec46e4.jpg be7e746d002f06941f613b3ffcdfe220 https://staging.drfop.org/files/original/c42e1a9caf2711b34235fffd340b847a.jpg b9f313905f981a7b1b591b553ac76025 https://staging.drfop.org/files/original/65483353f040cfd3076c229f9103ba79.jpg f7f25aeeda8fcb9417fcb2a3f14480d5 https://staging.drfop.org/files/original/48332643526aa1b923893a54d16f1d14.jpg 6fdbc24c287659b506d32920ab794a07 https://staging.drfop.org/files/original/2bfcb2f521edd120186e036fda6d7d8f.jpg 6ecc7fab73b16908b5797aa5757d6bfd Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_066.pdf Text Any textual data included in the document <h2>A Physiologic Rationale for Orthotic Prescription in Paraplegia</h2> <h5>Robert L. Waters, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Leslie Miller, R.P.T.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>A difficult clinical decision to be made when treating a paraplegic patient is deciding if walking is a realistic goal, if orthoses should be prescribed, and what the functional outcome will be. It has been demonstrated that the energy expenditure for paraplegics, utilizing a crutch assisted swing-through gait pattern, is markedly elevated. Many patients have learned to walk with crutches and orthoses, but discontinued their use after discharge from a rehabilitation center.<a></a> Studies of other forms of bracing also reveal elevated energy expenditure.<a></a></p> <p>In this review, we will describe the indications for prescribing ankle-foot orthoses and knee-ankle-foot orthoses. We will then outline the criteria used at Rancho Los Amigos Medical Center to determine whether or not a paraplegic is a candidate for ambulation. These criteria are based on the results of energy expenditure measurements of 150 patients with traumatic paraplegia.<a></a> Further investigation of the data collected revealed that the proprioception level or pattern seemed a reliable indicator of which patients would achieve ambulation, while muscle function seemed to determine the quality of their ambulation. These results have helped us to develop guidelines for projecting the functional outcome of ambulation of paraplegics.</p> <h3>Orthotic Prescription</h3> <p>The goal of orthotic management in paraplegia is to provide the external support necessary to compensate for the motor and sensory deficits. Joint range of motion, muscle strength, proprioception, sensation, and spasticity are evaluated when determining the orthotic prescription.</p> <p><i>Knee-Ankle-Foot Orthosis (KAFO)</i></p> <p>Quadriceps strength less than "Fair+" on manual muscle testing is the most common indication for a KAFO. The KAFO is locked at the knee while walking. Although some patients with less than "Fair+ " strength are able to ambulate a short distance without a locked knee (knee stabilization), knee instability usually occurs after a few steps. The exception is the patient with severe quadriceps spasticity which maintains the knee in extension, eliminating the need for external support.</p> <p>Another indication for a KAFO is impaired or absent knee proprioception. The lack of proprioception can result in knee instability even when the quadriceps strength is "Fair+" or greater, as the patient is unable to monitor joint position. If light touch sensation is present on the front of the thigh, a KAFO which allows knee flexion is usually sufficient to control the knee. The anterior stop of the knee mechanism limits extension at 180 degrees and the patient feels pressure from the anterior thigh cuff. In this regard, the brace serves as a transducer that converts proprioception (which is not perceived) into pressure (which is perceived).</p> <p>The final indication for extending bracing above the knee is a severe hyperextension thrust during stance. Paraplegics whose gait is characterized by a hyperextension thrust may develop ligamentous instability, due to attenuation of the posterior cruciate ligament and posterior knee capsule resulting in hyperextension deformity.</p> <p>Range of motion at the hip from 0 degrees of extension to 110 degrees of flexion should be present. In the absence of hip extensor muscles, full hip extension range is necessary to allow the patient to lean backwards and move the center of gravity of the trunk posterior to the hip joint (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg"><b>Fig. 1</b></a>). Hip flexion to 110 degrees, with the knee extended, enables the patient to come to standing with locked KAFO's and rise from the ground after a fall. Full knee extension is required for optimal fit.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg"><strong>Figure 1. Standing posture.</strong></a><br /> <p>Ten degrees of dorsiflexion at the ankle is the minimum necessary for unassisted upright balance (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg"><b>Fig. 1</b></a>). Normal proprioception in at least one hip also facilitates unassisted standing.</p> <p>Inability to meet the joint range requirements described above commonly occurs and is most often due to spasticity or contracture. If satisfactory orthotic fit and posture cannot be achieved, a physical therapy regime that includes stretching exercises or serial casting is often successful when spasticity is mild and the deformity is not longstanding. When severe spasticity or deformity is present, or the deformity has been present for an extended time, the patient should be referred to an orthopedic surgeon.</p> <p>Good trunk strength is necessary to maintain an erect posture in the standing position without excessive weight bearing in the arms. High level paraplegics without adequate trunk strength must exert a strong upwards force by the arms throughout the entire gait cycle to prevent forward collapse and accomplish forward progression. This contributes to the high energy demand. (All swing-through gait candidates are required to perform 50 consecutive dips on parallel bars to insure they have sufficient upper extremity strength and endurance.)</p> <p><i>Ankle-Foot Orthosis (AFO)</i></p> <p>Quadriceps strength greater than "Fair" should be present to stabilize the knee if an AFO is prescribed. The patient must also have adequate hip flexion strength to swing the leg forward to achieve a reciprocal gait pattern. The indications for AFO are numerous and include any or all of the following: plantarflexion strength less than "Good," dorsiflexion strength less than "Fair," impaired ankle proprioception, and moderate to severe plantar-flexion spasticity.</p> <p>During normal walking, the plantarflexors are active during the stance phase of gait to prevent excessive forward advancement of the tibia. As a result of forward momentum, the knee passively extends as the body advances forward over the stabilized tibia, and the demand placed on the quadriceps is minimal. Customary manual muscle testing methods fail to place a sufficient load on the plantarflexors to evaluate the force required during gait. The strength required to provide ankle and knee stability is present in patients who can perform 15 to 20 toe raises on one leg. Failure to provide adequate orthotic stabilization of the ankle in patients with inadequate plantarflexion strength may result in ankle instability and knee instability, if the quadriceps and/or hip extension strength is also inadequate.</p> <p>Knee wobble can be a sign of impaired ankle proprioception and/or weakness. This can be eliminated by an AFO with a rigid ankle or anterior ankle stop, which provides distal stability and kinesthetic information via the calf cuff.</p> <p>An AFO may be utilized to hold the ankle in the neutral position when dorsiflexion strength is impaired or there is excessive plantarflexion spasticity. When spasticity is severe, it may not be possible to maintain the foot in neutral, and the patient should be referred to an orthopedic surgeon if non-operative measures prove inadequate.</p> <p>When the ankle is held in a rigid orthosis, ankle stability is gained during midstance. However, a forward thrust is imposed, forcing the knee into flexion at the moment of heel contact. (This knee flexion torque is generated because the rigidly immobilized ankle rotates forward about the point of heel contact.) During normal gait, this torque is avoided by ankle plantarflexion, minimizing the effect of the heel lever.</p> <p>There are two courses of action available to provide ankle stability during stance, while still maintaining knee stability at heel strike. If the patient has "Fair+ " or better ankle dorsiflexion strength and intact proprioception, we fit a metal AFO with a double adjustable ankle joint. A set screw in the anterior channel provides an adjustable stop that prevents excessive dorsiflexion. The posterior stop is left open to allow free ankle plantarflexion. Springs can be added posteriorly if dorsiflexion strength is less than "Fair+." The advantage gained is that restriction of motion during terminal stance is maintained while the normal plantarflexion motion during heel contact is preserved, avoiding the undesired knee flexion torque. If the patient has less than "Fair" dorsiflexors or absent proprioception at the ankle, then the ankle is locked and either metal or plastic is used. To avoid the excessive knee flexion torque when the AFO is locked, the heel of the shoe is undercut. This decreases the heel lever and, thus, the knee flexion torque.</p> <h3>Orthosis Weight</h3> <p>Weight is an important factor to some patients, as is the availability of joint motion of the orthotic system. Plastic, because of its potential to be lighter than metal, is sometimes preferable. For the patient with weak hip flexors, efforts to minimize weight are warranted since any extra weight at the end of the limb will make it more difficult to lift the foot and advance the leg. Lehneis, et al.<a></a> found that improving orthotic stability at the ankle reduces energy costs. It follows, then, that in any orthotic design, stability (control about a joint) should not be sacrificed merely to achieve lighter weight.</p> <h3>Exercise Physiology</h3> <p>It is necessary to understand several fundamental principles of exercise physiology to interpret the results of energy expenditure measurements in paraplegic patients.<a></a> The use of oxygen consumption is based on the fact that during sustained exercise, most of the ATP for muscle contraction is generated by aerobic metabolic pathways. After several minutes of exercising at a constant submaximal workload, the rate of oxygen consumption rises until it reaches a level sufficient to meet the metabolic demands of the exercising muscle. Measurement of the rate of oxygen consumption at this time reflects the energy cost of the activity and indicates the exercise intensity. The oxygen cost per meter walked determines the efficiency of ambulation.</p> <p>The principle fuels for aerobic metabolism are carbohydrates and fats. The oxidation of glucose can be summarized by the following equation:</p> <p>GLUCOSE + 36 ADP + 6 O₂ --&gt; 6 CO₂ + 44 H₂O + 36 ATP</p> <p>During exercise, the extent to which anaerobic pathways contribute to the production of energy depends upon the intensity of the effort. In mild to moderate exercise (approximately 50 percent of the maximal aerobic capacity for untrained individuals), the oxygen supplied to the tissue for the aerobic energy producing reactions is usually sufficient to meet energy requirements. During more strenuous exercise, anaerobic oxidation processes also occurs.</p> <p>The amount of energy that can be produced by anaerobic means is limited. Nineteen times more energy is produced by the aerobic oxidation than by anaerobic oxidation. Also, accumulation of lactate in muscle and blood leads to acidosis, limiting the extent to which intense exercise can be performed. From a practical standpoint, anaerobic oxidation provides an extra supply of energy for sudden bursts of strenuous effort, but these pathways cannot be routinely utilized for a prolonged time. In contrast, when exercise is performed below anaerobic threshold, an individual can sustain exercise for many hours without exhaustion.</p> <h3>Maximal Aerobic Capacity</h3> <p>The maximal aerobic capacity (VO₂ max) is the single best indicator of physical work capacity and fitness. It measures the individual's maximum energy production capability. Generally, an individual is able to reach the VO₂ maximum within two to three minutes of instituting strenuous exercise. Any disorder of the respiratory-cardiovascular muscle or metabolic systems that restricts the supply of oxygen to the muscle decreases the VO₂ max. A physical conditioning program can increase aerobic capacity by several processes which include improving cardiac output, increasing the capacity of the muscle to extract oxygen from the blood, increasing the level of hemoglobin, and increasing the muscle mass. On the other hand, the maximal aerobic capacity can be reduced due to blood loss, paralysis, surgery, negative nitrogen balance, or bed rest.<a></a> The important clinical implication is that the paraplegic patient is usually severely deconditioned as a consequence of the injury. The prescription of orthoses and a walking program should not be initiated until the patient has sufficient strength and maximal aerobic capacity to meet the required energy demand. The deconditioned paraplegic patient will respond to a physical conditioning program just as an able bodied subject with respect to increased strength, endurance, and maximal aerobic capacity.<a></a></p> <p>In able bodied subjects, the VO₂ max also depends on the type of exercise. During lower limb exercise, the VO₂ max is greater than the VO₂ max for the upper limbs. Since paraplegic patients rely on the upper extremities to walk with the aid of crutches, their energy production capability is inherently limited. The problem in paraplegics is further compounded by the effects of the spinal injury. The upper extremity VO₂ max for paraplegics is lower than for able bodied subjects, presumably due to the effects of paralysis and interruption of the autonomic neurological pathways which regulate blood flow and cause venous pooling in the lower extremities.<a></a> For the typical adult male paraplegic, we establish a VO₂ max of 20 ml/kg-min during upper arm cranking as the minimal criteria acceptable for entering gait training if a swing-through crutch assisted gait pattern will be required.</p> <h3>Energy Expenditure</h3> <p><i>Wheeling Versus Normal Walking</i></p> <p>On a hard, level surface paraplegic wheelchair use is as efficient as normal walking. A comparison of the data in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a> indicates that when propelling a chair around a 60.5 meter circular track, the speed was almost as fast as normal walking (72 versus 80 m/min).<a></a> The oxygen rate was approximately the same (11.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>), as was the oxygen cost (.16 versus .15 ml/kg/ min). The heart rate was higher in paraplegics using the wheelchair than in normal walking (123 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>). As previously mentioned, this relates to the lower upper maximal aerobic capacity in paraplegics during arm exercise. From a clinical standpoint, it may be concluded that the wheelchair is a highly efficient means of transportation whose speed and energy requirements are comparable to that of normal walking.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><strong>Figure 2. Average velocity in normal subjects and in patients using wheelchairs or orthoses.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><strong>Figure 3. Rate of oxygen consumption in normal subjects and in patients using wheelchairs or orthoses.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><strong>Figure 4. Heart rate in normal subjects and in patients using wheelchairs or orthoses.</strong></a><br /> <p><i>Swing Through Gait</i></p> <p>Crutch walking with a swing-through gait requires the arms and shoulder girdle to lift the entire weight of the body and swing it forward with each step. The average speed in paraplegics trained to use a swing-through crutch assisted gait was 64 percent lower than normal walking (20 versus 80 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a>); the rate of oxygen consumption was 38 percent greater (16.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>); the oxygen cost was 560 percent greater (.84 versus .15 ml/kg/min); and the heart rate was increased 46 percent (145 versus 99 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>).<a></a> This rate of energy expenditure requires most of the aerobic capacity of the typical adult male paraplegic with a complete T12 lesion and is well above the anaerobic threshold. The extreme exertion required for a swing-through gait demands a greater intensity of physical effort than a normal individual customarily expends on sports activity such as recreational jogging. Consequently, it is not surprising that while the athletic paraplegic may be willing to expend this level of exertion for recreational purposes, he is unwilling to sustain these efforts for normal activities of daily living. Even those patients, who are physiologically capable of sustaining the intense physical effort of a swing-through gait for a sustained time period to travel longer distances, find tachypnea (rapid breathing), tachycardia (rapid heart rate), and hidrosis (sweating), unacceptable for routine activities of daily living.</p> <p>We believe that the highly motivated paraplegic who is willing to exercise strenuously should not be discouraged from walking, but a more realistic approach should be taken for the average patient. The average patient should be given walking training and bilateral knee-ankle-foot orthoses only if walking is necessary for psychological reasons, for purposes of exercise, or because of architectural barriers in the living environment. It should be clearly explained that the wheelchair should be considered as the primary means of mobility.</p> <p>We have tested three patients with "Fair+" hip flexors who used bilateral KAFO's and preferred a reciprocal gait pattern.<a></a> Interestingly, the effort expended by these patients was just as great as in swing-through gait (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>).</p> <p><i>Energy Expenditure: Reciprocal Gait</i></p> <p>In a review of spinal cord injured patients, Hussey and Stauffer found that those patients who were able to walk in the community had pelvic control with at least "Fair" hip flexor strength and at least "Fair" extensor strength in one knee so that a maximum of one KAFO was required, enabling the patient to achieve a reciprocal gait pattern.<a></a> Having "Fair+" or greater quadriceps strength sufficient to stabilize one knee eliminates the need for one KAFO and enables the patient to walk with a crutch assisted reciprocal gait pattern at a rate of energy expenditure and heart rate that are significantly below that required for a swing-through gait pattern (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>). Surprisingly, we found no difference in the speed and rate of energy expenditure in patients with one free knee or two free knees and requiring bracing only below the knee (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>).</p> <p>Nevertheless, paraplegics who have intact hip flexion and knee extension bilaterally require orthoses only below the knees, and those who use a reciprocal crutch assisted gait pattern are still severely impaired (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b>,</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b>,</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>). Compared to normal walking, the rate of oxygen expenditure is 20 percent greater (16.3 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>), the heart rate 31 percent greater (131 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>), and the speed 67 percent slower (80 versus 20 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a>).<a></a> The typical paraplegic who uses crutches and a reciprocal gait still exerts a force of 25 to 50 percent of total body weight on the crutches with each step, accounting for the increased rate of energy expenditure. The only spinal cord injured patients we have tested whose energy expenditure during walking does not exceed normal values are those patients with minimal involvement who have intact sacral function (in addition to lumbar function) and a sufficient hip abductor and extensor strength to maintain an erect posture without crutches.</p> <p>The average distances necessary to perform different daily living activities are listed in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg"><b>Fig. 5</b></a> and were obtained from numerous measurements made in different types of urban areas in Los Angeles.<a></a> Since the average speed of walking in low lumbar paraplegics who used bilateral ankle-foot orthoses and a reciprocal crutch assisted gait pattern was only 26 m/min, it would take more than five minutes to travel 150 meters. Because five minutes of walking will require a strenuous effort, it is apparent why even the typical low lumbar paraplegic is a limited walker outside the home and is not able to routinely ambulate comfortably for activities which require walking a longer distance. In this regard, clinicians are justified in prescribing a wheelchair to any spinal injury patient who requires crutch assistance. The patients should be encouraged to use the wheelchair as necessary and be reassured that reliance on the wheelchair, when necessary, should not be considered a failure.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg"><strong>Figure 5. Average distances necessary to perform customary activities of daily living.</strong></a><br /> <p><b>References:</b></p> <ol> <li>Aastrand, P.O. and K. Rodahl, <i>Textbook Work Physiology</i>, Ed. 2, McGraw-Hill, Inc., New York, 1977.</li> <li>Cerny, K., R. Waters, H. Hislop and J. Perry, "Walking and Wheelchair Energetics in Persons with Paraplegia," <i>Physical Therapy</i>, 60:1133-1139, 1980.</li> <li>Clinkingbeard, J.R., J.W. Gersten, and D. Hoehn, "Energy Cost of Ambulation in the Traumatic Paraplegic," <i>American Journal of Physical Medicine</i>, 43:157-165, 1964.</li> <li>Gordon, E.E., "Physiological Approach to Ambulation in Paraplegia," <i>JAMA</i>, 161:686-688, 1956.</li> <li>Huang, C.T., A.B. McEachran, K.V. Kuhlemeier, M.J. DeVivo, and P.R. Fine, "Prescriptive Arm Ergometry to Optimize Muscular Endurance in Acutely Injured Paraplegic Patients," <i>Arch. Phys. Med. Rehab.</i>, 64:578-582, 1983.</li> <li>Hussey, R.W. and E.S. Stauffer, "Spinal Cord Injury: Requirements for Ambulation," <i>Arch. Phys. Med. Rehab.</i>, 54:544-547, 1973.</li> <li>Lehneis, H.R., E. Bergofsky, and W. Fresina, "Energy Expenditure with Advanced Lower Limb Orthoses and with Conventional Braces," <i>Arch. Phys. Med. Rehab.</i>, 57:20, 1976.</li> <li>Lerner-Frankiel, M.B., S. Vargas, M. Brown, L. Krusell, and W. Schoneberger, "Functional Community Ambulation: What Are Your Criteria?" <i>Clin. Man. in Phys. Ther.</i>, 6:12-15, 1986.</li> <li>Waters, R.L., H.J. Hislop, J. Perry, and D. Antonelli, "Energetics: Application to the Study and Management of Locomotor Disabilities," <i>Orthop. Clin. North America</i>, 9:351-377, 1978.</li> <li>Waters, R.L. and B.R. Lunsford, "The Energy Cost of Paraplegic Locomotion," <i>Journal of Bone Joint Surgery</i>, 67A: 1245-1250, 1985.</li> <li>Wolf, E. and A. Magora, "Orthostatic and Ergomet-ric Evaluation of Cord-injured Patients," <i>Scandinavian Journal of Rehabilitation Medicine</i>, 8:93-96, 1976.</li> </ol> <em><b>*Leslie Miller, R.P.T. </b> Leslie Miller, R.P.T. is a spinal cord injury clinical specialist at Rancho Los Amigos Medical Center.</em><br /><br /><em><b>*Robert L. Waters, M.D. </b> Robert L. Waters, M.D. is Chairman of the Department of Surgery at Rancho Los Amigos Medical Center, HB-121, 7601 E. Imperial Highway, Downey, California 90242.<br /><br /><br /></em> Page Number(s) 66 - 73 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Physiologic Rationale for Orthotic Prescription in Paraplegia Creator An entity primarily responsible for making the resource Robert L. Waters, M.D. * Leslie Miller, R.P.T. * https://staging.drfop.org/files/original/275fab2ea3b3d6677f16b2fc3c4f84d4.pdf c2bbef75d554db7e69924d9f9f9c3be5 https://staging.drfop.org/files/original/945444737a803091f2f7bb1f33166de1.jpg a44bea2f00eb9d7426d0babc659224e9 https://staging.drfop.org/files/original/805377d1e0c88a555e639acf4505f9d9.jpg a43839ca800ea32a700efaf4bfa8c04c https://staging.drfop.org/files/original/765458c0a65fb32f59bc3f28a9e0a770.jpg aa8eff94b32c7b7db5b52dffb56eec36 https://staging.drfop.org/files/original/d780ea0687580fe5cebc29a049984303.jpg 5a3a3e48efd9f9539ee371ddb261a7a2 https://staging.drfop.org/files/original/d7de2d0bc53c05faa2e263ccba47e3c2.jpg 0245c6a4e08793989816f7455b5379d8 https://staging.drfop.org/files/original/c83d9d8de2014f43049249a501eaf7ac.jpg 8e116daad4f180da07481663e4931c0f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_119.pdf Text Any textual data included in the document <h2>Technical Note: RMB Reinforcement</h2> <h5>Robert O. Gooch, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Because of the humid climate, the Department of Prosthetics and Orthotics at Duke University Medical Center receives many prescriptions for hard socket below-knee prostheses. The great majority are supracondylar wedge suspension, utilizing the Removable Medial Brim (RMB) concept. For the past several years, we have designed and fitted approximately 150 such prostheses annually.</p> <p>Based on this experience, we have developed a method to reinforce the RMB structure and prevent gradual loss of alignment under the constant pressure of the femoral condyles. We now use this technique routinely, and find it greatly enhances the stability of the removable brim.</p> <h3>Method</h3> <p>Fabricate the socket in the conventional manner, following the instructions supplied by the hardware manufacturer.<a></a> Rather than packing the mechanism with clay, we prefer to substitute Johnson's Stik-Wax,<a></a> which is easier to work with and lubricates the assembly, allowing easier removal. Once the lamination is fully cured, break out the positive model.</p> <p>At this point, the medial brim is cut away from the socket. Although a variety of tools can be used for this operation, we prefer a simple modification of an ordinary hacksaw blade.</p> <p>Grind the fine-tooth hacksaw blade into the contour shown in (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg"><b>Fig. 1</b></a>). This is preferable to a commercial sabre saw blade, because its wide, thin shape creates a smoother, less irregular cut.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg">Figure 1.</a> Fine-toothed hacksaw blade, modified to fit sabre saw.</strong><br /> <p>Using the sabre saw, cut the anterior and posterior portion of the brim free, being careful not to nick the metal upright. Cut the area adjacent to and over the metal upright with a cast saw or sharp knife. Carefully pry the medial brim free with a thin-bladed screwdriver.</p> <p>Grind the distal end of the upright an amount equal to the saw kerf, to insure the wedge will seat fully (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg"><b>Fig. 2</b></a>). Place the brim back onto the socket to be certain it fits properly, with minimal gapping along the cut edge.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg">Figure 2.</a> Grind distal upright to insure the wedge fits without gapping.<br /></strong><br /> <h3>Reinforcement</h3> <p>Remove the brim and apply PVC tape<a></a> to the lateral surface and distal trimline. This serves as a parting agent, and prevents the resin used in subsequent steps from bonding the wedge back onto the socket.</p> <p>Roughen the socket immediately beneath the cut-line, to insure good adhesion for the reinforcement lip (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg"><b>Fig. 3</b></a>). Lubricate the cut edge with petroleum jelly and reapply the wedge carefully to avoid gapping.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg">Figure 3.</a> Tape wedge and roughen socket prior to lamination of lip.</strong><br /> <p>Cut three 1 1/2" wide strips of Xynole-polyester<a></a> fabric long enough to cover the saw cut. This material saturates readily when used with polyester resin and forms a thin, strong, and rigid reinforcement.</p> <p>Promote a small amount of pigmented polyester 4110 (rigid) resin. Paint the roughened area of the socket with resin, and apply one layer of Xynole reinforcement extending at least 1/2" onto the wedge (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg"><b>Fig. 4</b></a>). Brush additional resin onto the Xynole until it is fully saturated, and apply the second layer. Fully saturate this layer and apply the final layer. Saturate this in a similar manner.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg">Figure 4.</a> Saturate Xynole layers individually with the polyester resin.</strong><br /> <p>When the resin has gelled, but not fully set, remove the wedge. This insures that the wedge will insert smoothly, without binding, in the finished prosthesis.</p> <p>Once fully cured, trim the reinforcement to form a 3/16" lip (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg"><b>Fig. 5</b></a>). Using a felt arbor, bevel the inside edge of the lip and the outside edge of the wedge (<a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg"><b>Fig. 6</b></a>). This unobtrusive lip will significantly reinforce the wedge, particularly against malrotation.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg">Figure 5.</a> Trim lip to 3/16" above socket edge.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg">Figure 6.</a> Posterior view of lip with wedge in place. Note bevel on inner edge of lip and outer edge of wedge.<br /></strong><br /> <h3>Finishing</h3> <p>Once dynamic alignment and transferring are completed, the prosthesis is ready for the finish lamination. We typically set the wedge aside and relaminate the prosthesis without the proximal brim in place.</p> <p>An old RMB upright can be inserted into the channel and clamped in a vise. This prevents resin from filling the channel and provides a mandrel to secure the prosthesis during the lamination procedure. Lubricate the upright with Stik-Wax<a></a> to fully seal the channel.</p> <h3>Summary</h3> <p>Fabrication of a Xynole reinforcing lip significantly improves the stability of the supracondylar wedge when using the Removable Medial Brim procedure. Based on the Duke experience with hundreds of RMB prostheses, we recommend this be done routinely.</p> <p><b>References:</b></p> <ol> <li>Durr-Fillauer Medical, Inc.&nbsp;<br />P.O. Box 5189&nbsp;<br />Chattanooga, TN 37406&nbsp;<br />RMB Hardware Kit&nbsp;<br />Catalog #127019 (Heavy Duty)&nbsp;<br />Catalog #127001 (Standard Duty)</li> <li>S.C. Johnson &amp; Sons, Inc.&nbsp;<br />Racine, WI 53403&nbsp;<br />#140 Stik-Wax-15 oz. container</li> <li>Otto Bock Industries&nbsp;<br />4130 Highway 55&nbsp;<br />Minneapolis, MN 55422&nbsp;<br />Coroplast PVC tape&nbsp;<br />Catalog #616F8</li> <li>Durr-Fillauer Medical, Inc.&nbsp;<br />P.O. Box 5189&nbsp;<br />Chattanooga, TN 37406&nbsp;<br />Xynole-Polyester cloth&nbsp;<br />Catalog #211094</li> </ol> <em><b>*Robert O. Gooch, CP. </b> Robert O. Gooch, CP., is with the Department of Prosthetics and Orthotics at the Duke University Medical Center.</em> <div style="width: 400px;"><br /><br /></div> Page Number(s) 119 - 121 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_119/1986_03_119-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: RMB Reinforcement Creator An entity primarily responsible for making the resource Robert O. Gooch, CP. * https://staging.drfop.org/files/original/83648b0b711c382f195cc6bdaa6ab376.pdf 0d93f48bc78669170b984704c62a93b6 https://staging.drfop.org/files/original/51ee9f592b7e05126ec1e1eeec2c8f87.jpg e2e5e9a0ff445f9d032735045a3720b6 https://staging.drfop.org/files/original/cd87e6b8e63780897953794d33b1a88f.jpg 611cb47da091fa4220b0a84a5621f946 https://staging.drfop.org/files/original/ee0b549a0ac2ac1213258d9a7cf6bde6.jpg 13dc19f7b6d5ad835d26c445b688647b https://staging.drfop.org/files/original/9268367df64346914dfcd44ac7f8e280.jpg dccae3622fdb0d507ef88c33387b8ecf https://staging.drfop.org/files/original/748805f5859f6d87f7e3d2763cbd306e.jpg 4dd495359ed8ab36487f3abc0abf6221 https://staging.drfop.org/files/original/46b2b805c5456f6a9b6763b29e69dd6e.jpg c6ddf3929559d51cb9a4c5ac217b757d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_130.pdf Text Any textual data included in the document <h2>Adaptive Seating in Pediatrics</h2> <h5>Robert S. Lin, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Susan S. Lin, O.T.R.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Adaptive seating represents one of the most complex areas of orthotic management. No other area of clinical practice requires the degree of knowledge and application of biomechanics, design engineering, tissue physiology, wheelchair design and the clinical manifestation of the many neuromuscular disorders involved. No other area of management effects as many aspects of the patient's life and treatment programs initiated by other professionals. Therefore, it is imperative to solicit input from all members of the multidisciplinary team (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg"><b>Fig. 1</b></a>). The orthotist, physician, physical therapist, occupational therapist, educator, speech pathologist, social worker, psychologist, and wheelchair vendor must all take part in the prescription formulation (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-2.jpg"><b>Fig. 2</b></a>). Unfortunately, formal training for the aforementioned professionals provides very little, if any, information for the evaluation, assessment, and design of adaptive seating systems.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg">Figure 1.</a> Input from all members of the rehabilitation team is solicited.<br /></strong><br /> <h3>Development</h3> <p>To compound the difficulty of equipment provision, pediatrics offers additional complications that aren't as prevalent in management of the adult population. Because the child is still undergoing physical development and maturation, the clinical picture he/she presents is expected to change. Some of the changes are due to growth (longitudinal and/or circumferential), yet some are due to disease progression, developmental abnormalities, and psycho-social problems that result from an increasing awareness of the physically handicapping condition.</p> <p>The adaptive seating system must be able to accommodate growth, environmental, and clinical changes in the child. This is particularly important in view of the funding restrictions on equipment replacement set by state or private payment sources.</p> <h3>Education</h3> <p>Another very important consideration in positioning a child is the child's educational goals and limitations. Aside from the physical barriers that a school may present, safe transportation to and from the school in a bus or van must be achieved. Few wheelchair bases are compatible with the lock down mechanism used by local transportation systems. This basic mechanical problem can hamper the educational process even before it begins.</p> <p>Once the child is in the school environment, many subtle factors can influence the success and acceptance of the adaptive seating system. These factors include whether or not the child is mainstreamed or in a special education program; the physical design of the school such as elevators for multilevel institutions and overall wheelchair accessibility; whether the communication needs of the child are met in a group setting; desk height, which can profoundly effect actual integration; whether medical/nursing facilities are available; and the kinds of recreational provisions offered for physical education.</p> <h3>Information Collection</h3> <p>Because the breadth of information concerning the patient can be extensive, there must be a mechanism to facilitate the collection of this critical data. It is imperative that the primary treating professionals provide this input because of familiarity with the patient and pre-established goals.</p> <p>The following <i>In-take</i> form was developed by author Susan Lin, O.T.R. in an effort to provide a concise patient data collection sheet. While the completion of this form can be time consuming, we have found that access to this information is essential (<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-3.jpg"><b>Fig. 3</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg"><b>Fig. 4</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.jpg"><b>Fig. 5</b></a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-6.jpg"> <b>Fig. 6</b></a>).</p> <h3>One Approach To Adaptive Equipment Provision</h3> <p>In 1981, Newington Children's Hospital initiated its first formal Adaptive Equipment Clinic. The clinic is covered by seven members of the core team with three others forming the ancillary team. The core consists of a physician, orthotist, seating specialist, physical therapist, occupational therapist (who serves a dual function as the Adaptive Equipment Coordinator), speech pathologist, and social worker. The ancillary team is comprised of an educator, psychologist, and durable medical equipment vendor.</p> <p>The clinic is held one morning per week, divided into four one-hour appointments. Every third week of each month is reserved for a re-check clinic and follow-up care is provided every six months. The follow-up appointments are one half hour long, with eight patients checked in a morning.</p> <p>Prior to the first patient evaluation, the <i>In-take</i> forms for all new patients scheduled that day are reviewed and discussed. This enables us to establish a preliminary game plan as well as discuss certain confidential factors that may influence management. Formulation of the actual prescription occurs during the hour appointment, with various tasks assigned to appropriate team members to ensure follow-up of our recommendations.</p> <p>Over the past five years, the NCH Adaptive Equipment Clinic has provided an ideal forum for patient and equipment evaluation and prescription. The aforementioned protocol evolved slowly and has worked very well considering our resources, patient population, time and cost constraints.</p> <p>Those factors that have universal application are the need for a multidisciplinary approach, the need for follow-up appointments, and a sound understanding of seating principles.</p> <p>The recent emphasis on adaptive seating has finally enabled the orthotist to assist in management of the entire spectrum of patients, not just those who are candidates for ambulation. The appropriate seating system can be a therapeutic tool which enhances the quality of life and serves as an adjunct to other rehabilitation efforts.</p> <p><em><b>*Susan S. Lin, O.T.R. </b> Susan Lin, O.T.R., is the Director of Occupational Therapy at Forestville Nursing Center and an Adaptive Equipment Consultant at Hudson Home Health Care. She was the primary developer of the Adaptive Equipment Clinic at Newington Children's Hospital and was the Hospital's first Adaptive Equipment Clinic Coordinator from 1981 to 1985.</em></p> <p><em><b>*Robert S. Lin, C.P.O. </b> Robert Lin is the Clinical Coordinator of Orthotics at Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111.<br /><br /><br /></em></p> Page Number(s) 130 - 136 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_04_130/1986_04_130-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Adaptive Seating in Pediatrics Creator An entity primarily responsible for making the resource Robert S. Lin, C.P.O. * Susan S. Lin, O.T.R. * https://staging.drfop.org/files/original/02b69054e99fc08b4b12033c4c735d90.pdf a11820a4a41bad505f07eb0c2b9d0fc9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_017.pdf Text Any textual data included in the document <h2>Gait Analysis</h2> <h5>Ronald F. Altman, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The following series of articles on Gait Analysis were based on a project which was supported by the Newington Children's Hospital Research Fund.</p> <p>The following series of articles all have to do with using gait analysis, in orthotics as well as prosthetics, to improve function. The Gage/Hicks study traces gait analysis in prosthetics from Inman forward, and the individual articles illustrate contemporary laboratory approaches to the objective assessment of gait.</p> <p>Fundamental to optimal lower-extremity prosthetic/orthotic service is an analysis of the gait of the patient. To the extent the method of analysis fails to provide adequate objective or useful information about gait, it allows for the possibility and probability that a less than optimum fit and/or alignment configuration has been or will be achieved.</p> <p>While gait analysis has long been an established procedure of varying objectivity in prosthetics, in orthotics the use of gait analysis has been rather ineffectual in assisting to optimize gait, a process which for the most part fails to go beyond a most rudimentary observation. This is due in part to the rudimentary functional characteristics of most orthoses.</p> <p>Advances in our profession as well as technology and materials can and do result in more functional orthoses. If we are going to provide the optimal orthotic design configuration for any given patient, it is essential that we define gait characteristics more precisely and reliably.</p> <p>Though not yet universally available, the increasing number of gait analysis facilities will soon benefit us all—patients and practitioners alike—as we gain access to the resulting information flow in formats readily usable by orthotists and prosthetists.</p> <em><b>*Ronald F. Altman, C.P.O. </b> Director of Orthotics/Prosthetics Department at Newington Children's Hospital in Newington, Connecticut.<br /><br /></em> Page Number(s) 17 - 17 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gait Analysis Creator An entity primarily responsible for making the resource Ronald F. Altman, C.P.O. * https://staging.drfop.org/files/original/2110d586443d4b19b7fc9536683bc8db.pdf b96a92130c9eedff024e88641dc2063c https://staging.drfop.org/files/original/fb9ebe60dff913d9135a2935bdf2deda.jpg d13d55f144121d2cfb8b9d4b730617e3 https://staging.drfop.org/files/original/ed52127592e5a7556ac833dfac1e096e.jpg 09b1f0c571cdcf62a95b58b49c7de006 https://staging.drfop.org/files/original/7b8faeb9f25f51fe5128b4495503c950.jpg 99db08c49eea3368263b0db1627f47c4 https://staging.drfop.org/files/original/30dace90d04426eb54982c1e6db41b48.jpg 1ed343a6460af0febbb1795bc6c12e7e https://staging.drfop.org/files/original/f9b5fe8693775eed4668606286075472.jpg a15b89b39232a09a39e2b982223cb10c https://staging.drfop.org/files/original/3b8587872e5cd2828bb2963b8d88dbc6.jpg 0de0585464dffd0d381b1074931ae52c https://staging.drfop.org/files/original/ed4b52ce5ac75f7406ab601d3bcedf30.jpg 587647562e5551eb1a9ab4f918a8d05b https://staging.drfop.org/files/original/9d684744fe2af745dd567f69072abe94.jpg 6a8c37f94d45cf2102a83e1ba04ba532 https://staging.drfop.org/files/original/f47f13f4f517be2c68e4885132255a73.jpg 7a973ac6c580a0cd23a1aad0da06345e https://staging.drfop.org/files/original/ee934e7d6260f4fe6b2d0b475480c0c7.jpg 6a87da86f9c77268e89c2920e54290a7 https://staging.drfop.org/files/original/9eb67fe346807f23eb9721e730181cf6.jpg 3d6338336fa57f8e45e0c104c8e44f29 https://staging.drfop.org/files/original/d03ce299f5faed1b04bd1cb5d511348a.jpg 30c15358ad729c1d1b4c7c63b57d6e8f https://staging.drfop.org/files/original/f40a73ddf7abbe1bc363584464f188a0.jpg 8d3a34e6604c20c0b27728cfb136b495 https://staging.drfop.org/files/original/5c007bf3a01c041d44b41f637e3b98dd.jpg a3fad156c8637c58e8b2c697edb9aa86 https://staging.drfop.org/files/original/bbd4c7da3293e56cd493f889704a4ed4.jpg 40069e7ae5876d1e96e3a89a733cbb52 https://staging.drfop.org/files/original/36c833299af80c7d07ced66aa833331a.jpg 34987d61eca54e9e03b1ed422ae2ff44 https://staging.drfop.org/files/original/a1b4f107929b70c2c1e7b1bd1d4e4dcf.jpg 2f4d617a5b5753ac4821f7d6b284cd9b https://staging.drfop.org/files/original/840c46b44786ace3aff7daeaa6ff78f5.jpg 7e7806eb8e3e875d3fd8986e218f9c24 https://staging.drfop.org/files/original/6cda4b12ad5be268580aae44a30a5534.jpg b09bb8952a15ec26af4db027bbfc3382 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_044.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 44 - 66 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Body Segment Parameters: A Survey of Measurement Techniques</h2> <h5>Rudolfs Drillis, Ph. D. <a style="text-decoration:none;">*</a><br />Renato Contini, B.S. <a style="text-decoration:none;">*</a><br />Maurice Bluestein, M.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Human motor activity is determined by the response of the subject to constantly changing external and internal stimuli. The motor response has a definite pattern which can be analyzed on the basis of temporal, kinematic and kinetic factors.</p> <p>Temporal factors are those related to time: cadence (tempo) or the number of movements per unit time (minute or second), the variability of successive durations of motion, and temporal pattern. The temporal pattern of each movement consists of two or more phases. The relative duration of these phases and their interrelationships are indicative characteristics of the movement under consideration. For example, in walking, two basic time phases may be noted, the stance phase when the leg is in contact with the ground and the swing phase. The ratio of swing-phase time to stance-phase time is one of the basic characteristics of gait.</p> <p>The kinematic analysis of movement can be accomplished by studying the linear and angular displacements of the entire body, the joints (neck, shoulder, elbow, wrist, hip, knee, ankle) and the segments (head, upper arm, forearm, hand, thigh, shank, foot). For the purpose of investigation, the most important kinematic characteristics are: the paths of motion, linear and angular displacement curves, amplitudes or ranges of motion, the instantaneous and average velocities and their directions, and finally the linear and angular accelerations of the body segments under investigation. Information on these criteria can be obtained readily from objective (optical or electrical) recordings of the movements of a subject.</p> <p>The kinetic analysis is concerned with the influence of different forces and moments acting on the body or a body segment during the performance of a given activity. To determine these forces and moments, accurate data on the mass (weight), location of mass centers (centers of gravity), and the mass moments of inertia of the subject's body segments are required.</p> <p>At present there are limited data on body segment parameters, especially those for American subjects. Such data available are based on studies made on a limited number of dissected male cadavers. This cannot be regarded as a representative sample for our normal population with its wide range of age and difference of body build. There are no data available on female subjects in the United States.</p> <p>A precise knowledge of these body segment parameters has many applications, such as in the design of work activities or the improvement of athletic performances. It has particular value in understanding orthopedic and prosthetic problems. It would result in a better design of braces and prosthetic devices and more reliable methods for their adjustment. From these data it would also be possible to develop more precise and effective procedures for the evaluation of braces and artificial limbs. These procedures would replace the use of subjective ratings on performance by an amputee or a disabled person.</p> <p>The information on body segment parameters obtained by simple clinical methods can be very useful in general medical practice. It would provide a tool for the determination of:</p> <ol> <li>body segment growth and decay in normal and abnormal conditions</li><li>body segment density changes in normal and pathological cases;</li><li>body mass distribution asymmetry;</li><li>more precise body composition (fat, bones, muscles).</li></ol> <p>The aim of this article is to give a brief review of the methods used by different investigators for the determination of body segment parameters. Since some of the first treatises and papers are no longer available, we include some tables and figures which summarize the data obtained by some of the earlier researchers.</p> <p>Early Efforts</p> <p>Since ancient times there has existed an intense curiosity about the mass distribution of the human body and the relative proportions of its various segments. Those professions which had to select or classify subjects of varying body build were particularly interested in the problem. In spite of individual differences between particular subjects there are many characteristics which are common to all normal human beings. Thus the lower extremities are longer and heavier than the upper extremities, the upper arm is larger than the forearm, the thigh is larger than the shank, and other similar relationships.</p> <p>Historically this interest was first directed to the length relationships between the body segments. To characterize these relationships certain rules and canons were promulgated. Each canon has its own standard unit of measure or module. Sometimes the dimension of a body segment or component parts of a body segment were used as modules and occasionally the module was based on some abstract deduction.</p> <p>The oldest known module is the distance measured between the floor (sole) and the ankle joint. This module was used in Egypt some time around the period 3000 b.c. On this basis, the height of the human figure was set equal to 21.25 units. Several centuries later in Egypt a new module, the length of the middle finger, was introduced. In this instance body height was set equal to 19 units. This standard was in use up until the time of Cleopatra.(<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Egyptian middle finger canon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the fifth century B.C., Polyclitus, a Greek sculptor, introduced as a module the width of the palm at the base of the fingers. He established the height of the body from the sole of the foot to the top of the head as 20 units, and on this basis the face was 1/10 of the total body height, the head 1/8, and the head and neck together 1/6 of the total body height. In the first century B.C., Vitruvius, a Roman architect, in his research on body proportions found that body height was equal to the arm spread-the distance between the tips of the middle fingers with arms outstretched. The horizontal lines tangent to the apex of the head and the sole of the foot and the two vertical lines at the finger tips formed the "square of the ancients." This square was adopted by Leonardo da Vinci. He later modified the square by changing the position of the extremities and scribing a circle around the human figure.</p> <p>Diirer (1470-1528) and Zeising (1810-1876) based their canons on mathematical abstracts which were not in accordance with any actual relationships.</p> <p>At the beginning of the twentieth century, Kollmann tried to introduce a decimal standard by dividing the body height into ten equal parts. Each of these in turn could be subdivided into ten subunits. According to this standard, the head height is equal to 13 of these smaller units: seated height, 52-53; leg length, 47; and the whole arm, 44 units.(<b>Fig. 2</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Kollmann's decimal canon </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Previous Studies in Body Parameters</p> <p>Starting with the early investigators, the idea has prevailed that volumetric methods are best for determining relationships between body segments. There were basically two methods which were used for the determination of the volume of the body segments: (1) body segment immersion, and (2) segment zone measurement or component method. In these methods it is assumed that the density or specific gravity of any one body segment is homogeneous along its length. Hence the mass of the segment can be found by multiplying its volume by its density.</p> <p>Immersion Method</p> <p>Harless in Germany first used the immersion method. In 1858 he published a text book on <i>Plastic Anatomy, </i>and in 1860 a treatise, <i>The Static Moments of the Human Body Limbs. </i>In his investigations, Harless dissected five male cadavers and three female cadavers. For his final report, however, he used only the data gathered on two of the subjects.</p> <p>The immersion method involves determining how much water is displaced by the submerged segment. Previous researchers, including Harless, have relied on the measurement of the overflow of a water tank to find the volume of water displaced.</p> <p>Harless started his studies with the determination of the absolute and relative lengths of the body and its segments. The absolute lengths were measured in centimeters. For determining the relative lengths, Harless used the hand as a standard unit. The standard hand measurement was equal to the distance from the wrist joint to the tip of the middle finger of the right hand. Later Harless also used the total height of the body as a relative unit of length. In the more recent studies on body parameters, this unit is accepted as the basis for the proportions of the various segment lengths. The results of Harless' studies are shown in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For obtaining the absolute weights of the body segments, Harless used the gram as the standard. As a unit for relative weights, he first decided to use the weight of the right hand, but later established as his unit the one thousandth part of the total body weight. His results are given in <b>Table 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a very careful way Harless determined the volume and density (specific gravity) of the body segments. The results of these measurements are presented in <b>Table 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To determine the location of mass centers (centers of gravity), Harless used a well-balanced board on which the segment was moved until it was in balance. The line coincident with the fulcrum axis of the board was marked on the segment and its distance from proximal and distal joints determined. The location of the mass center was then expressed as a ratio assuming the segment length to be equal to one. Harless also tried to determine the location of segment mass center from the apex of the head by assuming that the body height is equal to 1,000. The data for one subject are shown in <b>Table 4</b>. From the table, the asymmetry of the subject becomes evident.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To visualize the mass distribution of the human body, Harless constructed the model shown in <b>Fig. 3</b>. The linear dimensions of the links of the model are proportional to the segment lengths; the volumes of the spheres are proportional to segment masses. The centers of the spheres indicate the location of mass centers (centers of gravity) of the segments.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Body mass distribution (After E. Harless). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Modified models of the mass distribution of the human body and mass center location of the segments have been made by several other investigators. It is unfortunate that up to now a unified and universally accepted subdivision of the human body into segments does not exist.</p> <p>In 1884, C. Meeh investigated the body segment volumes of ten living subjects (8 males and 2 females), ranging in age from 12 to 56 years. In order to approximate the mass of the segments, he determined the specific gravity of the whole body. This was measured during quiet respiration and was found to vary between 0.946 and 1.071 and showed no definite variation with age. The segment subdivision used by Meeh is shown in <b>Fig. 4</b> and the results of the segment volume measurements are presented in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Body Segments (After C. Meeh). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>C. Spivak, in 1915, in the United States, measured the volumes of various segments and the whole body for 15 males. He found that the value of specific gravity of the whole body ranged from 0.916 to 1.049.</p> <p>D. Zook, in 1930, made a thorough study of how body segment volume changes with age. In making this study, he used the immersion method for determining segment volumes. These were expressed in per cent of whole body volume. His sample consisted of youngsters between the ages of 5 and 19 years. His immersion technique was unique, but his claim that it permitted the direct determination of the specific gravity of any particular body segment does not seem to have been established. Some of his results are shown in <b>Fig. 5</b> and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean head volume change with age (After D. Zook). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean leg volume change with age (After D. Zook and others). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the period from 1952 to 1954, W. Dempster at the University of Michigan made a very thorough study of human body segment measurements. His investigations were based on values obtained on eight cadavers. Besides volumes, he obtained values for mass, density, location of mass center, and mass moments of inertia. The immersion method was used to determine volume. However, these data have limited application since all of Dempster's subjects were over 50 years of age (52-83) and their average weight was only 131.4 lb. The immersion method was used in Russia by Ivanitzkiy (1956) and Salzgeber (1949).</p> <p>The immersion technique can be applied for the determination of the total segment volume or any portion thereof in a step-by-step sequence. It can be applied as well on living subjects as on cadavers. In this respect it is a useful technique.</p> <p>There is some evidence that for most practical purposes the density may be considered constant along the full length of a segment. According to O. Salzgeber (1949), this problem was studied by N. Bernstein in the 1930's before he started his extensive investigations on body segment parameters. By dividing the extremities of a frozen cadaver into zones of 2 cm. height, it was established that the volume centers and mass centers of the extremities were practically coincident. It would seem therefore that the density along the segment was fairly constant for the case studied. Accepting this, it follows that the extremity mass, center of mass, and mass moment of inertia may be determined from the volume data obtained by immersion. However, it should be noted that for the whole body, according to an investigation by Ivanitzkiy (1956), the mass center does not coincide with the volume center, due to the smaller density of the trunk.</p> <h4>Computational Methods</h4> <p>Harless was the first to introduce computational methods as alternatives to the immersion method for determining body volume and mass. He suggested that this would be better for specific trunk segments since no definite marks or anatomical limits need be applied.</p> <p>He considered the upper part of the trunk down to the iliac crest as the frustum of a right circular cone. The volume (<i>V1) </i>is then determined by the formula:<b>Eq. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He assumed that the volume of the lower (abdomino-pelvic) part of the trunk (<i>V2</i>) can be approximated as a body between two parallel, nonsimilar elliptical bases with a distance <i>h </i>between them. The volume <i>V2 </i>is determined by the formula:<b>Eq. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On the basis of dimensions taken on one subject, using these formulas he arrived at a value for <i>V1 </i>of 21,000 cm cubed and 5,769 cm subed for <i>V2. </i>Using a value of 1.066 gr/cm cubed as the appropriate specific gravity of these parts, the total trunk weight was computed to be 28.515 kg. The actual weight of the trunk was determined (by weighing) to be 29.608 kg. The computed weight thus differed from the actual weight by 1.093 kg, or 3.69 per cent.</p> <p>Several subsequent investigators used this method subdividing the body into segments of equal height. For increased accuracy these zones should be as small as practically possible -a height of 2 cm is the practical lower limit. The zone markings are measured starting usually from the proximal joint of the body segment. The circumference of the zone is measured and it is assumed that the cross-section is circular. The volume may be computed and on the basis of accepted specific gravity values the mass may be found. From these values one may compute the center of mass and mass moment of inertia.</p> <p>Amar (1914) in order to compute the mass moment of inertia of various body segments made a number of assumptions. He assumed the trunk to be a cylinder, and that the extremities have the form of a frustum of a cone. The mass moment of inertia for the trunk about a lateral axis through the neck is determined from the formula:<b>Eq. 3</b><br /> and for the extremities by the formula:<b>Eq. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Weinbach (1938) proposed a modified zone method based on two assumptions: (1) that any cross-section of a human body segment is elliptical, and (2) that the specific gravity of the human body is uniform in all its segments and equal to 1.000 gr/cm cubed. The area <i>(A) </i>at any cross section is expressed by the equation:<b>Eq. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Plotting a graph showing how the equidistant cross-sectional areas change relative to their location from the proximal joint, it is possible to determine the total volume of the segment and hence its mass and location of center of mass. The mass moment of inertia (/) may be obtained by summing the products of the distances from the proximal joint to the zone center squared <i>(r squred) </i>and the corresponding zone mass:<b>Eq. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately both of Weinbach's assumptions are questionable since the cross sections of human body segments are not elliptical and the specific gravities of the different segments are not equal to 1.000 gr/cm cubed nor is density truly uniform in all segments.</p> <p>Bashkirew (1958) determined the specific gravity of the human body for the Russian population to be 1.044 gr/cm cubed with a standard deviation of ±0.0131 gr/cm cubed and the limits from 0.978 minimum to 1.109 maximum. Boyd (1933) determined further that specific gravity generally increases with age. Dempster (1955) showed that Weinbach's method was good for determining the volume of the head, neck, and trunk but not good for other body parts.</p> <p>It is evident that the determination of body segment parameters, based on the assumption that the segments can be represented by geometric solids, should not be used when great accuracy is desired. This method is useful only when an approximate value is adequate.</p> <p>Fischer introduced another approximate method of determining human body parameters by computation known as the "coefficient method." According to this procedure, it is assumed that fixed relations exist between body weight, segment length, and the segment parameters which we intend to find. There are three such relationships or ratios expressed as coefficients. For the body segment mass, the coefficient is identified as <i>C1</i> and represents the ratio of the segment mass to the total body mass. The second coefficient <i>C2 </i>is the ratio of the distance of the mass center from the proximal joint to the total length of the segment. The third coefficient <i>C3</i> is the ratio of the radius of gyration of the segment about the medio-lateral centroidal axis to the total segment length. Thus to determine the mass of a given segment for a new subject, it would be sufficient to multiply his total body mass by coefficient <i>C1 </i>corresponding segment mass. Similarly the location of mass center and radius of gyration can be determined by multiplying the segment length by the coefficients <i>C2 </i>and <i>C3</i> respectively.</p> <p><b>Table 6</b> compares the values of coefficient <i>C1</i>obtained by different investigators.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 6</b> shows that the differences between the coefficients obtained by different investigators for particular segment masses are great. The difference is highest for the trunk and head mass where the coefficients vary from 49.68 to 56.50 per cent of body mass. Next highest difference is in the thigh coefficients from 19.30 to 24.43 per cent of body mass. Since the number of subjects used in the studies, with the exception of that of Bernstein, is small and no anthropological information on body build is given, it is difficult to draw any definite conclusions about the scientific and practical value of these coefficients for body segment mass determination.</p> <p>As already mentioned, the data obtained by Harless are based on two decapitated male cadavers, and since the blood had been removed some errors are possible. The data of Meeh are based on volume measurements of eight living subjects. The large coefficient for the trunk is influenced by the assumption that all body segments have the same average density, where actually it is less for the trunk.</p> <p>Braune and Fischer (1889) made a very careful study of several cadavers. Their coefficients are based on data taken on three male cadavers whose weight and height were close to the data for the average German soldier. The relative masses (coefficients) of the segments were expressed in thousandths of the whole body mass. The positions of the mass center and radius of gyration (for determination of the segment mass moments of inertia) were expressed as proportional parts of the segment's total length. Fischer's coefficients have been accepted and used in most subsequent investigations to date.</p> <p>N. Bernstein and his co-workers (1936) at the Russian All-Union Institute of Experimental Medicine in Moscow carried out an extensive investigation on body segment parameters of living subjects. The study took care of anthropological typology of body build. The results of this investigation were published in a monograph, <i>Determination of Location of the Centers of Gravity and Mass (weight) of the Limbs of the Living Human Body </i>(in Russian). At present the monograph is not available in the United States. Excerpts of this investigation, which cover 76 male and 76 female subjects, 12 to 75 years old, were published by N. Bernstein in 1935 in his chapters on movement in the book, <i>Physiology of Work </i>(in Russian), by G. P. Konradi, A. D. Slonim, and V. C. Farfel.</p> <p><b>Table 7</b> shows data for the comparison of segment masses of living male and female subjects as established by Bernstein's investigation. The data are self-explanatory.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Determination of Mass Center Location</h4> <p>In the biomechanical analysis of movements it is necessary to know the location of the segment mass center which represents the point of application of the resultant force of gravity acting on the segment. The mass center location of a segment system such as an arm or a leg or the whole body determines the characteristics of the motion.</p> <p><b>Table 8</b> shows the relative location of the mass center for different segments. It is evident that the assumption that mass center of all segments is located 45 per cent from the proximal and 55 per cent from the distal end of the segment is not valid. Since the mass distribution of the body is related to body build it seems that the mass center location also depends on it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bernstein claims that he was able to locate the mass centers with an accuracy of ±1 mm. Hence the data of <b>Table 9</b> represent the result of very careful measurements. An analysis of these data shows that there is no definite trend of the coefficients differing with age or sex. The variance of the coefficients is very high and reaches nine per cent as maximum. Thus the use of the same coefficients for subjects with a wide range of body build is highly questionable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 7</b> and <b>Fig. 8</b> represent, in modification, Fischer's schemes for the indication of the mass center location of the extremities. The letters of the alphabet indicate the location levels of the mass centers on the human figure. The corresponding cross sections through the segments are shown separately. The letters designate the following:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Location of mass centers of the upper extremity (Redrawn from O. Fischer). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Location of mass centers of the lower extremity (Redrawn from O. Fischer). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>A</i>-mass center of upper arm</p> <p><i>B</i>-mass center of whole arm</p> <p>C-mass center of forearm</p> <p><i>D</i>-mass center of forearm and hand</p> <p><i>E</i>-mass center of hand</p> <p><i>F</i>-mass center of thigh</p> <p><i>G</i>-mass center of whole leg</p> <p><i>H</i>-mass center of shank</p> <p><i>I</i>-mass center of shank and foot <i>J</i>-mass center of foot</p> <p>The location of mass centers with respect to the proximal and distal joints as determined by W. Dempster (1955) is shown in <b>Fig. 9</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Location of mass centers of body segments (After W. Dempster). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is easy to find the equations for the determination of the coordinates of the mass center when the coordinates of the segment's proximal and distal joints are given.</p> <p>By using Fischer's coefficients for mass center of a particular segment the following formulas were developed:</p> <p>Coordinates of mass center of the:</p> <p>a. forearm:</p> <p><i>x = </i>0.42<i>xd</i> + 0.58<i>xp</i></p> <p><i>y = 0.42yd + </i>0.58<i>yp</i></p> <p>where <i>xd</i>, <i>yd </i>are coordinates of the distal (wrist) joint and <i>xp</i>, <i>yp </i>are coordinates of the proximal (elbow) joint.</p> <p>b. upper arm:</p> <p><i>x = </i>0.47<i>xd</i> + 0.53<i>xp</i> y <i>= </i>0.47<i>yd</i> + 0.53<i>xp</i></p> <p>where <i>xd, yd </i>are coordinates of the elbow joint and <i>xp, yp </i>are coordinates of the shoulder joint.</p> <p>c. shank:</p> <p><i>x = </i>0.42<i>dx</i> + 0.58<i>xpy = </i>0.42<i>yd</i> + 0.58<i>yp</i>where <i>xd, yd </i>are coordinates of the ankle</p> <p>joint and <i>xp, yp </i>are coordinates of</p> <p>the knee joint.</p> <p>d. thigh:</p> <p><i>x = </i>0.44<i>xd</i> + 0.56<i>xp</i> <i>y = </i>0.44<i>yd</i> + 0.56<i>yp</i></p> <p>where <i>xd, yd </i>are coordinates of the knee joint and <i>xp</i>, <i>yp </i>are coordinates of the hip joint.</p> <p>For the case of three-dimensional recordings of motion, similar equations for <i>z </i>are used. The coordinates of the mass center of trunk <i>(t) </i>are:</p> <p><i>xt = </i>0.235 <i>(xfr + xfl) + </i>0.265 <i>(xbr + xbl), </i>with similar equations for the <i>yt </i>and <i>zt</i> coordinates.</p> <p>Here <i>xfr </i>is the coordinate of the right hip and <i>xfl </i>is the coordinate of the left hip, and <i>xbr </i>is the coordinate of the right shoulder and <i>xbl </i>is the coordinate of the left shoulder.</p> <p>In the same manner the equations for segment systems are developed:</p> <p>a. entire arm:</p> <p>mass center <i>x </i>coordinate given by: <i>xac </i>= 0.130 <i>xgm + </i>0.148 <i>xm </i>+ 0.448 <i>xa + </i>0.27 <i>xb</i>, where</p> <p><i>xac</i>-entire arm mass center <i>x </i>coordinate <i>xgm</i>-mass center of the hand <i>xm</i>-wrist joint <i>xa</i>-elbow joint <i>xb</i>-shoulder joint</p> <p>Similar equations for <i>y </i>and <i>z </i>coordinates are used:</p> <p>b. entire leg:</p> <p>mass center <i>x </i>coordinate given by: <i>xlc = </i>0.096 <i>xgp</i>+ 0.119 <i>xp + </i>0.437 <i>xs + </i>0.348 <i>xf , </i>where</p> <p><i>xlc</i>-entire leg mass center <i>x </i>coordinate <i>xgp</i>-mass center of foot <i>xp</i>-ankle joint <i>xs</i>-knee joint <i>xf</i>-hip joint</p> <p>Similar equations are developed by the <i>y </i>and <i>z</i> coordinates.</p> <p>By analogy the formulas for coordinates determining the location of the mass center of the entire body in two or three dimensions can be developed.</p> <p>As regards the coefficient <i>C3, </i>it is known that the mass moment of inertia (<i>I</i>) is proportional to the segment's mass and to the square of the segment's radius of gyration <i>(p). </i>Fischer found that the radius of gyration for rotation about the axis through the mass center and perpendicular to the longitudinal axis of the segment can be established by multiplying the segment's length <i>(l) </i>by the coefficient <i>C3</i> = 0.3. Hence the mass moment of inertia with respect to the mass center is <i>Ig</i> = <i>mpp </i>= <i>m(0.3l)(0.31) </i>= <i>0.09ml squred.</i></p> <p>For the rotation of the segment about its longitudinal axis, Fischer found the coefficient <i>C4</i> = 0.35, so that the radius of gyration <i>p = </i>0.35 <i>d, </i>where <i>d </i>is the diameter of the segment.</p> <p>Since for living subjects the segment rotates about the proximal or distal joint and not the mass center, the mass moment of inertia that we are interested in is greater than <i>Ig </i>by the term <i>mee, </i>where <i>e </i>is the distance of mass center from the joint. It follows that the mass moment of inertia for segment rotation about the joint is equal to <i>Ij = mpp + mee = m(pp </i>+ <i>ee).</i></p> <h4>New York University Studies</h4> <p>At present the Biomechanics group of the Research Division of the School of Engineering and Science, New York University, is engaged in the determination of volume, mass, center of mass, and mass moment of inertia of living body segments. The methods employed will now be discussed. Some of these techniques are extensions of the methods used by previous researchers; others are procedures introduced by New York University.</p> <h4>Determination of Volume</h4> <p>The two methods being investigated by New York University to determine segment volumes are (1) immersion and (2) mono- and stereo-photogrammetry.</p> <p><i>Imersion Method</i></p> <p>The Biomechanics group at New York University uses water displacement as the basis for segment volume determination. However, the procedure differs from that used by previous researchers in that the subject does not submerge his segment into a full tank of water and have the overflow measured. Instead his segment is placed initially in an empty tank which is subsequently filled with water. In this way, the subject is more comfortable during the test, and the segment remains stationary to ensure the proper results.</p> <p>A variety of tanks for the various segments- hand, arm, foot, and leg-has been fabricated. It is desirable that the tank into which the segment is to be immersed be adequate for the extreme limits which may be encountered and yet not so large as to impair the accuracy of the experiments. A typical setup is shown in <b>Fig. 10</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Determination of the arm volume. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The arm is suspended into the lower tank and set in a fixed position for the duration of the test. The tank is then filled to successive predetermined levels at two-centimeter increments from the supply tank of water above. At each level, readings are taken of the height of the water in each tank, using the meter sticks shown. The volume occupied by water between any two levels is found by taking the difference between heights of water levels and applying suitable area factors. Thus to find the volume of the forearm the displacement volume is found for the wrist to elbow levels in the lower tank and between the corresponding levels in the upper tank. The difference between these two volumes is the desired forearm volume.</p> <p>To find the center of volume obtain volumes in the same manner of consecutive two-centimeter sections of the limb. Assuming the volume center of each section as one centimeter from each face, sum the products of section volume and section moment arm about the desired axis of rotation. The net volume center for the body segment is then this sum divided by the total volume of the segment. In a similar fashion, using the appropriate combination of tanks, we find the volumes of other segments, hand, foot, and leg. The use of an immersion tank to find hand volume is shown in <b>Fig. 11</b>. The data on volume and volume centers can also be used along with density as a check against methods of obtaining mass and center of mass.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Determination of the hand volume. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Photogrammetry Method</i></p> <p>In order to find the volume of an irregularly shaped body part such as the head or face a photographic method may be employed. Such a procedure, called photogrammetry, allows not only the volume to be found, but a visual picture of the surface irregularity to be recorded as well. The two types of this technique are mono- and stereophotogrammetry. The principles are the same for each, except that in the latter procedure two cameras are used side by side to give the illusion of depth when the two photographs are juxtaposed. The segment of interest is photographed and the resulting picture is treated as an aerial photograph of terrain upon which contour levels are applied. The portions of the body part between successive contour levels form segments whose volumes can be found by use of a polar planim-eter on the photograph as described by Wild (1954). By summing the segmental volumes, the total body segment volume can be found. A controlled experiment by Pierson (1959) using a basketball verified the accuracy of such a procedure. Hertzberg, Dupertuis, and Emanuel (1957) applied the technique to the measurement of the living with great success. The reliability of the photographic technique was proven by Tanner and Weiner (1949). For a more detailed discussion of the photogram-metric method, refer to the paper by Contini, Drillis, and Bluestein (1963).</p> <p><i>Method of Reaction Change</i></p> <p>In searching for a method which will determine the segment mass of a living subject with sufficient accuracy, the principle of moments or of the lever has been utilized. The use of this method was suggested by Hebestreit in a letter to Steinhausen (1926). This procedure was later used by Drillis (1959) of New York University. Essentially it consists of the determination of reaction forces of a board while the subject lies at rest on it. The board is supported by a fixed base at one end <i>(A</i>) and a very sensitive weighing scale at the other end <i>(B). </i>The location of the segment center of mass can be found by the methods described elsewhere in this paper. The segment mass is <i>m, </i>the mass of the rest of the body is <i>M. </i>The reaction force (measured on the scale) due to the board only should be subtracted from the reaction force due to the subject and board. First the reaction force <i>(S0) </i>is determined when the segment (say the arm) is in the horizontal position and rests alongside the body; second, the reaction force <i>(S) </i>is determined when the segment is flexed vertically to 90 deg. with the horizontal. The distance between the board support points <i>A </i>and <i>B </i>is constant and equal to <i>D. </i>The distance <i>(d) </i>of the segment mass center from the proximal joint is known and the distance <i>b </i>from the proximal joint to support axis <i>A </i>can be measured. From the data it is possible to write the corresponding moment equations about <i>A. </i>The solution of these equations gives the magnitude of the segment's mass as: <b>Eq. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To check the test results, the segment is placed in a middle position, approximately at an angle that is 45 deg. to the horizontal, in which it is held by a special adjustable supporting frame shown at the right in <b>Fig. 13</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Reaction board with supporting frame. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The magnitude of the segment mass in this case will be determined by the formula:<b>Eq. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By replacing the sensitive scale with an electrical pressure cell or using one force plate, it is also possible to record the changing reaction forces. If the subsequent positions of the whole arm or forearm in flexion are optically fixed as in Stick Diagrams, the corresponding changing reaction forces can be recorded by electrical oscillograph.<b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Determination of the arm mass (reaction board method). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is assumed that in flexion the elbow ioint has only one degree of freedom, <i>i.e., </i>it is uniaxial; hence the mass determination of forearm and hand is comparatively simple. The shoulder joint has several degrees of freedom and for each arm position the center of rotation changes its location so that the successive loci describe a path of the instantaneous centers. If the displacement <i>(e) </i>of the instantaneous center in the horizontal direction is known from the Slick Diagram, the magnitude of the segment mass will be: <b>Eq. 9</b>(<b>Fig. 14</b> and <b>Fig. 15</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Stick diagram of forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Stick diagram of arm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Quick Release Method</i></p> <p>This technique for the determination of segment moments of inertia is based on Newton's Law for rotation. This law states that the torque acting on a body is proportional to its angular acceleration, the proportionality constant being the mass moment of inertia. Thus if the body segment, say the arm, can be made to move at a known acceleration by a torque which can be evaluated by applying a known force at a given distance, its moment of inertia could be determined. Such a procedure is the basis for the so-called "quick release" method. To determine the mass moment of inertia of a body segment, the limb is placed so that its proximal joint does not move. At a known distance from the proximal joint at the distal end of the limb, a band with an attached cord or cable is fixed. The subject pulls the cord against a restraint of known force, such as a spring whose force can be found by measuring <i>its deflection. </i>The activating torque about the proximal joint is thus proportional to the force and the distance between the joint and the band (moment arm). The acceleration of the limb is produced by sharply cutting the cord or cable. This instantaneous acceleration may be measured by optical or electrical means and the mass moment of inertia about the proximal joint determined.</p> <p>This technique is illustrated in <b>Fig. 16</b>. The subject rotates his forearm about the elbow, thereby pulling against the spring shown at the right through a cord wrapped around a pulley. The mechanism on the platform to the right contains the cutter mechanism with an engagement switch which activates the circuit of the two accelerometers mounted on the subject's forearm. The potentiometer at the base of the spring records the force by measuring the spring's deflection. The accelerometers in tandem give the angular acceleration of the forearm and hand at the instant of cutting. A scale is used to determine the moment arm of the force. This method is further discussed by Drillis (1959).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Quick release method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Compound Pendulum Method</i></p> <p>This technique for finding both mass moment of inertia of the segment and center of mass may be used in one of two ways: (1) considering the segment as a compound pendulum and oscillating it about the proximal joint, and (2) making a casting of plaster of Paris or dental stone and swinging this casting about a fixed point.</p> <p>Using the first method, it is necessary to find the moment of inertia, the effective point of suspension of the segment, and the mass center; thus, there are three unknown quantities.</p> <p>A study by Nubar (1960) showed that these unknowns may be obtained if it is assumed that the restraining moment generated by the individual is negligible. In order to simplify the calculations, any damping moment (resulting from the skin and the ligaments at the joint) is also neglected. The segment is then allowed to oscillate, and its period, or time for a complete cycle, is measured for three cases: (1) body segment alone, (2) segment with a known weight fixed to it at a known point, (3) segment with another known weight fixed at that point. Knowing these three periods and the masses, one can find the effective point of suspension, the center of mass, and the mass moment of inertia from the three equations of motion. If the damping moment at the joint is not negligible, it may be included in the problem as a viscous moment. The above procedure is then extended by the measurement of the decrement in the succeeding oscillations.</p> <p>In the second procedure, the casting is oscillated about the fixed suspension point. The moment of inertia of the casting is found from the measurement of the period. The mass center can also be determined by oscillating the segment casting consecutively about two suspension points. This method is described in detail by Drillis <i>el al. </i>(1963). Since the weight of both the actual segment and cast replica can be found, the measured period can be corrected on the basis of the relative weights to represent the desired parameter (mass center or mass moment of inertia) of the actual segment. The setup for the determination of the period of oscillation is shown in <b>Fig. 17</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Compound pendulum method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The photograph in <b>Fig. 17</b> has been double-exposed to illustrate the plane of oscillation.</p> <p><i>Torsional Pendulum Method</i></p> <p>The torsional pendulum may be used to obtain moments of inertia of body segments and of the entire body. The pendulum is merely a platform upon which the subject is placed. Together they oscillate about a vertical axis. The platform is restrained by a torsion bar fastened to the platform at one end and to the ground at the other. Knowing the physical constants of the pendulum, <i>i.e., </i>of the supporting platform and of the spring or torsion bar, the measurement of the period gives the mass moment of inertia of the whole body. The principle of the torsional pendulum is illustrated schematically in <b>Fig. 18</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Torsional pendulum method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> and <b>Fig. 20</b> describe the setup in use. There are two platforms available: a larger one for studying the supine subject and a smaller one for obtaining data on the erect or crouching subject. In this way, the moments of inertia for both mutually perpendicular axes of the body can be found.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Body dimensions on torsion table. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Mass moment of inertia determination (squatting position). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> shows a schematic top view of the subject lying supine on the large table. Recording the period of oscillation gives the mass moment of inertia of the body about the sagittal axis for the body position indicated. Figure 20 is a side view of the small table used for the standing and crouching positions. This view shows the torsion bar in the lower center of the picture encased in the supporting structure.</p> <p>This method can also be used to find mass moments of inertia of body segments. Nubar (1962) describes the necessary procedure and equations. Basically it entails holding the rest of the body in the same position while oscillating the system for two different positions of the segment in question. Knowing the location of the segment in each of these positions, together with the periods of oscillation of the pendulum, the segment moment of inertia with respect to the mediolateral centroidal axis may be found. This technique is illustrated by the schematic Figure 19 for the case of the arm. The extended position is shown; the period would then be obtained for the case where the arm is placed down at the subject's side.</p> <p>Both the mass and center of mass of the arm can be determined using the large torsion table. The table and supine subject are rotated for three arm positions-arms at sides, arms outstretched, and arms overhead-and respective total moments of inertia are found from the three periods of oscillation. Assuming that the position of the longitudinal axis of the arm can be defined, <i>i.e., </i>the axis upon which the mass center lies can be clearly positioned, the following equations may be applied:<b>Eq. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>where <i>I1, I2, I3 </i>are the total moments of inertia of table, supports, and subject, found from the periods of oscillation, for the subject with arms at sides, outstretched, and overhead, respectively.</p> <p><i>h </i>is the distance from middle fingertip when arms are at the sides to the tip when arms are overhead.</p> <p><i>l</i> is the total arm length (fingertip to shoulder joint).</p> <p><i>g </i>is the distance from middle fingertip to the lateral center line of the table when the arms are at the sides.</p> <p><i>p </i>is the distance from middle fingertip to the lateral center line when the arms are outstretched.</p> <p><i>s</i> is the distance between the longitudinal center line of the table and the longitudinal axis of the arm when the arms are at the sides.</p> <p><i>d </i>is the distance between the mass center of the arm and the shoulder joint.</p> <p>In this case, the subject is placed so that his total body mass center coincides with the table's fixed point of rotation and there are no initial imbalances. The explanation of the above symbols may be clarified by reference to <b>Fig. 19</b>.</p> <p><i>Difficulties in Obtaining Proper Data</i></p> <p>In the commonplace technical area, where it has been necessary to evaluate the volume, mass, center of mass, etc., of an inanimate object, this object is usually one of fixed dimensions; that is, there is no involuntary movement of parts. The living human organism, on the other hand, is totally different in that none of its properties is constant for any significant period of time. There are differences in standing erect and in lying down, in inhaling and in exhaling, in closing and in opening the hand. It is necessary, therefore, to develop a procedure of measurement which can contend with these changes, and to evaluate data with particular reference to a specified orientation of the body.</p> <p>One ever-present problem in dealing with the body is the location of joints. When a segment changes its attitude with respect to adjacent segments (such as the flexion of the elbow), the joint center or center of rotation shifts its position as well. Thus, in obtaining measurements on body segments, it is necessary to specify exactly what the boundaries are. As yet there is no generally accepted method of dividing the body into segments.</p> <p>When an attempt is made to delineate the boundary between segments for purposes of experimental measurement, one cannot avoid the method of placing a mark on the subject at the joint. This mark will have to serve as the segment boundary throughout the experiment. Unfortunately an error is introduced here when the elasticity of the skin causes the mark to shift as the subject moves. This shift does not correspond to a shift in the actual joint.</p> <p>In an analysis of a particular body segment involving movement of the segment, such as the quick release, reaction, and torsional pendulum methods which have been described, one must take care to ensure that only the segment moves. Usually this involves both physical and mental preparations on the part of the subject.</p> <p>Finally, the greatest error in obtaining results on body parameters is due to variations in body build. As can be seen from the previous data brought forth, different researchers using identical techniques have gotten quite dissimilar data on the same body segment due to the use of subjects with greatly varying body types.</p> <p>In an effort to resolve this conflict, the Biomechanics group at New York University is endeavoring to relate their data on body segment parameters to a standard system of body typology.</p> <p><i>Anthropometric Studies</i></p> <p>In order to develop a means of classifying the subjects according to body build, the method of somatotyping is utilized. Here the body build is designated according to relative amounts of "endomorphy, ectomorphy, and mesomorphy" as described by W. H. Sheldon <i>et al. </i>(1940, 1954) in the classic works in the field. In order to determine the subject's somatotype, photographs are taken of three views: front, side, and back. These are illustrated in <b>Fig. 21</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Photographs for somatotyping. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Biomechanics group of New York University has obtained the services of an authority in the field, Dr. C. W. Dupertuis, to establish the somatotype of the subjects. The photographs also will be used to obtain certain body measurements.</p> <p>The aim of the study is to develop relationships between body parameters and body build or important anthropometric dimensions so that a pattern will be established enabling body parameters to be accurately found for all body types.</p> <p>If sufficient subjects are measured it should be possible to obtain a set of parameter coefficients which take into consideration the effect of the particular body type. When these coefficients are applied to some set of easily measurable body dimensions on any new subject, the appropriate body parameters could easily be determined.</p> <p>It is planned to prepare tables of these body parameter coefficients (when their validity has been established) for some future edition of <i>Artificial Limbs.</i></p> <p><b>References:</b></p> <ol> <li>Amar, J., <i>Le moteur humain, </i>Paris, 1914.</li> <li>Bashkirew, P. N., <i>Human specific gravity in the light of its practical importance to anthropology and medicine </i>(in Russian). Soviet Anthropology, 2 (2): 95-102, Moscow, 1958.</li> <li>Bernstein, N. A., O. A. Salzgeber, P. P. Pavlenko,and N. A. Gurvich, <i>Determination of location of the centers of gravity and mass of the limbs of the living human body </i>(in Russian), All-Union Institute of Experimental Medicine, Moscow, 1936.</li> <li>Boyd, E., <i>The specific gravity of the human body,</i> Human Biology, 5: 646-672, 1933</li> <li>Braune, W., and O. Fischer, <i>The center of gravity of the human body as related to the equipment of the German infantryman </i>(in German), Treat. of the Math.-Phys. Class of the Royal Acad. of Sc. of Saxony, 26: 1889.</li> <li>Contini, R., R. Drillis, and M. Bluestein, <i>Determination of body segment parameters, </i>Human Factors, 5 (5): 1963.</li> <li>Dempster, W. T., <i>Space requirements of the seated operator, </i>USAF, WADC, Tech. Rep. 55-159, Wright-Patterson Air Force Base, Ohio, 1955.</li> <li>Drillis, R., <i>The use of gliding cyclograms in the biomechanical analysis of movement, </i>Human Factors, 1 (2): 1959.</li> <li>Du Bois, J., and W. R. Santschi, <i>The determination of the moment of inertia of the living human organism, </i>paper read at the International Congress on Human Factors in Electronics, Institute of Radio Engineers, Long Beach, Calif., May 1962.</li> <li>Fischer, O., <i>Theoretical fundamentals of the mechanics of living bodies </i>(in German), Berlin, 1906.</li> <li>Harless, E., <i>Textbook of plastic anatomy, Part III </i>(in German), Stuttgart, 1858.</li> <li>Harless, E., <i>The static moments of human limbs </i>(in German), Treatises of the Math.-Phys. Class of the Royal Acad. of Sc. of Bavaria, 8: 69-96 and 257-294, 1860.</li> <li>Hertzberg, H. T., C. W. Dupertuis, and I. Emanuel, <i>Stereophotogrammetry as an anthropometric tool,</i> Photogrammetric Engineering, 24: 942-947, 1957.</li> <li>Ivanitzkiy, M. F., <i>Human anatomy </i>(in Russian); Part I, 3rd ed., Moscow, 1956.</li> <li>Meeh, C, <i>Volummessungen des menschlichen Korpers und seiner einzelner Teile in der verg-chiedenen Altersstufen, </i>Ztschr. fur Biologie, 13: 125-147, 1895.</li> <li>Nubar, Y., <i>Determination of characteristics of the compound pendulum by observing oscillations, </i>unpublished report, Research Division, College of Engineering, New York University, 1960.</li> <li>Nubar, Y., <i>Rotating platform method of determining moments of inertia of body segments, </i>unpublished report, Research Division, College of Engineering, New York University, 1962.</li> <li>Pierson, W. F., <i>The validity of stereophotogram-metry in volume determination, </i>Photogrammetric Engineering, 25: 83-85, 1959.</li> <li>Salzgeber, O. A., <i>Method of determination masses and location of mass centers of stumps </i>(in Russian), Transact. Scient. Researc Inst. of Prosthetics in Moscow, 3: Moscow, 1949.</li> <li>Sheldon, W. H., S. S. Stevens, and W. B. Tucker,<i>The varieties of human physique, </i>New York, 1940.</li> <li>Sheldon, W. H., C. W. Dupertuis, and C. McDermott, <i>Atlas of men, </i>New York, 1954.</li> <li>Steinhausen, W., <i>Mechanik d. menschlichen Korpers,</i>in Handbuch d. Normalen n. pathologischen Physiologie, 14: 1926-1927.</li> <li>Tanner, J. M., and J. S. Weiner, <i>The reliability of the photogrammetric method of anthropometry, with a description of a miniature camera technique, </i>Am. J. Phys. Anthrop., 7: 145-186, 1949.</li> <li>Weinbach, A. P., <i>Contour maps, center of gravity,moment of inertia, and surface area of the human body, </i>Human Biology, 10 (3): 356-371, 1938.</li> <li>Wild, T., <i>Simplified volume measurement with the polar planimeter, </i>Surveying and Mapping, 14: 218-222, 1954.</li> <li>Zook, D. E., <i>The physical growth of boys, </i>Am. J. Dis. Children, 1930.</li> <li>Zook, D. E., <i>A new method of studying physical growth, </i>Junior-Senior High-School Clearing House, 5: 1932.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice Bluestein, M.M.E. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini, B.S. </b></td></tr><tr><td class="clsTextSmall">Senior Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rudolfs Drillis, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Senior Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-9.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Body Segment Parameters: A Survey of Measurement Techniques Creator An entity primarily responsible for making the resource Rudolfs Drillis, Ph. D. * Renato Contini, B.S. * Maurice Bluestein, M.M.E. * https://staging.drfop.org/files/original/eadb68192d9b2fd8666172557a83275b.pdf 8628bf8a26a7358be776d63ecd50ba6b https://staging.drfop.org/files/original/683a272758a01a47d6dd619c491baf61.jpg 7ea1b0286f3578fec1cf44dd5a141b9e https://staging.drfop.org/files/original/daa86023b71672f0a988e985dd93a419.jpg 5eb13779da4b535642b8ac5e1a5c5226 https://staging.drfop.org/files/original/cac34132ec07e39e8a9063fc6f68b271.jpg 9bef4a8ac31752e52b0f209b8931e0c7 https://staging.drfop.org/files/original/407678256598a48985a5feb419cc10d5.jpg a2ec8084e42fc4e0b67846e1a2bba35a https://staging.drfop.org/files/original/c93608737f30dfd643676d669a794a64.jpg 2ed98b712bd84d285f960a725db0fcf7 https://staging.drfop.org/files/original/22027ce38ca9febc705ae68ae2d16d29.jpg d0562d55da5fc853efdff575c4b3b3a4 https://staging.drfop.org/files/original/14871e7f9a505732ae822f2edbca77f7.jpg 43818bdcb8084b609ccc5bf9c32af638 https://staging.drfop.org/files/original/ddc66f3e4c72ff82e42e8f893269b9bd.jpg 669fc27dd0a2411e77fc9fcbf0a70eff https://staging.drfop.org/files/original/0cec4ba5780fb4f35866dc6af5c54369.jpg 6aecaf5252c3c3574490ef7a65c71e61 https://staging.drfop.org/files/original/345253512930834516888667968141f5.jpg 257a926d196f4a06d609e70a91762ed0 https://staging.drfop.org/files/original/abff7786ca0707d90e783c3c76bbdd31.jpg 9a00399a1136593653b1fd885778d8b5 https://staging.drfop.org/files/original/8b502451ff1f3d43c09d55eb60739c97.jpg 5df759b91e24e21517cafeee940aaebe https://staging.drfop.org/files/original/0210b549389d0d1b7535a201fae94c59.jpg efb4ea591ef51d962f2784a5b9be02ca https://staging.drfop.org/files/original/d5875f021ebf8d742348602b3a498be5.jpg 1ff76c735ab9211f0bb7ac2323c571b0 https://staging.drfop.org/files/original/592e7093372ede7dc18e9aba9afdc43a.jpg 26778cea8e1db5412ea480d941294dd3 https://staging.drfop.org/files/original/2c4da75e6ccb1c8871d09849b20b2ccc.jpg b9e1e2ba106d0e7a9a3ffd6c9ed5d4cd https://staging.drfop.org/files/original/550140a7e8d57308f9dcee01377b0e5f.jpg e28e9978a9f3891ea1c3cc360c261c4a https://staging.drfop.org/files/original/9791acd3b4bc1ea260a21ef4f3386641.jpg 7d78e1beb99b5ec8d612e7e97a9d6982 https://staging.drfop.org/files/original/19341294a016736c920b22eb3d7c6c29.jpg 7e6bc6f995213c9adcf5f7fa316d613e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_004.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 4 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prosthetics Research and the Amputation Surgeon</h2> <h5>Rufus H. Alldredge, M.D. <a style="text-decoration:none;">*</a><br />Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Except in abnormal circumstances, man is born into his world with four mobile members which extend from his trunk like branches from a tree. These so-called "limbs" he uses in manifold complex patterns, first to serve his immediate personal needs and second to shape his own environment as best he can. Although in early life man reveals the history of the race by crawling about on all fours, he shortly assigns to two of the limbs chiefly, but not exclusively, the functions of supporting the body and of moving it from place to place. The "legs" thus become the principal weight-bearing members and the generally accepted means of locomotion.<a style="text-decoration:none;">*</a> To the more versatile "arms" man assigns most of the more complex functions of daily living and of creative activity. No doubt to this "division of labor" can largely be attributed the rather remarkable development of art and science and literature and industry and most of the other creative manifestations of human life.</p> <p>Because, however, the limbs extend from the body proper, they are particularly susceptible to damage, either from lack of nutrition and disease or by external forces of one kind or another. Since the limbs are not "vital" organs in the same sense as, say, the heart or the liver, it is possible under favorable conditions to remove one or more without loss of the whole living organism, especially since the advent of modern surgery, anesthesia, and the newer drugs and blood substitutes. That is to say, a man has a chance of living on, though a natural member be discarded. We thus have as a result of war, accident, and disease a sizable number of individuals lacking part or all of one or more limbs, and to these must be added those persons born with malformed or missing limbs. All these people, now known generally as "amputees," are obviously handicapped, to greater or lesser degree, in the performance of all those functions ordinarily carried out by the arms and legs, and in extreme cases there may be no residual function at all. To restore lost functions in as great a measure as possible has long presented a challenge to certain people, mostly, as might have been expected, to amputees themselves.</p> <h4>The Background</h4> <p>Early amputations undoubtedly were more often than not traumatic events leading to a prompt death. Occasionally, however, history records amputees who survived their bloody and painful experiences. One famous example was Hegesistratus, who, captured and chained by the Spartans, amputated his own foot in order to escape.<a></a> With the slow development, over the centuries, of surgery in general, amputations came to be performed more frequently. Typically they were desperate efforts to save life. Such works as those of Pare,<a></a> of the sixteenth century, described the techniques. In some cases, a tight tourniquet was applied and left intact until the distal portion was lost by spontaneous amputation. In others, the amputation was conducted with knife and saw, and bleeding was controlled by cauterization.</p> <p>From the beginning it seemed obvious that the amputation should be as distal as feasible in order to conserve the maximum bony lever. Many surgeons, however, preferred a disarticulation at a joint whenever that was possible. For they had found that infection was relatively unlikely to enter the bone through the normal surfaces which could be retained with disarticulation, whereas, in the days before aseptic surgery, osteomyelitis was all too common when the marrow cavity was opened by amputation through the shaft of a bone.</p> <p>Roughly a century ago the introduction of anesthetics made prolonged surgery possible, and not long after that the germ theory and antiseptic and aseptic surgery greatly increased the chances of surviving either accidental wounds or surgery. These factors made possible the comparatively long and complicated amputations now taken for granted, the revision of otherwise unsuitable stumps, and the elective amputations in cases of serious disease or deformity.</p> <p>At about the same time, wars involving European powers, and especially the American Civil War, led to large numbers of surviving amputees. Also, and again more or less simultaneously, the rapid development of heavy industry and of railroading resulted in many traumatic amputations in civilian life, especially in the United States. All these factors increased interest in amputation surgery and in limb-making for the large numbers of surviving amputees.</p> <h4>Amputation Surgery and the Art of Prosthetics</h4> <p>Artificial limbs of one kind or another date from antiquity. Particularly during the fifteenth, sixteenth, and seventeenth centuries, crudely functional artificial arms came to be made, chiefly by armorers, who were already experienced in a related field. Of many known examples, the arm and hand made about 1509 for Goetz von Berlichingen <a></a> is by far the best known (<b>Fig. 1</b>), numerous copies having been constructed for museums. In this and others of the period, joints were flexed by the other hand and locked by ratchets. Springs returned the joints when the ratchets were released by pressure on a projecting knob. In all such armorlike arms and hands, iron was used, sometimes with holes punched to reduce weight. Leather doublets or sockets, often with laces, commonly were used for several centuries.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> <p class="clsTextCaption"><br /> Fig. 1. Typical "sites of election" for amputation in the upper extremity, from well-known texts, by permission of the respective publishers. In general the sites became progressively less restricted. <i>A, </i>Recommendations of zur Verth,<a></a> as reproduced by Vasconcelos<a></a> reporting to the 3rd Brazilian and American Surgical Congress, Rio de Janeiro, November 1943. Original caption labels left drawing as representing functional values for an "intellectual," right drawing as for a "workman." Note that zur Verth favors more lever for a "working man." <i>B, </i>Recommendations of Langdale-Kelham and Perkins.<a></a> They state, ". . . but limb-makers are unable to fit a limb that allows the patient to pronate and supinate, for the circumference of the forearm changes its shape during rotation and the socket is either too tight to permit the change of shape or too loose to secure a firm hold on the stump. . . ." C, Recommendations of Kirk .<a></a> Note increasing emphasis on saving all length possible. Kirk's text suggests that wrist disarticulation is rather unsatisfactory and that few if any prostheses make use of pronation. The elbow disarticulation is tolerated but criticized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Near the end of the eighteenth century, Klingert<a></a> introduced an above-elbow arm with most of the natural motions controlled by ten catgut cords fastened to a vestlike garment and moved individually by the sound hand. Since in most cases the sound hand might better have performed the intended action, this impractical prosthesis was a classic pioneer in exceeding what some nowadays call the "hardware tolerance" of the amputee. In 1818, Peter Ballif<a></a> of Berlin developed the first voluntary control by use of trunk and shoulder muscles. His hand was of the voluntary-opening type<a></a> with springs to close the fingers and thumb. To the Dutch sculptor, Van Peeterssen, is attributed the first above-elbow prosthesis with harness control permitting voluntary flexion of the artificial elbow joint.<a></a> </p> <p>As the art of armormaking declined, limb-making on the Continent came to be carried on usually in conjunction with the making of braces, and consequently the artificial legs produced there typically evidenced steel sidebars and molded leather corsets similar to those used in braces. At the time of the Napoleonic Wars, the wooden leg, used from earliest times, was provided, for example, by Potts of London for the Marquis of Anglesey and others.<a></a> Wood reinforced by rawhide was used customarily in the United States, although a variety of other structural materials has been suggested in the journal literature and in patents.</p> <p>Comte de Beaufort<a></a> invented a number of artificial arms as well as legs, some of which were approved for French veterans of the Crimean and Italian campaigns. In 1858, he presented to the French Academy of Medicine a hand with an alternator mechanism and a double-spring hook.<a></a> Dorrance<a></a> introduced in America the well-known voluntary-opening split hook with rubber bands to close a movable finger against a rigid one. He and others rapidly produced a variety of hook shapes intended for specific trades.</p> <h4>World War I</h4> <p>World War I led to a revival of interest in amputations and in artificial limbs, notably in Germany, Belgium, and England. All these countries had rather extensive programs involving the cooperation of surgeons, limb-fitters, and engineers. Publications based on World War I experience<a></a> indicated considerable progress in understanding of amputation techniques, of the need for prompt rehabilitation of amputees, and of the importance of fit and alignment of the prosthesis. The development of many new devices and components for artificial limbs for both upper and lower extremity was described perhaps most impressively in Ersatzglieder und Arbeitshilfen.<a></a> Martin's second book <a></a>, prepared for the International Labour Office, and Little's text <a></a> were particularly useful because they offered critical analyses following impartial descriptions of prostheses and mechanisms.</p> <p>The wooden leg came to be used widely throughout the Continent as well as in England and in the United States. Aluminum, introduced by Desoutter<a></a> in England in 1912, was used particularly in England and to a lesser extent elsewhere. The fiber leg was used by a substantial number of limbmakers, particularly in the United States. Despite the large number of knee locks and ankle joints permitting lateral motion, described in patents and in medical and technical literature, most above-knee amputees used a simple uniaxial hinge for the knee joint and a single-axis ankle joint. Rubber bumpers were used widely in place of the tendons popular in the nineteenth century. It is interesting to note that in 1922 Little remarked<a></a> that most leg amputees had to use at least one stick.</p> <p>For the upper extremity, a great many artificial arms, hands, and working tools were developed during World War I, as can be seen from the major books on prostheses of the period .<a></a> American designers generally used the split mechanical hook closed by rubber bands and separated from the forearm by a rubber washer which provided stability by friction but which at the same time permitted pronation-supination by means of the other hand. Europeans generally preferred passively operated clamps and special tools so designed as to be interchangeable by a disconnect at the wrist. Either a clamp, as on a machine tool, or a locking bolt engaging any one of a series of holes in a disc was used to fasten the tool in the selected position of pronation or supination. For working purposes, the attachment for the tool was often placed at the end of the socket, far above the normal hand level, so as to decrease the leverage of the load on the stump. For dress wear, a cosmetic forearm and terminal device could be attached in place of the tool.</p> <p>Various wooden hands, usually with spring-loaded or voluntarily controlled thumbs, were shown in the literature of many countries. Generally, it was assumed that such hands were for dress and for light office use only, either bare or covered with a leather or fabric glove. Often the fingers were curved permanently to carry a briefcase. The Carnes arms and hands,<a></a> patented in 1912, 1922, and subsequently, were widely sold in the United States for many years. During World War I they were widely admired abroad and were described in detail by Schlesinger<a></a> and to a lesser extent by Martin<a></a> and by Little.<a></a> </p> <p>Similar devices, under the general name "Germania," were built in Germany after entrance of the United States into hostilities. Most authors admired the dexterity achieved by the Carnes devices-particularly because of their ingenious construction, the passively adjustable wrist flexion, and the possibility of coordinating supination with elbow flexion to assist in eating-but criticism was leveled at complexity, relatively heavy weight, lost motion, and the restriction against interchange of a hook for the hand.</p> <h4>World War II</h4> <p>Surgical authorities during World War II advocated<a></a> typical "sites of election" <b>Fig. 1</b> and <b>Fig. 2</b>) based upon the extensive practical experience of the surgeons as well as on the advice of many of the more active limb-fitters, who were notably successful in fitting good stumps at these "sites of election" but who had encountered serious difficulty in fitting such stumps as the wrist disarticulation, the very short below-elbow stump, the knee disarticulation, or the Syme stump. Typical prostheses for the so-called "sites of election" are shown in <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical "sites of election" for amputation in the lower extremity, from well-known texts, by permission of the respective publishers. <i>A</i>, Recommendations of Langdale-Kelham and Perkins.<a></a> These authors condemn the Syme. <i>B, </i>Recommendations of Kirk <i>. </i><a></a> Although Kirk does not show a Syme, he agrees with the Canadians that a properly fitted Syme's amputation is ideal for the "laboring man." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Typical prosthesis for amputation below the elbow, made about 1945-47. Note modled leather socket, steel sidebars and single-axis joints permitting elbow flexion only, full upper-arm cuff with two straps, heavy leather shoulder saddle and webbing cheststrap, and double leather thong passing over pulleys at the elbow joint to open the voluntary-opening hook. Rubber bands closed the hook and determined the gripping force. Changing the number of rubber bands to vary the gripping force was possible but inconvenient. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans A administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Conventional prosthesis for amputation above the elbow, made about 1945-47. Note the molded leather socket (with the unusual rear opening and laces), wooden elbow shell and forearm, and push button projecting from lower surface of forearm to control elbow locking by pressure on table top through the sleeve or by use of the opposite hand. Such elbows provided a maximum of five locking positions. A relatively complex harness of cotton webbing supported the prosthesis on the stump and controlled a helically wound rawhide thong sliding through short lengths of stiff housing rigidly mounted above and below the elbow. Tension in the thong flexed the elbow when it was unlocked. When the elbow was locked, tension was transmitted to close the hand, which could be locked by means of the button projecting from the volar portion near the wrist. A desirable disconnect in the thong and a screw thread at the wrist permitted substitution of a hook for the hand. The harnessing pattern for a given level of amputation varied markedly among different limb-makers. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Conventional wooden prosthesis for amputation below the knee, made about 1947. Note the usual leather thigh corset, leather thong or lace, leather back-check to prevent hyperextension of the knee, single-axis mechanical knee and ankle joints, and wooden toe fastened to wooden foot by a belting hinge. Usually a webbing waist belt was connected by an elastic strap to an inverted Y-strap straddling the patella and attaching near the front brim of the shank to help suspend the prosthesis and to extend the knee. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Conventional wooden prosthesis for amputation above the knee, made about 1947. Note reinforced pelvic band and single-axis hip, knee, and ankle joints. Elastic straps from front and rear of pelvic band are joined by a leather strap passing under a roller ahead of the knee bolt so as to extend the knee from a flexed position. In other prostheses of the same type, refinements of workmanship included inlaying the hip joint into the wood and reinforcing it with rawhide, covering the metal pelvic-band reinforcement with leather, and providing a continuous leather-covered sponge-rubber layer on the sole of the foot. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It will be noted, for example, that all levels of forearm amputation, from the wrist disarticulation to the short below-elbow, were fitted with the same type of forearm composed of a molded leather socket, usually laced, extending into a cosmetic shell and reinforced by volar and dorsal metal sidebars which formed a crosspiece at the wrist supporting a screw thread or bayonet-type attachment for the hook or artificial hand. Typically, the terminal device could be rotated passively by the opposite hand against the friction of a rubber washer but could not be pronated or supinated actively. The metal sidebars were hinged in line with the humeral epicondyles to permit elbow flexion in relation to a buckled or laced cuff about the upper arm. Usually the terminal device was operated by a leather thong which passed over a pulley or through a short length of helical wire housing at the elbow joint so as to be independent of elbow flexion. Since the prosthesis did not provide for pronation-supination, whatever of this function was originally available in a stump amputated at the "site of election" soon disappeared owing to muscular atrophy.</p> <p>The elbow lock for above-elbow arms generally was operated, in the case of a unilateral amputee, by the opposite hand, or, in the bilateral arm amputee, by pressure against the body or against a table. It usually consisted of a sliding bolt engaging one of three or four holes in a metal strap surrounding the carved wooden elbow portion below the molded leather or fiber humeral socket. Cotton webbing and rather heavy leather shoulder saddles were commonly used in the arm harness, and leather thongs transmitted forces to flex the elbow and to operate the terminal device.</p> <p>During the period of World War II, the typical unilateral leg amputee in the United States, including many hip-disarticulation cases, walked without the aid of a cane, although the above-knee amputee usually walked with the relatively fixed cadence for which the fixed friction about the knee bolt was adjusted. Any attempt to walk faster or slower led to excessive heel rise or to a tendency to drag the toe. The below-knee artificial leg was often carved from a wooden block by trial-and-error fitting. Alternatively, a leather socket, molded over a modified plaster replica of the stump, was inserted into a fiber, metal, or occasionally a wooden shank. Sometimes, in an effort to increase conformity to the stump, a certain degree of softness or of ability to flow plastically was imparted by a thin lining of felt, wax, or relatively pliable leather.</p> <p>The above-knee leg was occasionally held to the body by suspenders, but by 1945 a large percentage of above-knee amputees used a pelvic band and metal hip joint. Usually the hip joint permitted the leg to swing in one plane only, although in some designs an additional axis permitted abduction and adduction. In England, and rarely in the United States, a third axis, substantially vertical, also permitted a limited amount of rotation, although about an axis outside the body several inches from the ball and socket of the natural hip joint.</p> <h4>Era of Antobacterial Techniques</h4> <p>During World War II, blood, plasma, and antibiotics came to be used widely to increase the chances of survival at the time of injury as well as to permit more extensive surgery. The Surgeon General of the U.S. Army ordered open amputation exclusively, to be followed by skin traction until a revision operation could be performed. This flat order unquestionably reduced the incidence of infection and gangrene<a></a> from combat injuries to U.S. Servicemen in World War II, as compared to experience in previous wars or to the experience of certain other military forces. It undoubtedly led also to the conservation of many stumps which, under other circumstances, would have been reamputated at the "site of election" above the next joint in order to avoid rapid spread of infection and gangrene. According to Veterans Administration records, for example, the U.S. forces had over two thirds of their lower-extremity amputations below the knee, whereas during the American Civil War and among the Filipino Scouts and guerrillas<a></a> and the Yugoslavian guerrillas<a></a> in World War II, it was estimated that at least half of all lower-extremity amputations were above the knee. Little, <a></a> in a sample of 1030 amputations among the English forces in World War I, found only 219 "leg" (below-knee) and 441 "thigh" (above-knee) stumps in a total of 723 lower-extremity amputations.</p> <p>On the other hand, there is no question that the order for open amputation, followed by traction and a second, or revision, operation, led to prolonged hospitalization for some cases which safely could have been performed primarily as closed amputations, particularly as antibiotics became available late in World War II. Furthermore, many of these "military" amputations, performed as they were far behind the lines, were really essentially civilian in nature. It seems very questionable that there would be a need for performing as many open amputations in civilian practice where risk of infection and gas gangrene is relatively low. The surgeon has a responsibility to use open amputation and traction when there is a clear risk, yet to consider prudently the much shorter care which will be needed with a primary closed amputation when it is feasible medically.</p> <h4>New Concepts in Rehabilitation</h4> <p>The large military amputation centers in World War II provided an excellent opportunity to study the entire problem of amputee rehabilitation.<a></a> Although civilian surgeons generally had been in the habit of dismissing the patient when the amputation scar had healed, leaving him to search for limbfitting services with only the guidance of the classified telephone directory and the perplexing visits of amputee salesmen and demonstrators, the military Services reawakened the responsibility of the surgeon for more complete rehabilitation through the stages of prosthetic fitting, training, and subsequent follow-up. Similarly, the Services assumed responsibility for the necessary vocational guidance and counseling.</p> <h4>Wartime Problems</h4> <p>Because of the dramatic concentration of hundreds of amputees in a single hospital, however, the large military amputation centers drew considerable public attention-both favorable and unfavorable and generally over-dramatic. In operating their limbshops, they encountered difficulties because of the scarcity of experienced personnel (P). This problem was partially corrected, though never completely solved, by diligent effort to locate limbfitters who had been drafted and to see that they were reassigned to limbshops at amputation centers. In every case, however, the bulk of the limb-shop staff was necessarily made up of men who perhaps had mechanical aptitude but who were without previous training or experience in the limb industry.</p> <p>At the same lime the commercial artificial-limb industry was kept very busy with its private cases from civilian life and with the veterans from previous wars, while some of its younger men were drafted into the Services. Besides this, the generally good business conditions during and immediately following World War II, together with the manpower shortage, led to the employment or advancement of a great many amputees who, during the previous depression, had had great difficulty in finding and holding jobs. Many of these people wished to procure new limbs, thus further overloading the commercial limb industry.</p> <p>To add to the difficulties, the industry was then neither certified nor licensed, and it consisted, as it does today, of several hundred relatively small workshops. While some of its members had had formal education in other fields, there had never existed in this country any means for formal training in the arts and sciences basic to limbmaking and limbfitting. The sudden release, within a limited number of months, of some 21,000 veterans from military amputation centers imposed upon the industry an exceptional burden. These men had been fitted in the military centers with a serviceable, adequate, but admittedly "temporary" prosthesis, with the understanding that soon after their release the Veterans Administration, through civilian contractors, would provide a permanent prosthesis. Indeed, an additional or spare permanent prosthesis also was provided as a matter of policy.</p> <p>The confused state of affairs about the end of World War II, and during the year or so immediately thereafter, was further complicated by a series of sensational stories in some of the newspapers concerning difficulties with the limbs provided by the military centers and covering a series of indictments and trials of certain members of the commercial limb industry for alleged violation of the Antitrust Acts. The rather emotional atmosphere then prevailing in regard to amputees led to dramatic stories but in many cases to neglect of the basic difficulties.</p> <h4>Casualities From Korea</h4> <p>Substantially all factors concerned have since been greatly improved, so much so in fact that there were no difficulties of this type over the treatment of amputees returning from the Korean conflict. The relatively calm and orderly handling of these casualties, with the close cooperation of all concerned, was a tribute to the progress which had been made since 1945 in both technical and administrative aspects. Much of this change has been due to the fine cooperation of the commercial limb industry, now emerging into a prosthetics profession. It also has been influenced by the greater interest of surgeons in amputations and amputee rehabilitation, by the development of the team concept in this area as in so many other areas of medicine (and indeed in science generally), by the contributions of many sound administrators, and by the results of much hard work in the research and development laboratories.</p> <p>Some of the major changes which have influenced the amputation surgeon have been proven clinically by experience with casualties from Korea. Concepts of level of amputation and certain of the techniques of surgery have been affected. Perhaps most important, there is now a greater interest in postoperative care and in the rehabilitation responsibilities of the medical profession.</p> <h4>Level of Amputation and Modern Prosthetic Replacement</h4> <p>The surgeon's first decision in amputating is the selection of the site. Perhaps the influence of the Artificial Limb Program, sponsored by the Government and coordinated by the Committee on Artificial Limbs of the National Research Council, can be shown most dramatically by a review of the changes in recommended level. From a few definite "sites of election," the development of new principles and devices has made possible reaffirmation of the policy<a></a> of "save all possible length." Every level, with the possible exception of the below-knee amputation, has benefited, particularly in the upper extremity, where it is now possible to define at least nine amputee types (<b>Fig. 7</b>), all of which can be fitted successfully. In many cases the new devices not only permit satisfactory fitting of longer stumps but often replace additional functions beyond the important increase in bony lever.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Definitions of upper-extremity amputee types. Lengths above elbow are measured as percentages of distance from acromion to epicondyles; lengths below elbow are measured as percentages of distance from epi-condyles to styloid. From <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <h4><i>The Below-Elbow Cases</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br /> The wrist-disarticulation prosthesis is a good example of the development of a simpler appliance which yet permits better appearance and additional function than did the conventional prosthesis of 1945. At the end of World War II, the wrist disarticulation, if retained at all and not later reamputated at a higher level, was fitted with a laced, molded leather socket supported by steel sidebars jointed at the elbow, quite similar to that shown in <b>Fig. 3</b>, with rather bulky harness and a leather thong for power transmission. Elbow flexion and terminal-device operation were the only functions provided, pronation-supination being prohibited by the single plane in which the elbow hinge operated. The entire appliance was bulky, the uncoated leather soon absorbed perspiration and became objectionable, and the almost complete encasing of the forearm made the prosthesis uncomfortable in warm weather. Because of the screw thread attaching it to the wrist, the terminal device, whether hook or mechanical hand, projected appreciably beyond the opposite natural hand, resulting both in limited function and in undesirable appearance. No cosmetic covering faired the gap between the mechanical hand and the wrist.</p> <p>In contrast, there has been developed under the program of the Advisory Committee on Artificial Limbs a light and sanitary plastic-laminate prosthesis (<b>Fig. 8</b>) which covers only the distal portion of the stump and extends only a short distance up the radial side to support tipping loads while still permitting pronation and supination. <a></a> Extending farther up the ulnar aspect, the socket provides adequate leverage and bearing area to permit comfortable resistance to large loads on the terminal device which tend to tip the socket about the stump when the forearm is in the horizontal position. The snug, "screw-driver" fit of the bony prominences at the wrist into the terminal portion ensures rotation of the socket and terminal device as the radius glides around the ulna. Since this rotation decreases progressively up the forearm until, at the elbow, there is no relative displacement, it is necessary to cut away as much as possible of the radial aspect from the socket. But removal of socket material decreases both the weight of the prosthesis and discomfort in warm weather. The plastic-laminate socket and nylon coating of any leather<a></a> used in this or any other prosthetic or orthopedic appliance will prevent absorption of perspiration and the consequent development of odors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Cutaway views of light and simple plastic prosthesis for wrist disarticulation, with APRL hand attached to plate embedded in end of forearm to conserve length. The plastic cosmetic glove drapes neatly over the junction. A separate socket similarly attached to a hook (as in Figure 9) is easily substituted to avoid disconnecting the terminal device, as is customary in the usual forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very simple harness is adequate. For the rare amputee requiring only an extremely light-duty prosthesis, the socket can be held on the bulbous stump by a strap like that for a wrist watch to close a keyhole slot so as to clamp the socket firmly just above the bulging styloids. In this case, the only harness necessary is the cable and loop about the opposite shoulder. Practically all amputees, however, require a somewhat more secure, yet still minimum harness, as shown in <b>Fig. 9</b>, with a light triceps pad held by an inverted Y-strap whose fork is higher than the fully tensed biceps. A very simple figure-eight harness is used, and the steel Bowden cable transmits energy quite efficiently without stretching and without catching the shirt sleeve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Prosthesis and harness for wrist disarticulation or long below-elbow stump. Note simple figure-eight webbing entirely across back, with no cheststraps. A steel Bowden cable transmits energy to the hook with improved efficiency. An open upper-arm harness, consisting of triceps pad and inverted Y-strap, leaves biceps free from pressure. Flexible leather straps as elbow hinges, suggested years ago but seldom used, permit pronation and supination as well as elbow flexion. The APRL hook case may be laminated into the forearm to conserve length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To shorten the prosthesis markedly in order to match the length of the opposite arm, the proximal wall of the APRL No. 4C hand<a></a> may be fastened to a plate built into the distal wall of the plastic-laminate socket, as shown in <b>Fig. 8</b>. Thus the plastic cosmetic glove can readily bridge the gap between the hand and the prosthesis and extend up under the shirt or coat sleeve of the wearer. A similar plan can be followed with the APRL hook<a></a> by removal of the stainless-steel stud and plate by which the hook case is normally fastened to the wrist disconnect. On other types of hooks, the stainless-steel stud can be removed or shortened and a suitable fastening plate added by welding or brazing. For wrist friction, thin rubber 0-rings may sometimes be used instead of thicker rubber washers, thus further decreasing length.</p> <p>In many cases, it has been found entirely feasible, both technically and economically, to supply two sockets, one laminated to a hand and the other to a hook, to be worn interchangeably. The added length due to a conventional wrist disconnect and stud is thus avoided. Snap fasteners between the flexible leather elbow hinges and the forearm socket, plus the disconnect feature of the control-cable attachment post, permit interchange of prosthesis without changing the harness. Thus the amputee can make the interchange from hand to hook simply by rolling up his sleeve, it being unnecessary for him to remove his shirt.</p> <p><i>The Long Below-Elbow Case. </i><br />In many shorter below-elbow stumps, a similar type of prosthesis, but without the bulges for the styloids, can be applied to permit the amputee to use his remaining pronation and supination. The key factors are flexible elbow hinges and the "screw-driver" fit of the end portion of the stump in the socket with increasingly loose fit proximally. The fact that pronation and supination may be retained encourages the surgeon to make every effort to avoid fusion of the radius and ulna owing to bone spurs or similar causes and to instruct the amputee to participate in physical therapy designed to redevelop muscular control.</p> <p><i>The Medium Below-Elbow Case. </i><br />In the medium below-elbow stump, the limited amount of pronation and supination is worth retaining, yet it is inadequate to permit direct control of the prosthesis. Accordingly, the step-up type of rotation device (<b>Fig. 10</b>) has been developed. Early attempts at an automatic lock were frequently disappointing, particularly if the amputee tended to snap the prosthesis when used with a wrist-flexion unit, because the high inertia forces jammed the locking surfaces and caused permanent dents which thereafter caused chattering or even failure to lock. Instead, a simple lock has been supplied on an experimental basis, some mechanical problems remaining to be solved. A simple bolt in the stabilized outer socket engages one of a series of holes in the rotating portion of the wrist whenever the elbow is flexed more than a few degrees but is withdrawn at maximum elbow extension (<b>Fig. 10</b>, detail). This device is particularly desirable even with a short, almost conical below-elbow stump which, with elbow extended, participates in humeral rotation from the shoulder. The entire extremity rotates within the triceps pad and outer socket, which are stabilized by the harness. With the socket and terminal device rotated to the desired position, the amputee returns his stump to its normal position with the elbow axis parallel to the mechanical elbow hinges, flexes the stump, and thus locks the wrist in the desired position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. APRL-Sierra wrist-rotation step-up unit showing details of locking mechanism and of hinges used in control of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In such applications, step-up gears are normally provided to increase the rotation of the terminal device in relation to that of the socket. A lock is desirable partially to transmit torsional loads on the terminal device through the elbow hinges to the open humeral cuff, but it is particularly desirable with outside Bowden-cable control of the terminal device to permit the torsional component of tension in the cable, when it spirals about the forearm, to be transmitted to the upper arm without stress upon the stump. The mechanical advantage of torque at the terminal device or control cable over the stump is due, of course, to the step-up gearing used to increase rotation of the terminal device.</p> <p><i>The Short Below-Elbow Case. </i><br />For rather short below-elbow amputations, a geared poly-centric hinge (<b>Fig. 11</b>) has been developed. In some cases, it permits easier fitting of the socket and may hold the socket more firmly on the stump. For still shorter stumps, the socket may be attached to the link connecting the two axes of rotation, while the forearm is attached to the lower geared segment (<b>Fig. 12</b>), thus providing a <i>fixed </i>ratio of 2:1 between degree of flexion of the artificial forearm and degree of flexion of the below-elbow stump and socket. It has been found, however, that this fixed ratio has only limited application.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer PC-100 polycentric hinge, particularly suited for medium to short below-elbow stumps. By virtue of the mechanical linkage, it sometimes aids in permitting extreme flexion in cases where the stump retains a full range of motion so that step-up hinges are unnecessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Geared step-up hinge (Hosmer MA-100) for very short below-elbow stumps of limited range of motion. The stump socket is fastened to the center link connecting the two geared links, which in turn are fastened to the upper-arm cuff and the forearm shell. The ratio of flexion of the forearm shell to that of the short stump is thus 2:1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The short below-elbow stump is another example of the new principle of saving all possible length. Formerly, most surgeons and limbmakers would have agreed that such short below-elbow stumps could not be fitted satisfactorily. Such a stump tends to slip out of the conventional socket and also may exhibit no useful control of the elbow joint. Frequently, it was advised that such cases be reamputated at the "site of election" in the humerus. Late in World War II, however, both in Canada and in at least one U.S. Army amputation center, hinges were developed, similar to those shown in <b>Fig. 13</b>, which permitted a step-up of forearm movement as compared to stump movement, a <i>variable </i>ratio compensating roughly for the resistance encountered and the strength of the stump at various positions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As seen in <b>Fig. 14</b>, the short below elbow, biceps are feasible.<a style="text-decoration:none;">*</a> Since there is no appreciable pronation-supination at this level, the biceps tendon remains in a fixed position rather than tending to migrate from medial toward lateral as it does when a longer stump moves from pronation to supination. The posterior rim of the socket is carried as high as possible, substantially to the olecranon. In some cases it is possible to hook the socket brim over the olecranon to help pull the stump into the socket during flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Prosthesis with variable-ratio step-up hinges for short below-elbow stumps. An above-elbow type of cable control assists in flexing the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The middle pivot of the step-up hinges is substantially opposite the humeral epicondyles, which define the anatomical elbow axis. The lower hinge moves in its slot during elbow flexion, as indicated in <b>Fig. 13</b>. The lower proximal end of the forearm shell must be cut out in order to clear the short stump at extreme elbow flexion. But since this type is used on short below-elbow stumps, there is no serious protrusion of the stump beyond the general line of the forearm socket and, therefore, no appreciable bulge in the coat sleeve.</p> <p>Customarily, an auxiliary lift for the forearm is provided by an above-elbow type of harness, with two separate pieces of cable housing attached to the forearm and to the triceps cuff but bare cable running from a space between the two separated pieces of housing, as shown in <b>Fig. 14</b>. By voluntarily controlling the position of the stump, the amputee can effectively "lock" the forearm as if by a mechanical elbow lock and can thus operate the terminal device by increased tension on the control cable without causing further flexion of the forearm. By means of stump action, he also can press downward firmly enough on the forearm to perform functions such as holding papers on a table or holding a fork to stabilize a piece of meat while it is cut by a knife held in the opposite hand.</p> <p><i>The Elbow-Disarticulation Case</i><br /> The elbow disarticulation was for many years frowned upon because of the difficulties of fitting it with a conventional prosthesis with laced molded-leather socket and elbow lock and joint requiring a bolt extending the full width of the elbow. In such a design, of course, the mechanical lock was necessarily fitted below the end of the stump, thus making an overly long humeral section and a correspondingly short forearm section, usually preventing the amputee from reaching his mouth with the terminal device, as well as creating an awkward appearance and difficulty in using the amputated elbow as a support on the desk top, and the like. Capable of end-weight-bearing, the elbow-disarticulation stump, however, is useful as a support without the prosthesis, as in rolling over in bed. Its bulbous and irregular shape serves as a key to stabilize the prosthesis against rotation about the long axis of the humerus.</p> <p>To conserve these functions, therefore, the external lock shown in <b>Fig. 15</b> and <b>Fig. 16</b> was developed to fit on the <i>outside </i>of the socket in line with the humeral epicondyles and the anatomical axis. The artificial forearm can thus be of a conventional length, and the terminal device can be brought to the mouth readily. The locking circle is, however, necessarily of a smaller diameter than would be available in a conventional above-elbow type of prosthesis, so that in the present model the number of locking positions is reduced to five (<b>Fig. 16</b>). Although numbering more than in the earlier conventional above-elbow or brace locks, the five positions are less than the 11 or even infinite number of positions provided by above-elbow locks which have been developed in the ACAL research program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Prosthesis for elbow disarticulation, with APRL-Sierra external elbow lock (Figure 16) and same dual control as used on above-elbow prostheses. To accommodate bulbous humeral condyles, a channel may be left in the socket, a lacer may be used, or a slotted, flexible, plastic-laminate socket and clamping strap may be loosened and expanded enough to permit entry and withdrawal and yet provide adequate control during use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematic diagram of APRL-Sierra external elbow lock, intended for elbow disarticulation but also useful with very short below-elbow stumps or with paralyzed arms. Top, locked position. Next pull on lock-operating cable in upper right withdraws locking plunger from the wedge-shaped notch in forearm piece and raises the alternator crosshead, thereby compressing the two helical springs. Pin on the thin leaf spring follows right side of inverted heart-shaped cam until it slips into notch at bottom of cam. Relaxing cable drops the alternator cross-head slightly until the pin and leaf spring hold the cam and locking plunger in the unlocked position (middle). Subsequent tension on the cable raises the alternator crosshead enough so that the leaf spring can straighten until its pin follows the left side of the heart-shaped cam back to original position. Meanwhile the helical springs force the crosshead down and push the locking plunger into a tooth in the lower portion attached to the forearm (bottom). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The APRL-Sierra outside-locking elbow hinge has another special application in the very short below-elbow stump where range of motion is insufficient to operate a forearm through a step-up elbow hinge but where a small residual motion is adequate to operate the locking mechanism diagrammed in <b>Fig. 16</b>. In the arrangement shown in <b>Fig. 17</b>, elbow locking is effected by stump motion rather than by motion of the shoulder, thus giving a more natural appearance and more freedom than could be obtained with an elbow disarticulation or an above-elbow stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Prosthesis for very short below-elbow stumps of such limited motion that step-up hinges are inadequate. The external elbow lock is controlled by a convenient cam, lever, or cable system triggered by the limited stump motion, and the forearm shell is flexed by an above-elbow type of harness. By this system the elbow lock is more easily operated than in a conventional above-elbow type of control. The Northrop-Sierra voluntary-opening two-load hook <a></a>shown here is usually considered to be a left hook, that is, as used on a right arm the operating lever is in the little-finger position rather than in the thumb position. This arrangement results in <i>a. </i>more nearly straight control cable of higher efficiency than is possible when the operating lever is on the medial side, in which case the cable must spiral over the forearm. More often, particularly in the case of bilateral arm amputees, voluntary-opening hooks are fitted with the operating lever, and also the control button for changing the load, located on the medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The external elbow lock has already been used occasionally for applying artificial-arm principles to arm braces. The situation in that entire field should improve rapidly in the near future. Occasionally, patients have requested, or surgeons have recommended, amputation of an arm when disease or injury have left a flail elbow. It has seemed that improved artificial arms would actually provide the patient with more function. It must be remembered, however, that the damaged arm provides at least some support and perhaps sensation, and consequently every effort should be made to replace the lost functions of stability, control, and voluntary movement by suitable bracing. Polio cases, retaining sensation and an erratic distribution of muscle activity, offer a special challenge.</p> <p>The outside-locking hinge of <b>Fig. 16</b> is normally fitted as shown in <b>Fig. 15</b> and <b>Fig. 17</b> for control from the proximal joint. Presumably, though, it could be inverted and controlled from the distal end of the arm if some portion capable of even a little voluntarily controlled movement with very nominal forces were available in the hand or wrist. A ring on a finger or extreme hyperextension of the wrist could, for example, be used to trigger the elbow lock, thus simplifying the harnessing, particularly if the shoulder were also weakened.</p> <p>It may be noted parenthetically that some work has been done<a></a> both by rehabilitation centers and by prosthetists and orthotists to drive paralyzed fingers with mechanisms adapted from the artificial-hand field or to hyperextend a paralyzed hand on a "cock-up" wrist splint and substitute a hook on a rotary or even on a ball-and-socket mounting on the volar aspect of the wrist. Even with a quadriplegic there has been enough control of shoulder movement to provide the necessary voluntary control for the hook, supplementing at least a weak biceps action for forearm flexion and supination. The relatively heavy hook extending from the volar aspect of the wrist will provide by gravity forearm extension and a tendency toward pronation. Since the degree of paralysis and of loss of sensation may be so variable, in the entire field of arm bracing the role of the doctor is even more important than it is in rehabilitation after amputation. Correspondingly, there is an even greater challenge to the ingenuity of the prosthetist, the engineer specializing in prosthetics, and the manufacturer in adapting or developing special appliances for the individual case and to the patience of the therapist in redeveloping even faint voluntary movements which might control triggers for locking mechanisms.</p> <h4><i>The Above-Elbow Cases</i></h4> <p>In the above-elbow stump, as much as possible should be saved consistent with the nature of the injury or disease. Even a very short above-elbow stump may be useful as an anchor point, and in experimental work on electric arms<a></a> such a stump has been used to control the necessary switches and clutches (<b>Fig. 18</b>). A stump of nothing more than the head of the humerus helps to round out the shoulder and to provide a much more secure stabilization of the "shoulder-disarticulation" socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Shoulder cap for electric control by shoulder motion or by short humeral stump or both. From Alderson .<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Nevertheless there remains a challenge to the engineer and prosthetist in providing improved shoulder-disarticulation and very high-above-elbow arms with passive or voluntarily controlled humeral flexion and abduction. A number of designs were shown in the literature<a></a> after World War I, but none appears to have been practical. The sectional plates<a></a> used in the ACAL research program have facilitated independent construction of the socket and remainder of the prosthesis and their subsequent alignment. Sometimes they have been provided with rotation to facilitate donning of clothing with the humeral section flexed, followed by return of the humerus to a vertical position. Such joints of the humeral section to the shoulder cap have not permitted abduction, however, and have not normally permitted voluntary or passive forward flexion of the humeral section about the shoulder joint to bring the elbow forward and permit the terminal device to reach the mouth.</p> <p>The conventional sectional plates have been solid and thus have been suited only for a true shoulder disarticulation, but it should be feasible to leave an opening through which a very short stump, such as the head of the humerus and its surrounding socket, could protrude into the hollow humeral section. Provision of a sector of a complete circular track, rather than the elongated D-shape which has been used, would also result in better cosmetic appearance when the artificial humeral section is flexed forward. Possibly a simple lock to stabilize such humeral flexion could be controlled by a very short above-elbow stump, even if passive adjustment with the other hand, or by gravity in connection with torso movement, were necessary because of the weakness of the stump.</p> <p>Attempts to provide voluntary control of humeral abduction and rotation have been reported in the literature. Alderson <a></a> developed an experimental arm of the shoulder-disarticulation type in which shoulder lift against the anchorage of a groin strap generated either elbow flexion followed by humeral abduction or humeral abduction alone, depending on whether the elbow were free or locked. At least one commercial limb manufacturer recently has experimented with a "universal shoulder joint" permitting a combination of actively and passively controlled motions including upper-arm rotation by means of a turntable located in the humeral section.</p> <h4>The Lower Extremity</h4> <p>In the lower extremity, although there have been definite changes in techniques and devices, the influence of the Artificial Limb Program has not as yet markedly changed the levels of amputation. Work is, however, going forward rapidly, particularly at the Lower-Extremity Clinical Study operated at the University of California using facilities of the U.S. Naval Hospital at Oakland. It is to be expected that in the next few years more definite changes can be recommended.<a></a> Meanwhile, the principal effects of wartime experience and of the ACAL research program have been increased emphasis on the Syme and knee disarticulation and a better understanding of muscle functions, particularly in relation to the suction socket for above-knee amputees.</p> <h4><i>The Below-Knee Cases</i></h4> <p><i>The Syme Amputation. </i><br />While the Syme amputation is more than a century old, it has until recently been considered controversial, with firm advocates and bitter opponents. In some cases, criticism has rightly been directed toward very long below-knee stumps which, however, were not true Syme amputations with the normal heel flap and capable of full end-weight-bearing. Experience at military amputation centers during World War II seems to have confirmed the successful results which have been reported by the Canadians ever since World War I<a></a>. A recent Canadian report<a></a> on the Syme amputation describes surgical precautions, conventional and experimental Syme prostheses, and clinical experience.</p> <p>Although the Syme amputation requires meticulous surgery, in the absence of sepsis, and careful attention to all details, a successful result provides much greater freedom of action for the amputee and enables him to remain on his feet for long periods. The broad surface of tissues anatomically adapted to weight-bearing offers the Syme amputee a great advantage over the below-knee amputee with limited areas offering a wedgelike support for the stump and pressing upon tissue which has not been accustomed to weight-bearing.</p> <p>The prosthesis for the Syme has been improved, on an experimental basis, by the Canadians (<b>Fig. 19</b>) and, more recently, by the Prosthetic Testing and Development Laboratory of the Veterans Administration (<b>Fig. 20</b>). Both types use a plastic laminate in place of molded leather for greater sanitation as well as for greater strength with decreased weight and bulk. Both use Fiberglas extensively for high strength.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Prostheses for Syria's amputation. Above, conventional Syme prosthesis with typical bulky and unattractive design at ankle and with bothersome shank lacer. Below, Syme prosthesis developed by the Canadian.<a></a> Same stump in the two cases. Note improved cosmetic appearance and simplified method of donning. The Canadian model consists ol a perforated plastic-laminate shell with thin, cellular-rubber lining, the whole considerably lighter than the conventional design above. Rear portion can be opened to admit bulbous stump. yet material is effectively distributed to withstand large bending loads. No ankle joint is used, but the foot is formed of cemented layers of cellular rubber around a reinforcing tongue projecting from the socket to the ball of the foot. Pressure on heel compresses the rubber to give the equivalent of plantar flexion. <i>Photos courtesy Canadian Department of Veterans Affairs.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Experimental Syme prosthesis designed and tested at the VA's Prosthetic Testing and Development Laboratory on request of the Orthopedic and Prosthetic Appliance Clinic Team, New York. It combines a molded plastic-laminate shell with rear opening, thin sponge-rubber lining, and an adaptation of the U.S. Navy functional ankle <a></a> using two-durometer rubber block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable success has attended efforts to reduce the bulk at the ankle by eliminating the steel sidebars which, in earlier prostheses, projected beyond the malleoli on the medial and lateral aspects, thus adding thickness to a zone already the broadest portion of the ankle. The steel sidebars had, in any case, been mechanically rather ineffective in sustaining bending loads, as when the weight of the amputee is supported on the ball of the foot, because the material was close to the neutral axis or central portion of the bars.<a></a> In the newer designs, this portion over the malleoli is relatively thin, but bending moment is resisted more effectively by the most anterior portion, ahead of the tibial crest, and by the posterior portion at a greater lever arm than was available in the older, narrow, metal bars. To avoid fatigue failures, special care must be taken to achieve a smooth posterior cut in the shell-like prosthesis. The bulbous malleoli are introduced into the prosthesis by opening a posterior portion, which may then be closed either in trap-door fashion by a hinged portion of the shell or by a fabric- or nylon-coated leather portion held by a slide fastener, laces, or adjustable straps.</p> <p>The shell-like combination socket and shank section, with the end-bearing pad, is molded over a plaster model of the stump to attain uniform fit. A slightly soft lining may be used throughout the socket. Relief is provided along the sharpest portion of the tibial crest so as to maintain comfort when weight is carried on the ball of the artificial foot and there is a tendency for the socket to press sharply on the upper portion of the tibia. Under such conditions, firm counterpressure, distributed comfortably, is also required just above the malleoli on the posterior portion of the tibia and fibula. Ankle action may be provided by a laminated sponge-rubber heel which is compressed at heel contact, giving the equivalent of plantar flexion, or by a rubber-block ankle joint with a shallow V-shaped section removed to accommodate the long stump.</p> <p><i>The Short Below-Knee Case. </i><br />Short, badly scarred, below-knee stumps have heretofore sometimes been reamputated above the knee or have been used in a permanently flexed position in the so-called "bent-knee" or "kneeling-knee" prosthesis reminiscent of pirate tales. In either case, the advantages of voluntary control of knee-joint movement are lost.</p> <p>The U.S. Navy below-knee "soft" socket, <a></a> an outcome of recent research, consists of a plastic lining backed by a thin layer of sponge rubber and a rigid or, recently, a rather flexible shell (<b>Fig. 21</b>). An improvement on earlier commercial sockets with felt or wax lining, it may be fitted to any below-knee stump, but particularly it has permitted conservation of short, sensitive, badly scarred stumps. The weight-bearing impression of the stump dipped in plaster yields a much more accurate replica than do most wrapped plaster-bandage impressions. In general, it seems reasonable to believe that any technique for making a socket from a cast is likely to produce a more accurate fit more rapidly and with less discomfort than is a trial-and-error carving process.<a></a> The thin sponge-rubber lining giving the "soft" socket its name seems to be only one of several factors contributing to its usefulness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. U.S. Navy "soft" socket for below-knee amputation, cut to show plastic sheet lining rolled over brim, thin (1/8-inch) sponge-rubber lining, and flexible plastic-laminate outer shell, all formed over male plaster model of the stump. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Careful location of the mechanical knee joints is always important. The work of the University of Denver<a></a> indicated the possibilities, for below-knee amputees in general, of improved fitting of conventional legs with single-axis knee joints by more careful location of the knee joints. Particularly recommended were fixtures and tools to ensure that the mechanical joints on opposite sides of the prosthesis are on a common axis. Poly-centric joints did not seem necessary. The report considered, however, the possibility of a mechanical joint of the single-axis type at the knee, but mounted high up on the thigh corset by a pivoting joint of limited angular range, in place of rigidly riveting the upper joint bar to virtually the full length of the corset. This idea has been proposed in the German literature.<a></a> In such a case, probably a reinforcing band should be mounted in the thigh corset to ensure that the upper joints are kept on a common axis.</p> <p>The very short below-knee stump, with the tibia amputated in the broad condylar area and with trabecular bone structure, is often suited to take a high fraction of weight-bearing on the distal end, in contrast to the usual below-knee stump of much smaller diameter, limited bearing area, and with thick, hard cortex surrounding a medullary canal. If the thickness of pads at the end of the stump is gradually increased, particularly if the pad in contact with the stump end is carefully molded to the irregularities of the stump, an increasing fraction of end-weight-bearing may often be tolerated.</p> <p>These circumstances deserve careful investigation before any thought is given to re-amputation above the knee, which in the past has often been suggested for such stumps. End-weight-bearing is both more nearly normal with respect to mechanical characteristics, promoting calcification, and is desirable in avoiding any tendency toward lordosis. The very short below-knee stump often can be fitted successfully by very careful forming of the socket. Special care is needed in shaping the posterior brim to accommodate the hamstring tendons, yet to rise into the popliteal space as much as possible without cutting off circulation. The "slip" socket, elastically supported to stay in contact with the stump during the swing phase, is an old idea often indicated for short stumps.</p> <p>Even if a very short below-knee stump cannot take appreciable weight-bearing on its end and on the flaring tibial condyles, it may be fitted with a long, ischial-supporting thigh corset and the sturdy external mechanical joints which would be used in a knee-disarticulation prosthesis. In this case the below-knee amputee, like the above-knee amputee, must rely upon mechanical stability of the prosthesis during the stance phase with the knee in full extension, but at a minimum he has proprioceptive sense of knee position and usually some limited ability to control slight knee flexion to return the knee to full extension, thus saving himself from some falls. Partial control of heel rise at the beginning of the swing phase and of knee extension at the end of the swing phase permit a more graceful gait and a better range of cadence than generally can be attained with above-knee prostheses.</p> <h4><i>The Knee-Disarliculation Case</i></h4> <p>The knee disarticulation, an old type of amputation, typically has been fitted with a molded leather socket provided with a lacer to permit the entry of the bulbous end of the stump. This type of prosthesis has mechanical joints and sturdy metal sidebars similar to those in the below-knee prosthesis. Normally, no mechanical friction has been used, and consequently gait tends to be limited to a single cadence. Any attempt to walk more rapidly leads to excessive heel rise and to "slamming" of the artificial shank into full extension just before heel contact.<a></a> Normally, extension is limited by thongs similar to the back-check in a below-knee artificial leg. Since the knee cannot be extended or stabilized voluntarily, the joints are arranged to give mechanical stability at full extension, as in an above-knee leg.<a></a> </p> <p>Many prosthetists have objected to the knee disarticulation as a level of amputation because of discomfort of the long, molded, leather socket, tendency toward breakage of the sidebars, and the lack of mechanical friction. Amputation at a higher level has frequently been advocated. The knee disarticulation, however, provides definite advantages over the above-knee amputation. If the end of the stump is properly fitted, a broad weight-bearing area is available. Normal transmission of weight through the shaft of the femur minimizes the tendency toward the lordosis often developed in above-knee amputees as the result of weight-bearing on an ischial support located back of the normal hip joint. <a></a> Clearly, disarticulation offers the maximum bony lever of any amputation at or above the knee.</p> <p>A recent informal survey of some of the knee-disarticulation cases performed under supervision of one of the authors (R.H.A.) at Thomas England General Hospital during World War II has indicated satisfaction of the patient with this type of amputation and prosthesis. In spite of the gait deficiencies noted, these knee-disarticulation amputees feel that they walk well, continue to prefer this level of amputation, and refuse any consideration of reamputation above the condyles to become more conventional above-knee amputees. Although some knee-disarticulation prostheses providing knee friction are reported in the literature, <a></a> much more needs to be done in this respect.</p> <h4><i>The Above-Knee Cases</i></h4> <p>In the above-knee amputation, at all locations as much length as possible should be conserved. Gritti-Stokes and similar end-bearing stumps have in many cases been fitted successfully with the suction socket,<a></a> although attachment of the muscles is then particularly important to avoid development of excessive negative pressure owing to displacement of muscle bulk in the necessarily limited clearance volumes available with long stumps and end-bearing pads. Some have found difficulties in fitting such cases with the suction socket and have preferred to rely on a conventional pelvic-band suspension, perhaps with a second hinge permitting abduction. In either case, the longer the above-knee stump the better.</p> <p>As regards the above-knee case, the principal development thus far of the Artificial Limb Program has been the reintroduction of the suction socket, with many far-reaching effects on stump shape, muscle conservation, socket fit, and alignment, accompanied by increased need for the cooperation of many disciplines and the launching of a program of education and certification. As for the first of these, the suction-socket program shifted emphasis from the excessively flabby, conical stump (<b>Fig. 22</b>) desired for the so-called "plug" fit to a more nearly cylindrical stump with firm muscles stoutly attached to the bone. In the suction socket, the muscles are needed both to control the newly found freedom about the hip join and to provide a gripping action by bulging against the walls of the socket, thereby decreasing the negative pressure required to carry the weight of the prosthesis. Similarly, introduction of the suction socket led to replacement of the typical conical socket of triangular or circular cross section (<b>Fig. 23</b>) by a more nearly rectangular socket (<b>Fig. 24</b>). The latter, developed in Germany within the last generation, has a better basis in physiological and anatomical fact, appears to be a necessity with the suction socket, and has, of course, also been used successfully with an increasing number of pelvic-band conventional limbs without use of suction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. An above-knee socket with nearly circular cross section and steeply conical form intended to support a conical, atrophied stump by side-bearing. Typically, a substantial roll of flesh developed over the rim around most of the circumference. The straps were used with suspenders. Adjustment for atrophy and shrinkage of the stump was easily made by additional stump socks, since the stump was regarded as a jellylike mass whose shape was easily distorted, with little definite relation between socket shape and stump shape. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Conventional socket for "plug" fit of above-knee stumps, showing rounded, triangular top portion of prosthesis for right thigh (looking forward and laterally). Note shelving flare below gluteal crease and ischium and broad, horizontal flare through perineum and adductor region. A considerable roll of flesh develops over this flare also, as in Figure 22. Socket shown here is made of metal and perforated, but the style often was used in wooden sockets as well. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Substantially rectangular or quadrilateral plan of top of socket for left above-knee prosthesis (seen from the rear), typically used for the suction socket but also applicable with soft belt or mechanical hip joint and pelvic band. Note the definite but narrow ischial support, slightly sloping forward and down and well rounded on its forward edge. The medial wall is thinner than the flare in a "plug" fit, since it should <i>not </i>provide a shelf or support against vertical load but should, in order to provide horizontal support during the stance phase, reach into the perineum as high as feasible without striking the pelvis. A nearly square anteromedial corner provides relief for the prominent adductor tendons. A high forward wall keeps the ischium on its support. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for alignment, introduction of the suction socket has forced the prosthetist to pay more attention to details, since, unlike the case of the conventional above-knee leg, errors in alignment cannot here be concealed by trial-and-error bending of the pelvic band and metal, single-axis hip joint which forced conventional legs to swing in a single plane regardless of their inertia and the gait of the amputee. With the suction socket in correct alignment, the amputee balances his weight completely on the leg, since he has no pelvic band and hip joint to lean against for support. Conversely, however, attention to better alignment has led to decreased stress in the hip joints and pelvic bands of those legs which, for one reason or another, are still fitted with pelvic bands. If one thinks of the suction socket as being fitted with an imaginary hip joint carrying zero stress, it is apparent that a comparable alignment will result in minimum stress in a real hip joint and pelvic band of a conventional leg and, therefore, to greatly reduced risk of breakage.</p> <p>In a very short above-knee leg, the suction socket <i>plus </i>auxiliary suspension, either the Silesian bandage (<b>Fig. 25</b>) or the conventional hip joint and pelvic band (<b>Fig. 6</b>), has permitted conservation of greater <i>effective </i>stump length than would be possible with the same stump in a conventional leg with hip joint and pelvic band but with a "plug" fit. In donning the suction socket, the flesh is pulled into the socket with stockinet, in contrast to the tendency of the conventional stump sock and "plug" fit to push the soft tissues upward and out of the socket. The auxiliary suspension provides greater control and stability than would be available in a pure suction socket. The more logical anatomical fit of the quadrilateral shape, including some ischial support, avoids the roll of flesh in the adductor region and the skin irritations and furuncles so commonly seen with the "plug" fit. Thus, some very short above-knee stumps fitted with this combination of suction socket and auxiliary suspension can function as if with a conventional above-knee leg without the necessity of flexing the stump permanently in a tilting-table type of socket such as would be used for a hip disarticulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Model of German suction-socket prosthesis with Silesian bandage, or trochanteric belt, with padded horseshoe encircling the trochanter, soft leather belt posteriorly around the pelvis, and V-shaped strap from anterior of socket through ring of the belt. The pelvic belt aims to assure vertical support during the swing phase, while the V-strap provides support against unwanted abduction and external rotation. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extremely short above-knee stumps, with little more than the neck of the femur, can be fitted in some cases with the "saucer" type of socket<a></a> in place of the tilting-table type generally used throughout the world with a true hip disarticulation.<a></a> Often the knee joint is locked during standing and walking, so that the amputee walks stiff-legged. In this case the prosthesis is often built shorter than the sound leg. Sometimes, however, adequate alignment stability can be obtained to permit a free knee joint. The thigh section is sometimes locked to the tilting-table socket so that the back muscle can function to stabilize a free knee as do the hip extensors in the above-knee amputee.</p> <p>Hiyeda, <a></a> in 1942, and independently the Canadian Department of Veterans Affairs<a></a> have used free joints at both hip and knee, with the hip joint farther forward and the knee farther to the rear than usual (<b>Fig. 26</b>). A posterior elastic strap helps to extend the hip joint. Either the saucer socket or the tilting-table type may be built of plastic laminate instead of from the older, molded leather, but if for some reason leather is used, the nylon coating developed at the Army Prosthetics Research Laboratory<a></a> will make it much more sanitary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Hip-disarticulation prosthesis developed by the Canadian Department of Veterans Affairs. Anterior view-shows three points of suspension© and full width of hip joint. Lateral view shows standing and sitting positions. From McLaurin.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Partial Amputations</h4> <p>Wherever possible, of course, partial hand or foot amputations should be performed in preference to major amputations.<a style="text-decoration:none;">*</a> Much work was done during and immediately following World War II on the surgery of the hand,<a></a> and interest has been lively since the formation of the American Society for Surgery of the Hand. In the recent Korean conflict, a great many partial hand and partial foot amputations were performed safely, whereas in previous times many of these cases would have required major amputations, probably as below-elbow or below-knee amputations at the former "sites of election."</p> <p>In recent years, satisfactory cosmetic gloves have been developed by the commercial prosthetics industry<a></a>, at the Army Prosthetics Research Laboratory, <a></a> in the Navy,<a></a> and in the Veterans Administration's Plastic Artificial Eye and Restorations Clinics. These have made possible adequate cosmetic fitting of many partial hand amputations while retaining some function. Moreover, various operable terminal devices for partial hand amputations have been developed both commercially and on an experimental basis in the ACAL program. Sometimes a small hook is mounted on a molded socket and controlled by a conventional cable or by wrist movement. On an experimental basis, the mechanism and wrist plate of an APRL hand have been removed, the transmetacarpal stump allowed to fit within the hand shell, and the side frames of the mechanical hand hinged opposite the anatomical wrist joint to a light forearm cuff. Thus wrist flexion and forearm rotation are preserved. Such cases clearly present individual challenges to the prosthetics clinic team <a></a> and to the designer and manufacturer.</p> <h4>Recapitulation</h4> <p>Decision as to the level of amputation, then, can be recapitulated in terms of saving all length possible.<a style="text-decoration:none;">*</a> This policy is justified not only by new devices, developed predominantly in the Artificial Limb Program, but also by the spectacular advances in recent years in many fields of medicine and related sciences. Blood, plasma, and antibiotics have helped to control shock and infection and have made possible prolonged and precise operations. Medical schools and residency training programs are only beginning to give more attention to education in the broad field of prosthetics to make the new findings available to the practitioner. The various medical societies are now devoting to this broad field more and more time on their programs and more space in their exhibits. Special courses, such as those on the suction socket held at various locations throughout the country, and the Institutes on Upper-Extremity Prosthetics at UCLA,<a></a> are bringing specialized knowledge to the doctor, the prosthetist, and the therapist. More attention is given to individual prescription rather than to "sites of election," with increasing cooperation and expert consultation from the prosthetist as to devices available but without dictation of sites merely because they might be more convenient. Best of all, there is now greater interest in over-all rehabilitation and continued follow-up on the part of the medical profession to see that every amputee, regardless of level of amputation, achieves the greatest possible restoration to normal life.</p> <h4>New Techniques in Amputation Surgery</h4> <p>There is no need here to describe in detail the techniques of amputation surgery, since they are all so well presented in numerous other sources, for example, by Slocum.<a></a> Certain points reflecting the experience of the Artificial Limb Program<a></a> may, however, be worthwhile. These may first be illustrated in terms of a typical amputation with primary closure, chiefly that producing an above-knee stump for which suction socket is intended, followed by notes on some of the special conditions at other levels of amputation.</p> <h4>The General Case</h4> <p><i>Skin Flaps and Subcutaneous Tissue</i></p> <p>In general, the skin flaps are approximately equal on the anterior and posterior sides and are so curved as to meet neatly without undue skin tension but without leaving "dog ears." The usual amputation has a central scar, although in some of the special cases of weight-bearing stumps there is usually a longer flap on one aspect so as to move the scar out of the end-weight-bearing zone. Even for the belowknee amputation without end-weight-bearing, a longer posterior flap has sometimes been advocated to take advantage of the presumably richer blood supply and more liberal muscle and fascia, but the advisability of this technique has not yet been sufficiently evaluated for it to be recommended here. Since when divided the skin and other soft tissues retract, the skin flaps are initially outlined distal to the intended level for sawing the bone, thus compensating for the successive retraction of the various layers and permitting the bone eventually to be sawed through at the edge of spontaneously but temporarily retracted tissues.</p> <p>The subcutaneous tissue may be regarded as a gliding mechanism, enabling the skin to move freely over the deeper fascia and achieving the goal of freely movable skin without an adherent scar. The subcutaneous tissue is cut perpendicularly to the skin, without beveling, and both are allowed to retract as they are cut, without undermining.</p> <p><i>Fascia</i></p> <p>A complete fascial envelope is very desirable, primarily to secure the severed muscles to each other and to the bony lever. Besides this, as Lawrence<a></a> has suggested, piston action of the bone within the soft tissues of the stump may help to pump fluid from the stump. Presumably this action is more effective if the fascial envelope is completely closed in order to force fluid displacement upward through the veins and lymphatic channels. In contrast, an opening in the fascial envelope may permit a compensating pulsation of the soft tissues through the defect, thus failing to generate effective pumping action. Although as yet there is little direct evidence to support such views, the reasoning seems logical.</p> <p>A further advantage of the fascial envelope is to avoid bulging of muscle through a defect in the deep fascia. Accordingly, it is also desirable, when feasible, to repair traumatic defects in the fascia and to refrain from removal of fascia during any plastic operations intended to remove bad scars.</p> <p>The tough fascia lata plays a special role while the above-knee amputee is on the artificial leg during the stance phase. Acting as a guy wire at the most favorable leverage to balance body weight falling medial to the ischial support, it helps to support the pelvis in a substantially horizontal position with minimal expenditure of muscular energy. Hence every reasonable effort should be made to secure firm attachment of the severed end of the fascia lata to the bony lever and to the fascia on the medial side of the stump in order to replace its former anchorage below the knee, as in the intact leg.</p> <p>The incision through the fascia is parallel to the initial skin incision but at the level of the retracted superficial tissues. Like all aspects of amputation surgery, it should be clean and precise.</p> <p><i>Muscles</i></p> <p>The importance of muscles has been emphasized by the Artificial Limb Program in connection with the suction socket <a></a>as a vital part of the cineplasty studies<a></a> and in analysis of the forces, motions, and hence the energy costs of both normal and pathological gait.<a></a> Only from reattachment of the severed ends of the muscles is it possible to attain control of the stump, particularly when greater freedom of action is made possible by improved devices, as, for example, by the suction socket. Moreover, the muscles must be held at substantially their original "rest length" in order to attain the greatest force during contraction.<a></a> Appreciation of this fact was brought out especially in connection with the cineplasty program, but of course the principle applies to all other muscles. A brief review of muscle physiology, mostly of features known for over 50 years but re-emphasized by recent research, is in order.</p> <p><i>The Nature of Muscle Forces. </i></p> <p>The muscle studies at the University of California in connection with cineplasty <a></a> have re-emphasized the importance of the early studies by Blix <a></a> of force-length characteristics. Briefly, as shown in <b>Fig. 27</b>, the force developed by a muscle is related to the length of the muscle at the time the force is exerted. Any attempt to stretch a relaxed muscle beyond its rest length results in an increasing resisting force, as shown by the "passive-tension" curve. If the muscle is restrained at its rest length and then stimulated as vigorously as possible, a certain maximum force can be generated. Full excitation of all the fibers, as by electrical stimulation, yields this maximum force for isometric contraction, although in practical voluntary use only part of the muscle fibers are activated at a given instant, so that a much lower value is attained when the subject "tries as hard as possible."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Idealized length-tension curves for a typical muscle. Note that the passive-tension curve rises sharply when the relaxed muscle is stretched beyond rest length and that maximum voluntary force with isometric contraction is available at or near rest length. Clearly, use of a muscle in a contracted position yields both lower force and less available energy. From Inman and Ralston.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If now the muscle is allowed to shorten, that is, to move toward the left of the rest length in <b>Fig. 27</b>, stimulation results in some maximum isometric muscle force less than the value attained at rest length. Continued shortening results in decreasing forces measured isometrically until, at some value of contraction varying somewhat in different muscles but roughly 60 percent of the original length of the muscle, no force can be exerted.</p> <p>Beyond rest length, an increased total tension may be developed upon isometric contraction. The exact shape of the curve varies with the nature of the muscle, its past history of stretching or contraction <i>over </i>prolonged periods (especially noticeable in muscles in which the cineplastic operation has been performed), and with the individual case. When the passive-stretch force is subtracted from the total tension attained by isometric contraction, the resulting <i>net </i>force available voluntarily tends in general to decrease again as the muscle is elongated beyond the rest length. Thus the curve of the <i>net </i>force is roughly an inverted parabola with its maximum at or slightly beyond rest length. Since this curve varies with individuals and with training and exercise (which affect both the cross-sectional area of a muscle and the shape of the passive-stretch curve), examples can be found which depart markedly from this schematic pattern. Nevertheless, the general principle leads to a number of interesting conclusions relating to the surgery of both upper and lower extremities.</p> <p><i>Applications of Muscle Mechanics. </i></p> <p>It is immediately apparent from <b>Fig. 27</b> that, if a muscle is allowed to retract, temporarily or permanently, it cannot attain a voluntary force as great as would be possible at or near the original rest length. Prosthetic devices should be utilized, as far as practicable, with the appropriate muscles near, perhaps slightly beyond, the rest length. A cineplastic tunnel, for example, should be so harnessed that most objects will be picked up with the tunnel near the rest length.<a></a> As is well known, the hamstrings, if reattached to the end of the femur in an above-knee amputee, can serve as hip extensors. On the basis of known muscle mechanics, they will be most effective when the hip is somewhat flexed but will be considerably less effective when the hip is fully extended or when it is hyperextended just at the end of push-off. The amputee may then attempt to supplement hip extension by using his back muscles, thus producing lumbar lordosis. Alignment of the socket bore and condition of the back-check controlling extension of the thigh socket relative to the shank will both affect the length of the hamstrings and hence the ability of the amputee to stand securely and to push off forcefully.<a></a> Permanent contracture of a muscle will result in a movement of the passive-tension curve toward the left in <b>Fig. 27</b> and, in general, in a steeper shape of the curve, thus resulting in greater passive tension with only little stretching of the muscle. Thus the maximum force which can be attained voluntarily will be reduced substantially, and the effect may be more serious than the simple reduction in range of motion. Avoidance of contractures is thus mandatory.</p> <p>Workers at the University of California have studied the moment (or force X leverage) available about the hip joint in relation to the angle of adduction or abduction of the stump. Since the gluteus medius and tensor fasciae latae are at their rest length when the stump is in its normal position, under slight passive stretch with an adducted stump, but allowed to contract when the stump is abducted, it is not surprising to find that the available moment about the hip joint decreases markedly from the adducted into the abducted region. Forcible abduction of the stump against the socket wall is essential to keep the pelvis level during the stance phase ,<a></a> and consequently maximum available abduction moment about the hip is desirable to avoid an apparent gluteus medius limp. Therefore, workers at the University of California have reasoned, it is highly desirable to maintain as much adduction as feasible of the socket bore in space and in relation to the remainder of the prosthesis. Experiments with controlled fitting and alignment on the University of California adjustable leg<a></a> have indeed shown this reasoning to be valid. In contrast, fitting of the socket to an abducted stump and "straight" alignment of the shank to the socket result in an appreciable limp.</p> <p><i>Stump Muscles in Prosthetic Control. </i></p> <p>Muscles may have within a socket several actions particularly favorable in the above-knee suction-socket leg. General bulging of the muscle belly during contraction increases the diameter of the stump in the zone of the maximum muscle belly, thus helping to grip the walls of the socket and producing frictional forces which help to support the prosthesis. Muscle bulging and even the contour of the relaxed muscles help to key the correspondingly irregular socket against rotation about its longitudinal axis and thus aid in voluntary control of rotation of the prosthesis.</p> <p>Conversely, the muscles of the thigh sometimes become detached from the cut end of the bone and the overlying fascia but by some mischance become attached to the superficial tissues, as through the scar. Contraction of such muscles causes a pistonlike retraction of the end of the stump, a condition that may cause discomfort in any case, especially if simultaneous contraction of opposing muscles tends to stretch the scar, and one that is particularly undesirable in a suction socket. Pistonlike retraction of the stump end, analogous to withdrawal of the plunger from a hypodermic syringe, develops additional negative pressure in the space between the end of the stump and the floor of the socket. Such excessive negative pressure, far beyond that necessarily created by the weight of the prosthesis, may tend to cause edema.</p> <p>If stump retraction seems apt to occur, the physician should consider all factors carefully before prescribing a suction socket and, if he decides to proceed with one, should caution the limbmaker to leave adequate clearance volume between the end of the stump and the sealing floor. In that case, the change of volume owing to movement of the soft tissue will be only a small percentage of the original volume, so that the resulting negative pressure will be only a correspondingly small fraction of the barometric pressure. But with long above-knee stumps, because of the problem of locating the mechanical knee joint, it may not be feasible to allow adequate clearance volume, in which case the suction socket may be contraindicated.</p> <p>Movements of muscle bellies also may create a wedging action within a relatively conical socket, thus tending to force the socket off the stump and to increase negative pressure in a suction socket, but this effect is not likely to prove serious in the relatively cylindrical, well-muscled stump recommended.<a></a> Wedging action may, however, be desirable in the thigh muscles of a below-knee amputee so as to provide additional support on the somewhat conical thigh corset, thus relieving the below-knee stump of some of the pressure to which it would otherwise be subjected.</p> <p>Muscles or tendons passing over the brim of the socket may also tend to force the prosthesis from the stump when the muscles are tensed, again tending to increase negative pressure in a suction socket. This effect can be minimized by careful fitting of the socket.</p> <p>Muscle tissue acts as a pump to promote return circulation of blood and lymph, as is well known. Obviously, this effect is particularly important in the suction socket to reduce tendency toward edema, and hence vigorous muscle activity is doubly desirable.</p> <p><i>Securing Muscles at Rest Length. </i></p> <p>For all these reasons, it is highly desirable that the muscles be secured to the end of the stump at their rest lengths. Accordingly, the muscles are cut at the levels of the spontaneously retracted superficial tissue and fascia. If necessary, the cut muscles may be sutured to their overlying fascia. Later, when the fascia is closed and sutured over the end of the stump, the muscles will be carried back from their spontaneously retracted position substantially to their rest lengths. It is desirable to have not a mass of loose muscle tissue over the end of the stump but rather a neatly tailored muscle and fascial closure with the muscles restored to their rest length, that is, simply pulled back against the natural tone.</p> <p>To suture muscles to each other at the end of the stump, as has sometimes been recommended in the past, is unnecessary. In fact, the sutures would probably pull out of muscle alone. Suturing of the tough fascia is much more effective, so that it is unnecessary, as well as undesirable, to suture muscles to holes drilled in the bone.</p> <p>In a few special cases, the tendons of the muscles may be sutured together. For example, in the case of knee disarticulation, the tendons of the hamstrings and quadriceps may be sutured in the patellar notch. Generally, the intention is to secure, by healing and scarring processes, the cut ends of the opposing muscles to each other, to their overlying fascia, and to the bone.</p> <p><i>Bone</i></p> <p>With the possible exception of the below-knee amputation (see footnote, page 30), the surgeon will plan to save the maximum practicable length of bony lever. The saw line is made at the level of the naturally retracted soft tissues. Before the bone is sawed, the periosteum is cut cleanly around with a sharp scalpel, taking special care to avoid loose flaps of periosteum, which may later form bone spurs. The bone is then sawed off squarely. There is no need to remove a periosteal cuff, and there should be no attempt to elevate the periosteum.</p> <p>In general, it is not necessary to bevel the bone cortex.<a style="text-decoration:none;">*</a> Preliminary anatomical studies of bone ends at the U.S. Naval Hospital at Oakland, California, and at the University of California Prosthetic Devices Project have shown that the bone end, when treated as already described, may round over spontaneously within a few months so that the medullary cavity tends to become sealed <a></a>. This simply confirms clinical observations already made from amputation of long duration.</p> <p><i>Nerves</i></p> <p>The aim of the surgeon is to sever the nerves in such a manner that the inevitable neuroma will be embedded in soft tissue at a point where it will not be stimulated. Thus, it should not be permitted to reattach to scar or bone in such a manner that the fibrils of the neuroma become stretched at every step owing to piston action of the bone within the tissues or to movement of the scar as a result of muscular action. The neuroma should also be far enough up the stump so that it is not subjected to unusual pressure from use of the prosthesis.</p> <p>The most desirable technique, it has been realized for some years, is to dissect the nerve carefully from the neurovascular bundle, pull it gently from its sheath, and cut it cleanly with a sharp instrument. The severed nerve is then allowed to retract up its nerve sheath into soft tissue. The major cutaneous sensory nerves, which are less obvious, deserve the same careful attention given to the major nerve trunks.</p> <p>Contrary to the advice in some earlier texts, experience of the past decade has shown clearly that no injections of alcohol or other chemicals should be given. Rather, the nerve should be left entirely alone after it has retracted into the tissue. Much clinical experience, and recently the studies of the Pain Project at the University of California <a></a>have indicated that formation of a neuroma must be expected at every cut nerve. Resection of a neuroma once formed will therefore merely lead to development of another neuroma at a higher level. Difficulties are encountered from a neuroma only if it is stretched or compressed. Although phantom pain is sometimes triggered by the stimulation of a neuroma, there are so many other possible causes that repeated surgery to remove a neuroma each time one forms generally is not justified.</p> <h4>The Special Cases</h4> <h4><i>The Upper Extremity</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br />In the wrist disarticulation, the distal joint between the radius and ulna must carefully be preserved to permit free motion of the radius over the ulna during pronation and supination. Occasionally it may be wise to round off any exceptionally sharp surfaces on the styloids, but in general the styloids can be accommodated by careful fitting of the molded plastic-laminate socket (<b>Fig. 8</b> and <b>Fig. 9</b>).</p> <p><i>The Long Below-Elbow Case </i><br /> Similarly, in the long below-elbow stump, every effort should be made to preserve free motion of the radius over the ulna to retain pronation and supination. Cutting of the bones permits the radius to approach the ulna, resulting in shortening, and hence weakening, of the pronator teres. Although with training the weakness can be overcome, the proximity of the radius to the ulna makes bone spurs or actual bony bridging between the two bones much more of a hazard to adequate pronation-supination. Thus careful, clean cutting of the periosteum is of particular importance.</p> <p><i>The Short Below-Elbow Case </i><br />Where there is the possibility of a very short below-elbow amputation, the short stump always should be preserved if at all medically feasible, in preference to amputation at or above the elbow. In some cases, for example where rolling and notching of the socket brim (<b>Fig. 14</b>) might be inadequate to prevent an intact biceps from pushing the socket from the stump during elbow flexion, the surgeon may consider cutting the biceps tendon to permit fitting the socket brim higher than usual. If biceps cineplasty is performed for such cases, the biceps tendon will, of course, be resected and the cut end carefully covered over or imbricated to prevent reattachment. In this case severing the biceps tendon may in some instances permit higher fitting of the socket while simultaneously preserving a useful function for the biceps muscle.</p> <p><i>The Elbow-Disarticulation Case </i><br />The elbow-disarticulation prosthesis with the new external lock (<b>Fig. 15</b>) has encouraged the preservation of the elbow-disarticulation stump whenever feasible medically. As with any end-bearing stump, it is probably desirable to place the scar line away from the weight-bearing area. The irregular shape of the humeral condyles may be retained to assist in anchoring the socket against rotation. Careful attention to the nerves is desirable to prevent formation of sensitive neuromata in the areas which will be subject to load during end-weight-bearing or as a result of bending loads upon the prosthesis when the elbow is locked.</p> <p><i>The Short Above-Elbow Case </i><br />The very short above-elbow stump should be preserved so far as medically feasible in preference to a true shoulder disarticulation or, worse, forequarter amputation. Even the short stump will serve to key the socket and provide greater stability. In some cases the short stump can be used for control of a lock. In experimental work on an electric arm, a very short above-elbow stump has been used to operate a keyboard of switches and clutches (<b>Fig. 18</b>) for control of the electrically driven motions as well as to control an electric elbow lock while a turntable lock above the elbow joint was controlled by a button pressed by the pectoral muscle.<a></a> </p> <p><i>Cineplasty Cases </i><br />In general, upper-extremity candidates for later cineplasty operations<a></a> can undergo the original amputation in the same manner as do those amputees who will use conventional prostheses. Thus far ACAL has accepted cineplasty in the intact biceps of a below-elbow amputee only (<b>Fig. 28</b>; see also <b>Fig. 12</b>, page 61), and in the case of a veteran prior approval from the VA Central Office is required. For many years cineplasty has been performed in a variety of locations and by many different techniques. In the Artificial Limb Program, it has been performed experimentally in a number of locations in various individuals, including the biceps in above-elbow amputees and the pectoralis major for short above-elbow and shoulder-disarticulation cases.<a></a> But before such procedures can be recommended, problems remain to be solved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Typical biceps muscle tunnel in below-elbow case, six months postoperative. <i>Courtesy Army Prosthetics Research Laboratory.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The general principle is to preserve muscle length and attachment at the time of the original amputation so as to prevent permanent contraction. The distal end of the muscle is released only at the time of the cineplasty operation so as to permit prompt exercise and stretching of the muscle soon after the tunnel has healed. Special attention should, of course, be given to repair of any injuries proximal to the intended saw line in order to assure full innervation and blood supply and to avoid serious scarring of the remaining stump.</p> <h4><i>The Lower Extremity</i></h4> <p><i>The Syme Amputation. </i><br />In the Syme amputation, in contrast to amputation at many other levels, preservation of the normal heel flap permits weight-bearing on tissue normally accustomed to full body weight and impact. The incision has a special shape across the instep so as to permit the shelling out of the calcaneus from the heel flap and the later formation of a suture line across the anterior aspect of the stump. <a></a>To provide good bearing, the bones are sawed just above the articular cartilage and in such a plane that the cut surfaces will be parallel to the floor when the amputee stands (not necessarily perpendicular to the long axes, as, for example, in the case of a bowlegged or knock-kneed patient).</p> <p>To ensure preservation of circulation in the heel flap, little if any tailoring is performed. Dog ears left at each side of the heel flap will disappear with proper postoperative wrapping. Contrary to the usual rule, the tendons are simply cut and permitted to retract without attempting to suture the tendons in place or to attain fascial closure. If a good Syme stump cannot be obtained, the surgeon should perform a conventional below-knee amputation, since a very long below-knee stump extending to the lower third of the shank frequently breaks down from poor circulation.</p> <p> <i>The Knee-Disarticulation Case</i><br />In the knee disarticulation, an exceptionally long anterior flap is necessary for closure of the stump and so that the suture line may be posterior and out of the end-weight-bearing zone. In general, the cartilage is simply left in place. The patella, although routinely left in place, may be removed to give extra length to the anterior flap when needed for adequate closure. The patellar tendon is sutured to the hamstring tendons in the patellar notch between the femoral condyles, but no attempt is made to prevent the tendons from gliding.</p> <h3>Summary</h3> <p>Techniques advocated, partly as a result of World War II and subsequent experience and partly as a result of the ACAL program, may be summarized as follows:</p> <ol> <li>With the possible exception of the below-knec amputation, save all length of stump considered surgically feasible.</li><li>Preserve the muscles at their rest length.</li><li>Attempt to secure attachment of opposing muscles to each other and to the bony lever during the healing process through suturing of the opposing fasciae, without attempting to suture the muscles to each other or to the bone.</li><li>Avoid attachment of the muscles to the scar.</li><li>Secure a complete fascial envelope.</li><li>Secure a smooth and freely movable scar, usually central but displaced in the case of end-weight-bearing stumps (or possibly where skin on one side of the stump has a much better blood supply and gliding fascia than that on the other).</li><li>Sever a nerve cleanly and allow it to retract into soft tissue, without injection and with as gentle treatment as possible.</li></ol> <h4>Postoperative Care</h4> <p>The doctor should in every case maintain continuing supervision and responsibility for the postoperative care of the amputee. Just what are the relative responsibilities of the surgeon and of the doctor of physical medicine, where the latter is available, is subject to discussion and, in the present state of knowledge, will necessarily vary from place to place depending upon their respective interests, training, and available time for both professional and administrative duties. But it is important for the patient's welfare that there always be available some single physician who is familiar with the case and who can take responsibility for seeing that the patient receives maximum cooperative service from the nurses, therapists, prosthetist, vocational counselors, and others concerned.</p> <h4>Bandaging</h4> <p>Although the extremely shrunken, conical stump of former days is no longer desired, it is obvious that some muscles (such as the vastus group of the thigh in an above-knee amputation or the soleus in a below-knee case) will no longer have as important functions as before and can be expected to atrophy. It is desired that these muscles atrophy slowly without deposition of an equivalent amount of fat. Careful application of an adequately wide elastic bandage, in accordance with well-known techniques <a></a> will hasten the desired shrinkage.</p> <p>Immediately after the amputation, therefore, the wound is dressed and the stump wrapped with broad elastic bandage. But the bandage will become loose in a few hours and should be replaced by a fresh one, usually every four hours during the day. The used bandage is washed and dried, the usual precautions being taken to restore its elasticity. After a suitable interval, usually 10 to 14 days, sutures are removed, the wound re-dressed, and elastic bandage again applied. Meanwhile, the patient should be taught to cooperate in the application of the elastic bandage so that, when dressings are no longer needed, he may himself learn to reapply fresh elastic bandage several times a day as needed to prevent edema and to encourage shrinkage of tissues no longer functional.</p> <p>The bandage is made snug at the distal end, with no constriction at a higher point on the stump, and it must be carried above the next intact joint, for example up to the thigh in the case of a below-knee amputation or above the hip and around the waist as a hip spica in the case of the above-knee amputation. To avoid rolls of flesh, all parts of the stump must be bandaged, notably the adductor region high into the crotch in the case of the above-knee amputation. The patient must be cautioned against developing above the stump a local constriction which would lead to poor circulation. Likewise, bandaging should avoid a bulbous mass of soft tissue at the end of the stump, which would interfere with later fitting.</p> <h4>Bed Posture</h4> <p>Every effort should be made to restore full range of motion of the stump as early as possible without risk of tearing the muscles from their newly organizing attachments to the bone. The patient should be discouraged from remaining in a fixed position, such as sitting in a wheelchair with the hip and knee flexed, or lying in bed with the stump propped up on a pillow.<a></a> It should be carefully explained to him that some temporary discomfort and inconvenience will be necessary to ensure subsequent full range of motion and effective use of a prosthesis. The leg amputee should lie in bed with his legs parallel, without abduction and external rotation of a thigh stump or flexion of a below-knee stump.</p> <h4>Traction</h4> <p>In the event of a preliminary open amputation, the line of skin traction should be toward the center of the bed, and the patient should be checked frequently to be certain that he is lying with his pelvis parallel to the bottom of the bed. In no case should he be permitted to slant the pelvis and thus, in effect, to abduct the stump. In the more common closed amputation in civilian life, traction is seldom necessary unless, in an attempt to conserve greater bone length, exceptionally short skin flaps have been used and it is desired temporarily to remove tension from the suture line.</p> <h4>Exercises</h4> <p>Restoration of strength and of full range of stump motion can begin when the muscles have become adequately attached to the bone, with gentle voluntary exercises at first to prevent detachment. Restoration of strength will depend both upon developing maximum size of the cross section of the muscle and upon stretching of the muscle stump so that it operates near the amputation rest length, as already discussed. The role of a low passive-tension curve is particularly important, and of course exercises should be prescribed with due regard to the patient's general condition.</p> <p>Home exercises, conducted by the amputee first merely by setting the muscles and later by using simple and readily available apparatus, are particularly important. Much can be done with a flatiron, a pail filled with increasing amounts of water or sand, or other convenient weights attached by a piece of sash cord over a pulley or doorknob to a towel about the stump. Elaborate gymnasium equipment or exercise tables obviously are not essential, convenient as they may be for the well-equipped rehabilitation center. The amputee and his family should be convinced of the importance of sensible home exercises, not only immediately postoperatively but whenever indicated throughout the rest of the amputee's life to maintain good stump condition and to avoid the flabby, weak, and contracted stump so often seen in an amputee of long duration. The amputee should be convinced of the need for maintaining adequate range of motion and strength in order that he may use his prosthesis effectively, gracefully, and with minimum effort. But of course he should be discouraged from intermittent extremes leading only to exhaustion.</p> <h4>General Health</h4> <p>Finally, general body tone is important both for good health and good spirits as well as for effective use of a prosthesis. The leg amputee, for example, must have good triceps to use crutches when necessary and good abdominal muscles to minimize the risk of lordosis. The arm amputee will use muscles of the trunk and opposite shoulder in supporting, positioning, and operating his prosthesis. All young, healthy amputees should be encouraged to take part in swimming, skating, bowling, table tennis, or other sports as appropriate.</p> <p>Every amputee should be cautioned against obesity, which in the lower extremity increases the load on the stump and in any case increases the difficulties facing the prosthetist. Because of the difficulties encountered from alternate tightness and looseness of the socket, all wearers of prostheses, and especially those using the suction socket, should be cautioned against violent fluctuations of body weight. Where indicated, all possible conditions causing obesity should be corrected, and patients should be supervised by a physician to stabilize body weight at normal for the individual.</p> <h4>Rehabilitation Responsibilities</h4> <p>An important result of World War II military experience, of subsequent work under the ACAL program, and of the increasing numbers of amputation clinics both in the Veterans Administration and in private institutions has been the increased interest by the medical profession in its responsibilities for lifetime rehabilitation for amputees. These include not only the obvious medical responsibilities but also psychological aspects; pain and phantom sensations; teamwork with others concerned in the prescription, fitting, training, and checkout of the prosthesis; and referral for any necessary vocational counseling and retraining.</p> <p>Psychological aspects of amputation are particularly important.<a></a> In many cases the doctor can provide appropriate psychological services, but in other cases referral to a clinical psychologist or to a psychiatrist may be desirable. Sometimes preoperative discussion and psychological preparation may be possible, especially if the amputation is elective or if the need for amputation can be foreseen. The prospective amputee himself should, when possible, decide realistically that amputation is preferable to other alternatives and that it is not "the end of the road."</p> <p>In many cases the patient can be helped preoperatively or postoperatively to accept amputation and to begin a realistic estimate of the possibilities of worthwhile rehabilitation through discussion with other amputees of the same level who have been rehabilitated successfully. Clubs of amputees<a></a> are beginning more and more to provide, on request of doctors and hospitals, levelheaded, rehabilitated amputees for just this purpose. Such amputees are not to be confused with the overenthusiastic salesman type or with the psychologically disturbed exhibitionist, who so often has demonstrated his remarkable prowess without making the patient aware of the nature of his stump, the differences between his condition and that of the patient, and the fact that so much depends upon the general physical condition and the will power of the patient. Just as there are professional golfers, there are also professional amputees. These persons can often perform remarkable feats not ordinarily desirable in or to be expected of the average amputee and one, as is usually the case, unwilling to make a career of stunts with a prosthetic device. Realistic discussions of the responsibilities of the patient, yet of the many important and fascinating things which remain possible, will be most effective.</p> <p>A matter of great importance is attention to the attitudes of those associated with the patient. Members of the family will wish to help in every way, yet their efforts must be guided intelligently toward help in the real difficulties while avoiding overprotectiveness generated by pity, which all too soon might turn into rejection. The employer can be helped to realize that the amputee may again return to useful work, whether at his former job or at some other and perhaps better and more skilled job after suitable vocational guidance and retraining.</p> <p>Sometimes the handicapped person, perhaps for the first time receiving professional guidance and being forced to think carefully about his future, will aim at more education and a much higher economic level than before the amputation. After all, much of the heavy labor of industrial countries is being taken over by machines. Unaffected by the amputation, the patient's brain power and ability to make decisions and to control the machines will command a higher value.</p> <p>Friends and acquaintances too must learn to accept the amputee for the many qualities he has left and to admire his demonstrated fortitude and cheerfulness rather than to pity him or even to shrink from him because of past memories of an amputee beggar. Finally, society as a whole must learn to accept not only amputees but all handicapped and disabled persons on the basis of their inherent dignity, ability, and worth as human beings, not on the superficial basis of individual differences in physical condition due to crippling disease, congenital defects, or mutilating injuries. In the past, amputees, like members of other minority groups, have encountered unreasoning psychological prejudices unworthy of the brotherhood of man.</p> <h4>Pain and Phantom Sensation</h4> <p>The amputee will need counseling, both in the acute stage and perhaps occasionally throughout his life, about the nature of pain in the stump, phantom sensation, and phantom pain. Postoperatively, pain is handled as in the case of any other operation. But the amputee may be puzzled that he still has a sensation of the missing member, perhaps in some bizarre position. He can be assured that at least 85 percent of other amputees, and perhaps practically all amputees other than congenital, retain such feelings. Phantom sensations have long interested neurologists and psychologists and recently have come in for study in considerably more detail at the University of California.<a></a> It appears that such sensations are related to the continued activity of the cortex on which the missing limb was originally projected but which no longer receives the normal bombardment of constant new sensations of position, temperature, pressure, and so on.</p> <p>Phantom <i>pain </i>is rare. It occurs only in a small fraction of amputees. Sometimes it appears to be related to specific physical difficulties in the stump or in the remainder of the body, such as pressure on a neuroma or traction upon a neuroma which has, unfortunately, become caught in scar tissue and is stimulated by muscular movement or piston action of the stump in the socket. In other cases, it may be related to some cause further up the body which might have been sought immediately in a normal individual but which might be neglected in the amputee. For example, a ruptured disc in the spine immediately would be sought from certain classic patterns of pain radiating down the leg, but the same might be overlooked in an amputee who complains that pain radiates into his missing phantom limb.</p> <p>Studies at the University of California involved injecting salt solution, as a stimulant, into the various vertebral segments of both normal volunteers and amputees in order to produce radiation of pain which could be mapped systematically.<a></a> In some cases, radiation of the pain into the phantom limb of an amputee resulted in disappearance of the phantom sensation itself after a short period, concurrently with disappearance of pain in the rest of the body (<b>Fig. 29</b>). In other cases, distribution of phantom pain was altered, and in a few cases the phantom pain became worse. In general, however, workers at the University of California believed that phantom pain could be alleviated by one or more of a series of systematic attacks. No single remedy was found that applied to all cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical patterns of pain radiation in the phantom limbs of two subjects. <i>Courtesy University of California Medical School</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Clinic Teamwork</h4> <p>The duties of the physician on the prosthetics clinic team have been well outlined by Bechtol. <a></a>The increasing success of prosthetics clinic teams in overcoming the problems of the amputee, as well as those of the wearers of braces and orthopedic shoes, has brought a rapid expansion of amputee clinics in both government and private circles. Indeed, the teamwork concept has been utilized increasingly at many levels of rehabilitation for many kinds of disabilities and throughout scientific research generally. Each member of the team needs humble realization of his own limitations,<a style="text-decoration:none;">*</a> appreciation of the contributions to be made by each of the other members, and, of course, an understanding of the participation of the patient himself as a member of the team created in his behalf. Thus only can there be created a realistic basis for self-confidence in the total effectiveness of the team as an integrated unit. In the Veterans Administration's Orthopedic and Prosthetic Appliance Clinic Teams, the Chief of the Prosthetic and Sensory Aids Unit is the administrative "key" to the success of the individual clinic.</p> <h4>Lifetime Responsibility</h4> <p>The surgical responsibilities immediately after operation have, of course, long been obvious. But no more can the doctor dismiss the patient when the scar is healed-with advice to "look in the classified telephone book for a limbmaker." Rather, the doctor should serve as captain of the prescription team in its efforts to see that the amputee is provided with the best current prosthesis suited to the individual and with adequate training in its use, and he should assume continuing responsibility throughout the lifetime of the amputee.</p> <p>The doctor should, for example, have the clinic administrator arrange for periodic checkup examinations at proper intervals, perhaps once a year. Thus the amputee can be checked for adequate fitting and can be informed of new improvements as they become available, both from the commercial industry's own developments and from the Artificial Limb Program as it makes tested devices available to the industry. The gait of lower-extremity amputees can be observed, facility in the use of upper-extremity prostheses can be noted, and, if necessary, further periods of training may be prescribed. Other problems, such as obesity, spinal curvatures, skin difficulties, and so on can be detected and corrected before they become serious. Frequently, all the amputee needs is a reminder for encouragement to brush up on his old skills. Reassurance and renewed encouragement are of important psychological value to the amputee patient.</p> <p>Finally, the experienced patient, returning for his routine checkup, serves as an example to improve the morale of the more recent patients sitting in the waiting room. The successfully placed and well-rehabilitated patient, grateful for his own return to active life, will be glad to assist by visiting more recent patients in the hospital. He may be called upon whenever his unique physical condition, type of work, or hobby makes him especially suitable to help a person of similar circumstances.</p> <h4>The New Knowledge and the Medicla Profession</h4> <p>The challenge to the medical profession will thus be clear. There has been a rapid increase in knowledge of prosthetic devices themselves, in methods of performing amputations, and in the philosophy of amputee management. Medical education must somehow fit into the medical curricula and into the crowded training programs for interns and residents the new knowledge and changing viewpoint in amputee rehabilitation.<a></a> Exhibits at medical meetings and papers in the medical journals offer some of this new knowledge. The new 800-page collaboration, <i>Human Limbs and Their Substitutes </i>(see <i>Digest, </i>this issue, page 77) presents a much more extensive range of knowledge and broader point of view than is possible in a single article. The busy practitioner, especially the general surgeon to whom amputation is only a rather incidental part of practice, must somehow find time to keep abreast of new knowledge and philosophy while conserving the best principles he has learned in the past.</p> <p>Finally, there is a growing need for geographically spaced centers for performing amputations and to serve as bases for orthopedic and prosthetics clinic teams serving civilians as well as veterans. Perhaps only thus can those with specialized knowledge best serve the patients, especially those with unusual problems. Indeed, such centers could serve as agencies of the Artificial Limb Program, pointing out needs and priorities based on clinical experience and providing facilities for field tests and educational activities.</p> <h3>Conclusion</h3> <p>Thus, it can be seen that marked changes have taken place from the days of the few sharply delimited "sites of election" and the few types of prosthetic appliances available for them. The changes thus far have perhaps been most marked in the upper extremity, where a whole new armamentarium of appliances has been developed and rigorously tested both in the laboratory and in clinical studies. The findings have been made available to physicians, therapists, and prosthetists through a series of Institutes on Upper-Extremity Prosthetics at the University of California at Los Angeles. Even so, the present <i>Manual </i><a></a> shows interim devices which should be greatly improved in years to come. Improved function and appearance are certain, and perhaps there will be some limited sensibility of position, contact, and gripping force.</p> <p>In the meantime, however, a great deal of work also has been done on the lower extremity. Although relatively few new devices, such as the U.S. Navy above-knee artificial leg<a></a> and the suction socket have been accepted, a great many new devices and many changes in practice are being tested at the laboratory and clinical levels. It is to be expected that, in the next few years, <a></a> an equivalent to the upper-extremity armamentarium will be released in an array of new devices for the lower extremity, such as stable knees, means for preventing stumbling, and perhaps forcible ankle push-off. Current inventors' designs and test models eventually will be tested through a systematic transition procedure and released for routine use.</p> <p>To those close to the heart of the ACAL program for nearly a decade, the changes noted herein have occurred so slowly and so imperceptibly in the pressure of daily emergencies that they have not been realized fully. Until brought out by a systematic review or by a chance conversation with someone untouched by the genuine progress which has been made, the alterations lie buried in the seeming monotony of obvious "good practice." Yet all these little modified details in technique, new or revived appliances, and perhaps more profound changes in points of view and philosophy add up strikingly to benefit the individual amputee.</p> <h4>Acknowledgments</h4> <p>It is a pleasure to acknowledge the contributions received through past discussions with a host of associates in military amputation centers, Veterans Administration Orthopedic and Prosthetic Appliance Clinic Teams, the Artificial Limb Program, and private life. Some of the concepts described may be attributed particularly to Jerome Lawrence, of the Veterans Administration Clinic Team in New York; to Verne T. Inman, of the University of California; and to Herman Gladstone, Surgical Consultant to the Prosthetic and Sensory Aids Service of the Veterans Administration. Thanks are due George Rybczynski, who provided most of the line drawings. Photographs were supplied through the courtesy of the VA's Prosthetic Testing and Development Laboratory, the Army Prosthetics Research Laboratory, and the Canadian Department of Veterans Affairs.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee, </i>Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954. Fig. 11 and p. 40.</li> <li>Alderson Research Laboratories, Inc., <i>op. cit.</i> p. 20, Fig. 5</li> <li>Alldredge, Rufus H., <i>The management of war amputations in a general hospital, </i>N. Y. State J. Med., 44:1763 (1944).</li> <li>Alldredge, Rufus H., and T. Campbell Thompson,<i>The technique of the Syme amputation, </i>J. 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See especially pp. 34-35.</li> <li>Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, </i>24 August 1953.</li> <li>Department of Veterans Affairs, ProstheticServices, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Desoutter, E. R., <i>Back to activity, </i>DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</li> <li>Dorrance, D. W., U.S. Patent </li> <li>1,042,413, October, 1912.</li> <li>Eberhart, Howard D., Verne T. Inman, and BorisBresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon,<i>Suction-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues, </i>J. Bone &amp; Joint Surg., A, in press 1954.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks, </i>Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium, </i>Artificial Limbs, January 1954. p. 15.</li> <li>Gray, Frederick, <i>Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, </i>2nd ed., R. Renshaw, London, 1857.</li> <li>Haddan, Chester C, and Atha Thomas, <i>Status of the above-knee suction socket in the United States, </i>Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </li> <li>Hiyeda, Masatora, <i>Work leg for the hip exarticulation, </i>J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Kirk, Norman T., <i>Amputations, </i>a monograph from Vol. III of Lewis' <i>Practice of surgery, </i>W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</li> <li>Langdale-Kelham, R. D , and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</li> <li>Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves, </i>Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Little, E Muirhead, <i>A lecture on a new material (duralumin) for surgical appliances, </i>Brit. Med. J., 1:236 (1912).</li> <li>Little, E. Muirhead, <i>Artificial limbs and amputation stumps, </i>H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</li> <li>Little, <i>op. cit. </i>pp. 6-7.</li> <li>Little, <i>op. cit. </i>pp. 7-8.</li> <li>Little, <i>op. cit. </i>p. 8.</li> <li>Little, <i>op. cit. </i>p. 10</li> <li>Little, <i>op. cit. </i>p. 24.</li> <li>Little, <i>op. cit. </i>pp. 110-113.</li> <li>Little, <i>op. cit. </i>p. 249.</li> <li>Martin, Florent, <i>La prothese du membre inferieur,</i>Masson et cie., Paris, 1918.</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Martin, <i>op. cit. </i>pp. 260-279.</li> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis,</i>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</li> <li>Mommsen, F., and K Buchert, <i>Kunstliche Glieder, Heft 1, </i>Enke, Stuttgart, 1932. pp 4-5.</li> <li>Mommsen and Biichert, <i>op. cit </i>pp. 86-97.</li> <li>Murphy, Eugene F., <i>The role of an amputee club,</i>summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, <i>Description of a prosthetic hand appliance, </i>March 1, 1948.</li> <li>New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Shakedown test of the Navy above-knee prosthesis, </i>May 1951.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947. pp. 1.33-1.36.</li> <li>Pare, Ambroise, <i>Ouevres completes, </i>J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</li> <li>Personal communication from Verne T. Inman,University of California.</li> <li>Personal communication from representatives ofUNRRA, 1946.</li> <li>Possibilities Unlimited, Inc., Cleveland, Ohio, <i>Possibilities unlimited, </i>Vol. II, Issue 2, 1950.</li> <li>Putti, Vittorio, <i>Historic artificial limbs, </i>Hoeber, New York, 1930. p. 7.</li> <li>Putti, <i>op. cit. </i>pp. 1-3.</li> <li>Radcliffe, Charles W., <i>Alignment of the above-knee artificial leg, </i>Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower-extremity prostheses, </i>Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, <i>Mechanics of human isolated voluntary muscle, </i>Am. J. Physiol., 151:612 (1947).</li> <li>Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart,<i>The major determinants in normal and pathological gait, </i>J. Bone &amp; Joint Surg., <b>35A(3) </b>:543 (1953).</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, </i>Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Slocum, D. B., <i>An atlas of amputations, </i>Mosby,St. Louis, 1949.</li> <li>Spittler, A. W., and I. E. Rosen, <i>Cineplastic muscle motors for prostheses of arm amputees, </i>J. Bone &amp; Joint surg., 33A:601 (1951).</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The objectives of the upper-extremity prosthetics program, </i>Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</li> <li>Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thompson, T. Campbell, and Rufus H. Alldredge,<i>Amputations: surgery and plastic repair, </i>J. Bone &amp; Joint Surg., 26A:639 (1944).</li> <li>United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, <i>Philippine amputation and prosthetic unit, </i>n.d.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies on human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</li> <li>Upper-Extremity Technical Committee, ACAL,minutes of meeting at University of California, Los Angeles, February 5, 1953.</li> <li>Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, <i>The development of artificial arms for amputees who have had the cineplaslic operation, </i>1947.</li> <li>Vasconcelos, Edmundo, <i>Modern methods of amputation, </i>Philosophical Library, New York, 1945.</li> <li>Wagner, Edmond M , <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954. p. 16.</li> <li>Wagner, Edmond M., and John G. Catranis,<i>New developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</li> <li>War Department, Washington, D. C, TrainingManual 8-293, <i>Physical therapy for lower extremity amputees, </i>June 1946.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal</i><i>devices, </i>Orthop. &amp; Pros. Appl. J , March 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist-disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., <i>Die biologische Absetzung der menschlichenGliedmassen, </i>Muench. Med. Wschr., 82:525 (1935).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, Description of a prosthetic hand appliance, March 1, 1948.</td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Recent developments and future trends in the field of orthopedic appliances, Southern Med. J., 46:7 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Websters definition of teamwork reads in part as follows: Work done by a number of associates, usually each doing a clearly defined portion, but all subordinating personal prominence to the efficiency of the whole!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone &amp;Joint Surg., A, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Mommsen and Biichert, op. cit pp. 86-97.</td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Personal communication from representatives ofUNRRA, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, Physical therapy in aftercare of amputations of lower extremity, U.S. Nav. Med. Bull., 43:634 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, The lower-extremity amputee,Chapter XIX in Bierman and Licht's Physical medicine in general practice,3rd ed., Hoeber, New York, 1952.</td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis,New developments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplastic method in upper-extremity amputations, J. Bone &amp;Joint Surg., 30A:359 (1948).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone &amp;Joint Surg., A, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Pare, Ambroise, Ouevres completes, J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The single exception is the anterior tibial crest in the below-knee amputation, where beveling is desirable but without extending the beveled surface to the medullary cavity. In special cases, such as the Syme, there will be modifications of the general surgical technique. See page 36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">1,042,413, October, 1912.</td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, Philippine amputation and prosthetic unit, n.d.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b> 77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Langdale-Kelham, R. D , and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,The influence of new developments on amputation surgery, Chapter 2 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Anderson, Miles H., UCLA prosthetic course to open January 12, Orthop. &amp;Pros. Appl. J., September 1952. p. 14.</td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall">Anderson, Miles H, A report on the prosthetics training center at the University of California, Los Angeles, Orthop. &amp;Pros. Appl. J., December 1953. p. 27.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">An exception may be the below-knee amputation. At the present time, and until further information is available, the below-knee stump should not extend more than 6 in. below the tibial plateau.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper-extremity prosthetics program, Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, 2nd ed.,Lippincott, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In general, partial amputations should be considered only when normal sensation and good blood supply can be retained.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Mommsen, F., and K Buchert, Kunstliche Glieder, Heft 1, Enke, Stuttgart, 1932. pp 4-5.</td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown test of the Navy above-knee prosthesis, May 1951.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">McLaurin, C. A., Hip disarticulation prosthesis,Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, 24 August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The role of an amputee club,summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Canty, Thomas J., Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bechtol, C. O., and E. F. Murphy, The clinical applications of engineering principles to the problems of fractures and fracture fixation, American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In only apparent contradiction, Shallenberger, from experience in 1946-47 with two short-below-elbow amputees on whom the cineplastic operation had been performed, with consequent severing of the biceps tendon, recommended a high and almost horizontal front brim with adequate corners on the medial and lateral sides. He found that the flesh was thus restrained at the top and front of the stump and was instead forced out at the sides, where it could not interfere with elbow flexion. He thus found the bearing area to be much greater, with consequent relief of pressure on the stump. In general the same situation would not prevail in the ordinary below-elbow amputee whose biceps tendon is intact.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminaldevices, Orthop. &amp;Pros. Appl. J , March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Major amputations, Surg.Gyn. &amp;Obstet., 84:759 (1947).</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Amputations and prostheses,Chapter XII in Christopher's Textbook of surgery, 5th ed., Saunders, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The management of war amputations in a general hospital, N. Y. State J. Med., 44:1763 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Little, op. cit. p. 10</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Personal communication from Verne T. Inman,University of California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Thompson, T. Campbell, and Rufus H. Alldredge,Amputations: surgery and plastic repair, J. Bone &amp;Joint Surg., 26A:639 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Little, op. cit. p. 24.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 523-528.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Carnes, W. T , U S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 110-113.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Desoutter, E. R., Back to activity, DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Dorrance, D. W., U.S. Patent </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Little, op. cit. p. 8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 7-8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954. p. 15.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 397, 425, 509.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Little, E. Muirhead, Artificial limbs and amputation stumps, H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 404-405.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, The development of artificial arms for amputees who have had the cineplaslic operation, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist-disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., Die biologische Absetzung der menschlichenGliedmassen, Muench. Med. Wschr., 82:525 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Putti, Vittorio, Historic artificial limbs, Hoeber, New York, 1930. p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947. pp. 1.33-1.36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Possibilities Unlimited, Inc., Cleveland, Ohio, Possibilities unlimited, Vol. II, Issue 2, 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be recalled that with a little practice man can walk on his hands, but it is not a very comfortable behavior or one that can long be continued.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office), Veterans Administration, 252 Seventh Avenue, New York City; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rufus H. Alldredge, M.D. </b></td></tr><tr><td class="clsTextSmall">Formerly Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Regional Office, New Orleans, Louisiana; member, Advisory Committee on Artificial Limbs, National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_004/fig1A.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_004/fig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetics Research and the Amputation Surgeon Creator An entity primarily responsible for making the resource Rufus H. Alldredge, M.D. * Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/2579b493cff96641963df1959617da9c.pdf 7a040dc0c6d8940381d830ff94df216c https://staging.drfop.org/files/original/9b5a594f58f0c51923251fd92a135602.jpg 57b06d3b863d2d96e319e45c7e311ec2 https://staging.drfop.org/files/original/b27d9746413c7245b9c9d57b6c78296c.jpg c3f708f42d9205528c3d92eaa69c5f8d https://staging.drfop.org/files/original/489333ee5663a0918fc1188cd04de355.jpg 6246ddbb7c073c52f3680d9cc2e692d5 https://staging.drfop.org/files/original/0f1a2c0ffe09ce58f56c671508caf8d0.jpg 9ace1443273e65a96546085fac38ccff https://staging.drfop.org/files/original/b757babe164755ddc45d09d746d12a25.jpg bb43beeaee57a9d23d027255cfe57a90 https://staging.drfop.org/files/original/28098c9ae09a1b29b5e2746fbf9dae57.jpg 146ed72dacbc879d115802dfe7b040ec https://staging.drfop.org/files/original/101b4a63eb00b02f48dd5cceb047df08.jpg a8b81c922b4a290b5521ca6debc85bc1 https://staging.drfop.org/files/original/72a60b523a40a4d235c1d18c8b9b7261.jpg c8c5932ddfd82c4f9b5bb9c021a4057c https://staging.drfop.org/files/original/dca53dfdadc820d9695f082cef6c3cc6.jpg 6844b1ba2d83cec4968a44656a93d8c4 https://staging.drfop.org/files/original/4a2c27c0bdc553dc08831ffd607191a8.jpg 28ad5e1095f6eea7da754bc99dddcfd2 https://staging.drfop.org/files/original/895503c909a9093928949c6025df2493.jpg b6dcdac7b597f6d539a04096e67f49a8 https://staging.drfop.org/files/original/ce093d59e2f69e93fb1e12645cdaa70c.jpg 4d30dc7c5aaece3d4f6ec528523d2cc3 https://staging.drfop.org/files/original/85aef58e9738f2b66ee033e80c6a23e1.jpg 8d5b678b30f6204ae837a9fe4db7cd24 https://staging.drfop.org/files/original/03c3b38192c1044ec4565bd3d585f5d9.jpg a1b1b398e8264b9b4130b912c592a94d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_020.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 20 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Skin Problems of the Lower-Extremity Amputee</h2> <h5>S. William Levy, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Since the establishment, in the autumn of 1954, of the skin-study group of the Lower-Extremity Amputee Research Project at the University of California, other physicians within the Project have referred to us for observation and treatment those amputees having cutaneous problems associated with the wearing of a prosthesis. Out of this nidus, specific information regarding the various clinical problems has been assembled and correlated in an effort to benefit the individual amputee. Some of the clinical problems have aroused interest in basic dermatologic research, so that investigation has not been of a purely clinical nature.</p> <p>The cutaneous difficulties associated with the wearing of a leg prosthesis have been evaluated in more than 200 patient-visits, and every effort has been made to classify cutaneous disorders specifically. Approximately the same number of above- and below-knee amputees have been carefully screened and examined. Complete histories have been taken, and physical examinations of the skin have been performed. Skin biopsies have been obtained in many instances, and histopathologic sections have been examined carefully in an effort to determine the course of a specific disorder.</p> <p>Other laboratory aids, such as skin scrapings for fungi or patch tests for contact dermatitis, have been utilized. Stump hygiene is important in relation to many clinical disorders of the skin, and accordingly a specific hygienic program for the care of the stump is being developed.</p> <p>Skin lesions, however minute they may appear, are nevertheless of great importance since they may be the beginning of an extensive cutaneous disorder that may be mentally, socially, and economically disastrous to a given individual. It is best to view any minor irritation as a potentially dangerous symptom and to deal with it as early as possible. Once the skin problem has begun, it should not be ignored in the hope that it will heal of its own accord. Nothing can be more frustrating to the lower-extremity amputee than to be told to remain off his prosthesis or to go on crutches because he has neglected a minor skin eruption.</p> <p>This article is devoted to the common skin problems and danger signals associated with the wearing of a lower-extremity prosthesis. Most of our experience has been gained with the above-knee amputee using the suction-socket suspension, but it is believed that the same or similar problems arise in patients using the more conventional types of suspension.</p> <h4>Stump Hygiene</h4> <p>Hygienic measures are of the utmost importance in the daily care of amputation stumps and in the use of prostheses. A neglect of cleanliness can easily result in damage to the skin and thus open the door to a number of cutaneous disorders which can require temporary removal of the prosthesis. There is no unanimity of opinion on exactly what measures should be employed routinely. Amputees have come to us with many varied and weird ideas. Some have used strong soaps and alkalies on their stumps, some alcohol, and others formaldehyde. These hygienic measures have been handed down from one person to another and frequently without reason or logical explanation. Some patients fail to wash either the stump or the socket, thereby giving rise to maceration and malodor.</p> <p>A simple hygienic program using a sudsing detergent has in many instances prevented or eliminated a cutaneous disorder, and hence we frequently request an amputee to follow a given routine. He is advised against the use of any preparation which would leave a deposit in the socket or any solvent which might affect the interior finish. A simple procedure for cleaning the socket is to wash the inner surface with a lukewarm, soapy cloth or one containing a detergent, remove the soapy residue with a clean wet cloth, and then dry out the socket with a towel. The prosthesis should not be put on for several minutes so that it may have an opportunity to dry completely.</p> <p>For the stumps of most individuals, a bland soap or liquid detergent provides a good cleansing without irritating the skin. Soaps or detergents containing hexachlorophene provide a bacteriostatic action, in addition to cleansing, and may aid in reducing the danger of infection. An amputee is frequently advised to purchase a plastic squeeze bottle of pHisoHex,® an item available in every drugstore, relatively inexpensive, and to be had without a prescription. He is instructed to spread over the amputation stump a small amount of this antibacterial sudsing detergent containing hexachlorophene. A little water is added and the material worked into a lather. More and more water is added to increase the amount of sudsing. He is told to avoid washing off the suds until ready for thorough rinsing. When well cleansed, the site is then rinsed off with lukewarm water, and the stump is dried by patting rather than by vigorous rubbing. This simple routine should be followed nightly, or every other night, depending upon the rate of perspiration, the degree of malodor, and the bathing habits of the individual. In the treatment of some persistent eczemas of the stump, this simple hygienic program was found to be curative.</p> <h4>Clinical Problems</h4> <p>Some amputees go along for months or years without difficulty or irritation of the stump skin. In others, the skin is a weak tissue, and frequent difficulties arise. Persons concerned with amputees should be aware of certain pathologic conditions-certain danger signals-which are frequently the forerunners of seriously incapacitating cutaneous disorders. Early recognition and treatment of these conditions can avert much mental anguish and loss of social or economic activity. It should be remembered that, once on a prosthesis, the amputee desires to stay on, and it is of vital concern to the physician and prosthetist to prevent any disorder which may return him to crutches or bed rest. What, then, are some of these danger signals?</p> <h4>Stump Edema Syndrome</h4> <p>When an amputee first starts wearing a suction-socket prosthesis, he can expect to see edema or swelling and reddish-brown pigmentation, roughening, and drying of the skin of the terminal portion of the stump (<b>Fig. 1</b>). These changes are the almost inevitable result of the altered conditions forced upon the skin and subcutaneous tissues. They are relatively innocent, do not usually require therapy, and are partially prevented by gradually compressing the stump tissues with an elastic bandage prior to use of the prosthesis. An incorrectly fitted socket may predispose a leg amputee to this disorder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Stump edema syndrome. <i>A, </i>In a 33-year-old male above-knee amputee wearing a suction-socket prosthesis. Note the swelling of the <i>end </i>of the stump, with pigmentation and hemorrhage into the skin. <i>B, </i>Enlarged view of <i>A. </i>showing hemorrhagic nodules with superficial erosion. <i>C, </i>In a 38-year-old male above-knee ampulee wearing a suction-socket prosthesis, with swelling and hemorrhagic plaque. No erosion or ulceration has occurred. <i>D, </i>Same patient as in C, showing socket-rim pigmentation and irritation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In several of our patients the edema has been massive, and distal pigmentation has followed, with the formation of hemorrhagic papules and nodules. Superficial erosion of the skin in these regions is not uncommon, and, in rare instances, deep ulcers can result from the poor cutaneous nutrition (<b>Fig. 2</b>). Multiple biopsies have been taken in order to determine the pathogenesis of this disorder. Special staining of the sections revealed that the pigmentary changes were due to the blood pigment, hemosiderin, within the tissue (<b>Fig. 3</b>). The collagen of the dermis was thickened by newly formed fibrous connective tissue, and there was an abnormal proliferation and dilatation of blood vessels. It may be that this kind of disorder is vascular in origin and that a venous and lymphatic congestion is productive of the edema and hemorrhage. It is hoped that the basic pathogenesis will be clarified as more patients with this syndrome are studied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Chronic ischemic ulcer, in a 43-year-okl male below-knee amputee. Poor prosthetic fit with venous obstruction was productive of this lesion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Pigmentation following stump edema syndrome. <i>A, </i>Brown pigmentation of the skin of the distal portion of the stump. <i>B, </i>Microscopic section of A, showing a marked increase in the thickness of the epidermis, with sclerosis of collagen and infiltration of pigment-laden cells. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edematous portions of the skin of the distal part of the stump may become pinched and strangulated within the socket (<b>Fig. 4</b>). Such areas may ulcerate or become gangrenous owing to impaired blood supply.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Strangulated skin. Unusual view, showing the distal stump skin resting on the foam-rubber cushion, as seen through the valve opening of a suction-socket prosthesis. A portion of the skin has become partially strangulated, resulting in stasis, edema, and pain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Contact Dermatitis</h4> <p>Contact dermatitis (<b>Fig. 5</b>) is caused by contact of the skin with a chemical that acts either as a primary irritant or as a specific allergic sensitizer. As defined by Schwartz,<a></a> "A Primary Cutaneous Irritant is an agent which will cause dermatitis by direct action on the normal skin at the site of contact if it is permitted to act in sufficient intensity or quantity for a sufficient length of time." Again using Schwartz' definition <a></a>, "A Cutaneous Sensitizer is an agent which does not necessarily cause demonstrable cutaneous changes on first contact but may effect such specific changes in the skin that, after five to seven days or more, further contact on the same or other parts of the body will cause dermatitis." Contact dermatitis may be acute, subacute, or chronic, and moderately severe to severe itching is present in most forms. In the acute and subacute types, diffuse erythema, edema, oozing, and crusting predominate. In addition, vesicles are often present if a specific allergic sensitizer is the cause. In chronic forms, erythema, scaling, and lichenification (thickening) prevail.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Contact dermatitis. <i>A, </i>Chronic, of the distal stump skin, due to contact with a plastic-covered cushion on the bottom of a suction socket. Removal of the cushion provided complete clearing in one week. Patch tests were positive for allergic sensitivity to the plastic <i>B, </i>Of the distal stum]) skin, due to contact with a foam-rubber pad on the bottom of a prosthetic socket. Note the circular zone of erythema and edema. Rapid clearing and disappearance of itching followed removal of the pad C, Left, the foam-rubber pad removed from the socket of the patient in <i>B; </i>right, the small piece of the material (4 mm in diameter) used in patch-testing <i>D, </i>Skin of the upper arm of the same patient as in <i>B, </i>showing a positive reaction to foam rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>We have seen a number of patients with contact dermatitis of the amputation stump. In order to understand the problem, we have had to learn about the plastics and resins used in the external and internal finishes of the different types of prostheses. In some instances, we found only by carefully taken history that the use of a new cream, lubricant, or cleansing agent coincided with the onset of the dermatitis. Some amputees use a foam-rubber cushion, others a plastic-covered pad on the bottom of their socket. These are also capable of producing a contact dermatitis of the skin weeks, months, or even years after use (<b>Fig. 5</b>, <i>A </i>and <i>B).</i></p> <p>On patients exhibiting the clinical manifestations of contact dermatitis, every attempt has been made to determine the exact contactant. Patch tests (<b>Fig. 5</b>, <i>C </i>and <i>D) </i>have been most informative with respect to specific substances as the cause of the dermatitis. In diagnostic patch-testing, a small amount of the suspected substance is applied to a site of normal skin on the patient. It is covered with an innocuous, impermeable material such as cellophane, which is then sealed to the skin by adhesive plaster. It is usually sufficient to leave the patch on for 24 to 48 hours. Upon removal of the patch, a positive reaction is signified by erythema, vesiculation, or blister formation at the site of application.</p> <p>Because patch-testing with strong concentrations of known primary irritants will result in reactions on any skin, solutions of such substances are first diluted according to published lists<a></a> in order to prevent a false positive reaction and possible injury to the skin. A generalized eruption following the patch test indicates a high degree of sensitivity, but fortunately such eruptions are rare. Experience and good clinical judgment are necessary in choosing the correct chemical concentration of the irritant and the proper time for performing the patch test.</p> <p>The sockets of leg prostheses are commonly finished on the inside by the application of a varnish or lacquer and on the outside by coating with plastics and resins. These complex organic substances are capable of causing a contact dermatitis in a given individual who has become sensitized. This sensitization is similar to that produced by poison oak or poison ivy, and the intensity of reaction may vary under different conditions of heat, humidity, and friction. The epoxy resins,<a></a> if incompletely cured in their manufacture, may, in addition to being a specific allergic sensitizer, produce a primary-irritant dermatitis. These resins are frequently used to improve the appearance of a socket and to render it impervious to external agents. In the uncured state at room temperature they are viscous, amber-colored liquids. Curing agents, known as catalysts or hardeners, are added to solidify the plastic material. These agents are organic amines of various types and, when left in excess by incomplete baking or curing at high temperatures, are able to produce a primary-irritant dermatitis.</p> <p>We have had several patients with proven contact dermatitis to Ambroid,® C-8 epoxy resin, polyethylene, foam-rubber pads, and plastic-covered cushions. Removal of the suspicious contactant resulted in a cure, and subsequent patch-testing proved the diagnosis.</p> <p>In those instances of contact dermatitis where the irritant has not been obvious and the patch tests have been inconclusive, temporary therapy has alleviated the symptoms. Cool compresses, bland antipruritic lotions, and the topical use of hydrocortisone or fluorohydro-cortisone preparations have been most beneficial.</p> <h4>Post-Traumatic Epidermoid Cysts</h4> <p>Young, <a></a> in 1951, described the appearance of multiple cysts in the skin of an amputee's thigh in association with the wearing of an artificial limb. Other authors<a></a> have described similar nodules in the skin under the rim of the socket. In the typical case (<b>Fig. 6</b>), the cysts do not appear until the patient has worn an artificial limb for months or possibly years. They occur most frequently in above-knee amputees in the areas covered by the upper medial margin of the prosthesis but have also been described in below-knee amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Post-traumatic epidermoid cysts. <i>A, </i>Early phase, in a Negro patient. Tiny follicular keratin plugs have developed in the skin of the adductor region. Some have enlarged to form tender nodules. <i>B, </i>Slightly later phase, in a 15-year-old white female. <i>C, </i>Still later phase, in the adductor region of a white male, where the nodules are larger and have become firm, tender, and cystic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Characteristically, in the above-knee amputee small follicular keratin plugs develop in the skin of the adductor region of the thigh along the upper edge of the prosthesis. In the beginning they appear as small lumps or nodules and will, at times, disappear when the prosthesis is removed temporarily. Under the constant friction and pressure of the prosthesis, they become larger and more numerous. Some become pea-sized, round, or oval swellings deep within the skin. Gradually, with enlargement, they become sensitive and tender to the touch. The skin may break down and erode or ulcerate. With continued irritation by the prosthesis, the nodular swelling may suddenly burst and discharge an opaque, purulent fluid. The discharging sinus may become chronic and thus make it impossible for the patient to use his prosthesis. In other instances, the break may take place within the deeper portion of the skin, and subcutaneous intercommunicating sinuses may develop.</p> <p>The larger nodules become especially tender and necessitate removal of the prosthesis. These should not be confused with ordinary furuncles or boils (<b>Fig. 7</b>), which may occur on any portion of the stump. Surgical excision of the chronic, isolated, noninfected nodule may give relief, but no completely satisfactory method of treatment is known. In the acutely infected phase, hot compresses and antibiotics are indicated. As the process localizes, incision and drainage may be beneficial temporarily. <i>Micrococcus pyogenes (Staphylococcus aureus) </i>is frequently a secondary bacterial invader and at times resistant to many antibacterial agents. In some of the cystic lesions, the contained fluid is sterile.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Furuncle, or boil. Subsiding, on the distal stump skin of a below-knee amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cysts range in size from microscopic papules to large nodules that can be palpated with the fingers. The microscopic picture, therefore, is variable, depending upon the size of the lesion and the extent of secondary irritation or infection. In the earliest phase, a keratin plug is seen to form. Later this plug invaginates the epidermis, and pockets of keratin appear in the subepidermal region of the skin. The invaginated epidermis containing keratin may be superficial or deep within the corium. As the keratin cyst enlarges and becomes secondarily infected, acute, subacute, and chronic inflammatory cells are seen. Foreign-body giant cells and newly formed capillaries and fibroblasts are not uncommon about the disintegrating cyst wall.</p> <p>Many authors have written extensively on the cause of these so-called "prosthetic nodules and abscesses," so frequently the concern of the physician, the limbfitter, and the amputee. Their occurrence is not restricted to wearers of the suction-socket prosthesis, since amputees complained of these inflamed swellings long before the suction socket came into widespread use. In the first third of this century, German investigators<a></a> ascribed the lesions to foreign bodies and wrote of finding "chamois-leather" particles, fine hairs, talc, and amorphous substances in the giant cells of the fully developed cyst. Other writers <i>{2,3,15) </i>disputed these foreign bodies as the cause and attributed the formation of the nodules to pressure and irritation from the socket and to epidermal keratin forced inward by this pressure. Some present-day investigators<a></a> regard the cysts as sebaceous adenomata and speak of sebaceous adenitis as being of frequent occurrence in the adductor region of the thigh stump. These and similar lesions have also been described in the hands and fingers following trauma.<a></a></p> <p>Although our studies have been limited, and although we are only now beginning to see these nodules in various stages of development, it appears that the condition is one in which the surface keratin and epidermis becomes invaginated, acting as a "foreign body." Under the influence of friction and pressure from the prosthesis, the keratin plug and its underlying epidermis are displaced into the corium. The result is the production of nonspecific inflammatory tissue and implanted epidermoid cysts. These can remain quiescent for a long period of time or can, with secondary bacterial invasion, become abscessed and produce the characteristic clinical and pathologic picture previously described.</p> <p>Recurrent and secondarily infected nodules may require the attention of a dermatologist or a surgeon. Some lesions necessitate incision and drainage. For others, total excision of the cyst under local anesthesia is the treatment of choice. These methods, however, do not solve the entire problem and may only succeed in alleviating an acute phase. The chronic problem can, in some instances, be mitigated or successfully eliminated by proper fit and alignment of the prosthesis.</p> <p>At the present time we are attempting the clinical trial of topical agents in an effort to prevent or retard the formation of the keratin plug, which may be the precursor of the epidermoid cyst. We are endeavoring to develop a stump sock or adductor rim sock for use with the suction-socket prosthesis to prevent cyst formation, but to date this effort has been of an experimental nature only. In our experience, there is no completely satisfactory method of treatment, and each amputee with the problem offers a therapeutic challenge.</p> <h4>Folliculitis and Furuncles</h4> <p>Folliculitis, usually caused by staphylococci, is a superficial bacterial infection of the hair follicle in which the primary lesion is an inflammatory papule or pustule. In contrast, a furuncle (<b>Fig. 7</b>) is a larger, more deep-seated, painful, bacterial infection of the pilosebaceous apparatus and is invariably caused by a staphylococcus or a streptococcus. Whereas folliculitis typically consists of multiple, small. itching, red papules, the furuncle, or "boil," is usually a tender, deep-red nodule which eventually rises to the surface of the skin and discharges its necrotic core.</p> <p>Folliculitis is a commonly encountered problem in the amputee, particularly in dark-complexioned, hairy persons with an oily skin. The condition is aggravated by the use of an artificial leg (<b>Fig. 8</b>). It is usually worse in summer, when increased warmth and moisture from perspiration promotes maceration of the skin, which, in turn, favors invasion of the hair follicle by bacteria. Ordinarily this process is not serious, but sometimes it progresses to boil formation, cellulitis, or an eczem-atous, weeping and crusted, superficial pyoderma.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Skin changes acompanying the early use of prosthesis <i>A. B, </i>and <i>C </i>show the skin of the same below-knee amputee. .1, Normal stump skin before the prosthesis was worn. <i>B, </i>Reactive hyperemia with itching and tingling, shortly after the prosthesis was used for the first time. Compare the flush with the normal skin color, which returns under pressure by the glass slide <i>C. </i>Small areas of folliculitis on the skin, which began to develop after wearing of the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Folliculitis and boils may follow upon poor hygiene of the stump or the socket or both. In several patients, chronic recurrent folliculitis was essentially cured by having the amputee adhere to the routine hygienic program using pHisoHex.® The hexachlorophene in this product is a hundred times more effective than is soap in eliminating skin bacteria, and that circumstance possibly accounts for the effectiveness of this program. In other instances, therapy may require the use of wet dressings, the incision and drainage of boils after localization, the oral or parenteral use of antibacterial substances, and the application of local bactericides, but we do not subscribe to the use of epilating doses of roentgen-ray therapy, which has been reported by Heller.<a></a> Since these conditions of the stump are frequently chronic or recurring, it is best to choose relatively nonsensitizing substances for topical application.</p> <h4>Additional Cutaneous Problems</h4> <p><i>Fungous Infections</i></p> <p>Superficial fungous infections of the stump may be difficult to eradicate completely because of continued moisture, warmth, and maceration of the skin within the enclosed socket of the artificial leg. Tinea corporis<a></a> , or ringworm of the nonhairy portions of the skin, is characterized by oval to round, scaly, erythematous, itching lesions, usually appearing only on the part of the stump enclosed by the socket. The diagnosis is confirmed by microscopic demonstration of the fungal filaments in scales or vesicles removed from a lesion. Therapy consists of the application of fungistatic creams and powders over an extended period.</p> <p><i>Nonspecific Eczematization</i></p> <p>Nonspecific eczematization of the stump skin has been seen in a number of instances (<b>Fig. 9</b> and <b>Fig. 10</b>). Here the amputee presents a weeping, itching, nonhealing plaque of dermatitis over the distal portion of the stump. The lesion is dry and scaly and then suddenly becomes moist without reason. It waxes and wanes over a period of months to years and may be a major source of mental anxiety.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Erosion and eczematization ot the stump skin from poor prosthetic fit and alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Nonspecific eczematization. <i>A, </i>Of three months' duration on the stump skin of a 32-year-old above-knee amputee who presented unusually poor stump cleanliness. <i>B, </i>Enlarged view of <i>A, </i>showing erythema, edema, and vesiculation. After a simple hygienic program with a sudsing detergent containing hexachlorophene, the eczematous process disappeared completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>We have tried to find the cause through either history, physical examination, or laboratory tests, or through studying the clinical course of the eczematous process. At times we have been able to elicit a significant history of recurrent allergic eczema or to demonstrate active eczematous lesions on other portions of the body to account for the eruption on the stump. In other instances, the eczema was secondary to edema and congestion of the terminal portion of the stump, so that only with the alleviation of these problems did the condition clear. Drug sensitivities from the internal use of an agent such as penicillin may present themselves on the amputation stump. Ideally, whenever possible, the cause of the eczema should be found and removed. Temporary symptomatic treatment with topical hydrocortisone or fluorohydrocortisone preparations is effective, but the condition will frequently recur unless the cause is eliminated.</p> <p><i>Generalized Disorders</i></p> <p>The localization of other skin disorders on the amputee's stump is not an uncommon occurrence. We have seen patients with acne vulgaris of the face and back develop acne lesions of the stump. We have seen similar localizations in patients with seborrheic dermatitis, folliculitis, and eczema. There are recorded instances of psoriasis and lichen planus developing on the stump skin with few lesions present elsewhere on the body <i>{9). </i>Here again, it is important to diagnose the generalized cutaneous disorder and to treat it der-matologically in order to improve the stump condition.</p> <p><i>Intertriginous Dermatitis</i></p> <p>An intertriginous dermatitis is an irritative condition of those skin surfaces which are in constant apposition and between which there is a hypersecretion and a retention of sweat. This situation usually occurs in the crotch (<b>Fig. 11</b>), but on occasion it occurs in the folds at the end of the stump where two regions of skin rub each other and where the protective layer of keratin is removed by the friction. A chronic disorder may develop, with deep, painful fissures and with infection and eczematization. Hygienic measures to cleanse the apposing folds and the use of drying powders are beneficial. At times, it may be necessary to re-excise the bulky, infolded stump skin in an effort to provide a linear scar which would preclude this form of disorder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Skin irritation in the crotch area. <i>A, </i>Chronic, resulting from continued friction and pressure from the socket. <i>B, </i>Enlarged view of <i>A</i>, showing thickened (lichenified) and pigmented skin containing the early phase of post-traumatic epidermoid cysts. The skin of this area may become eroded or ulcerated. In some instances, these problems may be corrected by proper prosthetic fit and alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Adherent Scars</i></p> <p>With repeated infection and ulceration of the skin, the scar may become adherent to the underlying subcutaneous tissues (<b>Fig. 12</b>), a condition which invites further erosion and ulceration. Long wear and tear from the use of a prosthesis may necessitate surgical revision in order to free the scar in the bound area.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Scar tissue of several years' duration on the distal stump skin. Through repeated years of wear and tear from using a prosthesis, the skin has become adherent to the underlying tissue. Such abnormalities are capable of causing repeated infection, erosion, and ulceration. This below-knee amputee .was treated by surgical revision of the scarred area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Chronic Ulcers</i></p> <p>Chronic ulcers (<b>Fig. 2</b>) of the stump may result from bacterial infection or from poor cutaneous nutrition secondary to an underlying vascular disorder. In every instance, the underlying cause should be investigated and appropriate treatment provided. Malignant ulcers have developed within old, persistent stump ulcerations, and hence every effort should be made to diagnose the condition before it becomes chronic.</p> <p><i>Tumors</i></p> <p>Tumors of the stump may be malignant or benign. We have seen innocent hyperkeratosis, or callus formation, and have removed verru-cae, or viral warts, from the stump skin. Simple "skin tags," or cutaneous papillomas, are easily removed dermatologically under local anesthesia. A cutaneous horn (<b>Fig. 13</b>) on an amputation stump has been recorded<a></a>, and we have removed one from a below-knee amputee wearing a conventional prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Cutaneous horn of several years' duration in a below-knee amputee. Local excision of the lesion was curative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extensive verrucous hyperplasia (<b>Fig. 14</b>) of the entire terminal stump skin has been seen in one instance. A surgical biopsy failed to reveal the pathologic picture of viral verrucae. This hyperplastic condition was felt to be secondary to an underlying vascular disorder, bacterial infection, and poor prosthetic fit and alignment. Treatment to date has consisted of adequate control of the bacterial process and gradual end-bearing maneuvers to improve the vascular stasis. A new prosthesis is being manufactured to correct the fit and alignment. Here is an example of the need for the services of the entire clinic team to provide the maximum benefit to the individual amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Verrucous hyperplasia of the distal stump skin. <i>A, </i>Distal view, showing the warty nature of the skin. This hyperplastic condition was felt to be secondary to an underlying vascular disorder, bacterial infection, and poor prosthetic fit and alignment. <i>B, </i>Microscopic section of a warty nodule in <i>A. </i>Note the hyperplasia of the epidermis, with sclerosis of the collagen and chronic inflammation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Malignant tumors of the stump skin have been recorded by others, but we have not as yet encountered any primary cancers in our series of patients.</p> <h4>Summary</h4> <p>The cutaneous problems of the lower-extremity amputee are many and varied. They are real problems, which can begin insidiously without creating additional disability and then, through neglect and mistreatment, seriously threaten the social and economic rehabilitation of the amputee. A variety of skin disorders are found to localize on the skin of the lower-extremity stump because of the many new insults to which it is subjected when a prosthesis is worn. These disorders may require dermatologic consultation for either diagnosis or treatment.</p> <p>In the past year, the cutaneous difficulties associated with the wearing of a leg prosthesis have been evaluated during more than 200 patient-visits to the Lower-Extremity Amputee Research Project at the University of California Medical Center in San Francisco. Hygiene is important in relation to many skin disorders of the stump, and consequently a specific hygienic program is being developed, The danger signals and the clinical problems which have been found to require medical attention include the stump edema syndrome, contact dermatitis, post-traumatic epidermoid cysts, folliculitis and furuncles, superficial fungous infections, nonspecific eczematization, intertriginous dermatitis, chronic ulcers, and tumors of the stump.</p> <p>The skin-study group is a comparatively recent addition to the Lower-Extremity Amputee Research Project of the University of California. It is hoped that, through this study group, the varied cutaneous disorders associated with the lower-extremity amputee will, over a period of time, be fully classified and thereby be prevented.</p> <h4>Acknowledgments</h4> <p>The author is indebted to Mrs. Ellen Brennan for her coverage of the literature and to Mr. Leo Sakovich for his help with the photographs. Sincere appreciation is expressed to these laboratory technicians and to the other personnel of the University of California Medical Center in San Francisco for their aid in the completion of this paper.</p> <p><b>References:</b></p> <ol> <li>Conn, H. R., <i>Amputation stumps of lower ex- tremities: the causes and treatment of prolonged disability, </i>Surg., Gyn., &amp; Obstet., 43:524 (1926).</li> <li>Gillis, Leon, <i>Amputations, </i>William Heinemann Medical Books, Ltd., London, 1954.</li> <li>Gillis, Leon, <i>Infected traumatic epidermoid cysts, the result of rubbing by an artificial limb, </i>Proc. Roy. Soc. Med., 47:9 (1954).</li> <li>Heller, W., <i>Zur Behandlung von Furunkeln und Follikuliliden, am Amputationsstumpf, </i>Deutsche med. Wchnschr., 69:812 (1943).</li> <li>King, E. S. J., <i>Post-traumatic epidermoid cysts of hands and fingers, </i>Brit. J. Surg., 21:29 (1933).</li> <li>Makai, Endre, <i>Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten)</i>, Zent-ralbl. f. Chir., 57:590 (1930).</li> <li>Mayne, F. E., and L. O'Shaughnessy, <i>Cutaneous horn on an amputation stump, </i>Brit. Med. J., 1: 624 (1931).</li> <li>Savitt, Leonard E., <i>Contact dermatitis encountered in the production of epoxy resins, </i>A. M. A. Arch. Dermat. &amp; Syphilol., 71:212 (1955).</li> <li>Schamberg, I. L., <i>Dermatitis of lower limb amputa- tion slump, </i>J. Am. Med. Assoc, 150:1653 (1952).</li> <li>Schwartz, Louis, <i>Allergic occupational dermatitis in our war industries, </i>Ann. Allergy, 2:387 (1944).</li> <li>Schwartz, L., L. Tulipan, and S. M. Peck, <i>Occupa- tional diseases of the skin, </i>2nd ed., Lea &amp; Febiger, Philadelphia, 1947.</li> <li>Slocum, Donald B., <i>An atlas of amputations,</i> Mosby, St. Louis, 1949. pp. 254-288.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945. pp. 54-67.</li> <li>Wohlvill, Fr., <i>Über "Prothesenrandknoten," </i>Virchows Arch. f. path, Anat.. 288:576 (1933).</li> <li>Young, Freida, <i>Post-traumatic epidermoid cysts,</i> Lancet, 1:716 (1951).</li> <li>zur Verth, [M.], <i>Prothesenrandknoten und Pro- thesenrandabszesse, </i>Zentralbl. f. Chir., 63:322 (1926).</li> <li>zur Verth, [M.], <i>Prothesenrandknoten und ihre Entstehung, </i>Dermat. Wchnschr., 88:45 (1929).</li> <li>zur Verth, M., and K. H. Vohwinkel, <i>Prothesen- randknoten, </i>Deutsche Ztschr. f. Chir., 205:302 (1927).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Mayne, F. E., and L. O'Shaughnessy, Cutaneous horn on an amputation stump, Brit. Med. J., 1: 624 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Schamberg, I. L., Dermatitis of lower limb amputa- tion slump, J. Am. Med. Assoc, 150:1653 (1952).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Heller, W., Zur Behandlung von Furunkeln und Follikuliliden, am Amputationsstumpf, Deutsche med. Wchnschr., 69:812 (1943).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Conn, H. R., Amputation stumps of lower ex- tremities: the causes and treatment of prolonged disability, Surg., Gyn., &amp;Obstet., 43:524 (1926).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">King, E. S. J., Post-traumatic epidermoid cysts of hands and fingers, Brit. J. Surg., 21:29 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations, Mosby, St. Louis, 1949. pp. 254-288.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945. pp. 54-67.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Makai, Endre, Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten), Zent-ralbl. f. Chir., 57:590 (1930).</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Wohlvill, Fr., Über 'Prothesenrandknoten,' Virchows Arch. f. path, Anat.. 288:576 (1933).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und Pro- thesenrandabszesse, Zentralbl. f. Chir., 63:322 (1926).</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und ihre Entstehung, Dermat. Wchnschr., 88:45 (1929).</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">zur Verth, M., and K. H. Vohwinkel, Prothesen- randknoten, Deutsche Ztschr. f. Chir., 205:302 (1927).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Gillis, Leon, Amputations, William Heinemann Medical Books, Ltd., London, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Gillis, Leon, Infected traumatic epidermoid cysts, the result of rubbing by an artificial limb, Proc. Roy. Soc. Med., 47:9 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Makai, Endre, Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten), Zent-ralbl. f. Chir., 57:590 (1930).</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945. pp. 54-67.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Wohlvill, Fr., Über 'Prothesenrandknoten,' Virchows Arch. f. path, Anat.. 288:576 (1933).</td></tr><tr><td class="clsTextSmall"><b> 16.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und Pro- thesenrandabszesse, Zentralbl. f. Chir., 63:322 (1926).</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und ihre Entstehung, Dermat. Wchnschr., 88:45 (1929).</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">zur Verth, M., and K. H. Vohwinkel, Prothesen- randknoten, Deutsche Ztschr. f. Chir., 205:302 (1927).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Young, Freida, Post-traumatic epidermoid cysts, Lancet, 1:716 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Savitt, Leonard E., Contact dermatitis encountered in the production of epoxy resins, A. M. A. Arch. Dermat. &amp;Syphilol., 71:212 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Schwartz, L., L. Tulipan, and S. M. Peck, Occupa- tional diseases of the skin, 2nd ed., Lea &amp;Febiger, Philadelphia, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schwartz, Louis, Allergic occupational dermatitis in our war industries, Ann. Allergy, 2:387 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schwartz, Louis, Allergic occupational dermatitis in our war industries, Ann. Allergy, 2:387 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>S. William Levy, M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Instructor in Dermatology, School of Medicine, University of California Medical Center, San Francisco, and supervisor of the Study Group on Dermatology, Lower-Extremity Amputee Research Project, University of California, Berkeley and San Francisco.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b001.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b002.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b003.jpg Figure 4 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b004.jpg Figure 5 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b005.jpg Figure 6 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b006.jpg Figure 7 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b007.jpg Figure 8 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b008.jpg Figure 9 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b009.jpg Figure 10 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b010.jpg Figure 11 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b011.jpg Figure 12 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b012.jpg Figure 13 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b013.jpg Figure 14 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b014.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Skin Problems of the Lower-Extremity Amputee Creator An entity primarily responsible for making the resource S. William Levy, M.D. *