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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/1984_02_004.pdf Text Any textual data included in the document <h2>The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries</h2> <h5>Andre Bähler&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The last decades have shown a marked increase in the number of people, both young and old, participating in sporting activities. As a result of systematic education and schooling, it has become generally recognized that a certain amount of physical exercise is necessary for a healthy body.</p> <p>The mass media—radio, television, the press—as well as schools and private insurance companies, have systematically reported the advantages to be gained by participating in physical activities.</p> <p>Sports are no longer the prerogative of the young; there is no age limit for those engaged in sports in one form or another. Senior citizen keep-fit groups, jogging, and the like, have proven to many older people that age is not a justified reason to neglect physical fitness, and they have become aware that exercise is a means of showing the body the respect it deserves.</p> <p>However, this almost revolutionary attitude towards sports is not limited to amateurs, but has also brought changes into the world of top athletes. Today, the degree of involvement is greater than ever before, but so accordingly are the associated risks. Many forms of sports seem to have lost sight of the original ideal of sportsmanship. Enjoyment and leisure have been replaced by a deadly seriousness in attitude that only total dedication will bring the desired results. Not only in the competition itself, but in the long months and sometimes years of training prior to it, the body is stretched to its utmost. Success at any price is the motto of the day, and such an attitude consciously calculates and accepts casualties and losses as part of the "game."</p> <p>It has been proven that this type of approach to sports results in an increase in injuries, strain, and general wear, particularly in the joints of the lower limbs. Clearly, modern sports put the knee-joint under great pressure. Be it cycling, football, skiing or ice-hockey, the movement of the knee is of central importance, as changing techniques increase the pressure put on it.</p> <p>The large number of knee injuries are a cause of great concern to modern sports medicine. The top athletes in particular, are anxious to start training again as soon as possible after injury. Although the knee is capable of taking great strain, mobility is often restricted, either by external injuries, or because of wear within the joint itself.</p> <p>Immobilization of the joint after injury or surgery can damage the cartilage, hindering the assimilation of nutrients. The ligaments begin to lose their tensility, there is a loss of coordination between muscle groups, and muscles atrophy.</p> <p>Finally, immobilization of a limb also affects the whole organism, particularly circulation, respiration, and the digestive system, and last but not least, the psychological effect of immobilization should not be underestimated.</p> <p>Controlled movement of the knee-joint after ligament surgery has great advantages during rehabilitation: movement between 20-60 degrees does not strain the collateral or cruciate ligaments to any degree.</p> <p>The muscles are also activated within pre-controlled limits. In tests, Hettinger found that 20-30 percent of the maximum pressure was sufficient to retain normal muscle strength. However, in order to increase muscle strength, the pressure must be at least 40-50 percent, and this is not possible after surgery. Therefore, rehabilitation requires electro-stimulation. A pre-condition of functional treatment is the exact restoration of all the anatomical elements, (e.g. cruciate and collateral ligaments).</p> <h3>Rehabilitation Phases</h3> <p><i>Pre-operative Treatment</i></p> <p>When reconstructive surgery is required in the case of an old injury to the knee, the time before the operation should be used to improve and retain muscle strength, for coordination exercises, and to instruct and explain the postoperative treatment</p> <p><i>Post-operative Treatment</i></p> <p><b>Day 1</b>: For the rest period, the leg should be held in a preoperative prepared plaster-splint with a flexion angle of 20-30 degrees.</p> <p><b>Day 5</b>: A knee-orthosis with a 20-50 degree range of movement is fitted and a gentle swinging movement is allowed. The orthosis is also worn in the pool but the injured leg should not actually be used for swimming. Rehabilitation at this stage should also include controlled extension and flexion exercises between 20-60 degrees and isometric quadricep training.</p> <p><b>Fifth to sixth week</b>: Flexion and extension exercises from 0-90 degrees should be practiced. For walking, the orthosis must be locked in extension with the swiss-lock.</p> <p><b>After eight weeks</b>: The lock can be removed and the patient may be allowed to walk with free movement of the joint. The orthosis is usually worn for approximately one year.</p> <h3>The Principles of Fixation and Correction with the Orthosis</h3> <p>Both the upper and lower leg must be securely held all round. If necessary, support at the thigh is given on the same principle as a prosthetic support. If the upper and lower leg are kept straight, then it is best to use a physiological (polycentric, Ed.) knee-joint.</p> <p>However, if the securing bands of the orthosis are made of rubber or a similar material, then a simple single-axis knee-joint is sufficient.</p> <p>Besides the above mentioned points, the orthosis for post-operative rehabilitation after ligament reconstruction must also exhibit the following characteristics:</p> <ol> <li> <p>The program of correction or fixation must be exactly determined in advance.</p> </li> <li> <p>The upper and lower leg must be securely held in the orthosis.</p> </li> <li> <p>The construction of the joint must allow for varying ranges of mobility:</p> <ol> <li> <p>20-50 degrees</p> </li> <li> <p>0-90 degrees with the option of a locking device</p> </li> <li> <p>0-120 degrees with free movement.</p> </li> </ol> </li> </ol> <h3>Procedure to Relieve the Medial or Lateral Ligaments</h3> <p><i>Principle: Triple-point correction (<a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg"><b>Fig. 1</b></a>)</i></p> <p><strong><a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg">Figure 1</a>. Triple-point correction to relieve the medial or lateral ligaments.&nbsp;</strong><br /><br />The principle underlying the triple-point correction, forms the basis for efficient correction of genu varum or genu valgum. With young patients, it is possible to position the correcting pressure-pads exactly, but with older patients, because of the flaccid tissue, pressure must be applied over as large an area as possible, e.g., with splints which distribute the pressure equally. For technical as well as anatomical reasons, it is often not possible to apply pressure at the centre of the joint itself, therefore pressure must be applied above and below the joint, but as near to it as possible.</p> <p>If the splints do not fit securely, then the orthosis will twist inwards when bent and this results in a reduction of the correcting forces at extension.</p> <h3>Procedure for Controlling the Posterior Drawer</h3> <p><i>Principle: Posterior pressure on the proximal lower leg and anterior pressure on the distal upper leg (<a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg"><b>Fig. 2</b></a>)</i></p> <strong><a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg">Figure 2</a>. Controlling the posterior drawer.</strong><br /> <p>There are two biomechanical procedures to choose from:</p> <ol> <li> <p>Fixation of the upper and lower leg with the orthosis on the basis of the triple-point method. With this method, the splints are fitted individually to the upper and lower leg and the correcting pressures are placed so that a posterior drawer is held firmly.</p> </li> <li> <p>Placing the correcting pressures in such a way that together with the knee-joint of the orthosis, they act as a lever. Here too, it is advantageous to distribute the pressure over as large a surface as possible (<a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg"><b>Fig. 3</b></a>).</p> <strong><a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg">Figure 3.</a> An alternative approach</strong></li> </ol> <h3>Procedure to Correct the Anterior Drawer</h3> <p><i>Principle: Anterior pressure on the proximal lower leg and posterior pressure on the distal upper leg</i></p> <p>This involves, first, the fixation of the upper and lower leg with the orthosis on the basis of the triple-point principle (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg"><b>Fig. 4</b></a>), and second, placing the correcting pressure so that together with the knee-joint of the orthosis, they act as a lever. The greater the distance between the knee and the external counter-pressure, the better the corrective effect (<a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg"><b>Fig. 5</b></a>).</p> <strong><a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Figure 4</a>. Fixation of the upper and lower leg.&nbsp;</strong><br /><br /><strong><a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Figure 5</a>. Increase the distance between the knee and the external counter-pressure</strong><br /> <h3><br />Restricting Rotation</h3> <p>The restriction of rotation depends on how well the orthosis fits the upper and lower leg. The efficiency of the orthosis in restricting rotation is determined less by the type of orthosis, than by the size and type of the surface area of support. In practice, the following points must be checked:</p> <ol> <li> <p>Any fixation of the knee-joint must conform to the principles of biomechanics.</p> </li> <li> <p>The orthosis and all bandages should cover the leg properly to ensure that the orthosis does not slip.</p> </li> <li> <p>The orthosis must fit so as not to hinder or limit muscle activity.</p> </li> </ol> <p>As we found that the orthotic devices available at present did not completely satisfy our needs, we devised a system of our own which we would now like to explain with the help of some photographs.</p> <h3>Type I: Sport Orthosis for Old Injuries to the Knee, or for Instability of the Joint</h3> <p>In order to keep the reduction in fitness to a minimum, the athlete aims to return to training as soon as possible. However, the knee is often not strong enough to cope with the high demands made upon it and needs some form of support, without however, limiting the range of movement.</p> <p>This orthosis guides the joint and eliminates the forward and backward drawer as well as movements to the side (<a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg"><b>Fig. 6</b></a>, <a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg"><b>Fig. 7</b></a>, <a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg"><b>Fig. 8</b></a>). If necessary, it can also be fitted so as to restrict all extreme movements. The half-splints of the orthosis are made of the new Plexiglass XTO (natur) by the Röhm Company (Darmstadt 1). This material is much tougher than the well-known Plexidur. It is easy to form, and locks can be fitted to the joints without first having to be strengthened. In order to stop the splints from slipping, they are lined with a thin layer of foam-rubber. The best results are achieved when the orthosis is formed from a plaster model of the leg.</p> <strong><a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Figure 6.</a> The sport orthosis eliminates forward and backward drawer.&nbsp;</strong><br /><br /><strong><a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg">Figure 7.</a> The orthosis can be fit to eliminate all extreme movements.&nbsp;</strong><br /><br /><strong><a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg">Figure 8.</a> The half-splints are made of Plexiglass XTO.</strong><br /> <h3>Type II: Orthosis for Operative Ligament Reconstruction, or Other Similar Serious Knee Injuries</h3> <p>Basically the same orthosis is made as in Type I (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg"><b>Fig. 4</b></a>, <a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg"><b>Fig. 5</b></a>, <a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg"><b>Fig. 6</b></a>) but with the difference that a lock and positioning-screw are fixed to the outside of the splint (<a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg"><b>Fig. 9</b></a>, <a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg"><b>Fig. 10</b></a>). As already mentioned, the positioning screw allows a movement between 20-60 degrees. After a while, this can be removed and the lock used to hold the leg in extension.</p> <strong><a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg">Figure 9</a>. A lock and positioning screw are fixed to the outside of the splint.</strong><br /> <p><strong><a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg">Figure 10</a>. The positioning screw allows movement between 20-60 degrees.&nbsp;</strong><br /><br />Depending on the injury, the half-splints are placed either at the front or at the back of the upper and lower leg. Securing straps and pressure-pads increase the corrective effect.</p> <em><b>*Andre Bähler </b> Andre Bähler is an Orthotist/Prosthetist from Zurich, Switzerland.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-05.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/1984_02_004/1984_02_004-06.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-03.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-10.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 The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries Creator An entity primarily responsible for making the resource Andre Bähler * https://staging.drfop.org/files/original/785f66484a457dd5ea36486281669c63.pdf 2a13be21d16b3cba581d0f5c39829307 https://staging.drfop.org/files/original/de0295080d2342091ee8d35f8b9eb492.jpg 67f6018770a74ed03cb90a1fdcf80b22 https://staging.drfop.org/files/original/a2e780143e6e8508bc090f38eec6847b.jpg ce791d7bd02f539672bfd6aafc1c7955 https://staging.drfop.org/files/original/01140c6f2bcd0a25691175b8982667e4.jpg e646a27436a751e896353b213a2dacc9 https://staging.drfop.org/files/original/039eec2639e19736a06618dc61593eb5.jpg 8c7aaa7044354c386391909637bb056e https://staging.drfop.org/files/original/2acaa9f6178a16d99894a0ec19c23ef7.jpg 4a7f9f5704a2518e642edd71b92c8c87 https://staging.drfop.org/files/original/fb289d965166e603e52ef903cea429f0.jpg 5c402e4e8983f7fc34a947dfa7335046 https://staging.drfop.org/files/original/d63440c21a0f69b8b5fb63b022e61190.jpg 66831f497f8cdab5da95d86117ef5763 https://staging.drfop.org/files/original/85b340c5dff8d0a0258af2bdad391640.jpg e637b228d06590314f7d668b4f83decf https://staging.drfop.org/files/original/3db34f12dfb1ec30ad911b4f9f24f9b3.jpg 47a226f4750a71f160e119ae48cff694 https://staging.drfop.org/files/original/20eafe5419c83630cf610007cac7a089.jpg 1863122494926efc5d49d2ad8f203365 https://staging.drfop.org/files/original/874cfc1d92441810888b9aa4c0d9f3ae.jpg da650953df53e1189a6777e2c01b1726 https://staging.drfop.org/files/original/7dc88dda4cf9dc97e0c41a5b9d4df0d9.jpg cad29965382e0be70dcc5c64fea49d17 https://staging.drfop.org/files/original/4ad6c948c583a6f956dd404eb175790b.jpg 78415e090cb4b1a74fd776db498158fb https://staging.drfop.org/files/original/41b685212583f4394899d15ff59a4ff5.jpg a6bbba17a745d1a8aed594e0f6dd0292 https://staging.drfop.org/files/original/65118f6ccc79f81819690361de395d17.jpg 9e265f25fc1297f5a01dd3614e1cd25e https://staging.drfop.org/files/original/194efbb8bfd7cd41bd9e251cf5345c21.jpg cf723eb59e370d89b74acefbeb52cb82 https://staging.drfop.org/files/original/df9ae6774a07620814409dcd6667d120.jpg 47ea548a6ed55d80d656723d22946d5f https://staging.drfop.org/files/original/0ca4197cba7b3be9c1adb317f610eeb7.jpg f97971b37ea237eb8c1ce8cbaef544a9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_057.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 57 - 64 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/1970_01_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_057.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>Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material</h2> <h5>Anthony Staros <br />Henry F. Gardner <br /></h5> <p> Prior to forming the socket, a careful evaluation of the stump must be made. The usual prosthetics data must be noted, especially any stump characteristics which would require special considerations for socket comfort. </p> <p> With the patient seated, a lightweight cast sock is applied snugly <b>Fig. 1</b> to maintain tension. The top of the sock is clamped to a strap encircling the patient's hips. The strap is made of two halves of mating Velcro for easy adjustment behind the patient's back, and the two free ends are equipped with Yates clamps, which are placed medially and laterally at the top of the sock. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of a lightweight cast sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A strip of 1/4-in. felt, cut to form a tib-ial-crest relief, is positioned from the superior border of the tibial tubercle to <i>and over the end of the stump </i><b>Fig. 2</b>. The portion of the pad over the tubercle is made approximately 1 1/4<i> </i>in. wide, tapering to a 5/8-in. width for the entire length of the tibial crest relief. All edges are carefully skived. If adhesive-backed felt is not available, medical adhesive may be used to attach the pad. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Placement of the relief for the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A second lightweight cast sock is pulled snugly over the tibial relief and fastened in the same manner as the first sock <b>Fig. 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stump with second cast sock applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Using the VAPC knee caliper, the anterior-to-posterior knee measurement at the level of the patellar tendon is taken <b>Fig. 4</b>. The medial-to-lateral dimensions of the epicondyles of the femur are measured in the same manner. These dimensions are useful in determining the accuracy of the socket. The maximum depth of the patellar ledge is determined by the A-P measurement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Measuring stump dimensions with the VAPC caliper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Socket Forming </h4> <p> A section of Polysar<a style="text-decoration:none;">*</a> X-414 synthetic rubber tubing with a 1/4-in. wall is selected. The diameter of the tubing should be one-third of the mid-stump circumference. The tube length should be approximately one and one-half times the distance measured <i>from the top of the knee to the end of the stump </i><b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Determining the proper length of tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A section of Helenca stockinet 36 in. long is used to pull the heated tube over the stump. One end of the stockinet is pulled up on the stump as shown in <b>Fig. 6</b>. The other end is passed through the heated tube. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The stockinet in position over the stump for pulling on heated plastic tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The inside surface of the tube is thoroughly cleaned to remove all plastic dust. (When heated, the dust would cohere to the inner walls, causing undesirable irregularities.) </p> <p> The dust-free tube is softened by immersing it in water heated to 180 deg F, or just under the boiling point, for four to six minutes. Because the inner walls of the tube would cohere instantly if permitted to touch when heated, <i>the tube is placed on its end in the water container.</i> </p> <p> To facilitate slipping the tube over the knee, the upper half is enlarged by spreading (hands together, palms out). The end of the stockinet hanging from the stump is pulled through the heated tube. The tube is pushed on the end of the stump and carried up over the stump by a continuous pull on the stockinet <b>Fig. 7</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Pulling the heated tube over the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Twists or folds in the stockinet should be avoided while drawing the stockinet and plastic tube over the stump. </i>The forming pressures which compress the soft thermoplastic produce a slight imprint of the stockinet material on the inner surface of the socket, and any folds or twists in the stockinet will cause undesirable irregularities in the inner socket wall. The top of the stockinet is then clamped in the same manner as the cast socks. </p> <p> The upper socket borders are trimmed with bandage scissors, leaving the posterior borders approximately 1/2<i> </i>in. higher than the required measurement, for later rolling out of the material to form a relief for the hamstrings <b>Fig. 8</b>. The remainder of the socket border is cut transversely above the superior edge of the patella. The lower tube end and the stockinet are trimmed to provide an extension of 3 in. beyond the stump. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Trimming the upper socket borders before molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stump is held relaxed in 5 to 10 degrees of flexion. Starting approximately 1/2<i> </i>in. above the stump end, a snug wrap of 1-in. elastic pressure-sensitive tape is applied over the tube in a continuous anterior-to-medial spiral, with increasing </p> <p> tension approaching the level of the medial tibial flare and continuing over the knee <b>Fig. 9</b>). The tension is controlled best if one steadies the socket while the other wraps half of the circumference. The hands then change functions to wrap the other half of the circumference. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Application of pressure using an elastic pressure-sensitive-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The section of soft tubing extending below the stump will tend to sag. This must be prevented by supporting this section until it cools while molding the material. Approximately 10 minutes are required for the material to harden. During this time, the socket is molded to provide freedom over the anterior end of the tibia by massaging the taped surface of the socket to define the tibial crest and medial flares of the tibia <b>Fig. 10</b>. During the molding process, all surface irregularities may be pressed out of the socket. The socket should not be removed from the stump until the thermoplastic is no longer deformable by hand. The tape is removed, and with the knee flexed to at least 90 degrees, the socket is forced from the stump. Later, pressure-sensitive fiberglass or nylon tape may be put on the socket as a circumferential (barrel hoop) reinforcement, usually required only around the proximal brim. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Hand molding to define the medial tibial flare and tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The resulting open-end socket will permit easy attachment of the shank. Once the socket extension has been secured to the shank, the end of the socket chamber is filled with foam, or another type of resilient end pad is provided. </p> <h4> Socket Modifications </h4> <p> To modify the socket, heat is focused with a heat gun fitted with a cone <b>Fig. 11</b>. With one hand placed inside the socket against the surface to be modified, heat is directed to the <i>immediate area from close range </i>until the heat is sensed by the fingers through the socket wall. <i>Large areas should not be heated, nor should heat be directed against the socket for a prolonged period of time, because excessive temperature will cause the plastic to boil and discolor. </i>When molding for a pressure point, one finger should press from inside the socket, and the surrounding areas should be supported on the outside of the socket with the fingers of the other hand. After the molded area has cooled sufficiently to retain its shape, the socket should be chilled with cold water or refrigerated for a short interval to reset the plastic. <i>Caution must be exercised to avoid heating the entire socket. The heat should be concentrated on the one spot until the pressure applied with the fingers inside the socket causes the material to yield.</i> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Heat gun with modified cone for control of heated area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A similar procedure is followed to shape the patellar-tendon ledge. For patients who have previously worn prostheses, the A-P measurements obtained by caliper are used to determine the depth of the ledge. For recent amputees, the patellar-tendon ledge is not molded to the maximum depth in one adjustment. Instead, three or more adjustments should be made at intervals of one month until the required A-P dimension is reached. </p> <p> The proximal posterior socket border is heated and rolled out to form a smooth radius for comfortable knee flexion <b>Fig. 12</b>, the border being maintained at approximately the patellar-ledge level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Rolling out the softened posterior socket wall. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> An adjustable pylon is prepared with a wood socket-attachment block 1 V'2 in. thick and 3 in. in diameter, with a Vi-in. deep circumferential groove at the midpoint of the block. The block is tapered to a slightly smaller diameter around the bottom, then fastened permanently to the pylon with bolts and cement <b>Fig. 13</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. The pylon and socket ready for assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The tube end extending distally from the socket is heated, then fitted over the wood pylon-attachment block, with the groove helping to make a good bond. <i>A 1-in. space between the stump end and the attachment block must be maintained. </i>The tube is taped tightly to the wood block and permitted to cool <b>Fig. 14</b>. Any excess tubing extending below the wood can be trimmed while the plastic is still soft. When hardened, the tube is fastened permanently to the wood block with four screws set at 90-degree angles to one another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The heated socket bottom is joined to the pylon with elastic-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Suspension </h4> <p> To provide for suspension, the socket can be trimmed at the regular PTB level and a separate cuff used above the knee. Of the several kinds of PTB suspension that can be provided with this socket, suprapatellar-supracondylar suspension is described. </p> <p> The patient is seated in a chair with his knee flexed at approximately 45 degrees, and the stump is covered with two cast socks. The upper socket walls above the level of the upper border of the patella are softened by holding the socket (bottom up) in hot water. When the socket top is heated, the stump is pushed into the socket. The plastic is molded against the thigh over the condyles by wrapping tightly with pressure-sensitive tape and hand molding. </p> <p> After the patient has been fitted and the prosthesis aligned, the bottom of the socket chamber should be foamed to obtain a total-contact fitting. To avoid difficulty in quickly inserting the stump into the socket, the stump is covered with a lightweight sock and a powdered PVA bag. Three 1/8-in. holes are drilled through the lower socket wall at the level at which the stump begins to taper inwardly, away from the socket wall. A foam mixture is prepared and poured into the socket <b>Fig. 15</b>. The patient's stump is inserted into the socket and the patient stands still until the foam has set. The. foam mixture may vary, depending upon the type of stump and condition of the distal tissues. Usually a combination of foam and RTV rubber is used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pouring the foam mixture to form the total-contact socket bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Shaping and Finishing</h4> <p> A leg shape can be made from prefabricated sections of semirigid foam, Koroseal Spongex.<a style="text-decoration:none;">*</a> Beginning at the level of the patella, a paper pattern is cut to fit around the socket at this level. The pattern is traced upon one foam section <b>Fig. 16</b>. The foam is carefully sanded to form a hollow for the socket. It is necessary to obtain a tight, gap-free fitting of the foam to the socket; best results are obtained from a slight stretch fit. For this, the foam is heated in an oven at 180 deg F before placement over the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Foam blocks prepared for fitting over the pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To cover the remaining part of the pylon, a foam block is cut to correspond to the measurement between the bottom of the foam surrounding the socket and the top of the foot plus 1/4 in. A hole is made through the length of the block large enough to receive the pylon tube. Since the foam is semirigid, the areas for the alignment coupling and ankle plug of the pylon are cut slightly undersize to permit a snug fit about the pylon <b>Fig. 17</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Foam blocks fitted over the socket and pylon and rough-shaped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A 1/2-in. hole is bored transversely through the foam block to permit entry of a screwdriver to fasten the tube clamp. The two foam sections are <i>not </i>glued together, in order to facilitate removal for alignment adjustments. Compression of the foam block between the socket base and the foot will prevent any movement of the block. </p> <p> The blocks are shaped with a band saw or knife and sanded with a drum or cone sander. For cosmesis, either a flexible poly-urethane coating over the foam or a stocking cover is recommended <b>Fig. 18</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The prosthesis with a flexible plastic coating over stocking-covered foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <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>Footnote</b></td></tr><tr><td class="clsTextSmall">B.F. Goodrich Co.</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">Registered trademark of the Polymer Corporation Limited</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-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 Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material Creator An entity primarily responsible for making the resource Anthony Staros  Henry F. Gardner  https://staging.drfop.org/files/original/b55c999f394c95f22da4376f0a7fd130.pdf 5101740961929f47b6d05aa1fc10398e 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/1980_01_002.pdf Text Any textual data included in the document <h2>Guest Editorial: Of Prosthetics And 1980</h2> <h5>Anthony Staros&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The survey of prosthetics components shown in this issue yields conclusions mostly related to above-knee amputees, as indicated in the text associated with Tables I and II. Fortunately more lower-limb amputations today are below-knee, so one really cannot tell much about trends in prosthetics practice from these data except to note that the SACH foot is indeed a success. This however should not make us complacent about this design, for we should never be happy with anything that we have in prosthetics. Our objective should always be constant improvement.</p> <p>As suggested, data are needed on below-knee fittings to give us a better impression of the state of lower-limb prosthetics today. Surveys of suppliers will show little; needed are data from the fitters of the country.</p> <p>Many of you know that the support of the VA Research Program of the University of California at Berkeley and San Francisco many years ago yielded the crucial bio-mechanical parameters in lower-limb amputee prosthetic service associated with fit and alignment. But never to be overlooked as very significant to service is the "tender loving care" and the training provided to the patient by the emphatic prosthetist. In any case, components although secondary are still important. But clearly recognized is the need to get the prosthesis properly interfaced and the amputee motivated. Perhaps a survey covering rotators might produce helpful data about how these have been used to reduce fitting problems by the diminution in shear stresses.</p> <p>The post-World War II education program has been primarily based on the teaching of the biomechanics and techniques of fit, those of alignment and to some extent but a lesser one, teaching about components. Even though these are of lesser importance, have we overlooked some essentials?</p> <h3>On Prosthetic Knees.</h3> <p>We really don't fault the survey, but recognize its limitations. It nevertheless does show that for above-knee knee joints at least there may be some lapses in the teaching of prosthetists, in the teaching of other members of the clinic team and most importantly, in orienting the administrators representing third party payers. Perhaps the low number of hydraulic knees (as a %) can be attributed to the larger percentage of amputees who are geriatric. But aren't these supposed to be mostly below-knee amputees these days?</p> <p>Not to be overlooked is the value of properly selected hydraulic knee mechanisms for certain cases. The selection of large numbers of "safety" knees is noted; but isn't it that clinic teams seem to get hooked on these, not trying others, or perhaps they have become disillusioned with price or maintenance burdens?</p> <p>Today, the safety knee is the unit of choice but we wonder whether even these are being used properly. For example, are they in fact being used to exploit the value of the stance phase characteristics in initiation of swing phase? Are the alignments such that one provides more "trigger" for initiation of knee flexion?</p> <p>The low numbers for polycentric knees bother us. If properly understood, some of the polycentric knee systems can be very beneficial in providing improved function to amputees with very short above-knee residual limbs and those with very weak hip musculature. How about their use in geriatrics?</p> <p>Are indeed the polycentrics really understood? Are those that are being used being fitted and aligned properly? Do clinicians really understand the real values of the polycentric systems?</p> <p>The system developed at the Orthopaedic Hospital, Copenhagen for example, can be used not only for end-bearing above-knee amputees but can also be applied for shorter amputation levels. The University of California at Berkeley is now developing other improvements in polycentric systems; we hope to see some of those soon presented through manufacturers.</p> <p>Unfortunately we sense that clinics tend to adopt particular "pet" knee mechanisms or pet prescriptions. We worry that for various reasons (valid?) the full range of knee mechanisms has not been given a complete trial. Our publications have tried to get the information across about the pros and cons of each system. Perhaps we have failed.</p> <p>For example, some of the rehabilitation achievements we have been able to make in our own clinic with the hydraulic knees are in fact extraordinary. Alongside the other important factors, the Mauch SNS in particular has been a boon to many of our above-knee amputees, particularly bilateral cases we have had from the Viet-Nam conflict and some Israeli cases from the October (Yom Kippur) War which were referred to us.</p> <h3>A Case in Point</h3> <p>One interesting case from Viet-Nam, a bilateral above-knee amputee, not only now sky dives but snow skis and disco dances on his above-knee prostheses, both with SNSs. This gentlemen has personal drive and motivation; he was an athlete before he was wounded, but now and this is important, he has been given the "tools" in those knee mechanisms: tools which can be used by him to achieve activity levels to which some of us nonamputees could aspire. Here, the SNS provided the wherewithal; matching these with the man's motivation and well-fitted sockets properly aligned, we were able to provide what can be considered a maximum degree of rehabilitation.</p> <p>This is not an isolated case. There have been many people fitted with the SNS and with others that are spin-offs of this design. We in the Veterans Administration put money into these developments, and we continue to purchase them because we have confidence in them. And our patients do. The problem is that others don't. Perhaps primary cost and maintenance experiences detract. But more so, other third party payers do not or cannot value these units as we do for our service-connected amputees who we believe deserve no less.</p> <h3>How about Modular Systems?</h3> <p>We are concerned about the low percentage of modular systems used. Less than one in four are shown. But these, in this survey, are directly linked to above-knee and higher amputations. Again, the geriatric amputee experiences and thus the more common below-knee amputation levels are not reflected. For these, modular or endoskeletal systems may be used most commonly, more than the rugged, heavier crustacean systems of wood and the like. We hope at least that more and more lightweight below-knee prostheses either using endoskeletal systems or polypropylene would be used to the benefit of this group of amputees.</p> <h3>Finally, on Research and Development</h3> <p>The component survey also doesn't really indicate anything about the needs for research and development. Inferred are some gaps in our link with the prosthetist and the clinic team mainly in the channels of information flow about all kinds of hardware. But one cannot draw too many conclusions.</p> <p>We are pleased to inform you that the National Amputation Foundation with the assistance of Dr. Jerome Siller of New York University has now nearly completed for the VA Prosthetics Center a nation-wide survey of 900 service-connected veteran amputees. Provided from this survey will be data about prosthetic, medical, surgical, employment and psychosocial experiences and statuses of veterans from all wars since and including World War II. We expect the investigators to give a report at the 1980 World Congress of ISPO to be held in Bologna, Italy. From this, we expect to have some significant directions for research and development.</p> <p>On this matter of research and development, it seems to us that as soon as you become extremely successful with a particular item you might look at it again to see what you can do to improve on it. Besides more durable SACH feet more functional types of foot-ankle systems seem needed. Are there ways, for example of achieving the same function with less complexity than presented in the current "universal" ankle joints?</p> <p>There appears to be no need to focus again on knee joint development; we would seriously worry about a further proliferation of new knee mechanisms. A few research groups are working on EMG control of valves on hydraulic knees, to produce voluntary control of knee function. This we can accept as long-range.</p> <p>You should also know that Federal support of research and development in prosthetics and orthotics (our own Center's deemphasis is an example) has been decreased to some extent. We do assist in evaluations; we do a little bit of development, primarily as a result of case presentations in our clinics, but we offer no great effort in prosthetics and orthotics development at this time; we have diverted scarce resources to attack the problems of the very severely handicapped: the spinal cord injured, the blind, the non-vocal, and the cumbersome complexities of the debilitated aged.</p> <p>So there'll be no mistake, know that we're still involved in prosthetics and orthotics, but we honestly believe that prosthetics and orthotics development has come a long way. We in the VA believe we have done much to contribute to this process, especially in funding projects around the country. We have also had our own laboratories involved. But now with a mature profession in place, these responsibilities can be carried primarily by the professional with the Government only assisting when necessary. The manufacturers as a group are certainly participating in development, evaluation, and even in training. Outstanding examples are several in the United States and those from Europe who have done an extremely good job in making the quality and function of components of high quality. And the competition among them has been welcomed by us.</p> <p>We think that the prosthetics (and orthotics) professional especially when it comes to process and device development is contributing enormously. Therefore the Government can turn its attention to that which the private sector cannot economically handle. But we always will be ready to help.<br /><br />*<em><strong>Anthony Staros</strong></em><br /><em>Director, VA Prosthetics Center</em><br /><em>New York, N.Y. 10001</em></p> Page Number(s) 2 - 4 Year 1980 Volume 4 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello 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 Guest Editorial: Of Prosthetics And 1980 Creator An entity primarily responsible for making the resource Anthony Staros * https://staging.drfop.org/files/original/3a52a8d4775fa3efd09318a22cf6e7b3.pdf 820ff6a0c1135f0effa1bae156a7f712 https://staging.drfop.org/files/original/a1127c14978be6ddba76a103d184fb20.jpg be7afb490777286577070fbfccb774fc https://staging.drfop.org/files/original/78848ce98a4983ca8bf83352f38fd5eb.jpg 254b27df04281f573e9df2cee9c33abc https://staging.drfop.org/files/original/6825c3c6eea1009afaf91c7abf8227ca.jpg 166a7fea19db92181e6cbf2a89d08b40 https://staging.drfop.org/files/original/aaf817a225ef897343a8c2a894b1cb69.jpg 537a989bf8ed7128316bdca570ab2915 https://staging.drfop.org/files/original/14f06bf8a55bb3dfed87489cacd1e28a.jpg fac89206bdc9aba86a21e615d9c70faf https://staging.drfop.org/files/original/f985278fc90ed029c1cc392206138e17.jpg 228d46ddc1545dc9fe5b34cf26bc0a72 https://staging.drfop.org/files/original/dab6c070737e365ed5aabce3fcf2bde1.jpg 6305700f03605ff97f24df6a08155562 https://staging.drfop.org/files/original/2d289146083105144b69c9c79a98b25a.jpg 5fd23e93a85b7ff731445a12a77fad61 https://staging.drfop.org/files/original/b63a1c7506812aa1f371254f1f53b919.jpg e3d7a7321d595d0fdfa23dd3c162429d https://staging.drfop.org/files/original/6cc643811deadfa2ead2f26357104ceb.jpg 5b94dac9a6d3f5727b81c3abfb6f7875 https://staging.drfop.org/files/original/2e7a46fb0b770171b5189860ba9f368d.jpg e82ff8d146f3473fbc167b759af9a148 https://staging.drfop.org/files/original/23562bc9cb410180cad1610a008e5cc1.jpg ff7b7f3b0ce7d6269d5364de3956538e https://staging.drfop.org/files/original/d92a31d65ae1a659d76f5e29b10d470d.jpg 25398ed94e7c48ac3b146aa62c192d24 https://staging.drfop.org/files/original/57a0d24e094a84654d83bd92944f70dc.jpg 3262f1eacd42160e24ca088febd063c8 https://staging.drfop.org/files/original/f40eee279da314366168879def856866.jpg 842e6fcd496ecdbae607d0554dea8d78 https://staging.drfop.org/files/original/3a999ee1d480ce73e8f934dd4e2117a2.jpg 2e3f15ea4f5f19befc8183e0723376d8 https://staging.drfop.org/files/original/e0315e1fb3761348b30e9c2a1a2d86d8.jpg 3cc0d759597ea5812be8ae99b3c204fb https://staging.drfop.org/files/original/8c2dc6b9dac90d6aa61cae8c1791afd5.jpg 56951aad21e6f648183614a200b26b17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_031.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 31 - 42 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/1963_01_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_031.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>Dynamic Alignment of Artificial Legs with the Adjustable Coupling</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p> Since World War II one of the most significant advances in limb prosthetics has been the introduction of rational principles for fitting and aligning artificial legs.<a></a> The University of California (Berkeley-San Francisco), sponsored by the Veterans Administration, has been primarily responsible for the steady improvement in methods and devices used by prosthetists in artificial-leg construction. </p> <p> To assist the prosthetist in carrying out these principles, a number of mechanical aids or tools were devised. The two adjustable legs-one for above-knee cases (<b>Fig. 1</b>), the other for cases below the knee (<b>Fig. 2</b>) and an alignment duplication jig (<b>Fig. 3</b>) were developed by the University of California, and are now recognized as important tools of the prosthetist.<a></a> And dynamic alignment of artificial legs is a standard part of the curriculum of prosthetics schools<a></a> and standard operating procedure in most limbshops. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An above-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 2. A below-knee adjustable leg used in current practice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alignment duplication jig. A, Adjustable leg mounted in jig. B, Adjustable leg has been removed and wooden set-up substituted. Prosthetist is sawing shank to proper length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But there have been problems. For one, the limbshop must have a minimum of two adjustable legs for adult cases, and two smaller ones for child cases. A shop of any size requires multiple quantities because frequently a given unit must remain attached to a socket for a particular amputee for an extended period of time. And to make best use of the adjustable legs an alignment transfer jig is needed. </p> <p> Other limitations in the above-knee adjustable leg appeared when knee units or knee-shank-foot units with fairly complex functions were introduced. Use of the UC adjustable AK leg, with its single-axis, constant friction joint for achieving alignment which is to be transferred to a permanent leg having a somewhat different type of function, is a questionable procedure; i.e., alignment suitable for a constant friction unit may not make proper use of the functions provided by more sophisticated devices. Some prosthetists have learned to accommodate for the required deviations by rules of thumb, but essential are some method and some tool for dynamic alignment to be made directly on the knee or knee-shank-foot mechanism to be used in the final prosthesis. </p> <p> Ideally, the device should be of simple design and useful for both above-knee and below-knee cases. For the above-knee case, such a device should be inserted between the socket and permanent prosthetic knee for "functional" alignment. </p> <p> If the unit were simple enough, it would be expected that more generalized use of alignment tools might result, and that facilities in other countries, where it is difficult to procure adjustable legs, could enjoy the advantages of dynamic alignment. Moreover, the alignment-transfer process needed scrutiny to see if simplifications in the equipment necessary might result. </p> <p> For these reasons, the VA Prosthetics Center developed the Adjustable Coupling, sometimes termed the "Staros-Gardner Coupling." </p> <h4> Description of the Adjustable Coupling </h4> <p> The adjustable coupling (<b>Fig. 4</b>) consists essentially of two plate assemblies held together by a central toggle pin. Mounted to a middle or intermediate plate but part of one plate assembly are four screw subassemblies, spaced 90 deg. apart, which contain independently adjustable, knurled screws used to "lock" the entire coupling as well as to provide adjustment for adduction-abduction and flexion-extension. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The adjustable coupling assembled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 5</b> are illustrated the major assemblies of the coupling. The single-flange part of the toggle and the top plate constitute the top assembly. The bottom assembly contains the "box" part of the toggle, the bottom plate, the intermediate plate, the four tilt-screw subassemblies, and the toggle pin. The bottom and intermediate plates both contain "A" and "P" marks to indicate the anterior and posterior sides, respectively. The two assemblies contain countersunk holes for screws used for attachment to the prosthesis. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Major assemblies and parts of the adjustable coupling. The toggle pin is permanently located in the semi circular channel just above the AA marks on the intermediate plate.<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The top assembly, primarily offering medio-lateral and tilt adjustability, contains a 1-1/4 in., 1/8 in. increment scale for gauging medio-lateral adjustments (with an index on the single-flange toggle which is free to slide with respect to the top plate). A tilt scale<a style="text-decoration:none;">*</a> is provided by markings on the threaded bushings of the four tilt-screw subassemblies. The indexes for tilt scaling are the lower surfaces of the knurled screws. Scale sensitivity for tilt adjustment is 2 deg. </p> <p> The bottom assembly provides rotation about the vertical axis and anteroposterior adjustability because the intermediate plate (and toggle "box") is free to move with respect to the bottom plate. On the anterior surface of the bottom plate is the 20-deg. (2-deg. increment) rotation scale. The index is located on the intermediate plate. The anteroposterior adjustment scale consists of a series of arcs, 1/8 in. apart for 1-3/4 in., etched on the top surface of the bottom plate. The index for this scale is simply the outer contour of the intermediate plate. </p> <p> The coupling, made primarily from an aluminum alloy (except for the toggle assembly which is steel), weighs 12 oz., is 3-3/4 in. in diameter, and is 1-1/8 in. thick when the plates are parallel. Ranges of adjustment are as follows: </p> <ol> <li><i>Mediolateral: </i>Total Range-1-1/4 in. <ul> <li>Increment of Scale Markings-1/8<i> </i>in. </li> </ul></li><li><i>Anteroposterior: </i>Total Range-1-3/4 in. <ul> <li>Increment of Scale Markings-1/8 in.</li> </ul></li><li><i>Tilt: </i>Total Range-10 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li><li><i>Rotation: </i>Total Range-20 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li></ol> <p> The coupling is disassembled by first lowering each of the four tilt screws two increments on the tilt scale. This operation loosens the entire assembly because it is held together as a result of the forces produced by tightening the force screws, and the toggle pin can thus be disengaged from the toggle box and flange. The top assembly and bottom assembly can then be separated. </p> <p> Installation of the coupling into a prosthesis is made with the coupling so separated. </p> <h4> Installation of the Coupling for Dynamic Alignment<a></a> </h4> <p> (<b>Fig. 6</b> and <b>Fig. 7</b>) show the coupling in position for dynamic-alignment trials. When installed, the coupling should be located as close as possible to the distal end of the stump. A piece of material may have to be added to accommodate the wood screws without affecting the socket sealing plate itself. By so locating the coupling, small tilt adjustments on the coupling will produce major changes in the geometrical relationship of stump to prosthetic components distal to the coupling. When the "bench" or static alignment is reasonably close, the 10 deg. range of tilt adjustment is more than adequate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The coupling installed in an above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The coupling installed in a below-knee prosthesis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the socket is constructed and the components approximately dimensioned<a style="text-decoration:none;">*</a> lengthwise, the top assembly of the coupling is attached to the bottom of the socket using as many wood screws as possible (<b>Fig. 8</b>). The bottom assembly then is attached to the top assembly by placing the single-flange part of the toggle within the "box" part and pushing the toggle pin through the holes in both toggle parts. One must make certain that the "A" marks (or "P" marks) are located properly with respect to the socket. The coupling is then set with all adjustments on "neutral" so that top plate and bottom plate are parallel and coaxial, care being taken to ensure that the intermediate plate is not rotated with respect to the bottom plate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Attaching the top assembly of the coupling to the bottom surface of the above-knee socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket with the coupling attached is then temporarily placed on the above-knee setup (knee-shank-foot) or on the below-knee setup (shank-foot). A height check<a style="text-decoration:none;">*</a> is made with the amputee standing on the prosthesis. </p> <p> Since the coupling has not been fully assembled into the prosthesis, the prosthetist must, of course, assist the amputee in maintaining stability. After the height check has been made, the section of the prosthesis below the coupling (on the knee block or shank) can be sanded to obtain the correct height. </p> <p> One must consider the desired static or bench alignment before fully attaching the bottom plate assembly to the prosthesis. A recently published chart<a></a> shows recommended guides for "bench" alignment when the SACH foot is used. In any case, care should be exercised in locating the bottom assembly to assure that the ranges of adjustment available in the neutrally set coupling will not be exhausted during dynamic alignment. </p> <p> When the bottom plate is being installed, the countersunk clearance holes are made accessible by shifting the intermediate plate with respect to the bottom plate (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Attaching the bottom assembly of the coup ling to the top surface of the knee block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Dynamic alignment can begin when the coupling is reassembled and "locked" in the neutral position. This procedure should ordinarily be carried out in the following fixed sequence, making the linear adjustments first and the lilt adjustments second: </p> <ol> <li>With the amputee seated, loosen only the two front tilt screws and make the anteroposterior adjustment. Tighten the two front screws.</li><li>With the amputee seated, loosen only the two front till screws and make the mediolateral adjustment. Tighten the two front screws.</li><li>With the amputee standing, provide tilt adjustment by turning down one of the two tilt screws on the side to be depressed (The screw should be turned down only as far as needed for the angular adjustment desired.) Then tighten the till screw diagonally opposite to establish the angular adjustment desired. Next loosen (the same amount) the second screw on the side to be depressed and tighten the screw diagonalh" opposite to complete the angular adjustment and "lock" the coupling.</li><li>rotation may be established or reestablished before the screws are completely tightened in any of the above three adjustments. The rotation scale reading may be recorded before making any adjustment so that the position of rotation may be readily restored.</li></ol> <h4> Alignment Transfer </h4> <p> No special jig is required for alignment transfer with the coupling. Actually, alignment is not "transferred" but rather "maintained" while the coupling is replaced with a permanent material. </p> <p> Around the periphery of the bottom plate of the coupling, there are ten radial holes located 36 deg. apart that serve as centers for a special compass which is used for scribing reference marks on the socket after dynamic alignment has been completed. The alignment compass is inserted in each of the holes in the periphery of the bottom plate, and small arcs are drawn or scribed on the socket base (<b>Fig. 10</b>). The <i>tops </i>of these arcs are then connected bv a circumferential line which will be exactly 2 in. above the bottom surface of the bottom plate and parallel to it. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 10. Use of the special compass for an alignment-transfer reference. The vertical reference lines will be used to reestablish anteroposterior, mediolateral. and rotation positions. The horizontal line tangent to the tops of the compass arcs will reestablish tilt. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At least four vertical reference lines (90 deg. apart) are made on the socket and continued onto the distal component (knee block or shank). </p> <p> The toggle pin of the coupling is removed and the top and bottom plate assemblies are detached from the socket and from the knee block (or shank). </p> <p> A saw cut is then made in the socket base<a style="text-decoration:none;">*</a> <i> just below </i>the horizontal circumferential line (<b>Fig. 11</b>) and the socket base is sanded to the line (<b>Fig. 12</b>). A 2-inch-thick wood or foam block (with parallel top and bottom surfaces) is then placed between the socket and the knee block (or shank). The wood or foam block is then firmly attached (with cement, resin, and/or other fastening media) to both socket and knee block (or shank), care being taken to restore the coincidence of the vertical reference lines on the assembled components (<b>Fig. 13</b>). Although not necessary, an apparatus for holding the parts together during cement or resin cure can be used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Using the band-saw to cut the socket immediately below the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Sanding of the socket to the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Replacement of the coupling with a 2-in. wood block. Coincidence of the vertical reference lines must be restored in the alignment-transfer process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> If one wishes, the standard alignment transfer jig may be used instead. Following standard procedures, the prosthesis with the coupling may be fixed in the jig and then the coupling removed. Saw cuts through the socket base and knee block (or shank) and substitution of an appropriately sized block of wood will be needed. In the above-knee limb transfer, one saw cut in the socket base will be sufficient if the prosthesis is mounted in the jig with the bottom plate of the coupling perfectly perpendicular to the long axis of the jig. </p> <h4> Experience with the Coupling </h4> <p> The coupling, although primarily designed as a simple device for alignment of "permanent" lower-extremity prostheses, can also be used for temporary, or interim, prostheses. </p> <p> The coupling has been in routine use in the Limb and Brace Section of the VA Prosthetics Center since March 1961. The numbers of permanent prostheses aligned with the coupling in the 22-month period ending December 31, 1962, were as follows: </p> <table> <tbody><tr> <td>Hip_disarticulation............</td> <td>13</td> </tr> <tr> <td>Above-knee....................</td> <td>130</td> </tr> <tr> <td>Knee-bearing...................</td> <td>16</td> </tr> <tr> <td>"Bent" Knee.....................</td> <td>3</td> </tr> <tr> <td>Below-knee....................</td> <td>192</td> </tr> </tbody></table> <p> In addition, 34 above-knee and 22 below-knee sockets were replaced on existing prostheses by use of the coupling. </p> <p> Experience indicates some economic benefits in use of the adjustable coupling. Starting at the same point in an above-knee prosthesis fabrication (with the socket roughly fitted), the adjustable leg-transfer jig procedure takes, on the average, slightly over 1/2 hr. more than the coupling-compass procedure. The end point for this time measure, in both procedures, is completion of alignment transfer with the prescribed prosthetic components assembled. </p> <p> A more significant advantage of the coupling accrues from its use in aligning above-knee prostheses when special knee or knee-ankle mechanisms have been prescribed. A prosthesis system with functional features providing more than just a mechanical-friction control at the knee may require some deviation from that alignment which might be used with only mechanical friction. Even an extension bias strap will affect the alignment to be used. Thus, for such devices as the Bock Safety Knee, the Hydra-Cadence (with a relatively free plantar-flexion control), the Mauch hydraulic devices, polycentric linkages, and others, it is well to align the prosthesis with the prescribed special-function system installed. The coupling is designed primarily for dynamic alignment of such systems. </p> <p> Added to the economic advantage of one device for both below-knee and above-knee use is the simple and inexpensive process for alignment transfer. For a new shop, this means that investment in an expensive jig is not mandatory. Also, because of the comparatively low cost of the coupling itself, many more alignment devices can be available in the shop. Thus, shifting alignment apparatus already installed in a setup awaiting an amputee trial may not need to be as frequent as formerly. </p> <p> The coupling also facilitates the alignment of replacement sockets. Fitting problems often require the fabrication of a completely new socket before the remaining parts of the prosthesis need replacement. The new socket and coupling can be installed on the "old" prosthesis for dynamic alignment and replacement-socket fitting. This process is more expeditious than one in which the adjustable leg is used and then transfer is made to the "old" components. Also, proper fairing of new socket to "old" components can be assured by the coupling method of realignment because fairing problems can be readily observed and immediately corrected. When the adjustable leg is used, fairing problems can be noted only at the time of transfer. Major corrective procedures may then be necessary. </p> <p> Many foreign practitioners have read and appreciated the various United States' documents which have emphasized the importance of dynamic alignment. But also, many have felt frustrated for, even though they have realized the value of dynamic-alignment apparatus, economic or technical handicaps prevented them from enjoying the use of the devices the practitioners in the United States had readily available. The coupling, therefore, because of its simplicity, can make a significant contribution to the benefit of the disabled all over the world, particularly in developing areas. </p> <p> The coupling was introduced into Yugoslavia in 1961.<a></a> At about the same time, Denmark became interested in its use. E. Lyquist of the Orthopaedic Hospital, Copenhagen, has published a report on the coupling<a style="text-decoration:none;">*</a> and on the apparatus he designed for clamping the prosthesis on a band-saw bed for alignment transfer<a></a>. See (<b>Fig. 14</b>). Dr. B. Zotovic of Belgrade has kindly offered the photograph (<b>Fig. 15</b>) of a prosthesis with the coupling now in use in Yugoslavia. In 1962, the coupling was introduced into Argentina. Still more applications to foreign use are anticipated. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Special band-saw jig used by Danes during alignment transfer. This jig holds components of the prosthesis in a fixed position to allow parallel band-saw cuts on both sides of the coupling. Subsequent clamping after cementing of wood block to replace coupling is also facilitated by this device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A Yugoslav above-knee prosthesis incorporating the adjustable coupling tor dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Many clinicians have realized the importance of temporary or interim prostheses<a></a> for preliminary trials by an amputee. When temporary limbs which have alignment adjustability are used, dynamic stump conditioning and, especially for geriatric cases, evaluation of an amputee's ability to cope with a prosthesis are possible before a final prosthesis is ordered. Of utmost importance in temporary limb use is that prosthesis <i>"function</i>not be seriously compromised".<a></a> A well-fitted, soundly designed socket must be used, and all parts should be continually maintained in proper alignment. Straps provide additional reinforcement of socket to coupling assembly- mostly for horizontally directed loads. For plaster sockets, they are especially helpful since they can be contained within an outer, reinforcing plaster wrap.</p> <p> There are now available several devices which might be used for temporary prostheses.<a></a> Among these is the coupling. (<b>Fig. 16</b>) illustrates a temporary or interim above-knee. prosthesis incorporating the coupling and making possible the use of the type of knee (and function) anticipated for a permanent prosthesis. Now, not only fit and alignment can be '"tuned" to each other, but both can be "tuned" to function. And, if necessary, function can possibly be altered by a rather rapid change from one knee-shank mechanism to another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. The adjustable couplingused with a plaster -of-Paris above-knee temporary sockel and an unfinished knee shank. The three straps are eaeh 1/8 in by 3/4 in. low-carbon steel. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 17</b>) shows the coupling used in a below-knee temporary, or interim, prosthesis. For this level of amputation, the practitioner has the choice of the coupling or the Northwestern Adjustable Below-Knee Pylon shown in (<b>Fig. 18</b>). This apparatus also has sufficient alignment adjustability available for most below-knee applications in both temporary and permanent prostheses. When attached to a "permanent" (plastic or wood) socket, its advantage is that it can remain in the prosthesis after the dynamic-alignment process is complete. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig, 17. The adjustable coupling used with a plaster-of-Pa.ris below-knee temporary socket and unfinished shank. The three straps have the same cross-section as those used with the above-knee socket. The position of the carbon steel straps in both the above-knee and below-knee sockets should be reinforced with an extra plaster-of-Paris bandage wrap, as illustrated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. A temporary or interim prosthesis with the Northwestern adjustable below-knee pylon, plaster-of-Paris patellar-tendon-bearing socket and SACH foot, The three straps are similar to those of the previous two illustrations. An adaptor plate must be provided to iittach the straps to the pylon. In addition to the alignment adjustability available in the pylon, the position of the socket can still be altered if necessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Further Development </h4> <p> The Northwestern Adjustable Below-Knee Pylon demonstrates a design principle long sought in alignment apparatus. With it, adjustments needed for dynamic alignment can be made as usual during the early stages of prosthesis fabrication, but the adjustable apparatus is now made a part of the limb obviating a transfer process but sometimes causing a slight increase in limb weight. At a later date, if the cosmetic-shank design allows it, readjustment of alignment can be made without a complete alteration of the prosthesis. Use of a relatively flexible cosmetic cover will probably be best for this purpose; if a plastic-covered foam shank is used, only destruction of the shank before realignment and a foam replacement and plastic finishing after realignment will be required. </p> <p> Most desirable would be one apparatus, perhaps coupling-like, which could be used in above-knee and below-knee prostheses alike. The present adjustable coupling is both too heavy and too expensive for this purpose. A. B. Wilson, Jr.<a style="text-decoration:none;">*</a> and Victor T. Riblett<a style="text-decoration:none;">*</a> have designed a simple and inexpensive plastic, tapered-disc device which might remain in the prosthesis after the primary alignment trials (<b>Fig. 19</b>). At present the device usually must be partly trimmed during the shaping of the limb for cosmetic finishing. Therefore, it could probably not be used at a later date for realignment purposes. But still this device will obviate transfer after initial alignment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Schematic drawing of the "Wilson-Riblett wedge," as applied to the VAPC coupling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In eliminating only the primary-transfer process, a so-called "leave-in" alignment device must be priced at a level which would offer some gain to the prosthetist-user. If, at least with the regular coupling, alignment transfer involves an investment of approximately $5.00 in labor and materials by the limbshop, then the <i>one-time, </i>"leave-in" alignment device should cost somewhat less. But even so, possible saving per prosthesis or additional profit is of a very low order of magnitude. </p> <p> Needed is a device (and prosthesis design) which would allow realignment at a later date without major reconstruction of the prosthesis. Economic benefits would accrue to prosthetist and amputee alike; at least some of the major cost-saving in the realignment process can be passed along to the customer. Perhaps many prostheses now condemned for alignment reasons would not need to be. </p> <p> But most of all, such a device would offer convenience, allowing almost immediate accommodation to an amputee's needs. Instead of major delays in receiving a new alignment in a new or grossly altered older prosthesis, rather prompt prosthetist attention can be focused on an alignment problem in the existing limb. The prosthetist, if uncertain of an amputee's over-all fitting problem, can start with realignment of the existing prosthesis in his progressive analysis of the situation. He might be able to overcome what may seem to be socket-fit difficulties without major changes there. But, in any case, he would have readily available the mechanism for study of the problem and the problem's dependency on alignment. </p> <p> Prosthesis design must of course be changed to accommodate the permanent installation of such a unit. A below-knee shank should preferably be a pylon-cosmetic-cover type, somewhat similar to the Northwestern device. Preferably, the lower part of the above-knee limb thigh (where this device would be placed) should have an easily removable cosmetic cover. Perhaps a simple plastic finish over foam forced into the spaces around a lightweight, inexpensive coupling would be adequate. The foam would need to be cut away (or possibly dissolved by appropriate chemical means) when realignment was necessary. But even with present plastic-laminate finishing methods, realignment would involve only destruction of the laminate and then refinishing. </p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy,<i> Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars)</i>, Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, <i>The locomotor mechanism of the amputee</i>, Chapter 16 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954. </li> <li>Lyquist, Erik, <i>Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01</i>, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artificial Limbs, January 1955, p. 35. </li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputees</i>, Artificial Limbs, Spring 1957, p. 41. </li> <li>Staros, Anthony, and Henry Gardner, <i>Report on orthotics-prosthetics research developments in Yugoslavia</i>, Department of Health, Education, and Welfare, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Suggestions for fitting and aligning the SACH foot</i>, a chart, May 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Temporary prostheses for lower-extremity amputees</i>, Technical Report 1, September 1, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Use of the alignment coupling</i>, a chart, July 1962. </li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program</i>, Artificial Limbs, May 1954, p. 8. </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>Footnote</b></td></tr><tr><td class="clsTextSmall">Supervisor, Mechanical Development Branch, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Forest Glen Section, Washington 12, D. C.</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">Technical Director, CPRD, NAS-NRC, 2101 Constitution Ave., Washington 25, D. C.</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">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </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">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </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">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </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">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </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">Lyquist, Erik, Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </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">Lyquist (in November 1962) reported that the coupling was being used in all patellar-tendon-bearing fittings at the Orthopaedic Hospital. Some above-knee use was also reported.</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>7.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry Gardner, Report on orthotics-prosthetics research developments in Yugoslavia, Department of Health, Education, and Welfare, 1962. </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">Normally, if there is enough material here for the wood screws to attach the coupling, there will be enough material for this saw cut and the subsequent sanding without disturbing the socket itself.</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">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </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">Veterans Administration Prosthetics Center, Suggestions for fitting and aligning the SACH foot, a chart, May 1962. </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"> With especially long above-knee stumps, the knee center must be dropped during alignment trials because of the thickness of the coupling. Later, during transfer, true or near-true knee-center height can be restored.</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 over-all length of socket, knee unit, shank piece, and foot, plus 1-1/8 in. for the coupling, should be slightly larger than the amputees dimensional requirements. Later sanding after a height check will produce accurate longitudinal dimensioning.</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">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </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">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </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">All scales have neutral positions highlighted. The neutral positions on the tilt scales are most important in establishing the middle position of tilt, when top and bottom plates are parallel, or for disassembly, when it is important to unlock the coupling by having all four tilt screws down at least two increments below neutral.</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">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </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">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars), Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </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">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </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">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomotor mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954, 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>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Chief, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-034.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-035.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-036.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-037.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-038.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039b.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-041.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-042.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-043.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-044.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-045.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-046.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-047.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048b.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-050.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-051.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 Dynamic Alignment of Artificial Legs with the Adjustable Coupling Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * https://staging.drfop.org/files/original/ade32438fe78cc76b9983a4b8b03a966.pdf 24729f77c1e834d976420985feac692f https://staging.drfop.org/files/original/d92a7eff2668b5c4ae4ad1304d095fa8.jpg 835435b1ece19459b1ac8d1a17c66508 https://staging.drfop.org/files/original/b5aae5c48c7c5d7cb3451ea33d46ca35.jpg 7f2c8261672b992d5e23edec9c77f155 https://staging.drfop.org/files/original/c23813c8338bfd0e458ded21a75e5f4e.jpg 0f0b8b3e72dd2046648a7cd419c0d7a3 https://staging.drfop.org/files/original/05f26b792282c85b48f580e1eae102ec.jpg 99d0cf43ee5a531ada3afac54450494f https://staging.drfop.org/files/original/ce9fd6c6b75b551158c3744e94f094b7.jpg 73c12aa3dbf0a65f1f4fa64ac9dd6213 https://staging.drfop.org/files/original/07ee80f09471576171407de72fa75dd5.jpg 4f76e5e9d6715c10b86b5cb853ec87a4 https://staging.drfop.org/files/original/97a5dc6f83c442defa0fe8ace990f196.jpg e8575a35f4234f2cacbfae587bae4e43 https://staging.drfop.org/files/original/97b8c915a4b3c287a6f6d8da7f49a69a.jpg cbc601a2e8329c86d4569281990ed01c https://staging.drfop.org/files/original/06006f97bc193b21a924aebb7cc5e327.jpg 90544b8e8968a5c9e75adc9c7dca2a85 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_027.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 27 - 34 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/1965_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_027.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>Orthopaedic Shoes for Bilateral Partial Foot Amputations</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Most physicians and competent orthotists recommend the use of orthopaedic shoes in cases requiring shoe modifications or braces. However, in practice, the term "orthopaedic" is loosely applied to a variety of shoes of widely different cost, construction, function, durability, and appearance. Orthopaedic shoes are distinguished from stock or nonorthopaedic shoes by a steel shank, a long, high, reinforced counter and internal corrections; prescribed modifications are incorporated as elements of the shoe construction rather than added externally. These are clear differences, and the superiority of orthopaedic shoes is generally recognized.</p> <p>Although related, there are two vastly different types of shoes labeled "orthopaedic." One is the kind of shoe described above, which is usually referred to as the <i>custom </i>orthopaedic shoe; the other is the <i>stock </i>orthopaedic shoe. The latter usually contains a steel shank, and in certain instances it also includes a long medial counter and Thomas heel. At this point, however, the similarity to custom orthopaedic shoes ends. Additional corrections which are prescribed must be added externally. They do not include the reinforcement required to prevent "breaking" of the sole at undesirable points and to prevent lateral bulging of the uppers.</p> <p>Despite these disadvantages, stock orthopaedic shoes are frequently prescribed or selected by patients. Cost is probably a significant if not decisive factor since typical costs for stock orthopaedic shoes average half or less than half the cost of custom orthopaedic shoes. On analysis, however, cost differences tend to narrow, as the useful life of custom orthopaedic shoes is longer. In our opinion, the functional and cosmetic advantages of custom orthopaedic shoes far outweigh the cost differential.</p> <p>Apart from considerations of cost, stock orthopaedic shoes may be selected because the appearance to the untutored eye of a new pair seems adequate, and because the patient may seem initially to walk in much the same manner when wearing equally new custom orthopaedic and stock orthopaedic shoes. Not immediately apparent are the quick deterioration and shorter life of the stock orthopaedic shoe and the functional value of the custom orthopaedic shoe. Because of adaptive measures employed by the patient to overcome deficiencies in the stock shoe and to present a normal appearing gait, the external appearance of the gait pattern with the custom shoe may not always be superior. Adjustments made by the patient to adapt himself to the shoes are revealed in the interaction of forces between the foot and the ground during the stance phase of walking. It is primarily to these forces that the wearer of custom shoes reacts when expressing a preference for the function of one shoe over another, even though improvements by a reduction in gait deviations may go undetected during visual observation.</p> <p>A recent experience illustrates these points. A young man with congenital deformities of the feet, for whom orthopaedic shoes had been prescribed, was tested in our laboratory. (He also had congenital deformities of the hands.)</p> <p>He was considered an excellent subject for this type of analysis because of the remarkable adaptations he had made to his deformities. Despite their severity, he was an extremely adept walker with a nearly normal gait whether he wore shoes or not. We believed that his high adaptability would tend to mask, to an unusual extent, any gross differences in his gait and that, therefore, detectable differences could be attributed to the function offered by the shoe.</p> <h3>The Subject</h3> <p>The subject for this study was a 19-year-old congenital amputee with partial hands and feet (<b>Fig. 1</b>). At the initial examination he was wearing previously prescribed stock orthopaedic shoes with steel shanks as the only special feature. Added externally were sole and heel extensions (<b>Fig. 2</b>). After approximately 12 months of wear a severe break in the tarsal region of the right shoe and another, though less severe, of the left shoe were exhibited. The lateral walls of both shoes bulged excessively, resulting in permanent deformation and reduction of support. The short steel shank protruded through the sole at a point corresponding to the break, and the wear of the soles revealed a pattern of little or no support anterior to the shank which terminated at a point corresponding to the tarsometatarsal joint line (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Congenital bilateral amputations with absence of tarsals in the right foot and presence of tarsals in the left. A, Lateral view; B, frontal view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stock shoes showing deformation after 12 months' wear. A, B, Externally added heel and sole extensions can be seen. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stock shoes showing: A, break in tarsal region; B, uncosmetic external corrections; C, protruding short steel shank and a wear pattern indicative of lack of support in the metatarsal and toe areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He was fitted at a commercial establishment with a prescription for custom orthopaedic shoes recommended by the Veterans Administration Prosthetics Center (<b>Fig. 4</b>). These shoes were specially reinforced with long, flat steel springs and steel shanks installed between inner and outer soles to increase the resistance to dorsiflexion after mid-stance and to shift the "toe break" further forward. They also featured stiff, high, long counters and a wider heel base with a reversed Thomas heel on the right shoe to increase lateral support. An inside cork extension was prescribed to accommodate leg shortening. After four months of use the wear pattern of the soles indicated that the patient was receiving support; that is, resistance to dorsiflexion or "shoe break" extended all the way out to the toe (Fig. <i>4B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Custom shoes after four months' wear showing: A, cosmetic advantage; B, reversed Thomas heel and an even wear pattern indicative of support provided over entire surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <p>To record the gait performance of the patient as completely as possible, several methods were employed. Thirty-five mm. motion pictures were taken in both the anteroposterior and the mediolateral planes as the patient walked with his old shoes and with his new shoes. Similarly, cyclographic recordings were made of angular and linear displacements at the hip, knee, and ankle. Force plates were used to record the ground reaction forces during stance phase. Finally the patient's opinions were recorded.</p> <h3>Results</h3> <p>A motion-picture analysis showed that the subject walked very well with both stock and custom orthopaedic shoes. He was able to make small but significant compensations in his body alignment and in the timing of his movements with the result that the total body center of gravity maintained a smooth translatory path.</p> <p>In general, the more detailed cyclographic recordings clearly demonstrated a remarkable ability on the part of the patient to maintain a reasonably normal gait pattern despite differences in functional losses between right and left leg and substantial differences in the height and functional character of the shoes.</p> <p>As shown in <b>Fig. 5</b> and <b>Fig. 6</b>, displacement patterns-that is, the motions of the hip, knee, and ankle in space-were essentially similar with both stock and custom shoes. The consistently higher elevation of each of the major joints with the custom shoe was due simply to differences in the elevation of the shoes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Horizontal displacement of targeted points on the subject's right lower extremity during ambulation, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Horizontal displacement of targeted points on the subject's left lower extremity during ambulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although knee-flexion patterns with custom and stock orthopaedic shoes were generally similar, flexion of the left knee during the early stance phase was reduced substantially with the custom shoes (<b>Fig. 7</b>). This was attributed to the increased support provided by the custom shoes in the tarsometatarsal region with a consequent reduction of the "drop off" on the right leg during late stance. As a result of the excessive "drop off" due to the "break" of the stock orthopaedic shoes, the hip remained at a lower elevation than it would otherwise have attained. The lower hip elevation necessitated additional compensatory flexion of the left knee by the patient in order to walk in a reasonably symmetrical manner. Reducing the "drop off" maintained the hip at a higher elevation and made this additional knee flexion unnecessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A computation of the actual forces applied to the ground was made by resolving both vertical and horizontal force components. Indicated in the following tabulation are the peak forces applied to the ground during the period of heel contact to foot flat and between the instant of heel off and push off in two trial runs with the stock shoes and in two trial runs with the custom shoes. (<b>Table 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As the patient weighed 196 lb., it may be seen that the differences between the first and second peaks were substantially lowered on the right foot and somewhat less diminished on the left foot when the custom shoes were worn, demonstrating a more nearly equal application of forces to the ground. These differences were due primarily to his ability to maintain higher fractions of his body weight on the supporting foot after heel off.</p> <p><b>Fig. 8</b> graphically illustrates, for comparative purposes, the average peak magnitudes of the axial load during heel contact to foot flat, and during heel off to push off. The most significant effect on gait of the custom shoes was to diminish the magnitude of the force with which the heel was initially applied to the ground and to increase the force applied to the ground during the portion of stance corresponding to the period between heel off and push off. Although the absolute values of these changes are small, they had highly significant effects in reducing the patient's adaptive efforts and in reducing shoe wear. As might be expected in the complete absence of plantar-flexion in the right foot, the effects were greater on the right side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Subject's Opinion</h3> <p>The subject stated unequivocally that the custom orthopaedic shoes were far superior to the stock shoes that he had previously worn.</p> <p>They were more comfortable, they provided better support, and the inside buildup was more cosmetically desirable. The subject wore the custom shoes home and refused to take the stock shoes with him, discarding them on the spot.</p> <h3>Summary</h3> <p>There is very little question in our minds of the superiority of custom orthopaedic shoes over stock orthopaedic shoes. Even in the case described in this article when, at first glance, the need might be considered minimal, clear advantages were provided. On this functional basis alone preference should go to custom orthopaedic shoes. Further study of the life expectancy of custom and stock orthopaedic shoes should serve to clarify objectively where real economy in this matter lies.</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>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</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>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_027/spring65-27.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_027/spring65-28.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_027/spring65-29.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_027/spring65-30.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_027/spring65-31.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_027/spring65-32.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_027/spring65-33.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_027/spring65-99.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_027/spring65-34.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 Orthopaedic Shoes for Bilateral Partial Foot Amputations Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/9efbf424d1bfe2b5b84fe13f0d2fd516.pdf 0bcf1c41627ab178388a24b6e69db174 https://staging.drfop.org/files/original/9811319d59776c370a44ed906f991cfd.jpeg 00380d4a6a0059f69700b9ea0c517dc3 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_04_001.pdf Text Any textual data included in the document <h2>Rehabilitation Engineering and Prosthetics/Orthotics</h2> <h5>Anthony Staros, MSME, PE&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The words "Rehabilitation Engineering" are now commonly used to mean a paramedical practice which in its job characteristics and their demands, in the basic technical background needed, in its high activity level, and in its human service slant, is an extrapolation of professional prosthetics and orthotics. Prosthetics and orthotics are in fact very significant components.</p> <p>Rehabilitation engineering is defined as that broad discipline having as its ultimate objective the <i>application</i> of technology to enhance life's quality for the disabled. It includes subsidiary goals in research, development and education. But one doesn't need to be an engineer to <i>practice</i> rehabilitation engineering!</p> <p>With the recent advances in technical aids, prosthetics and orthotics included, there has been increasing need for those who currently serve the disabled with technology to expand the range of their commitment requiring a persistent demand for more knowledge. At the same time, there are counterpressures:—the potentially harmful low rates of increase in the numbers of practitioners. Fewer people are trying to do more while also needing more information for what they do. The effects that Government budget restraints will produce in this situation are difficult to predict, but clearly seen is that the pressures will be greater, that there will be real need for increased efficiency in all parts of society and more so for us committed to the delivery of high quality service to the disabled: increased productivity and more knowledge are conjointly required.</p> <p>Much of what rehabilitation engineering means in real practice is the selection of devices, the making of special systems, or the design of environments, and then the delivery of these, customizing them even further when necessary, and applying them to assist the disabled. Demanded is the achievement of independence through function and/or access with both comfort and control maximized. Training of the client is essential. These efforts are effected in a precise and deliberate process with full understanding of the patterns of disability presented and a substantial awareness of the personal wishes of the disabled person being served (and his/her family).</p> <p>Rehabilitation engineering includes aids fitted directly to the client as in prosthetics and orthotics, tools such as communication devices, and adaptations to environment, to work sites, to the home, or to the vehicles used to reach one or the other or to those mobility devices operated within an environment. Some of the technical aids may be very simple in design; most of those which are custom-made require biomechanically sound, creative, and often inventive approaches. The simplest may require the most creativity.</p> <p>In the rehabilitation engineering applications process, in supporting the physician's role in prescription or in the selection of aids and then in their application, the knowledgeable and interested prosthetist, orthotist, and therapist (physical, occupational, speech) can play the key roles. Especially <i>productive</i> and <i>cost effective</i> is the involvement of the skilled technician, an essential member of the rehabilitation engineering team. The team concept is crucial in that the knowledge needed comes out of the sharing of training and experience—and the creativity sought can usually come from the synergism in the group, especially including the client. The actual "making" although involving all to various degrees becomes the special province of the technician, with the "fitting" itself being a product of the team. The required contribution to benefit the patient will be a scenario of analysis and synthesis, idea and response, search and research, give and take, and then plain work.</p> <p>That which is rehabilitation engineering has been performed for many years, before it became stylish to use this expression to represent a special technology. But there is now in place an acceleration in the development of new technology in products and processes, many so recent that they are not known to members of the rehabilitation team who received preparatory training or post-graduate courses years earlier. Even now the newer information needed is not obtained in structured formats. Pathways should be constructed for each member of the team to broaden his/her own discipline to include constantly updated knowledge about all technology necessary for his/her personal professional contribution to the rehabilitation engineering team. And not to be overlooked is that the payers for services need to be instructed on the cost benefits of rehabilitation engineering.</p> <p>We recommend that these professionals (the prosthetist, orthotist, and therapist) have their own societies' publications and conferences include the information about the advance in rehabilitation engineering. They should also participate in those societies which meld the team, the <i>Rehabilitation Engineering Society of North America</i> and the <i>International Society for Prosthetics and Orthotics</i>, thereby advancing the practice of rehabilitation engineering through contacts with the other team members. Special seminars need to be structured for the 3rd party payers.</p> <p>In the team, or even in the individual practices, the added knowledge about rehabilitation engineering aids can only benefit. If the prosthetist or orthotist fitting a patient with an <i>upper-limb</i> deficit relates his fitting in part to the vehicle controls the disabled person may need to use, shouldn't he or she be knowledgeable about such controls and their installation? Beyond that, shouldn't both (prosthesis or orthosis <i>and control</i>) be "installed" under such professional supervision? Yet still, in this decade of rapidly advancing technology and of certification of those who dispense it, ordinary automobile repair garages install hand controls for licensed vehicles for disabled drivers. Why not the orthotist or prosthetist overseeing his/her technician?</p> <p>There are often frustrating limits to the mobility which can be provided in lower limb orthotic or prosthetic care. Under what circumstances does one use a wheelchair as a supplement or as a last resort? How is it selected? In what way should it be modified if at all? What kind of buttock and trunk support are required? Here the prosthetist, the orthotist, and the therapist should be involved for aren't these the professionals who can be and should be closely associated with wheelchair prescription and modification? In a national workshop held in 1978, WHEELCHAIR I,<a style="text-decoration: none;">*</a> mention was repeatedly made about the need for a "wheelchairist", a person to be concerned exclusively with wheelchair prescription and fitting. If prosthetists, orthotists, and therapists are indeed responsible for other aids for mobility, why not then the wheelchair? Isn't a functioning rehabilitation engineering team the "wheelchairist" sought?</p> <p>From the clinic team setting or from the counselor's desk, the usual site for the final selection and customization of technical aids and then their application is not unlike a prosthetics/orthotics laboratory, there blessed with talented technician support. In a recent paper,<a style="text-decoration: none;">*</a> we recommended that the prosthetics/orthotics profession develop the practice of rehabilitation engineering:</p> <p>"Recommended is that prosthetics and orthotics, with their foundation in clinical technology, constitute the basis for the establishment and certification of a broadly based rehabilitation engineering capability in the United States. Indeed, it would be well for prosthetists and orthotists to start expanding their scope to include the other technical aids in rehabilitation engineering and in collaboration with other members of the rehabilitation team, especially the orthopedic surgeon, provide the means for a wider coverage in the delivery of technology to restore independence and function to many handicapped individuals who are not now receiving the full, broad spectrum services they deserve."</p> <p><a href="/files/original/9811319d59776c370a44ed906f991cfd.jpeg"><b>Figure 1</b></a></p> <p>Is there then really need for the engineer, the graduate of a formal engineering curriculum to be the <i>applier</i>, the "clinical" practitioner of rehabilitation engineering? The rehabilitation <i>engineer</i> has a role: in design, development, research, and perhaps in management. The prosthetist, orthotist and therapist especially with technician support, as a team and as individuals can and should respond to the total technical needs of the patients presented to them; rehabilitation engineers should identify with the other (consulting) members of the medical-technical professional structure in the overall rehabilitation effort. To be called on only in the case of <i>special</i>, more complex problems, the engineer should be mostly involved in leading generalized design and development efforts, these to include others of the team as well.</p> <p>Total need, as the prosthetist, orthotist, and therapist well know, includes "tender loving care," this in the past demonstrated by the experiences of these professionals in analyzing then defining the problems of the disabled. For patients with the severer disabilities, those requiring broader rehabilitation engineering efforts, good practice requires more of such empathic yet deliberate reasoning to seek solutions: devices which yield function in a real sense and are more than just tolerated, used for their novelty, or accepted to please someone else. Seating, wheelchair designs, licensed vehicle modifications, electrical stimulation for pain relief or function, and home and job modifications are all parts of an armamentarium which spans the spectrum from modifications to the shoe to those to the motorcar, for mobility; from a mouth stick to a robotic system, for independent "prehensile" function; from a simple word-display board to synthetic speech, for communciation.</p> <p>Then, do we really need to cultivate large numbers of graduate engineers for rehabilitation engineering practices (other than for the employment of some smaller number in research and development)? Yes, if the prosthetist/ orthotist does not accept the alternative recommended: proper management of his/her practice integrating it with those of other team members and with the very significant role of their skilled technicians who become key constituents in that practice.</p> <p>Apparently some prosthetists and orthotists see an expanding future. The excellent document describing the professions of prosthetics and orthotics and recently published by the American Academy of Orthotists and Prosthetists<a style="text-decoration: none;">*</a> refers to the directions being taken by its professions, based for now on "bionics" referring specifically to automatic control of knee function and myoelectric control of powered upper-limb prostheses. These are presented as steps toward encompassing more and more technology, components of a rehabilitation engineering commitment. In fact the logo of this publication (shown here) presents the transition from orthotics and prosthetics to rehabilitation engineering over a natural pathway (or track) for growth.</p> <p>The essential initiatives now have to come from the current practitioners. In fact they could also abdicate their "clinical" role to the rehabilitation engineering equipment dealers!</p> <b>Footnote</b>The Academy brochure can be ordered from the National Office for $1.25 each.<b><br /><br />Footnote</b> Staros, A. and G. Rubin, The Orthopedic Surgeon and Rehabilitation Engineering in Orthopedics, March/April 1978, Volume 1/Number 2, Charles B. Slack, Inc., Thorofare, N.J.<br /><br /><b>Footnote</b> Moss Rehabilitation Hospital (REC) Wheelchair I; Report of a Workshop sponsored by RSA and VAPC, Dec. 6-8, 1977, Philadelphia, Pa.<br /><br /><em><b>*Anthony Staros, MSME, PE </b> Director, VA Rehabilitation Engineering Center New York, N.Y.</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_001/1981_04_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 Rehabilitation Engineering and Prosthetics/Orthotics Creator An entity primarily responsible for making the resource Anthony Staros, MSME, PE * https://staging.drfop.org/files/original/7726a0b6d065fcfc2a69ee0f0fbdd82a.pdf aaecbd42a917de5b36eeb049f73ef608 https://staging.drfop.org/files/original/907b3b60ab891d2c062f4ceb5bb2af8d.jpg 31530cab1a56fffba73f07af39b2d077 https://staging.drfop.org/files/original/3a4e9c51a778e57578a9fabe571b7158.jpg c30f2899c6c3b59f9ad0d33d8b10c9bf 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_02_090.pdf Text Any textual data included in the document <h2>Technical Note: The Soft Socket</h2> <h5>Arthur Forman, B.S., M.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Oftentimes we are presented with an above-knee amputee who poses difficult problems for a successful prosthetic fitting. Some of these problems include advanced age, atrophy, trigger points, bony prominences, surgical implants, cardiopulmonary problems, short residual limbs, and other complications. Any one of these conditions might make for a difficult fitting, but any combination of these could contribute to an unsuccessful fitting, or a situation which precludes ambulation.</p> <p>It is my contention that given the current generally accepted practices and when presented with an involved patient as indicated above, we are doomed to failure, in terms of comfort and ambulation. Further, it is my contention that very often, although these patients may be confined to a wheelchair even after prosthetic fitting, it is of paramount importance that they be fitted as comfortably as possible. Although they have lost a limb, they may be just as motivated as any other patient and can suffer psychological stigma.</p> <p>Therefore, it is our duty as prosthetists to provide a prosthesis that will allow these patients to ambulate as much as possible, resulting in both psychological and physical benefits.</p> <h3>Soft Socket Rationale</h3> <p>As we all know, the quadrilateral above-knee socket was originally designed and fitted for World War II traumatic amputees. They were fairly young, usually with no other complications, good musculature, and in many cases of long length. Today we are faced with a high geriatric amputee population with conditions quite different than the World War II veteran. The quadrilateral above-knee socket design impinges directly on the neurovascular bundle in the area of the Scarpa's triangle. The posterior seat area bears directly on an anatomical area which is usually atrophied to the point of being uncomfortable. These features alone call into question the viability of the quadrilateral design when considering an involved patient as described previously. The soft socket design as described, owes its inception to the CATCAM design.</p> <p>The soft socket is almost an exact anatomical negative duplication of the residual limb without extreme scarpas impingement and without concentrated ischial weight bearing. It is lined with 1/2" thick Plastizote, or similar forgiving material that enhances soft tissue bearing, hence "soft socket." It is compatible with all existing above-knee components, far more cosmetic, aligned using current practices, and is fabricated only in a slightly different fashion. Also, it will allow the amputee to ambulate in a comfortable non-restrictive manner.</p> <h3>Case Study</h3> <p>A seventy-six year old man was presented for prosthetic fitting. He was a traumatic amputee who had lost his leg during the Korean War and was left with a four inch length femur. He had been wearing an exoskeletal system with an hydraulically controlled knee, conventional quadrilateral socket, hip joint, and pelvic belt. The prosthesis weighed approximately 13 pounds. The lateral wall of the socket was modified at mid-femoral length to impinge on the femoral shaft. The patient had recently undergone surgery to repair a fractured femoral head on the amputated side due to a fall. He had also recently developed emphysema and had lost a significant amount of weight. During weight bearing on the sound leg, he exhibited extreme fatigue and loss of breath. Despite these contraindications to prosthetic fitting, he expressed great motivation.</p> <p>I proceeded with the standard impression technique using the Berkeley brim. The patient experienced discomfort while suspended in the Berkeley brim. He indicated specific areas of discomfort including the ischial/gluteal area and the lateral femoral area. This continued despite angular adjustments to the brim. An impression was taken. Upon examination of the impression and after discussion with colleagues, it was decided that a conventional fitting would not work. After mulling over the situation, it was decided to hand wrap a new impression, while the patient laid on his sound side. This was done in a very particular way, encompassing the gluteals, and hand forming the medial and posterior wall. A very anatomic impression was obtained. Modification was minimal and consisted mainly of smoothing up and adding a layer of 1/2" Plastizote (<a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg"><b>Fig. 1</b></a>) after lamination. The prosthesis weighed 7 1/2 pounds. This included a modular safety knee, extension assist, hip joint, pelvic belt, foam cover, foot, and shoe (<a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg"><b>Fig. 2</b></a>). The patient has been wearing this prosthesis and is quite satisfied.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg">Figure 1.</a> The Berkeley brim above the AK prosthesis with hip joint and pelvic band. Note presence of Plastazote pad in the ischial seat area.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.jpg">Figure 2.</a> The completed prosthesis.</strong><br /> <h3><br />Conclusion</h3> <p>It is my belief that we, as prosthetists, should approach our patients as individuals and if necessary, modify or completely discard commonly accepted techniques in order to successfully fit the uncommon patient. We should continue to examine our techniques in order to upgrade our profession and better serve the community.</p> <h3>Acknowledgments</h3> <p>Kevin S. Garrison, CP., Mahnke's Prosthetics-Orthotics, Inc., Fort Lauderale, Florida; Joseph Leal, C.P., Custom Prosthetics of Tucson, Arizona; John Sabolich, C.P.O., Sabolich, Inc., Oklahoma City; Thomas Guth, C.P., R.G.P. Orthopedic Appliance Co., Inc., San Diego, California; Ivan Long, C.P., Polycadence, Inc., Arvada, Colorado; Timothy B. Staats, C.P., Director of Prosthetics, education training programs, UCLA.</p> <b>*Arthur Forman, B.S., M.A. </b> Arthur Forman, B.S., M.A., is a prosthetist formerly with Mahnkes Prosthetics and Orthotics, Inc., 1915 N.E. 45th Street, Fort Lauderdale, Florida 33308. Page Number(s) 90 - 92 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_090/1986_02_090-2.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 Technical Note: The Soft Socket Creator An entity primarily responsible for making the resource Arthur Forman, B.S., M.A. * https://staging.drfop.org/files/original/bf963a7989acad403aa943778ba020f1.pdf 409d60d0518157719847a792bbaa57d6 https://staging.drfop.org/files/original/0106990b6dd41f117c47cb5fdca17da6.jpg df6ba1aeb28f1c6a9d86a606fe572db8 https://staging.drfop.org/files/original/f2e96714d806c927c09ba51bb59036d1.jpg 40fd5b62c3ecd7ff81b859972eb1341c https://staging.drfop.org/files/original/62eca765fb8a28647e1f1e9858e762b3.jpg d87f8fadb9907c263d1a3fde50944103 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_014.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 14 - 16 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/1968_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_014.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>Immediate Postsurgical Prosthetics Fitting in the Management of Upper-Extremity Amputees</h2> <h5>Augusto Sarmiento, M.D. <a style="text-decoration:none;">*</a><br />Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>In the experience of the authors of this article, immediate postsurgical prosthetics fitting has been the most satisfactory means of managing lower-extremity amputees. <a></a> The procedure has allowed better control of postsurgical edema, reduced postoperative pain, permitted more rapid conditioning of the stump, and shortened the time between amputation surgery and definitive prosthetic fitting. These conclusions are based on the experiences gained with 200 below-knee amputations followed by immediate postsurgical fittings at Jackson Memorial Hospital, the main teaching hospital of the University of Miami School of Medicine. The underlying cause of amputation in 85 per cent of these patients was peripheral vascular disease, usually with diabetes.</p> <h3>Four Upper-Extremity Cases</h3> <p>On four occasions there have been opportunities to apply temporary prostheses to upper-extremity amputees immediately after surgery. The patients in this small series showed a considerable reduction in postoperative pain, rapidly began to use their prosthetic appliances, and were impressive in their psychological adjustment to their disabilities.</p> <p>Brief clinical and prosthetics histories of these four patients follow.</p> <ol> <li>L.M. is a 32-year-old male who was struck in the right hand by a rattlesnake in November 1966. Despite a vigorous therapeutic regimen, extensive damage was sustained. The patient underwent several surgical procedures in attempts to restore function to his hand. One year later, because of a functionless, partially anaesthetic, two-digit hand, a wrist disarticulation was performed, with immediate fitting of prosthesis (<b>Fig. 1</b>). Seventeen hours after surgery, with no instruction other than the preoperative demonstration of the harness and hook control, the patient was capable of operating the terminal device sufficiently well to feed and dress himself (<b>Fig. 2</b>). The patient was fitted with a permanent prosthesis three weeks after amputation. The surgical wound had healed <i>per primam </i>when the stump was first inspected two weeks after the surgical procedure.</li><li>A.S. is a 57-year-old male who severely injured his hand in a meat grinder, requiring a wrist disarticulation. Because of the nature of the injury, it was elected not to close the wound but to perform an open carpal disarticulation. One week later, in the absence of infection or other complications, a wrist disarticulation was performed by conventional means. The patient was fitted immediately postoperative with a below-elbow temporary prosthesis, complete with harness and controls. The patient left the hospital four days after surgery; when seen as an outpatient one week after surgery, he was capable of using the terminal device satisfactorily. He was fitted with the final prosthesis four weeks after surgical procedure.</li><li>L.D. is a 57-year-old male who underwent a right below-elbow amputation in December 1967 because of extensive metastases to the right radius from a hypernephroma (<b>Fig. 3</b>). The operation was performed by conventional methods and a temporary prosthesis, with harness and controls, was applied immediately after surgery. Convalescence was uneventful and the patient was discharged 22 days after surgery, at which time he was capable of controlling the elbow and terminal device in a relatively satisfactory manner. He was fitted with a permanent prosthesis 60 days after the surgical procedure.</li><li>F.M. is a 57-year-old male who sustained a severe sideswipe injury to the left upper extremity, with multiple fractures and extensive arterial and nerve injuries. After approximately nine months and many surgical procedures, the patient was left with a functionless and nearly anaesthetic extremity. An above-elbow amputation was carried out by conventional means, with immediate fitting of the temporary socket. The postoperative course was uneventful. Harness and controls were added one week postoperative. Upon discharge four weeks after surgery, the patient was using the terminal device and elbow lock in a satisfactory manner.</li></ol> <h3>Discussion</h3> <p>The absence of severe peripheral vascular disease in the upper extremities appears to increase the possibility of successful immediate postsurgical prosthetics fitting even above that seen in the lower extremities. Since weight-bearing is not a factor, the possibility of stump damage as a result of excessive pressures is minimized. In all four cases reported in this article, primary healing took place and there were no complications. Phantom pain was not encountered in any instance. The four patients were fitted with plaster temporary prostheses with conventional harness and controls and were instructed to operate the terminal device as early as the first postoperative day. The two wrist-disarticulation patients were allowed to move their elbows freely, and the two above-elbow patients were encouraged to move their shoulders as freely as possible. The psychological advantage of early rehabilitation has been apparent. Immediate postsurgical prosthetics fitting of the upper-extremity amputee appears to have significant advantages.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Preoperative view of a functionless and partially anaesthetic hand resulting from the bite of a rattlesnake. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Photograph taken 24 hours after wrist disarticulation and immediate postsurgical fitting of prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Metastatic lesion of right radius resulting from hypernephroma. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de I'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck</i>, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</li> <li>Berlemont, M., <i>L'appareillage des ampulis des membres inferieurs sur le table d'operations, paper given at the International Congress of Physical Medicine</i>, Paris, 1964.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr.,<i> Management of lower-extremity amputees using immediate postsurgical Jilting techniques.</i> Prosthetic and Sensory Aids Service, U.S. Veterans Administration. 1967.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, Spring 1967, pp. 47-50.</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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de I'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Berlemont, M., L'appareillage des ampulis des membres inferieurs sur le table d'operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical Jilting techniques. Prosthetic and Sensory Aids Service, U.S. Veterans Administration. 1967.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, Spring 1967, pp. 47-50.</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>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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>Newton C. McCollough, III, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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>Augusto Sarmiento, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-03.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 Immediate Postsurgical Prosthetics Fitting in the Management of Upper-Extremity Amputees Creator An entity primarily responsible for making the resource Augusto Sarmiento, M.D. * Newton C. McCollough, III, M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/c79f3f5c06fbbad81bc534504137ea3e.pdf 56cedf7cb099c7fc851bdff7afeb1c91 https://staging.drfop.org/files/original/a7ac4b8b00ef3f5830653ebc22e659b2.jpg 335d2e274b5821d0d91ccc0338e156c0 https://staging.drfop.org/files/original/33504c7b98ac0853055ccefc9bc6b9c8.jpg 1a330b00bafa9bb15ec2d099bb159f06 https://staging.drfop.org/files/original/e71bdbc6078fbbac96e8b81e5d6678d2.jpg e1943727ad52b90951b681daddfdda85 https://staging.drfop.org/files/original/9408796397f1cbfaa3f48fa88b387d62.jpg 6bf9efb5b675a3eab952bd92fc036d38 https://staging.drfop.org/files/original/6e93d0f1a716dd100e308fbf39a5cd4b.jpg df5d4bd7e85ebc7852ce93f8010a48f7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_028.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 28 - 32 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/1967_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_028.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>Application of Prosthetics-Orthotics Principles to Treatment of Fractures</h2> <h5>Augusto Sarmiento, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Greater knowledge and understanding of bioengineering by the prosthetics and orthotics industries during the past twenty years have resulted in the development of highly functional and sophisticated appliances. For example, modern prostheses for lower- and upper-extremity amputees are now designed with proper attention given to energy expenditures and other physiological factors based on scientific information obtained from laboratory and clinical studies. Close liaison between medical and engineering disciplines has contributed enormously to the revolutionary changes that prosthetics and orthotics have undergone during the past two decades.</p> <p>Experience in the management of amputees has given the authors the opportunity to study the possibilities of utilizing prosthetics principles in the management of orthopaedic conditions. The first of these came as a result of clinical work with below-knee amputees. Prior to the development of the patellar-tendon-bearing (PTB) prosthesis in 1957, the below-knee amputee ambulated with an appliance which required a thigh corset to provide stability and to assist in the distribution of weight-bearing forces. The PTB prosthesis proved that the below-knee stump could take the pressures necessary for weight-bearing during ordinary activities without assistance from a thigh corset. The snug, total-contact fit and the firm contouring of the tibial flare and patellar tendon make possible weight-bearing ambulation without undue pressure being exerted over small areas or appreciable telescoping of the stump in the prosthesis.</p> <p>The traditional belief in orthopaedic circles has been that fractures of the tibia require the joints above and below the fracture site to be immobilized, the knee joint to be held in flexion to increase rotational stability, and weight-bearing to be avoided until fracture healing is complete. Some reports have appeared in the literature where ambulation on the fractured extremity is encouraged while the injured limb is stabilized in a groin-to-toe cast. This method, however, makes motion of the knee and ankle joints impossible <a></a>.</p> <p>Convinced that the patellar-tendon-bearing prosthesis can adequately stabilize the stump without excessive piston action or rotation, the senior author applied the principles of this appliance to the treatment of tibial fractures. Three and a half years ago, he constructed a total-contact, below-knee cast firmly molded over the entire leg and contoured over the proximal tibia in a.manner identical to that of the patellar-tendon-bearing prosthesis (<b>Fig. 1</b>). The results were encouraging, since the fracture united without loss of the reduction originally obtained and without additional shortening, angulation, or rotation of the fragments. Since then we have treated 200 patients with various fractures of the tibia, malleoli, or os calcis <a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Short-leg total-contact PTB-like cast for tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The impossibility of providing flexion in the proximal segment of the cast, as in the case of the PTB prosthesis, soon convinced the authors that the patellar tendon was not a major contributor to the distribution of weight-bearing pressures. In most cases, we do provide the patellar-tendon indentation and high condylar wings because they appear to be valuable in enhancing rotational stability, particularly in cases of high tibial fractures.</p> <p>With this short-leg, total-contact PTB-like cast, weight-bearing forces are transmitted from the ground to the proximal tibia, virtually bypassing the fracture site. At first glance, such a method of treatment appears to conflict with orthopaedic principles. It is the authors' belief, however, that it utilizes to a fuller degree the knowledge of basic principles governing osteogenesis and fracture repair. The active use of the extremity in a near-normal manner seems to place the fractured limb in a physiological environment more conducive to uneventful healing.</p> <p>Experience with the first 200 cases and the addition to the staff of the University of Miami School of Medicine of the junior author of this paper made it possible to attempt elimination of the foot and ankle portion of the cast, the object being the transmission of weight-bearing forces from the ground to the proximal tibia by means of metallic uprights attached distally to the patient's shoe and proximally to the cast (<b>Fig. 2</b> and <b>Fig. 3</b>). We have treated 40 tibial fractures with this cast-brace with encouraging results.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Short-leg total-contact cast-brace used in the treatment of tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Bilateral short-leg total-contact cast-braces used in delayed union of tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to utilize the benefits of a near-normal physiological environment in fractured limbs, we have used short-leg, total-contact casts with or without the orthotic components in many instances of delayed unions with or without associated chronic osteomyelitis. A complete report on these cases will be published in the near future.</p> <p>In the same manner that the patellar-tendon-bearing prosthesis led to the development of the short-leg, total-contact cast, we have introduced the principles of the quadrilateral, ischial weight-bearing prosthesis to the treatment of fractured femurs. We have constructed a cast-brace that stabilizes the fractured femur but permits freedom of motion of the hip, knee, and ankle joints (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Ischial weight-bearing cast-brace for femoral fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This cast-brace is applied with the patient standing on his normal limb while the ischium on the affected side rests on the platform of an above-knee casting stand. Ambulation results in transmission of weight-bearing pressures from the ground to the ischium, thus preventing shortening of the fractured fragments, angulation, and rotation. Our experience has been limited, and so we are in no position at this time to state whether or not this cast-brace will earn a place in the armamentarium of the orthopaedic surgeon.</p> <p>We have utilized the basic construction design of the Munster prosthesis as applied to the very short below-elbow amputee, and have constructed a cast in a manner similar to that of this prosthesis. To prevent rotation of the forearm, the cast is molded in such a manner that its anteroposterior diameter is as narrow as possible. The high condylar wings firmly contoured over and around the bony prominences of the forearm and humerus enhance rotational stability. A metal joint makes possible freedom of motion of the wrist joint (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cast-brace with articulated wrist joint for forearm fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The possible applications of these cast-braces may be numerous in the everyday practice of orthopaedics. Additional investigations should be conducted before arriving at any final conclusions regarding the value of these approaches.</p> <h3>Conclusion</h3> <p>Familiarity with prosthetic appliances has resulted in the application of their basic principles to the management of orthopaedic conditions of the upper and lower extremities.</p> <p>A functional short-leg, total-contact cast based on the patellar-tendon-bearing (PTB) prosthesis was developed and used in 200 cases of tibial, malleolar, and os calcis fractures. In addition, a short-leg, total-contact cast-brace which permits motion of the knee and ankle joint has been utilized in 40 cases of fresh and old tibial fractures.</p> <p>Attempts have also been made to stabilize femoral and forearm fractures with cast-brace appliances. These cast-braces are constructed with features resembling those of the ischial weight-bearing quadrilateral socket and the Munster prostheses used by above-knee and below-elbow amputees, respectively.</p> <p>There are many clinical situations in orthopaedics which provide opportunities for further study of the utilization of prosthetics-orthotics principles.</p> <p><b>References:</b></p> <ol> <li>Dehne, Ernest, C. W. Metz, P. A. Deffer, and R. M. Hall, Nonoperative treatment of the fractured tibia by immediate weight bearing, J. Trauma, 1:514-535, 1961.</li> <li>Sarmiento, Augusto, A functional below-the-knee cast for tibial fractures, J. Bone and Joint Surg., 49A:5, July 1967.</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>2.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, A functional below-the-knee cast for tibial fractures, J. Bone and Joint Surg., 49A:5, July 1967.</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">Dehne, Ernest, C. W. Metz, P. A. Deffer, and R. M. Hall, Nonoperative treatment of the fractured tibia by immediate weight bearing, J. Trauma, 1:514-535, 1961.</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>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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>Augusto Sarmiento, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_028/aut67-11.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_028/aut67-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_028/aut67-13.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_028/aut67-14.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_028/aut67-15.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 Application of Prosthetics-Orthotics Principles to Treatment of Fractures Creator An entity primarily responsible for making the resource Augusto Sarmiento, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/2a26fa46a936952d7346630a4fddeb3b.pdf 9bf1d7ad81311e350ca58227aa8ef3e4 https://staging.drfop.org/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg 12316de41cb85404fa07f030884d0bbd https://staging.drfop.org/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg 5c959a25cd8c901d6983309deb9ae306 https://staging.drfop.org/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg aa82aa97958a91904276e94a5b918415 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/1983_03_005.pdf Text Any textual data included in the document <h2>Some Comments on Cervical Orthoses</h2> <h5>Augustus A. White, III, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>The following was received past the deadline for the Spring C.P.O., for which it was intended. Because of the interest in the subject it addresses, we are printing these comments here. Anyone wishing to respond to the points the author raises may do so through letters to the editor. Our thanks to Dr. White for submitting his editorial.</i></p> <p style="margin-left: 10%;"><i>The Editor</i></p> <h3>Introduction</h3> <p>A classic history on the development of orthopaedic appliances, including some interesting material on cervical orthoses, has been written by J. W. Edwards (1952). A reading of this work quickly illustrates that many orthotic devices bear a striking resemblance to components of medieval armor. Particularly prominent in cervical orthotics is the work of Hugh Owen Thomas. This ingenious, chain-smoking, nineteenth century inventor developed a number of useful orthopaedic appliances, and is credited with the basic design of the cervical brace used today and known as the Thomas cervical collar.</p> <h3>Functions of Cervical Orthoses</h3> <p>Any cervical orthosis is really a device designed to apply forces to the cervical spine in order to control it in some way. The goal of that control is usually support, rest, immobilization, protection, or correction. The application of the forces restrains the normal or abnormal patterns of movement or alignment of the cervical spine. When the goal is to rest the spine, the device must assist or substitute for stabilizing muscle action. For example, a cervical collar may be used to prevent extension into a range that is painful or irritating to the patient. In another instance, the purpose of the orthosis may be to protect the vital spinal cord or nerve roots. This would be required when the spine has been rendered unstable by tumor, disease, surgery, or injury. A cervical orthosis can also function simply as a reminder and psychological "support." When the patient moves, he or she is made aware of the brace and therefore voluntarily restricts motion. In addition, the orthosis may provide warmth and physical support that is reassuring to the patient.</p> <p>After the physician makes a diagnosis, and elects to treat a particular problem with a cervical orthosis, it is helpful to identify the specific mechanical functions that are to be achieved with the orthosis (see <b>Table I</b>). Is the goal to support (rest), immobilize (protect), or correct the spine? It is helpful for the clinician to go through the process of determining which of various motions of the spine must be controlled. Is it flexion, extension, lateral bending, axial rotation, or some combination of these? By thinking through these questions, a more rational and precise orthotics selection can be made.</p> <strong>Table I. Systematic Analysis for the Selection of Orthoses</strong> <h3><img src="/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg" h3="" width="418" height="327" />Orthotics Evaluation Studies</h3> <p>Before discussing examples of cervical orthotics, it is helpful to review briefly the experimental work upon which we base our clinical recommendations. <i>In-vivo</i> cineradiography studies by Hartman and colleagues evaluated the effectiveness of immobilization of various orthotic devices on the cervical spine (Hartman et al. 1975). These studies compared five different cervical orthoses (Findings are shown in <b>Table II</b>). The investigators concluded that the motion that was most difficult to restrain was that between the occiput and C2.</p> <strong>Table II. Effectiveness of Cervical Spine Orthoses in Immobilization*<br /></strong><br /><img src="/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg" p="" width="568" height="192" /><br />An evaluation of cervical braces by Johnson and colleagues placed normal subjects in different orthotic devices Johnson et al. 1977). Photographs and radiographs were used to determine differences in range of motion with and without the subjects wearing various orthoses (Findings are shown in <b>Table III</b>). It was found that by increasing the vertical length and the rigidity of a given cervical orthoses, there is improvement in its ability to control motion. In general, it was found that controlling lateral bending and axial rotation is more difficult than controlling flexion/extension. The most effective conventional braces are able to restrict C1-C2 flexion extension by only 45% or normal. The halo apparatus restricts the motion by 75%. <br /><br /><strong>Table III. Efficiency of Cervical Braces in Immobilization*</strong><br /><img src="/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg" p="" width="422" height="254" /><br />In summarizing this experimental data, the following generalizations are valid. The soft collar does little in the way of immobilizing the cervical spine. The rigidity of the components at the chin and the occiput are the main elements in restricting motion. As one adds shoulder or thoracic fixation to the various conventional cervical collars, the immobilizing capacity of the orthosis is increased. When the added chest support is actually fixed to the thorax, the immobilizing efficiency is further improved.<br /><br /> <h3>Clinical Review of Some Specific Cervical Orthoses</h3> <p>To follow is a review of the major types of cervical orthoses. They are categorized on the basis of <i>effectiveness of control</i>. Thus, we have divided cervical orthotics into minimum, intermediate, and most effective control (<b>Table III</b>).</p> <p><b>Minimum Control</b>: The basic Thomas collar and numerous variations of it are examples of minimum control orthoses. These collars vary in height, contour and rigidity. They may be worn either forwards or backwards to increase or decrease the amount of flexion/extension possible. Generally, they are to be worn so that the chin rest, which is a convexity in the collar that points downwards, is anterior. However, some patients find it more comfortable to reverse this position, and certainly in cases where one is more interested in restricting extension than flexion, a reversal of this position will block extension more effectively. In other words, if a high portion of the collar is worn posteriorly there is relatively less extension. Although these collars probably do little or nothing in the way of immobilizing the spine, they do provide warmth as well as psychological comfort and support. They can be helpful to the patient in the treatment of a broad variety of conditions including some whiplash injuries, minor sprains and strains, cervical spondylosis, and some stable postoperative surgical constructs.</p> <p><b>Intermediate Control</b>: There are a number of orthotics that are appropriately classified in this group. The Philadelphia collar is a beefed-up version of a Thomas collar. It is more rigid, has an anterior and a posterior plastic reinforcement, a rigid chin support, and a significantly developed extension block posteriorly to support and restrict the occiput.</p> <p>In order to achieve a greater level of immobilization, some extension of the orthosis down into the shoulder and/or thorax is required. This lengthening of the orthosis provides a more effective anchoring, purchase, and immobilization. There are several braces that fit into this category, most notably the four-poster brace, the Duke brace, the Guilford brace, and the SOMI brace. The SOMI is the most effective immobilizer in this group. These orthoses are probably more effective in the standing and sitting positions. In the supine, prone, or side lying positions, relaxation and rotation of the shoulders and thorax minimize the effectiveness of these orthoses.</p> <p>We should also note that if we wish to prevent anterior displacement of C1 or C2 in a rheumatoid patient we cannot rely upon a soft cervical collar, a Philadelphia collar, a four-poster brace, or even a SOMI brace (Altoff and Goldie 1980).</p> <p><b>Most Effective Control</b>: If there is a clinical problem involving significant loss of clinical stability, the cervical orthosis hould provide the maximum amount of immobilization, unloading of the spine, and protection. Major control is needed in all of the parameters of motion. Depending on the particular clinical situation, it may be more important to control some particular motion or combination of motions.</p> <p>One option in this situation is a significantly more rigid version of the Thomas collar. The Minerva cast incorporates the concepts of extending the brace down towards the thorax and immobilizing the chin and occiput. This cast extends from the forehead down to the pelvis. The goddess Minerva was born by popping from the head of Jupiter, fully armored. From this Roman myth the cast has taken its name. This device, although not used very much currently, can be useful, especially in the protection of irresponsible patients. It should be kept in mind, however, that even with a well-applied Minerva cast, a few degrees of cervical spine motion are possible. Most of the motion occurs at the occiput-C1 region. The cast has to be open enough to allow an adequate range of motion for the mouth so that the patient can talk and chew. This same range of motion allows for motion at the occiput-C1-C2 joint complex. Thus, when your patients are in a Minerva cast but can talk and chew, you must be aware that they can move C1-C2.</p> <p>In difficult clinical situations, where there is extensive disease or surgery, or an injury has rendered the cervical spine unstable, use of a halo apparatus should be considered. This device is fixed to the skull with pins and is attached either to an individually molded plaster jacket or to a prefabricated jacket which comes in several sizes. Experimental studies generally agree that this device is the most effective immobilizer of the cervical spine. One should be aware that use of this device carries the risk of several complications. These include: penetration of the skull by fixation pins, brain abscesses, abducens, glossopharangeal and facial nerve palsy, and the development of cervical spondylosis. Facial complications can be recognized during the first few days after application by requesting patients to smile, roll their eyes, and stick out their tongue. If the patient is unable to do any of these three activities, careful neurological evaluation is indicated.</p> <h3>Resume</h3> <p>A rational approach to the use of cervical orthotics may be taken by posing several questions. What is the clinical condition of the spine? What are the therapeutic goals to be achieved by the brace? Is the goal to protect the spine, or to rest it? In what way should the mechanics of the spine be changed to achieve that goal? What kinds of forces are necessary in order to achieve these therapeutic aims?</p> <p>In the cervical spine, the standby orthosis for minimal immobilization is the Thomas collar. If one needs a high level of control, then an intermediate zone orthosis, such as the Philadelphia collar or any variety of collars that involve thoracic attachments, can be employed. The SOMI brace is the most effective in this intermediate group. If the therapeutic goal is to obtain maximum control and immobilization of the cervical spine, a halo apparatus with an individually molded plaster jacket is required. One should be aware that this apparatus carries the liability of exposure to complications. These complications can be minimized by diligent care techniques and follow-up evaluation.</p> <p><b>References:</b></p> <ol> <li>Altoff, B. and Goldie, I.F.: Cervical collars in rheumatoid atlauto-axial subluxation. A radiographic comparison. <i>Annals of the Rheumatic Diseases</i> 39: 485, 1980.</li> <li>Edward, J.W.: <i>Orthopaedic Appliances Atlas.</i> Vol. I, Ann Arbor, Michigan, American Academy of Orthopaedic Surgeons, 1952.</li> <li>Hartman, J.T., Palumbo, F., and Hill, B.J.: Cineradiography of the braced normal cervical spine. <i>Clinical Orthopaedics</i> 109: 97, 1975.</li> <li>Johnson, R.M. et al.: Cervical orthoses. A study comparing their effectiveness in restricting the cervical motion in normal subjects. <i>Journal of Bone and Joint Surgery </i>59A: 332, 1977.</li> <li>O'Brien, J.P.: The halo-pelvic apparatus. A clinical, bio-engineering and anatomical study. <i>Acta Orthopaedica Scandinavica</i> 163 (supplement), 1975.</li> <li>Victor, D.I., Bresnan, M.J., and Keller, R.B.: Brain abscess complicating the use of halo traction. <i>Journal of Bone and Joint Surgery</i> 55A: 635, 1973.</li> <li>White, A.A. and Panjabi, M.M.: <i>Clinical Biomechanics of the Spine</i>, Philadelphia, J.B. Lippin-cott, 1978.</li> </ol> <em><b>*Augustus A. White, III, M.D. </b> The Department of Orthopaedic Surgery Beth Israel Hospital and Harvard Medical School, and the Charles A. Dana Research Institute, Beth Israel Hospital, Boston, Massachusetts</em><br /><br /><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 7 Year 1983 Volume 7 Issue 3 Figure 2 TABLE II http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 TABLE III http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-3.jpg Figure 1 TABLE I http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-1.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 Some Comments on Cervical Orthoses Creator An entity primarily responsible for making the resource Augustus A. White, III, M.D. * https://staging.drfop.org/files/original/892fdbb362b8e10138add9644e5ab5c1.pdf bea506cbf5df4cebb34bc4911c8becb0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_001.pdf Year 1954 Volume 1 Issue 3 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/1954_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_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>Bioengineering- Blueprint for Progress</h2> <h5>Augustus Thorndike M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The limbs of man move in space and time, in response to systems of internal and external forces, and in accordance with the laws of mechanics. To restore to any satisfactory extent the functions lost through amputation of an extremity therefore requires intimate knowledge not only of the structure, form, and behavior of the normal limb but also of the techniques available for producing complex motions in substitute devices activated by residual sources of body power. Since adequate replacement of a natural limb with an artificial one requires successful integration of the human mechanism with a toollike device, the biomechanical features of the stump and the physical characteristics of the prosthesis must be wedded as nearly as possible into a single, functional entity.</p> <p>Two-sided as this problem would now obviously appear, it is only in comparatively recent years that the medical sciences of surgery, anatomy, and physiology and the physical one of engineering have been brought together in a unified attack upon the whole problem of amputee rehabilitation. Until recently, surgeons, with few exceptions, had little or no understanding of engineering problems. And heretofore the design and construction of artificial limbs has been conducted mostly by artisans who, however ingenious they may have proved to be, were mostly without formal education in engineering or anatomy. Besides this, except in isolated instances the two worked separately and alone. All of which no doubt accounts for the fact that, as late as World War II, the available artificial limbs fell far short of the standards of accomplishment attained in other fields of research and invention.</p> <p>In the research program coordinated by the Advisory Committee on Artificial Limbs, National Research Council, there have been brought together in harmonious working relationship the individual skills of surgeon and engineer in a sort of mutual bioengineering to produce truly functional artificial limbs. As a result, there has been in the field of prosthetics perhaps more progress during the past decade than in all the preceding 2000 years of limb-making.</p> <p>Because the lower limb is more essential to human activity than is the arm, and also doubtless because the basic functions of the leg are easier to replace than are those of the arm, progress in artificial arms and hands has from the earliest times always lagged far behind developments in artificial legs. This circumstance was reflected in the fact that, when the Artificial Limb Program was established in 1945, much more had already been accomplished in replacements for the lower extremity than in those for the upper. And consequently developments in the ACAL program to date have been most noticeable in upper-extremity prosthetics, despite extensive engineering studies of normal and amputee locomotion and refinements in the techniques of lower-extremity fit and alignment.</p> <p>In any case, the development of prosthetics had necessarily to follow the pattern of developments in surgery, and conversely the surgeon's philosophy with regard to "sites of election" and other matters was necessarily dictated by the character and availability of such prostheses as there were. Since the science of amputation surgery and the art of limbmaking proceed as one, the standards and practices in one field dictate standards and practices in the other, and vice versa. That each of these has now been brought to understand more fully the problems of the other may be looked upon as a major achievement in the art of prosthetics.</p> <p>In the following pages of this issue of Artificial Limbs is to be found substantial evidence that the engineering profession, working with the amputation surgeon, has provided new thoughts, new ideas, and new approaches to the problem of providing adequate functional replacements for the limbless. In the whole Artificial Limb Program there exists no better example of cooperation toward progress than is demonstrated here. In the first of two articles, a surgeon and an engineer collaborate in describing the latest devices and techniques arising from systematic research and the influence which these developments ought rightly to exert upon the philosophy of modern amputation surgery. In the second, an engineer outlines the methodology required in investigation of the normal limbs and in the design of useful replacements. Only through such teamwork in biomechanics can truly great advances in the field of prosthetics be expected. The development of the thirty Veterans Administration and other civilian orthopedic and prosthetic appliance clinic teams has resulted in the better distribution of new knowledge toward improved fitting and alignment of artificial legs and in the design and construction of improved artificial arms.</p> <p>The program of research coordinated by the Advisory Committee on Artificial Limbs involves the participation of government, university, and industrial laboratories. The Veterans Administration, the Army, and the Navy provide the necessary funds for the operation of their own establishments, while the VA provides the contractual authority with the funds necessary for work in the universities and in industrial laboratories. Out of this cooperative effort there have come within recent years improved functional prostheses for almost every level of amputation, particularly for those special amputee cases heretofore considered unsuited for an artificial limb. With the mutual cooperation of surgeon and engineer, there has resulted a cross-fertilization of ideas and a new set of modalities in the rehabilitation of amputees.</p> <p> Nevertheless, the presently available devices, though anthropomorphoid in form, are far from anthropomorphoid in function. Unfortunately, no artificial limb, however elaborate, can ever serve as an ideal substitute for a natural member unless it incorporates some of the features of sensory and muscular control characteristic of the limb it replaces. Therein lies the challenge of the future- to devise mechanisms which not only simulate the motions and the functions of normal limbs but which also provide appropriate feedback of information such as occurs in natural arms and legs. In our present state of knowledge, the ultimate goal of the limb designer is still a long way off. Further progress depends largely upon the continued cooperation of surgeon and engineer, of prosthetist and therapist, and of the amputee himself.</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>Augustus Thorndike M.D. </b></td></tr><tr><td class="clsTextSmall">Acting 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 Bioengineering- Blueprint for Progress Creator An entity primarily responsible for making the resource Augustus Thorndike M.D. * https://staging.drfop.org/files/original/a6f72a14629b7806dcca3b174e3141dc.pdf 59d6595db93d81ef8929c3f4dac05b45 https://staging.drfop.org/files/original/90a87026994734a6ca6470b2110bb6cb.jpg 4b459bfe7868166c8ebfce729b080b79 https://staging.drfop.org/files/original/ef5dbe6f889849aa0064644747edf282.jpg 5b9bbfcfb4d77f3ff2fcd6ed5c8a1773 https://staging.drfop.org/files/original/d52c95869fe6d55ff552dd83c67c000c.jpg e09a2be085c93cad6c6099eee0d57d8f https://staging.drfop.org/files/original/3a77241eaf3995510f53411b3c346397.jpg b8f4051742685bfa4f3ea535cb826cac https://staging.drfop.org/files/original/51816043e9faf56d792b7228710319bb.jpg 3a6888379382529c2f6cdfab9d8a8bcb https://staging.drfop.org/files/original/22957bf7e72d6292125d2fb56abe1b8a.jpg 5fa81fef76fccc4f2a1bbc19d49c4e1b https://staging.drfop.org/files/original/14aae14f9431ce4eb09dfe905d0c906b.jpg 98caf1dd5d9ab89ad4631f844719cc23 https://staging.drfop.org/files/original/b9d22a554d95e70fadd9e859a74c569d.jpg 869fcfb814ec950a3cc1f7428854b5b9 https://staging.drfop.org/files/original/e84537af8c9d23e37d303e3e0ebb5e04.jpg 7d06dc402deaaa85101fcb82ce962d8f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_016.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 16 - 24 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/1971_02_016.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_016.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 of the CAPP Cart</h2> <h5>Barbara A. Gehant <br /></h5> <p>Recent studies of juvenile amputees in the United States and Canada have revealed a sizable number of severely handicapped limb-deficient children. Fortunately, many of these amputees have been fitted with prostheses that enable them to perform skills necessary for daily activities. The quadrimembral amputee, however, presents particularly serious problems. While he may achieve considerable arm function with one or two upper-limb devices, the leg loss may not be adequately compensated for, especially in high-level amputees, and locomotion remains at best an exercise. In an effort to solve the problem of mobility for the most severely handicapped children, the Child Amputee Prosthetics Project at UCLA developed an electric cart. This article presents a study that was designed to determine the extent to which the CAPP cart assists children with quadrimembral deficiencies to achieve independent mobility.</p> <p>The CAPP cart (<b>Fig. 1</b>) is 17 in. wide and 23 in. long, and consists of a seat mounted on a chassis. In the driving position, the seat is 18 in. from the floor. The seat can be raised to 27 in. to enable the child to sit at a table or to transfer to a standard chair or bed. The cart, powered by a 12-volt battery, travels at a constant speed of 1 1/2 mph. It is guided by a lever that is controlled by the chin, and which operates on a "joy-stick" principle. The control arm can be swung to the side to facilitate transfer or activities at a table or desk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The CAPP cart. Power is provided by a 12-v battery; direction is controlled by the chin-operated lever. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sample</h3> <p>Since the cart was designed for the child with quadrimembral deficiencies, priority consideration was given to such candidates. The children were selected on the basis of the number of limb deficiencies and the degree of limitation. Eleven children from ten clinics participated in the study (<b>Table 1</b>). A twelfth child was provided with a cart (see Appendix) but not included in the sample, because this clinic already had two subjects represented in the study; additional data from the same reporters might have biased the study.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The sample included four boys and seven girls, six to fourteen years of age. Their weights ranged from 20 to 74 lb; the average weight was 30 lb. Trunk measurements were taken of each child from the bottom of the buttocks to the crown of the head. Sitting height averaged 25 in. and ranged from 20 to 32 in.</p> <p><b>Table 2</b> shows the skeletal deficiencies and prosthetic fittings for the eleven children. Of the five children with bilateral proximal femoral focal deficiencies (PFFD), two had not been fitted with lower-limb prostheses. One child ambulated with a lateral-sway walker, one wore below-knee orthoses bilaterally, and one wore a "brace-prosthesis" on the left and a socket, pylon, and SACH-foot prosthesis on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Four children had bilateral amelias. One wore hip-disarticulation prostheses with the knees locked, two used lateral-sway walkers, and the fourth child had not been fitted with any prostheses.</p> <p>One child had a very short below-knee stump on the right, and a knee disarticulation on the left; the last child had a fusion of the right knee and a left knee contracture. Neither had been fitted with prostheses.</p> <p>Again referring to <b>Table 2</b>, two children had bilateral upper-limb phocomelia, and neither had ever been fitted with arm prostheses.</p> <p>Of the two children with bilateral amelia, one wore two conventional shoulder-disarticulation prostheses, and the other had been fitted unilaterally, alternating between an experimental Michigan feeder arm and a conventional shoulder-disarticulation prosthesis.</p> <p>Of the four children with bilateral hemi-melia, three wore conventional above-elbow prostheses, and the fourth was fitted bilaterally with elbow-disarticulation prostheses.</p> <p>Three children had a combination of right amelia and left hemimelia. One wore a Michigan feeder arm on the left only, another wore a conventional shoulder- disarticulation prosthesis on the amelic side and an above-elbow prosthesis contralaterally, and the third had not been fitted with any prostheses.</p> <p>Three of the children were scoliotic, and three had skeletal problems involving the mouth. One child had bilateral hip dislocations; another had sacral agenesis, with associated loss of muscular mass in the lower extremities and bowel and bladder incontinence. Other abnormalities included hearing and visual deficiencies, and one child had an unspecified neuromuscular disorder manifested by generalized weakness.</p> <p>Five children alternated between the use of wheelchairs pushed by others or walked with their prostheses. Two children either were pushed in a wheelchair or carried by adults. Two were able to push themselves in regular wheelchairs, and one child used an electric wheelchair. One child used an adapted cart that had been constructed by his father.</p> <p>Six children lived in homes with steps at the outside entrance. The families of five of the children had ramps built to accommodate the CAPP cart. The sixth child lived in a two-story house, but used the cart only at school. Five children lived in homes with no stairs either outside or inside the building.</p> <p>All the children were of school age. Six attended special schools for the handicapped, and four attended regular classes in public schools. One child received private tutoring at home.</p> <h3>Procedure</h3> <p>The study was conducted over a six-month period, with evaluations performed at the clinics on three occasions. The results were submitted to New York University. Each clinic was responsible for the routine maintenance of the cart, with major repairs or adjustment that required disassembly of the cart being referred to NYU.</p> <p>The characteristics of each child, his physical and environmental conditions, and his prosthetic experience were recorded on the Selection Forms, which were returned to NYU.</p> <p>A representative of the New York University research staff was present when each cart was delivered and described the study to the child, parents, and clinic team. The training instructions and evaluation forms were discussed with the clinic therapist, and the maintenance instructions with the parents and the prosthetist.</p> <p>The child operated the cart under supervision until the clinic members felt that the child could drive it independently with safety. At the end of the training period, the therapist completed the Training Evaluation Form.</p> <p>The child returned to the clinic after he had used the cart for three months. The therapist, in consultation with the child's parents, evaluated the cart in terms of design, safety factors, and function, and recorded the information on the appropriate form. A maintenance check was made, and any necessary repairs and adjustments were also recorded.</p> <p>The child returned again to the clinic with the cart after six months. The clinic personnel recorded suggestions for improvements in the cart, the child was questioned as to his overall reactions to the cart, and all maintenance problems were recorded. The child's parents and teachers completed forms in which they described their reactions to the cart in terms of suggestions for cart modifications.</p> <h3>Results</h3> <p>Ten of the eleven children who participated in the study preferred the CAPP cart to other modes of transportation. Their parents were equally enthusiastic about the cart. The child who ultimately rejected the cart had a personality problem from the beginning; a strong mutual dependence between the child and her father was threatened by the increased independence offered her by the CAPP cart.</p> <p>The features of the cart that were most appreciated by both the parents and the children were the increased independence and mobility it provided. The main objection voiced by the parents was the weight of the cart. <b>Table 3</b> lists the features the children and parents liked best and least about the cart.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Operational Skills</h4> <p>As seen in <b>Table 4</b>, most of the children learned to control the cart with relative ease. The average training time was 5 1/2 hours. The oldest child (14 years) learned to operate the cart in 1/2 hour, while the youngest (6 years) required 14 hours of instruction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training items were divided into ' 'starting and stopping," "driving," and "turning". The children were asked to start and stop smoothly while driving forward and backward. Most of the children learned this with little difficulty; four learned with no formal training.</p> <p>The driving test consisted of moving forward and backward in a straight line and on a diagonal, crossing doorsills, and changing direction on command. The children learned to ascend and descend inclines of 10 degrees, to avoid obstacles, and to drive through a "slalom" course.</p> <p>Finally, the children were taught to turn the cart on its base, using a rear wheel as a pivot, 90 degrees forward and backward. Three children required no training to perform these tasks, and all of the children learned to perform all activities independently.</p> <p>Two of the younger children began training programs using cars with six-volt batteries because the speed of the cart with the larger battery frightened them at first. After training, they found the cart too slow, and the original twelve-volt batteries were reinstalled.</p> <p>Seven children considered driving backward the most difficult operation to learn. Other areas of difficulty mentioned by the subjects were the delicate control required in confined areas, and turning.</p> <p>Three children lost their balance while learning to operate the cart. One child lost his balance while turning and driving backwards and two, when they changed directions rapidly on a level surface. However, none of them lost sufficient balance to fall from the cart during the training period.</p> <p>Six children damaged property while learning to drive the cart: scraping walls, door frames, or furniture. One child scratched the family car; another, through continued reckless driving, endangered other persons who were in his way.</p> <h4>Safety</h4> <p>Five children wore safety belts while driving the cart.</p> <p>One child fell from the cart while at school. She was not wearing a safety belt, because it restricted her movements while in, and transferring in and out of, the cart. She had swung the control arm away while leaving the battery connected to the motor, and a classmate accidently touched the drive control, which sent the cart forward and caused the child to fall from the cart. Although the child was not injured, the episode dramatized the need for additional safety features.</p> <h4>Extent of Use</h4> <p><b>Table 5</b> shows the extent of cart usage. On the average school day, four children were in the cart at least 75% of their waking hours, three children utilized it between 40 and 70% of the day, and four children less than 10% of the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On weekends, two children used the cart more than 75% of the time; two children, 25 to 30%; and seven children, less than 25% of the day.</p> <p>In considering where the cart was used primarily, we found that four children used it both at home and at school; five, only in the home; and two, only at school. The principle reason for using the cart in only one location was its excessive weight, which made transportation difficult. Nine people commented on this problem. Those who used the cart only at home considered the danger of driving a cart with such sensitive controls too great to permit unsupervised use. Two clinics stated they were unable to rely on school personnel to pro- vide daily care for the cart, such as charging and filling the battery and reporting breakdowns.</p> <p>As shown in <b>Table 6</b>, most children were independent in such activities as driving through a 24-inch doorway, entering and leaving an elevator, approaching objects, and adjusting the seat height. The children with upper-extremity amelia and phoco-melia continued to require assistance for activities involving reaching, such as pushing elevator buttons and opening and closing cupboards and drawers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The majority of the children were independent in transfer activities (<b>Table 7</b>), e.g., cart to bed, toilet, or chair. The most troublesome transfer activities involved the toilet; presumably, these difficulties arose because of the narrowness of many bathroom doors and the lack of removable armrests on the cart.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After three months of use, most reporters noted a general improvement in driving and maneuvering skills.</p> <h4>Advantages And Disadvantages</h4> <p>Seven clinics reported that the greatest functional advantage of the cart was the adjustable seat (<b>Table 8</b>). Other assets reported were the increased maneuverability, easy control, the movable control arm that facilitated transfers, and the stability of the cart. The greatest disadvantages were the lack of an "on-off" switch, and insufficient ground clearance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Six children depended less on adult help while in the CAPP cart; four reported no change in the amount of adult help required; no information was available for the eleventh child. Nine parents reported that their children required less lifting; however, one child required more lifting. Before the arrival of the cart, this girl spent most of her time on the floor, where things had been built to accommodate her. Since she was unable to transfer in and out of the cart from the floor, she had to be lifted each time.</p> <p>One child was unable to use his prosthesis while in the cart, because the control arm was on the same side and interfered with its use. Most of the children felt that the chin control was not the optimal control site, and they preferred to use their arm stumps. Two therapists suggested that, if the control arm were placed to the side, a child could control the cart more efficiently with his stump. One therapist objected to the chin control because she feared damage to the child's lower jaw while driving the cart over rough terrain, although there was no report that this occurred. It was suggested that, if the control arm were relocated, a child could maintain a more normal sitting posture and turn his head for driving, and the control arm would not hinder activities at a desk.</p> <h4>Cart Maintenance</h4> <p>The twelve-volt battery required recharging every 24 hours. The batteries normally were charged overnight, and none needed replacement during the test period. Filling the battery with water was a considerable problem for parents because of the small storage space in the cart, which made battery-removal difficult.</p> <p>Most maintenance problems concerned the rear wheels and switches; five carts required wheel replacements. The rear wheels attach to the gear box and receive the power to drive the cart. Since they do not swivel as the front wheels do when the cart turns, a torque is applied. These wheels, which were commercially available as wheelchair casters, were not designed for this amount of force and broke as a consequence of the torque overload.</p> <p>All the carts required replacement of the switches in the control mechanism. The original switches were not the model ordered, but, for reasons of expediency (low cost and commercial availability), they were installed in the carts. When it became apparent that these were unsatisfactory, they were replaced with the model originally ordered, and the problems were eliminated.</p> <h3>Conclusions</h3> <p>With one exception, all the children and their parents were very enthusiastic about the CAPP cart and preferred it to other modes of transportation. It provided increased independence to ten of eleven children with quadrimembral deficiencies.</p> <p>Training did not present a problem, even for the youngest child; however, consideration should be given to introducing the very young or apprehensive child to the cart with a six-volt battery. Since the cart is very stable, most driving hazards arose because of recklessness or poor driving skills. Perhaps greater care should be directed toward predriving instructions, and the children should be given more opportunity to practice driving skills under supervision. It must be remembered, however, that children tend to be less responsible and less coordinated than adults, and more accidents are to be expected from them.</p> <p>The CAPP cart afforded the children more independence in terms of mobility and endurance. Hemimelic children were able to perform many activities, such as opening and closing cupboards and drawers, as a result of the adjustable seat, which allowed them to approach objects more closely and normally.</p> <h4>Design Considerations</h4> <p>Although a number of clinics suggested the inclusion of a seat belt, this would tend to restrict a child's independence if he were able to transfer in and out of the cart without assistance, since most arm amputees would be unable to manipulate the belt independently. Seat belts are readily available or easily devised, and the application of a belt might best be left to the discretion of the clinic or the child's parents. Another suggestion was the incorporation of an "on-off" switch that could be controlled by the child, or a switch that would automatically cut the power when the control arm is swung to the side.</p> <p>Although the present velocity of the cart is satisfactory for forward maneuvers, it is clearly too fast for driving backwards or for delicate control. Consequently, consideration should be given to including a variable speed-control mechanism.</p> <p>Although wheelchair casters are commercially available and relatively inexpensive, they are not designed to absorb the high torque forces that are applied to the rear wheels of the CAPP cart. Stronger drive wheels would probably have prevented many of the mechanical breakdowns that occurred. Consideration should also be given to including pneumatic tires, which provide greater traction and more comfort.</p> <p>Since most of the children preferred to control the cart with their arm stumps, consideration should be given to placing the control arm to one side, close to the shoulder or stump. This would also avoid interference with use of an upper-limb prosthesis. A second possibility, particularly for the upper-limb amelic child, is to lower the control arm to the level of the chair seat, which would allow the child to control the cart with his foot or leg stump while enabling him to sit straight and to turn his head freely.</p> <p><i>Note: </i>As a result of the findings of the evaluation study, a new control box was developed that incorporates a variable-speed mechanism, and an "on-off" switch that can be controlled by the child. All carts have been recalled to UCLA, where a detailed analysis is also being conducted of the effect of use on the mechanical segments of the cart. The new control mechanism and a set of stronger wheels have been installed, and the carts were returned to the children for continued use. Each clinic will provide any further training required to operate the cart with the new control system. After six to eight weeks of additional use by the child, the clinic and the children will be asked to record their reactions to the modified cart.</p> <h3>Recommendation</h3> <p>On the basis of the results of the clinical evaluation of this item, and the design modifications implemented by the developer, it is recommended that the CAPP cart be made available to all limb-deficient children for whom conventional methods of transportation are unsatisfactory.</p> <h3>Appendix</h3> <p>J. T. was an eight-year-old girl with bilateral upper-limb amelia and lower-limb terminal-transverse hemimelia (A/K type). Initially, the control arm on the cart was lowered to the seat level to allow her to operate it with her leg stump. She did not wear lower-extremity prostheses while she was in the cart.</p> <p>This child learned to operate the cart in approximately 2 1/2 hours; driving backwards and turning were the most difficult tasks for her to learn. As with the other amelic children, she was able to move about independently, but she continued to be totally dependent in activities involving the arms.</p> <p>She used the cart for the entire school day, but she did not use it at home because her parents found that its weight made transporting the cart very difficult.</p> <p>Both the child and her parents found that the cart was too slow for her to keep up with the other children. The child's other reactions were similar to those of the other children; that is, she liked the adjustable seat and the increased independence, but disliked the lack of an "on-off" switch and of sufficient ground clearance. Her teacher reported that the cart often became stuck in the school yard because of insufficient clearance.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-19.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-20.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-21.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-22.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-24.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-25.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-26.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-27.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 Evaluation of the CAPP Cart Creator An entity primarily responsible for making the resource Barbara A. Gehant  https://staging.drfop.org/files/original/7e93e0bcdf041bdab2526ad50b967102.pdf 67579faec9e3dcdd1e35e26939cf8fcb https://staging.drfop.org/files/original/e1b9eed5d68adfbea036b532c62633f8.jpg 56019fdc49083b59c5913801b8cb4f31 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1972_01_020.pdf Year 1972 Volume 16 Issue 1 Page Number(s) 20 - 50 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/1972_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1972_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 Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management</h2> <h5>Barbara L. Sypniewski <a style="text-decoration:none;">*</a><br /></h5> <h3>Introduction</h3> <p>This independent-study honors project dealt with congenital skeletal limb deficiencies. This paper discusses and reviews the literature concerning the prosthetic management of the individual with unilateral terminal transverse partial hemimelia of the upper extremity. Specific topics considered are: a general description of the entity, including etiology and incidence; psychological factors affecting the limb-deficient child and his parents; normal and abnormal biomechanics of the upper extremity; components of the prosthesis (terminal devices, wrist units, elbow hinges, cuffs, harnessing, and sockets); prosthetic prescription and fitting; the trend toward early fitting; preprosthetic therapy; and prosthetic training. One section discusses the information elicited from a survey conducted by letters and questionnaires that were sent to the 28 clinics participating in the Child Prosthetics Research Program, conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development to ascertain the age of the congenitally skeletally limb-deficient child at the time of his initial fitting for a prosthesis. An analysis of the data from the 12 clinics replying is presented, along with the developmental criteria for fitting.</p> <p>The scope of this paper is limited to the unilateral upper-extremity, below-elbow congenital amputee. Bilateral amputees, cineplasty, surgical conversion, or externally powered prostheses are not considered. The literature review was limited by time to the books and journals published in 1960 or later, with selected earlier articles. Articles published before 1960, as well as those not available at the Albany Medical College Library or through the inter-library loan system, are listed in the "Bibliography." Both reference lists were compiled from <i>Index Medicus; Amputees, Amputations, and Artificial Limbs </i>(published by the Committee on Pros-thetic-Orthotic Education of the National Academy of Sciences-National Research Council, Washington, D.C.); and the bibliographies of articles I reviewed.</p> <p>Terminal transverse hemimelia indicates congenital absence of the entire distal part of the limb below the elbow. The term is part of the modified Frantz-O'Rahilly<a></a> classification nomenclature. Hemimelia is the absence of a large part of a limb, from the Greek <i>melos </i>meaning limb and <i>hemi, </i>half. <i>Partial </i>hemimelia indicates that less than half the limb is missing. The defect we are considering is transverse rather than longitudinal, presenting a short or very short stump similar to that of an acquired below-elbow amputation.</p> <p>The etiology of skeletal limb deficiencies is largely unknown, except for the well-documented teratogenic effects of thalidomide. The thalidomide tragedy has led to an increased interest in, and awareness of, what can be done for the congenital amputee. <a></a></p> <p>The list of proposed etiological factors includes environmental conditions such as drugs, maternal health and nutrition, genetic factors or predisposition, and chromosomal aberrations.<a></a> Most congenital defects have their origin during the first eight weeks of embryonic life.<a></a></p> <p>Glessner<a></a> indicates that there are two distinct groups of congenital absence of limbs: (1) spontaneous intrauterine amputation after limb formation, caused by focal deficiencies, and (2) limb-bud arrests or agenesis of the terminal part of the limb. Amniotic bands wrapped tightly around part of an extremity may lead to necrosis and eventual intrauterine amputation.<a></a> Terminal deficiencies due to limb-bud arrests are by far the most common type of congenital absence.<a></a> The terms <i>congenital amputation </i>and <i>congenital skeletal limb deficiency </i>are used interchangeably in the literature.</p> <p>Terminal transverse partial hemimelia is the most common type of congenital limb deficiency. There is unexplained preponderance of left-sided absence (2 or 3 to 1), and females are involved more frequently than males. Studies by Bergholtz,<a></a> Davies, Friz, and Clippinger,<a></a> Munson and Dolan, <a></a> and Gehant<a></a> failed to show the greater incidence in females exhibited in Kay and Fishman's report.<a></a></p> <p>The measures of prosthetic management in habilitation of a congenital amputee are somewhat different than those employed in the rehabilitation of an "acquired" amputee. The child must learn functional skills that he never possessed, rather than relearning substitute functional activities. The fact that the juvenile amputee is neither skeletally nor emotionally mature is an important consideration in the prosthetic management. The growth and development of the limb-deficient child is essentially the same as that of the normal child; the environmental stimuli to motor development are not decreased significantly by unilateral deficiency. Ideally, prosthetic management should extend from birth through vocational training.</p> <p>Function of the upper extremity is extremely complex and relatively independent of the contralateral extremity. With unilateral absence, there is an increased use of the remaining extremity, since the ability of a prosthesis to compensate for the loss of an arm is significantly less than is possible in the lower extremities. Below-elbow amputees are least in need of externally powered prostheses.<a></a> They can effectively use body power to activate the prosthesis and receive the benefits of sensory feedback through the socket and harness. The prosthesis should be considered as an assistive device in bimanual activity. Because absence of one extremity can be easily compensated for, getting the unilateral amputee to use his prosthesis presents a great challenge. Fitting and training should be started as early as possible, before these compensations can develop.</p> <p>It is generally believed that a team approach is most successful in the management of the limb-deficient child. The foremost members are the mother, who spends the most time with her child and influences him the most,<a></a> and the child. Other possible members of this interdisciplinary team are the physician, orthopedist, prosthetist, occupational therapist, physical therapist, psychologist, social worker, and biomedical engineer. Each child presents unique problems to be met. Epps and Brennecke<a></a> outlined a sequence of treatment that includes referral, history and medical examination, intake evaluation, preprosthetic physical and occupational therapy, prescription, fabrication, thorough check-out by the team, training, and regular recheck every three or four months.</p> <p>Factors influencing the cost of the prosthesis are: age at initial fitting, regular maintenance, frequency of harness adjustment, wearing pattern, operating skill, acceptance, and components prescribed.<a></a>Average service for a prosthesis ranges from two to three years, but a child fitted during infancy may require three to five prostheses before school age.<a></a> The additional cost of early fitting is compensated for over the years,<a></a> especially in regard to the benefits of skill and acceptance.</p> <h3>Psychological Aspects</h3> <p>The importance of parental attitudes towards the child, his disability, and the idea of a prosthesis, and their effect on the eventual acceptance or rejection of a prosthesis, has been emphasized throughout the literature. There is no direct correlation between the degree of the child's deficiency and the mother's perception of the child's abnormality, her feelings toward him and the way she handles him.<a></a> The way in which parents deal with the birth of a limb-deficient child depends to a great degree on how they have coped with previous crises. Replacement of a missing extremity with a well-functioning artificial one is valuable only if the parents can accept the idea of a prosthesis. Often, children have rejected prostheses because the parents, consciously or unconsciously, could not accept the fact that it was necessary.<a></a></p> <p>The way in which the parents are informed of the child's deficiency may influence their later reactions. If he desires to do so, the father should be allowed to inform the mother, in the presence of a physician.<a></a> Mothers can be profoundly influenced by the reactions of the delivery-room staff.<a></a> The training of the limb-deficient child can best begin by providing the parents with a detailed, factual, realistic, and sympathetic appraisal of their baby and his prospects for future educational, vocational, and social rehabilitation.<a></a> Unrealistic claims that modern prosthetics and engineering can provide artificial devices as natural-looking and as efficient as the human hand can seriously hinder the habilitation program. The first few hours after the birth of the child are crucial; it is during this period that parents form attitudes and defenses that can have tremendously far-reaching effects.</p> <p>With the birth of a deformed child, the parents suffer a severe psychological shock, for which they are totally unprepared. Certain emotions have been commonly expressed by parents of congenital amputees: guilt, hopelessness, death wishes, fear, anger, rejection, despair, shame, repulsion, grief, shock, hostility, and abandonment.<a></a> The need for prompt, professional assistance is crucial. </p> <p>Parents are extremely sensitive to the reactions and attitudes of others, and they need help to know that they and their child are accepted. In addition to individual counseling by a psychologist, social worker, or other qualified persons, group sessions have been established.<a></a> Parents benefit from the opportunity to verbalize their feelings and receive support and help in handling their emotions and in developing constructive attitudes. Wallace<a></a> noted the impact of these group-therapy sessions on the fathers, citing fewer absences, less hesitation about expressing their feelings, and awareness that their attitudes affect the child's adjustment and help to mold his self-image.</p> <p>If, instead of realistic acceptance, strong defense mechanisms are built up by the parents during this early period, they will not be able to communicate with their child when he becomes aware of and questions his deficiency. One indication of the mother's acceptance of the child is the way she handles the baby. Some important factors to look for in observing parental behavior are: avoidance of direct contact with the baby, ritualistic organization and emphasis on cleanliness, barriers to communication, aggression toward professionals, and subconscious refusal to accept the existence of the child's abnormality.<a></a> The mother will eventually become the child's best therapist, and the early months must provide a basis for her later role. Parents must be aware of the importance of their love in the future rehabilitation of their child. Hall<a></a> and Mongeau and others<a></a> advocate that children become an integral part of the family immediately. Mongeau found that children taken home directly from the hospital after birth have shown greater capacity for adaptation than those who were institutionalized. A strong family basis can be of great help to the child when he may later face repeated hospitalizations for prosthetic training or other reasons. According to Gesell and Amatruda,<a></a> a child's basic behavior traits are fairly well established by the time he is a year old. Some of these traits are hereditary and some are absorbed from the attitudes of the family.</p> <p>Crisis intervention, as described by Brooks and others<a></a>, is the awareness of impending crises in the development of the limb-deficient child and the intervention by qualified professional personnel to aid in making those transitory periods as easy as possible. One such crisis is that of homecoming. The curiosity and concern of relatives and friends must be faced. The effect of the birth of a limb-deficient child naturally has a great impact on his siblings.<a></a> They too must be aided in adjusting to this stress situation. Other potential crisis periods are prosthetic fitting, entering school, and adolescence.<a></a> During the child's period of growth and development, he has the same needs for independence and self-sufficiency that normal children have. Dependence and overprotection must be avoided. Discipline must be consistent and realistic, neither extremely permissive nor extremely restrictive. The profound effects of the parents on the child cannot be overemphasized.</p> <p>The manner and degree to which the child is influenced by his deficiency is determined before he reaches conscious awareness of his condition. If he has been provided with a sense of security, acceptance, and love, he will have a strong basis from which he can develop a positive self-image and achieve independence. The limb-deficient child faces the same problems and sequence in emotional and social development as normal children, but each crisis is likely to be of greater intensity and magnitude.<a></a> The child who has received encouragement and support from his family will expect the same type of relationship from outsiders and will approach social contacts spontaneously, rather than attempting to avoid them. The child will attain a balance between the dominance of his parents' influence and the satisfaction he gains from his independence.<a></a> He should be encouraged to enter into social relationships with a minimum of special attention.</p> <p>Taylor<a></a> has discussed at length the psychological needs of handicapped children. In addition to the fundamental needs of love and acceptance, she cites the needs for adventure and exploration, rebellion to release pent-up frustration, limitation of freedom, friends and social experience, privacy, achievement as a basis of self-esteem, and the need for awareness of the child as a person. These needs are the same as those operating in all nonhandi-capped individuals.</p> <p>Gouin-Decarie<a></a> recognized that a pertinent problem in studying the psychology of a limb-deficient child relates to his conception of space, which is closely associated with the formation of the body image. She found that these children made use of a visual, rather than a tactile, image in recognizing familiar objects. Several authors have discussed the concept of body image, or schema, in child amputees.<a></a> All have indicated the absence of marked distortion of body image in most of these individuals. Alteration of body image is, however, a significant problem in noncongenital amputees. Centers and Centers<a></a> analyzed the results of a draw-a-person test administered to congenital amputees. The majority of amputees represented themselves realistically, either leaving out the missing limb or including the prosthesis. They concluded that, while body images differed in a matter-of-fact way, they did not differ markedly in signs of greater conflict, anxiety, or defensiveness. The study did not support the authors' hypothesis that amputee children will have more conflict and defensiveness about their bodies than will nonamputee children.</p> <p>The body image is critical in relation to the acceptance or rejection of a prosthesis. Congenital amputees experience the same processes in the formation of body image as normal children. The earlier the child is trained to wear a prosthesis, the easier it will become a part of his body image.<a></a> One factor in the ready incorporation of the prosthesis is that modern prostheses are functionally adequate for many of the activities engaged in by young children.<a></a> A prosthetic device is never really useful until it is integrated into the body schema. Acceptance and rejection of the prosthesis is more extensively considered in the section on early fitting.</p> <p>The question of the possibility of the phenomenon of phantom sensation in congenital amputees is an interesting one. A discussion of the theories concerning the cause of this phenomenon is beyond the scope of this paper. Hoover,<a></a> Lambert,<a></a> and Simmel<a></a> believe that neither phantom-limb sensation nor pain exists in this group of individuals. Lambert bases his belief on the principle that nerve endings going to the distal limb have never developed. Simmel attributes the impossibility of phantom sensation to the fact that the absent part has never been represented in the body schema. In their census of the juvenile-amputee population, Kay and Fishman<a></a> reported three instances of phantoms in congenital amputees, but these could not be substantiated by further interrogation. Weinstein and Sersen<a></a> reported phantoms in 5 out of 30 children with congenital deficiencies. If the presence of a phantom reflects the "need" of the child to experience a missing part, it should have functional properties. The phantoms reported in this study were usually shrunken, telescoped parts with gaps and missing appendages.</p> <p>Certain other psychological aspects can best be discussed as they relate to the chronological age groups of the congenital amputee. The significant divisions are: preschool, entry into school, latency, and adolescence.</p> <p>In the preschool category, a period of negativism and resistance occurs around two years of age. This is a normal reaction; the child is trying to establish his personality and achieve a little independence.<a></a> This period of negativism often conflicts with prosthetic-training procedures, especially terminal-device activation.</p> <p>Entry into school is an important milestone for any child. He moves from the security of his home environment into a competitive social society. The limb-deficient child needs a reliable basis for dealing with this new group of people. This is provided by his parents and family during the early childhood years. In his group experience, the child will test and validate ways of dealing with people outside his family <a></a>. Adjustment is facilitated if the teacher and class are prepared and informed in advance. Healthy curiosity is the most frequent reaction of classmates, and a factual explanation of the prosthesis and its use should lead to acceptance by the classmates and increased self-confidence of the limb-deficient child. Wilson <a></a> expresses the belief that it is preferable for the limb-deficient child to attend regular school. Unnecessary special consideration should be avoided. The handicapped child may experience feelings of social devaluation, which any member of a minority group feels.<a></a> Centers and Centers<a></a> discuss the results of a social-discrimination questionnaire. The hypothesis that peer-group children express more covert rejecting attitudes toward amputees than toward nonamputee children was supported. They attribute this finding to the fact that one of the most significant variables operating in social interaction is personal appearance. Centers and Centers conducted their study almost ten years ago. It would be interesting to retest this hypothesis in light of recent social trends toward greater acceptance of minority groups and increased emphasis on individual merit as opposed to sterotyped generalizations.</p> <p>The preadolescent latency period is relatively calm, with no major crisis periods. The normal child experiences many conflicts during adolescence, many of which are associated with appearance. These conflicts are all compounded in the limb-deficient child. During this period, a cosmetic hand is often prescribed for the adolescent amputee to replace the functional hook for social occasions. Vocational guidance becomes increasingly important during this period of adolescence.</p> <h3>Normal and Abnormal Biomechanics</h3> <p>The arm enables the hand to be placed in position for skilled functional activities. The most commonly recognized forms of prehension include tip, palmar, three-jawed-chuck, lateral, hook grasp, cylindrical grasp, and spherical grasp. Palmar prehension employing opposition of the thumb predominates in picking up objects and holding them for use. Long tendons with muscles at a distance permit the great variety of motion characteristic of the human hand. In addition to skill, the hand frequently functions in support postures. Sensation is another major function of the hand. The hand is richly supplied with sensory-nerve endings mediating touch, temperature, pain, and position. Large areas of the cerebral cortex represent the complex sensory and motor function of the hand. Boivin<a></a> advocates investigation into the prehension patterns and sequences commonly used in activities of daily living. Stabilization of the wrist in various positions aids prehension. For example, the wrist assumes an angle of 145° when very strong prehension is required.<a></a> Finley, Wirta, and Cody <a></a> studied the synergic action of muscles of the upper extremity resulting in a better understanding of the relationship between central and peripheral control of movement. The three major components of the response phenomenon that they noted were: cognitive, ballistic-type physical displacement, and apparent sensing to compare, confirm, or adjust to assure successful accomplishment of the desired act. The information regarding time sequences is useful as reference material in studying pathomechanics.</p> <p>Finger and hand movement, wrist flexion and extension, and varying degrees of pronation and supination are lacking in the congenital below-elbow amputee. Prosthetic replacement of the wrist and hand is poor, only crude prehension and positioning are possible, and there is no substitution for the lack of sensory feedback. Maximum utilization of the residual biomechanics is essential in prosthetic replacement.<a></a> The biggest challenge is to design an upper-extremity prosthesis that (1) can be powered by and controlled with little effort, (2) can perform through the almost spherical range of a normal arm, (3) has a terminal device that can achieve prehension, (4) will respond to sensation, and (5) is cosmetically acceptable.<a></a> Upper-extremity prosthetics are significantly deficient in all of these areas. Because of the fixed prehension pattern of the terminal device and the fixed wrist, nearly all fine orientation movements must be made at levels higher than the forearm by compensatory motions of the elbow, hand, and shoulder .<a></a> Prosthetic controls permit only the simplest motions decomposed into their basic elements and executed slowly, in series, one at a time.</p> <p>Stoner<a></a> notes that no prosthesis accomplishes any of the wrist-flexion movements. The reasons for this neglect of wrist replacement are: (1) usually no controls from the harness are available to furnish the power, (2) wrist motions are used in fine movement of the hand and are not essential to bring the hand into the major spheres of action about the body, and (3) loss of wrist flexion can be compensated for grossly by other arm motions. Preposition flexion devices are available and are useful for activity close to the body.</p> <p>Pronation and supination are functions of forearm length. Wrist joints allow passive positioning for the most advantageous angle of terminal-device operation. With shorter forearm stumps, the mechanical advantage of flexion is decreased, in addition to the loss of pronation and supination.</p> <p>Joint motions in congenital amputees are often bizarre<a></a>. Kruger and Breyan<a></a> report that, in an X-ray evaluation of 16 extremities with terminal transverse partial hemimelia, 13 showed dislocation of the head of the radius. Of these, 77% showed dislocation before prescription of the initial prosthesis. It is therefore concluded that the phenomenon is inherent in the disability itself. The dislocation is asymptomatic. The authors offer two possible explanations for the phenomenon: deficiency of the ligamentous structures, or unopposed action of the biceps brach-ialis muscle. They consider the latter explanation the more likely. In short stumps, the pronator teres muscle is absent, and the biceps in flexing and supinating meets no opposition, thereby dislocating the radial head.</p> <h3>Harnessing</h3> <p>Harnessing techniques for upper-extremity prostheses must be based on bio-mechanical analyses of the remaining movements. Successful use of the prosthesis requires a harness that allows the most efficient use of those movements that are available. The socket limits some of the residual motion of the stump itself, and the harness limits the motion of the sound extremity to some extent. The harness should distribute the weight of the prosthesis evenly over a wide area and be functional in as many positions of normal use as possible. It should transmit power with a minimum of interference and be operable by relatively inconspicuous body motions. Power is provided by the stump itself (elbow flexion) or by the relative motion between two body parts (glenohumeral flexion and/or scapular abduction). Control-cable systems transmit this power from the amputee's body to the prosthesis. The suspension system may use a figure-of-eight, figure-of-nine, or shoulder-saddle chest-strap type of harness. The most common suspension is a figure-of-eight harness with a Northwestern ring-type cross.<a></a> The Northwestern ring allows adjustment of individual harness straps. The figure-of-nine harness is often used for power transmission with Munster-type sockets, which do not require a great deal of additional suspension. The chest strap is useful in spreading the load in heavy work<a></a> and maintaining the prosthesis in the proper position in the presence of baby fat. The harness provides some degree of feedback from the environment. O'Shea<a></a> has described a shoulder-saddle chest-strap harness with the primary advantage of increased comfort. Hile<a></a> described the adaptation and reinforcement of a brassiere to replace the chest-strap harness when breast development occurred.</p> <p>Requirements for suspension and harnessing vary from individual to individual, and skillful use of the available power sources is essential to good prosthetic use. Rapid rate of growth and limited power are critical factors in designing harnesses for congenital amputees.<a></a> Frequent adjustment by the prosthetist assures optimum harness and prosthetic function.</p> <h3>Components of the Prosthesis</h3> <h4>Terminal Devices</h4> <p>Two major considerations in the design of a prosthesis for a child are the continual neuromuscular and skeletal changes due to growth and the child's limited sources for power and control. Linear growth is more rapid than circumferential growth. The prosthesis can be fabricated to allow for later adjustments for growth, thus extending the functional life of the device. The components must be sturdy enough to withstand vigorous use, yet must be light enough to be controlled by the child. Some of the problems involved in the prosthetic replacement of human body parts are control, feedback, reliability, size, and appearance.<a></a> Upper-extremity prostheses for children are essentially scaled-down models of adult types. However, Hall<a></a> and Wilson<a></a> note that recent advances in children's prosthetics include improved design and function of terminal devices, lightweight plastic sockets and shells, and more efficient harnessing methods. There are a large number of mechanical components available that can be combined to best meet the needs of the individual child. Split mechanical hooks stress the restoration of function at the expense of abnormal appearance, while artificial hands with cosmetic gloves attempt to combine modest levels of function with near-normal static appearance. Both hooks and artificial hands should be given the same care as the normal hand; since sensation is absent, they are more prone to damage.</p> <p>There are two mechanisms of terminal-device operation: voluntary opening and voluntary closing. In the voluntary-opening type, tension on the control cable opens against a variable spring force, while in the voluntary-closing type, control-cable tension closes against the spring force. Hooks and hands are available with either mechanism. Voluntary opening is the simplest form of prehension mechanism: the prehension force is provided by special heavy rubber bands. Among the disadvantages of this type are the inability to handle delicate or heavy objects, and the fact that this mechanism is opposite to the prehension of the normal hand. An advantage of the voluntary-closing terminal device is that it more accurately simulates normal prehension, and pressure can more easily be graded to the object to be grasped. Formerly, manually controlled locks were employed, but now automatic locking is available. The fact that, to release the lock, the cable pull must be greater than the pull that closes the terminal device may be a disadvantage. Neither mechanism has been proved superior in a wide range of activities,<a></a> but research to improve both types for juvenile amputees is continuing.</p> <p>Ritter and Sammons<a></a> have elaborated on the advantages of voluntary-closing devices for children's prostheses. The fact that normal prehension is simulated is especially relevant in bilateral grasping. Performing different hand patterns simultaneously, as is necessary with voluntary-opening devices, is particularly difficult for the preschool child to learn, since he is still developing refinement of prehension. A description of the Army Prosthetics Research Laboratories (APRL) voluntary-closing hand, which provides palmar prehension of the three-jaw-chuck type, has been presented by Stoner.<a></a> Teska and Swinyard<a></a> have described a test to evaluate its functional capacity, versatility, and durability. Research is also being conducted concerning the Robins-Aid voluntary-opening hand.<a></a> The concept of cosmesis, or the appearance of the prosthesis, is difficult to define, but is very important. It is a very individualized concept, having varying importance for different people. Function, cosmesis, and acceptance are almost inextricably allied.<a></a> The area of compromise between function and cosmesis is a delicate and crucial one. Those professionals vitally concerned with function must be careful not to look down on the parents who may seem to be overly concerned with cosmesis. Several new plastics have been reported<a></a> that, while not identical to the color and texture of the human skin, do convey an idea of softness and warmth. These new terminal-device designs represent an attempt to combine improved function with an aesthetically satisfactory appearance, but without trying to imitate representationally the characteristics of the missing part.</p> <p>It was formerly common practice to provide the congenital amputee with a plastic mitt or wafer as the initial terminal device. Dean,<a></a> Lineberger,<a></a> and Watkins and Ford <a></a> have presented arguments supporting this practice. Among the major reasons given are: cosmetic appeal, flexibility, support without slipping in creeping, avoidance of injury to the child himself or others during play, and other factors supporting early fitting in general.</p> <p>The infant passive hook is now considered the better choice as an initial terminal device. Some of the reasons for its preferred function are listed by Blakeslee<a></a>: (1) it provides for gross palmar prehension and body-support activities with skill equal to the mitt, (2) it allows the infant to hook over objects for support in pulling to a standing position, (3) it provides a holder for small objects that are placed in it, (4) it helps the infant to develop bilateral prehensile awareness, being recognized as a device to hold objects, and (5) parents who were willing to accept a prosthesis for their child readily accepted the passive hook. Shaperman<a></a> reported the results of an evaluation of the passive mitt and the passive hook with similar results. She also noted improved skill and increased speed of learning when the control cable was added to the passive hook. Initially, the hook presented a slightly greater safety hazard, but the injuries that did occur were minor. Shaperman noted that the hook was one ounce heavier than the mitt, but it appeared to be well within the limits of the infant's ability to lift and manipulate it easily.</p> <p>Hooks are available in a variety of sizes, shapes, and weights. The Dorrance 12P or 10P hook are commonly provided for the unilateral juvenile amputee. They are canted and plastic-covered. Proponents of prescribing hooks cite the advantages of greater prehensile function, with greater visibility and facility available. Numerous authors <a></a> have expressed a preference for the use of the hook rather than the hand. Edelstein maintains that the cosmetic appeal of a skillfully used hook is greater than that of a cadaverous-looking glove. The idea that the hook can only be accepted as a tool, and that therefore it is hard to see the need for a more cosmetic socket, has been expressed by Boivin .<a></a> Research toward improved hook design and function is being carried out. The literature reveals progress reports in the development of the Sumida hook,<a></a> the Northwestern University Center control hook,<a></a> the Steeper split hook no. 65,<a></a> and other more recent advances in prosthetics.<a></a> Carroll<a></a> conducted a study to analyze the prehension force needed by child amputees. The test items were related to function and varied with the age of the child. Most items tested static prehension only; the individual could either hold the object, or it slipped out of the hook because of insufficient prehension force. Dynamic prehension, or the child's ability to control the prehension force, was tested by the ability to hold a paper cup with water in it. The results of this study showed that more children were fitted adequately in regard to the size of the terminal device than in relation to the prehension force. None of the children were found to be wearing an excessive number of rubber bands. With the exception of the toddler group, the prehension force was found to be inadequate for performance of one or more of the test items. One result of this study was a set of suggested pinch forces for below-elbow amputees:</p> <table> <tbody> <tr> <td> <p><b><i>Age (years)</i></b>   </p> </td> <td> <p><b><i>Pounds of force</i></b>   </p> </td> </tr> <tr> <td> 2-4</td> <td>2.25 </td> </tr> <tr> <td> 3-9</td> <td>3.5 </td> </tr> <tr> <td> 5-9</td> <td>4 </td> </tr> <tr> <td> 8-17</td> <td>5 </td> </tr> <tr> <td> 15-20</td> <td>6 </td> </tr></tbody></table> <p>Greater consideration needs to be given to the adequacy of prehension forces for the functional activities of congenital amputees.</p> <p>Cosmetic hands are often prescribed when the juvenile amputee reaches adolescence. Interlocking wrist-unit mechanisms are available that permit the use of a hook for functional activities and a more cosmetic hand for social occasions. These hands usually provide a modified three-jaw-chuck prehension between movable index and middle fingers and a thumb that can lock in position. Hands available for children include the Dorrance no. 2 hand<a></a> and the APRL-Sierra child-size no. 1 hand.<a></a> One disadvantage that must be considered is the greater weight of the hand as compared to the hook. The APRL-Sierra no. 1 hand weighs 170 grams, while the Dorrance 10x hook weighs 60 grams.<a></a> This is especially important, considering that this additional weight has the mechanical advantage of a long forearm lever and the congenital amputee does not possess a great deal of muscle power.</p> <p>The APRL-Sierra no. 1 hand was developed to meet the need for a functional and cosmetically acceptable hand for juvenile amputees. It is a voluntary-opening mechanism with a hand shell of cast aluminum, articulated index and middle fingers, a two-position thumb, and nonarticulated but flexible ring and little fingers.<a></a> In this field study, only 7 of 77 children rejected the hand completely. The remaining participants fell into four groups: those that used the hand exclusively, those that used the hand predominantly, those that used both equally, and those that used the hook predominantly. The authors suggest that the age of the child is a major factor regarding hook or hand preference. Younger children may experience difficulty with hand weight and opening forces, may be more careless in their use of the hand, and may be less subject to social pressures toward cosme-sis. Sex appeared to be an even greater consideration than age. Girls of all ages appear to be potentially the best candidates for the Sierra-APRL no. 1 hand, while younger boys would seem least likely to accept the device. Fishman and Kay <a></a> performed a study to delineate the relative usefulness of the hook and the hand. The results were at variance with previous clinical impressions, which indicate that a hand is a significantly less functional terminal device than a hook. In an extensive evaluation of the Dorrance no. 2 hand in 72 bimanual activities, Gorton<a></a> found that no definite trends emerged to indicate that the hook was measurably more functional than the hand or that the hand was significantly more functional. The test employed by Fish-man and Kay analyzed general and specific patterns of grasp by means of functional activities. The rating scale for performance of activities was somewhat subjective, but the detailed analysis of the results was excellent. From this study, the authors concluded that: (1) the APRL-Sierra no. 1 hand was heavier and, in most cases, more difficult to operate than the previously used hook, but these were not serious drawbacks for the majority of subjects; and (2) the hand provided somewhat less pinch force than most of the hooks and a less precise grasp. While the majority of children reported that they could perform more activities better with the hook, they also were able to specify a number of activities that were performed better with the hand, such as picking up a pencil, grasping paper, and holding silverware for eating.</p> <p>Constant research and re-evaluation of prostheses is essential.<a></a> Boivin<a></a> has written an excellent article criticizing present artificial-hand design. He maintains that an inherent belief exists that the refinement of the normal hand cannot presently be reproduced, leading to the assumption that it can never be reproduced. He cites the apparent lack of coordination and integration in biomedical engineering research, and proposes that a reason for this is that the goal is providing normal hand function, but that this is being attempted without sufficient consideration for the actual anatomical and physiological functions of the hand according to the kinesiological data presently available. One example is the fact that artificial hands flex only at the metacarpophalangeal joint, while the flexor digitorum profundus, the most active finger flexor, flexes at the interphalangeal joints as well. Boivin presents two suggestions for modification of artificial-hand design: first, that the normal transverse arch be reproduced in artificial hands, adding to cosmesis and function; and second, that artificial hands be made smaller and covered with a soft subcutaneous tissue-like material under the glove. Besides improved cosmesis, this would improve grasp by allowing better molding of the fingers over the object to be grasped. This second approach is presently being used by the Otto Bock Orthopedic Industry, Incorporated, in their new modular arm. The catalogues illustrate an above-elbow arm, but it is quite possible to employ this system for below-elbow amputees by fabricating the socket, attaching the proper length tube and the terminal device. This "System Arm" can be used for every level of upper-extremity amputation except wrist disarticulation and extremely long below-elbow amputations. Child-size systems are available. (This information was received from personal communication with Otto Bock Orthopedic Industry, Incorporated.)</p> <h4>Wrist Units, Elbow Hinges, and Sockets</h4> <p>Wrist units perform the dual function of attaching the terminal device to the prosthetic forearm and providing terminal-device rotation for manual preposi-tioning. There are manual-friction, manual-lock, and active-rotation units. Manual-friction is the most commonly used type. A rubber washer and a metal washer are compressed as the terminal device is screwed into place. Behavior of the unit is unpredictable because of the uneven compression and the easy accumulation of dirt, but it has the advantages of simplicity and easy maintenance. Manual-lock units allow rotation and locking of the terminal device by separate steps through the use of cylindrical inserts that have index teeth around their circumference.<a></a> The inserts are threaded to fit the terminal-devicestud. Active-rotation devices use stump rotation to produce rotation of the terminal device and are able to amplify residual stump rotation.<a></a> Wrist-flexion units that provide partial replacement for lost palmar and dorsal flexion of the wrist are available. By adding the extra degree of freedom, they can minimize the need for compensatory motions at higher levels. These units are presently only suitable for light duty.<a></a> Clarke, Kral, and Shaperman <a></a> evaluated wrist-flexion units for children. The advantages of the addition of a wrist-flexion unit to an upper-extremity prosthesis include: (1) the ability to bring the arms close to the body for self-care activities,(2) the ability to bring the arms together in the midline for bimanual activities, and(3) less need for body exertion and bending to accomplish these activities. The authors found that one angle of flexion or flexion and radial deviation is sufficient for all activities. Wrist flexion of 25° or less is comfortable and useful, and there is no advantage above 25°. They advocate that the conventional wrist unit be laminated into the forearm unit in a flexed position, after careful evaluation to determine the most advantageous angle. This overcomes the disadvantages of wrist-flexion units for children, such as added weight of the terminal device, an additional component to preposition, and mechanical unreliability. It would seem that the need for dorsiflexion at the wrist for functional activities should be further evaluated, since this study only considered variable degrees of palmar flexion.</p> <p>Flexion of below-elbow prostheses is provided by hinges of various types; the main classes are "rigid," "semirigid," and "flexible." They can be made of metal, leather, or metal cable. Some elbow hinges are polycentric and have a step-up ratio to provide a greater range of motion for a short below-elbow amputation. This is useful if adequate power is available, since flexion strength is lost through this mechanism. When both power and range are insufficient, it is possible to utilize the stump power to activate a locking hinge. Flexion of the forearm is then provided by humeral flexion.</p> <p>Most below-elbow prostheses require an upper-arm cuff made of leather to help to stabilize the connection between the amputee and the prosthesis necessary to adequate control.<a></a> The most common types are the very light triceps pad and the open cuff. These would be the most useful for congenital amputees; the heavy-duty closed cuff would not usually be necessary.</p> <p>The socket is the foundation of all upper-extremity prostheses. The standard socket designs are used for juvenile amputees, but they may fit poorly because of the large amount of soft tissues in the child and the lack of well-developed bony prominences. It is through the socket that power and control are transmitted from the stump to the prosthesis and some degree of feedback is received. Double-wall construction allows a stump-fitted inner wall with an outer wall designed for structural uniformity and cosmesis. Retention of pronation and supination in short and very short below-elbow amputees is usually not a consideration, since pronation and supination are factors of forearm length. Another important matter is stability in flexion. In short and very short stumps, a single-axis hinge helps to provide this stability.</p> <p>Among the types of sockets available are single-socket, split-socket, preflexed socket, and Munster-socket designs. Single sockets are often lacking in the necessary flexion stability for congenital amputees. Because of limited range of motion, a short or very short stump may require a split socket with a step-up hinge. One degree of stump movement gives 2° or 3° of prosthesis movement, thereby increasing the range of motion, but two or three times normal force is needed to accomplish this. VanDer-werker and Rosenberger<a></a> described the mechanism and installation of a flexor assist for use with the step-up split socket. Pellicore <a></a> noted the unfavorable cosmesis of the split socket, which was later largely replaced by the use of a preflexed forearm. This improved the cosmesis somewhat and increased the functional forearm power, but the range of motion was limited to 100°-110° instead of the normal 135°.</p> <p>A great deal of the recent literature is devoted to a description and discussion of the Munster-type socket. The technique, involving intimate encapsulation of the stump, was developed by Dr. O. Hepp and Dr. G. G. Kuhn of Munster, Germany, and introduced into the United States in 1958. Short below-elbow stumps present a small attachment area, poor leverage, and a decreased useful range of motion. Some of the characteristics of the Munster technique that help to overcome these deficiencies are: (1) the elbow is set in a preflexed position yielding the most useful range of motion, usually about 35 deg., (2) a channel is provided at the antecubital space for the biceps tendon to avoid interference between the socket and biceps tendon during flexion, and (3) the posterior aspect of the socket is fitted high around the olecranon and the epicondyles, taking advantage of these bony prominences to provide attachment and stability to the socket.<a></a> These characteristics eliminate the need for split sockets with step-up hinges, giving improved prosthetic control and feedback, and often eliminate the need for a harness for suspension purposes. Younger congenital amputees may require more harnessing to maintain the prosthesis in place.</p> <p>Epps and Hile<a></a> described the fabrication techniques and evaluated the Munster prosthesis. Among the favorable points they found were: simplified harnessing, light weight, no perspiration problem, and excellent stability under axial-load testing. They also noted the elbow hyperextension characteristic of the individual with terminal transverse partial hemimelia. They concluded that the Munster-type prosthesis is the fitting choice for the child with a unilateral short or very short below-elbow amputation. In their investigation of the applicability of Munster-type fittings, Fishman and Kay<a></a> found that all of the subjects were definitely in favor of this type of prosthesis. The decrease in flexion range had no appreciable effect on prosthetic function for unilateral amputees. (Some modifications, such as lowering the anterior trim line and provision of a wrist-flexion device, may be necessary for the bilateral amputee.) Among the advantages cited are the facts that the stump does not slip out while performing overhead activities, and that less energy is required in operation of the prosthesis. They suggest that this type of fitting is functionally advantageous for amputees with very short to medium below-elbow stumps. Two factors limit the applicability of this technique for stumps of longer lengths: (1) the pronation and supination in these stumps cannot be harnessed with a Mun-ster prosthesis, and (2) the proximal socket opening at a sharp angle to the shaft presents increasing difficulty in donning and doffing the prosthesis as stump length increases.</p> <p>Gazeley, Ey, and Sampson<a></a> reviewed four cases of fitting children with Munster sockets and concluded that the technique is not satisfactory for bilateral amputees, because of the limited flexion. Except for that, they were very pleased with its use. Gorton,<a></a> Kay and Fishman, <a></a> and Pellicore<a></a> have all cited the usefulness of the Munster-type prostheses in fitting short and very short below-elbow stumps. Gorton found the positive factors to be: increased stability and socket retention, socket comfort with minimal stump motion within the socket, harness comfort with the elimination of the triceps pad and front support strap, and improved cosme-sis due to the minimization of the harnessing system. The negative features listed were: decreased range of motion (limited to about 70°), limited elbow flexion, and harness discomfort due to the control strap riding low across the back. The other authors discovered similar findings. With the limited range of motion, it is necessary to make this the most functional range. Partial flexion is necessary to keep the prosthesis on the stump. Complete extension is not as essential to functional activity as an adequate flexion range.</p> <p>The use of sockets that do not completely enclose the stump is more extensive in Germany than in the United States. With this type of prosthetic fitting, the end of the stump remains free for gripping and touching. According to Fletcher <a></a> and an article in the <i>British Medical Journal, </i><a></a> in congenital limb deficiency the end of the limb has a tactile sensation equivalent to that of a normal fingertip, even when the distal two-thirds of the forearm is missing. He attributes the prosthetic rejection by many children to the fact that standard prostheses rob them of this important sense of touch. He feels that fitting such an individual with an artificial limb is, in effect, performing a physiological amputation. Kuhn<a></a> and Jentschura, Marquardt, and Rudel<a></a> have described an open-end socket that enables the patient to use the sensory surface of his stump as well as the terminal device. The socket is provided with a friction joint on the dorsum of the prosthesis so that the terminal device can be bent away from the end of the stump. The economic advantage of an increased "life span" of the prosthesis, as well as the functional advantages of the open socket, have been presented by Jaramillo and Lehneis.<a></a> The preservation of tactile sensation is an important consideration in upper-extremity prosthetic design. Increased research on open sockets is indicated, since they seem to provide a critical advantage over the standard prostheses, especially for the bilateral amputee.</p> <h3>Prosthetic Prescription and Fitting</h3> <p>The prescription of a prosthesis for a congenital amputee, as for any amputee, is best achieved by a team approach. The child's functional needs and developmental status must be ascertained in order to provide the optimum combination of components. Actual fabrication is followed by a final check-out of the compatibility of the amputee and the prosthesis.</p> <p>The physician, prosthetist, and physical and occupational therapists are the main members of the prosthetic-clinic team.<a></a> The physician, in writing the prescription, must combine his knowledge of the individual with the results of evaluations performed by other members of the team. The prosthetist advises about possible solutions to the case, measures the patient, fabricates the prosthesis and harness, and evaluates the functional results of fitting. The physical and occupational therapists evaluate motor development, range of motion, and muscle strength, advise the physician and pros-thetist of available body power for control, suggest possible solutions to fitting problems, and perform the final checkout evaluation.</p> <p>As a functional replacement for the missing limb, the prosthesis must be a simple, lightweight device that will enable the child to perform certain tasks, but not necessarily all tasks. Stamp, Mahon, and Morgan<a></a> found that, with the unilateral below-elbow amputee, the use of a prosthesis improves the function of the opposite, normal extremity. The combination of a normal extremity and a prosthesis is much more functionally efficient than is the combination of a normal extremity and a stump.</p> <p>The functional needs of the child must be determined in order to provide a prosthesis that will fill these needs. Self-care needs are an important part of the functional evaluation. Observing the compensatory patterns that the child has naturally developed for holding or reaching yield an indication of his specific functional needs. One approach to functional evaluation<a></a> has been to observe which parts are missing and to formulate a prescription on the theory that these are the parts that need to be replaced prosthetically. This theory assumes that, once these are provided, the child will meet all of his activity needs. It is important that the total effect of the prosthesis is a significant gain in function. The advantages and disadvantages for each individual must be carefully considered.</p> <p>It is necessary in the early examination to determine the developmental status of the child.<a></a> This evaluation bears a significant relationship to the timing and type of prosthetic fitting. In much of the literature, the achievement of a secure sitting balance is designated as an important criterion to upper-extremity prosthetic fitting. (The criteria for fitting are discussed more completely in the section on the trend toward early fitting.) An important part of the evaluation is the observation of the infant's prehension patterns. The infant's ability to control and relate his various arm, hand, and body movements predicts his pattern of prosthesis operation and use <a></a>. The development of compensatory prehension patterns is one of the positive indications for fitting the child with a cable-operated hook. The child's interest, attention span, and coordination must also be determined. All of this information aids in prescribing a prosthesis and planning a training program.</p> <p>In addition to this evaluation of neuromuscular development, the therapist must also determine muscle strength and range of motion. The prosthetist needs to know which structures are present and which are absent, and what sources of power are available. Muscle defects may accompany skeletal defects, as pectoral agenesis occasionally accompanies below-elbow deficiency.<a></a> Some of the abnormalities of neuromuscular-system function to notice are: involuntary motion, deviations in the speed of motion, resistance to passive movement, atrophy, fatigue, and static or dynamic postural deviations.<a></a> Functional muscle testing as described by Daniels, Williams, and Worthingham<a></a> provides valuable information. Range-of-motion tests are useful in noting any contractures or other factors limiting the range and in determining the scapular movement available to operate the devices prescribed. Sequential testing and accurate recording are necessary in functional, motor-developmental, muscle-strength, and range-of-motion evaluations.</p> <p>Exact body measurements, both longitudinal and circumferential, are often made by the prosthetist at the time of fitting. In the unilateral amputee, the epicondyle-to-thumb length is important as a sizing reference for the total length of the finished prosthesis.</p> <p>The choice of the components for the prosthesis is based on a thorough knowledge of the functional needs and the potentials of the individual. It was formerly accepted practice to prescribe a passive mitt, but this practice has been replaced by the use of a passive, plastic-covered hook. The hook gives the child the opportunity to incorporate the concept of a prehensile device from the start. The manual-friction wrist unit is often useful for congenital amputees. At first it can be positioned by the parents, and later by the child himself. Sockets that permit rotation are not usually indicated in short below-elbow stumps, since residual pronation and supination is minimal. The Munster-type socket, or modifications of it, as well as conventional below-elbow double-walled laminated sockets, seem to be successful in fitting the individual with terminal transverse partial hemimelia. Harnessing and suspension are highly individualized and can make the difference between successful and unsuccessful prosthetic prescription. Some of the greatest problems in prescribing and fitting the congenital amputee arise from his rapid, uneven rate of growth, the presence of baby fat, the lack of well-defined bony prominences, and the almost constant mobility of all young children. It must be emphasized that good prescription of prosthetic components must be based on a thorough knowledge of the individual. The prosthesis should allow him to function at his highest level in his environment. For the congenital amputee, this may mean providing him with the opportunity to assume a normal pattern of development of bimanual activity. In unilateral amputees, the prosthesis functions as a helper, not as the dominant hand.</p> <p>Fabrication and interim fittings are performed by the prosthetist. After careful initial measurements, a plaster cast of the stump is made. This is used to make a mold of the stump. A full description of the techniques for fabricating the prosthesis is beyond the scope of this paper; however, a step-by-step account of fabrication is given in the <i>Manual of Upper Extremity Prosthetics.</i><a></a> There is no universally acceptable check-out procedure for the child amputee. The standardized adult forms are not useful, because child prosthetics is a relatively new field in which improvements in techniques are constantly being made<a></a>. Additional contraindications to a standardized form are the varied ages and developmental levels of the children, philosophies of case management and prescription which may vary from clinic to clinic, and the fact that so many modifications of the prostheses for congenital amputees are needed. The standard check-out forms must be adapted if they are to be used for child amputees. The clinic team must evaluate the fit and function. The pros-thetist's primary interest is the mechanical aspects, the therapist's is the child's functional benefit. The physician must coordinate the efforts of all of the paramedical personnel. Blakeslee<a></a> has presented some of the important considerations regarding check-out for the juvenile amputee.</p> <p><i>Prosthesis fit</i></p> <ol> <li>Is the prosthesis cosmetically acceptable? Is it well made, and does the workmanship follow all of the specifications of the prescription?</li><li>Is the prosthesis of the proper length, and is the socket fit satisfactory? Do bony prominences have sufficient space? Do the component controls appear to be within reach of the amputee?</li><li>In the upper-extremity prosthesis, is the harness adjusted properly and is it comfortable?</li><li>When the prosthesis is removed, are there any excessive pressure points in the socket area? </li></ol> <p><i>Functional considerations</i><br />All components must be checked to make certain they are in good working order, and must be adjusted for efficient operation by the child and/or adult. Some of the primary functional considerations are:</p> <ol> <li>Is the prosthesis properly aligned?</li><li>If it is an upper-extremity device, is the control system appropriate for this child? Will he be able to control the arm and operate the controls in the desired range of motion? Is the terminal device in good condition and does it operate smoothly? Does the harness appear to be correctly positioned and in balance?</li><li>Can the prosthesis be applied with ease? Is the amputee comfortable in the standing, sitting, and walking positions and while performing functional activities?</li></ol> <p>These check-out procedures emphasize the points to consider in preprosthetic evaluations, prescription of components, and fabrication. The prosthesis must be made to fit the needs of the child; the child should not be expected to adapt to the prosthesis.</p> <h3>The Trend Toward Early Fitting</h3> <p>A great deal has been written concerning the advantages of early fitting, and a variety of developmental criteria for fitting have been described. This section deals with the advantages of early prosthetic fitting for the upper-extremity juvenile amputee, a brief discussion of normal motor development, and a discussion of fitting at various ages. The age levels can be roughly grouped as follows: before school age, nine to twelve months, six to eight months, four to six months, and three months or younger. This grouping is the distribution that occurred naturally in the literature. The concept of prosthetic acceptance or rejection is also discussed in this section.</p> <p>The philosophy of early fitting is the dominant theme of much of the literature. The difference exists in the definition of the term <i>early. </i>Before this concept was accepted, prescription of an artificial limb was not advised until the patient reached the middle or late teens,<a></a> in order to avoid the expense of purchasing a device that soon would be outgrown. More recently, the child was fitted just prior to school age,<a></a> but still after the child had become oriented to one-handed function. Frantz<a></a> has presented a brief history of the management of the juvenile amputee during the past twenty years.</p> <p>Mongeau and others<a></a> recommend that the habilitation of congenitally deformed children be initiated at an early age. Many other authors have proposed reasons for early fitting. Friedmann<a></a> lists the following advantages: (1) to stimulate bilateral function, (2) to help the child and parents to accept the prosthesis for function or cosmesis, (3) to incorporate the prosthesis into the child's body image, (4) to improve balance, (5) to get the child accustomed to the normal length of the limb, (6) to prevent scoliosis and other skeletal abnormalities due to asymmetry, (7) to make the child aware of prehensile function, and (8) to promote eye/hand control. In addition to the advantage of greater acceptance, Blakeslee<a></a> cites the fact that early fitting leads to a more normal development of the residual parts and diminishes atrophy caused by disuse and hypogenesis. The prosthesis encourages physical activity, which increases growth and strength. The avoidance of substitute patterns of grasp, such as holding objects in the axilla or elbow-bend and working in an awkward or energy-consuming position, was noted as an advantage by Blakeslee<a></a>, Brooks and others,<a></a> Gillis,<a></a> and Klopsteg, and Wilson et al..<a></a> More of the movement patterns of the upper extremity are acquired than in the lower extremity, thus increasing the importance of early fitting. Gillis maintains that the movement patterns necessary to control the prosthesis are most perfectly developed at the same time as those for the natural limb. The possibilities of atrophy through disuse and the development of contractures are greater with later prosthetic fitting.<a></a> As the result of a study conducted at the Rehabilitation Institute of Montreal, Gingras and others<a></a> found that in a majority of cases there was hypotrophy of the deficient limb. They found an average difference of one centimeter between the lengths of the humeri. The hypotrophy was attributed to disuse because it had been observed that patients who had early prosthetic training were enabled to put their muscles to greater use and therefore they showed less limb-length inequality. An additional advantage of early fitting mentioned by Edelstein<a></a> is that it aids the limb-deficient child in crawling. Children learn to use the upper-extremity prosthesis as well as, if not better than, adults.<a></a> The advantages of skill in prosthetic use resulting from early fitting have been cited by Brooks and others,<a></a> Dean,<a></a> and Mayo.<a></a> Some of the favorable results of early prosthetic fitting for the unilateral below-elbow amputee presented by Brooks and Shaperman<a></a> include: (1) full-time wearing of the prosthesis, (2) skillful operation of the prosthesis, (3) natural and spontaneous patterns using the prosthesis and including it in normal activities, (4) good habits of prosthesis maintenance, and (5) good acceptance of the prosthesis by the child, family, and community.</p> <p>In reviewing the literature, the author noted that earlier fitting was advocated more often for children with bilateral and multiple limb deficiencies than for those with unilateral deficiencies. One possible explanation for this may be the comparatively greater need for sensory input for development and function by the former group. The supposition of earlier fitting was substantiated in a census study by Kay and Fishman.<a></a> They suggested that this may be related to the greater need by multiple limb-deficient individuals for prosthetic assistance.</p> <p>The developmental norms of Gesell and Amatruda<a></a> form the basis of much developmental evaluation. They are especially relevant to the unilateral congenital amputee. For instance, he may first be aware of his missing limb at about three months of age, when he attempts two-handed grasp. Vitali<a></a> cautions that a limb-deficient child should not be expected to achieve standards of developmental performance before others in his age group.</p> <p>In an analysis of data collected over a two-year period ending on June 30, 1967, Davies, Friz, and Clippinger<a></a> noted that a relatively high percentage (32%) of congenital amputees were not fitted until after their eleventh birthday. Since the current philosophy is to fit congenital amputees at a very early age, it would be interesting to know the reason for this delay. The authors could not determine whether the fault lay with the amputee clinics or with parents who were reluctant to take their children to clinics or ignorant of the prosthetic opportunities available to them.</p> <p>In discussing the advantages of early fitting, there is variability in the definition of <i>early. </i>Brooks and Shaperman,<a></a> Kay and Fishman,<a></a> and Watkins and Ford <a></a> support the idea of fitting the unilateral below-elbow amputee before school age, at the latest. Of those authors advocating fitting when sitting balance has been achieved, some are referring to independent sitting without support (about ten months of age) and others to sitting with support (about six months). In either case, this leaves the upper extremities free in a functional position. The group of proponents includes Aitken,<a></a> Brooks and others<a></a>, Caine and Reeder,<a></a> Catto and MacNaughtan, <a></a> Jansen,<a></a> Shaperman,<a></a> and Wilson.<a></a> Several authors indicate a preference for fitting at six to eight months of age. Among these are Blakeslee<a></a>, Gillis,<a></a> Hall,<a></a> Kempner,<a></a> Lineberger,<a></a> and Vitali.<a></a> Lineberger and Gillis have cited the benefit of having a prosthesis to aid in crawling and pulling to a standing position.</p> <p>Encouraging bilateral movement patterns and establishing familiarity with and tolerance for the limb are advantages of prosthetic fitting between four and six months of age. This is considered the best age for fitting by Edelstein,<a></a> MacNaughtan,<a></a> Martin,<a></a> and Mayo.<a></a> Lambert and others<a></a> maintain that the congenital amputee should be fitted with a prosthesis as soon as he needs it. For the unilateral upper-extremity amputee, this may be as early as three months. According to Gingras and others,<a></a> fitting this early is based not only on considerations of function, but also on the idea of helping the child incorporate the presence of an artificial arm into his body image and to accept it better. Tolerance and adaptation to the prosthesis as well as aid in developing sitting balance has been stressed by Nichols and others.<a></a> Prosthetic acceptance or rejection is a very complex concept. It is an accepted psychological principle that an individual is better able to achieve adequate adjustment to a total loss of function than to a partial one, yet prosthetic devices restore partial function. The relationship of the amputee to his prosthesis is that of man to machine. It is an intimate and long-term contact between a human being and a mechanical device. The gadget tolerance of the individual is of great importance, especially as the child grows older and develops greater skill in using the prosthesis. Both the visual consideration of cosmesis and the auditory factors of a mechanical device, such as the sound of a terminal device closing on an object, play major roles in the formation of the individual's attitude toward his prosthesis. If the prosthesis is regarded as a tool that makes him less different and gives him a better opportunity for integration into his peer group, then the child is more likely to wear and use his prosthesis. If he believes that the prosthesis accentuates the difference between himself and others, it is likely that he will reject it.<a></a> Throughout the literature, it has been emphasized that children usually accept a prosthesis without too much difficulty .<a></a> It helps if the individual can gain immediate satisfaction from its use, rather than feeling that it is a deterrent to his activity. A child can be helped to appreciate the usefulness of the prosthesis by providing him with toys and chores that require two hands. Both a full-time wearing pattern and the ability to talk freely and openly about the prosthesis are good indicators of acceptance.</p> <p>Several authors have emphasized the positive relationship between early fitting and good prosthetic acceptance. A patient most easily accepts a prosthesis if he obtains it before becoming accustomed to one-handed activity.<a></a> Kempner,<a></a> Mongeau and others,<a></a> and Wilson <a></a> believe that early fittings lead to complete patient and family acceptance. In evaluations by Brooks and Shaperman<a></a>, children with short below-elbow stumps fitted before two years of age received the best scores for "acceptance." Gingras and others<a></a> found that rejection is a common occurrence if prosthetic fitting takes place after adolescence, while Blakeslee<a></a> found excellent acceptance and utilization if the child was fitted before four years of age, and increased rejection after that age.</p> <p>Congenital amputees experience the same structuring process in regard to body image as do normal children. If a child is presented with a prosthesis during the critical stage when his body image is forming,, he will incorporate the limb into his pattern of activity and self-image.<a></a> Centers and Centers<a></a> note that modern prostheses are functionally adequate for many of the activities engaged in by children. This may be a factor <i>in </i>the incorporation of the prostheses into their body images. Personality factors are directly related to acceptance of a prosthesis.</p> <p>In the case of the congenital amputee, his parents' attitudes affect his personality and his acceptance or rejection of a prosthesis. Parental influence cannot be overemphasized. It is within the family structure that all of the child's attitudes are developed. A clear view of parental influence is presented by Brooks and Shaperman<a></a> in their discussion of a group of children who had rejected their prostheses. The group was characterized by a lack of parental support and guidance in the child's general behavior. There was a great deal of emphasis on the child's accomplishments without the prosthesis. These parents expected less of their children than their potential, openly expressed dislike for the appearance of the prosthesis, and had a limited ability to communicate feelings and problems. One review<a></a> indicated that the better-educated middle-class families are most likely to help their children accept prosthetic appliances.</p> <p>All of these considerations regarding acceptance and rejection are interrelated.</p> <h3>Questionnaire Survey Concerning Age at Initial Fitting</h3> <p>The questionnaire survey sought to document a trend toward earlier initial fitting of upper-extremity prostheses in the congenital amputee. As the most frequently occurring limb deficiency, unilateral terminal transverse partial hemimelia was selected as the focus of consideration. An extensive review of the literature had seemed to indicate a trend toward earlier fitting. While children were formerly fitted just prior to school age or even during the middle or late teens, the achievement of independent sitting balance is now a widely accepted criterion for prosthetic prescription. According to Gesell and Amatruda's studies of motor development,<a></a> the norm for the achievement of this maturational level is nine months (36 weeks).</p> <p>It was the belief of the author that (1) even earlier fittings are being performed in significant numbers, (2) a passive hook is most frequently prescribed, and (3) the development of the Münster-type socket has played a role in the trend toward earlier fitting.</p> <p>Questionnaires were mailed to the 28 clinics participating in the Child Prosthetics Research Program, a cooperative endeavor conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development. The information requested was of three types: age at time of initial fitting, type of socket and terminal device most frequently prescribed, and basic developmental levels considered essential for fitting the prosthesis.</p> <p>The sample consisted of 40 new patients with upper-extremity terminal transverse partial hemimelia who were initially fitted between March 1, 1969, and approximately March 1, 1971. The frequency of fittings is indicated 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>One clinic whose data arrived too late to be included in the chart reported fitting more than 200 cases. A relatively small number (between 15 and 20) were fitted between the ages of 6 and 9 months, and a much larger number (50 or 60) were fitted after the age of 12 months. Two other clinics indicated that the information needed to complete the questionnaire was not readily available. (One of these stated that all of their children were fitted after the age of 12 months.) In requesting the data, no upper limit was set on the last interval (later than 12 months). For this reason, no statistical analysis of the central tendency (mean or median) was possible. The return on this survey was 43%, the low response level being partly attributable to the fact that no date was designated for the return of the questionnaire.</p> <p>The frequency distribution indicated that 65% of the children were fitted under one year of age. Using nine months as the age for reaching the developmental level of independent sitting, the data indicates that 37.5% were fitted before that age. It is also interesting to note that 20% of the sample was fitted before six months and 7.5% before three months. This information indicates a trend toward fitting earlier than the widely accepted criterion of independent sitting balance. The very important concept of parental attitudes and other intangible factors were not considered, nor was the age when the child was first seen at the clinic taken into account in this study. If it were, perhaps an even stronger trend toward earlier fitting would be noticed.</p> <p>Regarding the type of terminal device, seven clinics prescribed a Dorrance 10P or 12P passive hook most frequently. One fitted a nonfunctioning hand (mitten) initially and changed to a hook at about two years of age. The other clinic listed both the passive hook and the passive hand in their response. Five of the clinics prescribed a conventional double-walled plastic-laminate socket most frequently, and four clinics most often prescribed a Münster or modified Münster socket.</p> <p>An interesting outcome of this survey was the compilation of the developmental criteria for fitting employed by the various clinics. In the following chart, the list of criteria is paired with the developmental norms described by Gesell and Amatruda.<a></a> </p> <table> <tbody> <tr> <td> <p><b><i>Developmental Criteria</i>      </b></p> </td> <td> <p>      <b><i>G and A Norms (mo)</i>  </b></p> </td> </tr> <tr> <td> <p>Beginning to prop on elbows</p> </td> <td>      3 </td> </tr> <tr> <td> <p>Readiness for bimanual activity</p> </td> <td>      4 </td> </tr> <tr> <td> <p>Head control</p> </td> <td>      5 </td> </tr> <tr> <td> <p>Object transfer</p> </td> <td>      7 </td> </tr> <tr> <td> <p>Beginning sitting</p> </td> <td>      8 </td> </tr> <tr> <td> <p>Independent sitting balance</p> </td> <td>      9 </td> </tr> <tr> <td> <p>Controlled voluntary grasp and release</p> </td> <td>      9-12</td> </tr></tbody></table> <p>One clinic responded that they did not adhere to any developmental criteria, but felt that as soon as the child was three or four months old, a prosthesis could be fabricated with adequate socket fit. It was their belief that the earlier the socket was fitted, the better.</p> <p>The data collected on this sample did not establish a relationship between the development of the Münster-type socket and the trend toward earlier fitting.</p> <p>It is hoped that persons responsible for prescribing prostheses might consider the criteria proposed by other clinics for fitting of prostheses for congenital upper-limb amputees. The advantages that prompted the change from pre-school-age fitting to fitting at the developmental level of independent sitting continue to exert an influence toward still earlier fitting. The greatest advantage claimed is that of acceptance of the prosthesis. Logically, if the artificial limb is provided before a one-handed activity pattern is developed, changes for acceptance are increased. It would further seem logical that, when the capacity for two-handed grasp in the midline develops (at approximately four months), a prosthetic limb should be there to oppose the normal limb. The proximal stability necessary for control is developed previously in the on-elbows position. Many factors interact to affect the age of initial fitting. The age at which the limb-deficient child is referred to the clinic is certainly a significant one. Parental attitudes are closely associated with this consideration. The development of prosthetic parts specifically designed for children is important, as is the increase in knowledge in the entire field of prosthetic management of the juvenile amputee. Dissemination of this knowledge to the related health fields, especially to those individuals in contact with the mother of the newborn child with limb deficiencies, may promote earlier referral to the appropriate prosthetic team.</p> <p>It is believed that the trend toward earlier fitting is advantageous. A difference in the practice of various clinics has been noted. A polarity exists with a tendency for some clinics to fit predominantly at a very early age range and others only later. Three of the clinics indicated fitting only after 12 months. It would be useful for all the clinics that participate in the management of congenital amputees to carefully evaluate their criteria for prosthetic fitting and training.</p> <h3>Preprosthetic Therapy</h3> <p>Preprosthetic care should begin as early as possible. Hall<a></a> believes that physical and occupational therapy should be started as soon as the child begins to take part in his environment. A highly individualized treatment program to correct the deficiencies in range of motion, posture, and muscle strength is an important goal of preprosthetic therapy. The evaluations described earlier as prerequisites to prescription are also a part of the preprosthetic therapy program. Jaramillo and Lehneis<a></a> suggest that the child's poor attention span or negativism may be due to the lack of preprosthetic training by means of a good exercise program, rather than to poor family cooperation.</p> <p>Several authors have emphasized the important role the mother plays as the therapist.<a></a> She can be the best therapist for her child, since she spends more time with him than anyone else. She must understand the purposes of the therapy program and carry out the program at home. A good home program will facilitate prosthetic training. A well-informed mother can help to prevent contractures and postural deviations and to correct existing problems. It is a significant psychological asset for the mother to be an active member of the prosthetic team. An additional consideration that is the mother's responsibility in the early stages of habilitation is stump hygiene. The stump should be washed, rinsed, and dried thoroughly and inspected daily for any minor irritation or abrasion. The limb-deficient child perspires more than normal because of reduced body area. <a></a> He should be dressed in light, unrestrictive clothing for cooling and to allow freedom of movement.</p> <p>Limitations of range of motion do not occur as often in the upper extremity, and when they do occur, they do not as markedly affect its use.<a></a>The best treatment is prevention. This can be accomplished by instructing the parents in positioning and active exercises to prevent contractures and build strength and endurance. Extreme caution should be used in stretching any joints in the congenital limb-deficient child. The elbow is especially vulnerable, and passive stretching is contraindicated. (The tendency for radial-head dislocation has already been discussed.) The best techniques for increasing range of motion are those that achieve relaxation of the shortened group by heavy resistance to the antagonist muscle group. The PNF techniques of repeated contractions, slow reversal, slow reversal-hold, rhythmic stabilization, hold-relax, or slow reversal-hold-relax, as described by Knott and Voss would be appropriate. Since the young child is more flexible in his muscular structure, it is easier to reverse the adaptive shortening of the muscles than it would be in adults. Blakeslee<a></a> also notes the use of passive stretching, casts, and braces for the correction of flexion contractures.</p> <p>The delay in the early neuromuscular development of children with congenital skeletal limb deficiencies has been noted by Blakeslee<a></a>, Hall <a></a>, Jaramillo and Lehneis <a></a>, and Steele.<a></a> The child may be delayed in the development of head and neck control, rolling over, creeping, and sitting. He may need assistance in achieving developmental tasks. For example, if the child lacks head and neck stability, placing a small pillow under his chest allows development of the trunk and neck extensors. During this early period, assistance may be needed to help strengthen the neck and trunk flexors, extensors, and rotators. Later, it may be necessary to stimulate bimanual activity, especially gross grasp, by providing large objects for the child to hold. The upper-extremity amputee may need help in pulling to a standing position so that he can adequately develop his lower-extremity musculature.</p> <p>Essential muscle groups are exercised to maintain mobility and increase strength. Specific muscle groups must be strengthened in order to provide sufficient power to operate the prosthesis. Bates and Honet<a></a> and Montero <a></a>advocate the use of isometric exercises for this purpose. Exercises for neck and back extensors, flexors, and rotators are best accomplished through play activity. Catto and MacNaughtan <a></a> suggest using mirrors to stimulate the desired movement. The sound side should be included in the exercise program. Emphasis on strengthening the shoulder-girdle musculature for elevation, depression, scapular abduction and adduction, and general chest expansion (respiratory exercises) is important, since these muscles are needed to operate the prosthesis.<a></a> For the below-elbow amputee, strengthening elbow flexion and extension and any available pronation and supination is of prime importance.<a></a> Blakeslee<a></a> has emphasized the importance of general conditioning. Limb-deficient children tend to have a low energy output. This was observed even in below-elbow amputees who were otherwise normal in appearance and physiognomy. Greater than average endurance and output are required to operate a prosthesis. He also mentions that individual and group sports and other group activities have been successful in increasing energy output and improving general physical condition. Swimming has been found particularly advantageous.</p> <p>A preprosthetic therapy program provides a good foundation for later training of the child in the use of the prosthesis.</p> <h3>Prosthetic Training</h3> <p>Prosthetic training begins when the congenital amputee receives his prosthesis and continues periodically through vocational training. The initial training and orientation with a passive terminal device is essentially the same as that with an active terminal device, so both are considered together in this section.</p> <p>Training is one of the most difficult and important phases in the management of the congenital amputee. It is essential that the child is enabled to handle his environment rather than adapting the environment to his needs. Training a congenital amputee is very different than training a traumatic juvenile or an adult amputee who once had a functional extremity. The functional level of a normal child of the same age should be the basis of achievement goals.<a></a> The program progresses naturally from gross bimanual grasp to skilled functional activity. Factors affecting training are the child's neuromuscular development, attention span, functional requirements, and parental cooperation.</p> <p>The parents play an important role in the training of the juvenile amputee. The care and function of the prosthesis must be carefully explained to the parents, and they must be very aware of what it can and cannot do. The importance of the parents in prosthetic training has been emphasized by many authors.<a></a> Unless contraindicated by medical or other reasons, full-time wearing of the prosthesis from the first application should be the aim. According to Blakeslee,<a></a> one advantage to achieving a full-time wearing pattern as early as possible is the avoidance of the habit of removing the prosthesis for little or no reason. Later in childhood, the wearing pattern will be interrupted for repairs and refitting, so a stable pattern is desirable. Infants accept prosthesis-wearing easily, unless there is discomfort or the parents do not allow the prosthesis to be worn all day. Mac-Naughtan, <a></a> Shaperman, <a></a> Steele,<a></a> and Watkins and Ford<a></a> advise a gradual increase in tolerance leading to full-time wear except for sleeping, bathing, and rough contact sports. This seems to be a more logical approach than to expect immediate full-time wearing after the child has become accustomed to complete freedom of movement. During the period when the child has a passive prosthesis, he should be encouraged to use it as a "helper" in bimanual grasp, crawling, and pulling to a standing position. Toys are an excellent medium for encouraging bimanual activity. The infant amputee who receives his prosthesis during the first year of life shows remarkably early proficiency in gross arm movements; he develops habits of including the arm as a total unit rather than any specific part of the arm such as the hook, tip, or elbow.<a></a> An awareness of the hook's holding function should be developed as early as possible.</p> <p>In response to the questionnaire survey conducted by the author, the University of California at Los Angeles included a discussion of the criteria for the addition of a cable. Some of the factors proposed as prerequisites for terminal-device activation are: the readiness for bimanual activity, a reasonable attention span (approximately five minutes), the ability to follow two-step directions, tolerance of handling by the therapist, the presence of sufficient neuromuscular development to operate the cable, a full-time prosthesis-wearing pattern, and an awareness of the hook's holding function. At UCLA, the cable is usually added at a developmental age of two or two and one-half years.</p> <p>Like the variations observed in the age of choice for initial fitting, similar variability occurs in the age at which the terminal device is activated. The usual age seems to be about two years. Mac-Naughtan<a></a> has expressed the opinion that training should be conducted at the 14-to-20-month age. Depending on the ability of the child and the nature of his deformity, active control can be accomplished at 16 to 24 months, according to Hall<a></a> and Kempner. <a></a> Edelstein<a></a> cites 18 months, and Lambert<a></a> cites 18 to 24 months for the below-elbow amputee. By the age of 21 to 24 months, the child has developed a two-handed functional pattern, and he shows signs of a need to develop a pinch grasp as opposed to purely palmar prehension. <a></a> By two years of age, according to Blakeslee<a></a>, the child is ready for effective terminal-device activation, although this is typically a period of profound negativism. Dean <a></a> and Mayo<a></a> suggest that a single control cable be activated at 24 to 30 months, while Gingras and others<a></a> believe that, if active prosthesis training is begun by age two or three years, control can be achieved by four years of age.</p> <p>A study by Trefler<a></a> reveals the drawbacks of normally fitting around two years of age. Some of these considerations are that the child is ready for bilateral grasp before that age; he may be difficult to work with at the "terrible twos" stage of hyperactivity and negativism, and he may have already developed compensatory patterns, which are more easily prevented than broken. The advantages of terminal device activation at 15 months of age with a goal of spontaneous terminal-device use are: (1) the child is easy to work with for short periods of time (he has an attention span of one to two minutes), (2) when the cable system is applied to the child's prosthesis, it often helps to eliminate the problem of excessive external rotation of the socket, and (3) the availability of active grasp can enhance the activity pattern of an intelligent child. No disadvantages of early terminal-device activation were discovered. The cable did not restrict the child's movement during play at all.</p> <p>Wendt and Shaperman<a></a> conducted an interesting study to determine whether an infant amputee with unilateral below-elbow deficiency who was fitted initially with a prosthesis that included a cable would achieve purposeful control of the terminal device as part of his normal developmental progression without formal training. The results indicated that only a minority of the patients (approximately 25%) did achieve spontaneously the degree of skill usually acquired after formal training. Some patients partially learned skills, and others remained unaware of the function of the hook. It is possible that some children were negatively conditioned by the experience of trying to operate the terminal device and finding that they were unable to do so because of a lack of skill and guidance and concluding that the hook was a poor and unreliable tool. An alternative method of case management that has been suggested is to add the cable when manual hook-opening appears and then to allow natural development of terminal-device control. If the skill does not develop spontaneously, the therapist should intervene with the training program. This emphasizes manual hook-opening as a relevant step toward the eventual development of active opening. It was found that children who do learn terminal-device operation without training develop good skill and use patterns. If they are going to do so independently, they give evidence of this well before two years of age and achieve a well-established pattern by that time. It seems that, if a child is ready to develop the skill for terminal-device operation naturally, he should be allowed to do so.</p> <p>Prosthetic training once the control cable has been added is composed of two parts: training in the control of the terminal device and later functional training in activities of daily living. The child's ability to operate a hook relates primarily to his maturity.<a></a> Because of the child's short attention span, brief, frequent training sessions are desirable. Patients may sometimes be required to enter the hospital for the initial training sessions and occasional retraining later. At home, the mother can encourage these brief, frequent practice sessions. The child can best learn the correct control operations and realize the potentials of this prosthesis through play. There is a tendency for the child to continue to use his prosthesis as a passive device even after active control has been added.<a></a> Early training before the control cable is added should establish the concept of the prehensile function of the prosthesis. Manual hook-opening, at first by the parent and later by the child, and placing toys into the hook, should be encouraged. Flexion of the humerus opens the terminal device. The child must be helped to achieve the awareness of the relationship of these two incidents. The concept of stabilizing the sound shoulder in order to operate the terminal device is a difficult one to grasp. Having the child reach toward the terminal device with his sound arm may be helpful, or the therapist may need to stabilize the harness. The technique of immobilization seems to be mastered abruptly and inexplicably<a></a>, but it may take a great deal of time. The important objective is to get the child to open the hook, no matter how awkwardly it is accomplished. It may be necessary to cut down on the number of rubber bands on the hook to enable the child to open it; at this point in training, a large prehension force is not needed. The therapist can help hy offering objects to the child and placing them so that the hook will open when he reaches for them. One of the most difficult things for a child to learn is to pick up objects from a horizontal surface.</p> <p>The sequence of learning grasp and release with the prosthesis has been described by Blakeslee<a></a>, Richardson and Lund,<a></a> Shaperman,<a></a> and Wendt and Shaperman.<a></a> Although there may be variations in the pattern among individuals, it is agreed that a pattern does exist for learning terminal-device operation. A brief summary of the patterns observed by the above authors is presented here.</p> <p>Children learn first to actively maintain the hook in an open position and then to initiate hook-opening actively. Early opening is often accomplished by abducting and internally rotating the arm rather than by flexing the shoulder. This closely resembles grasp by the normal infant. The child finds it easier to open the terminal device with the elbow extended than in any other position. There is a tendency for the child to place objects into the hook with the sound hand. The ability to actively close the hook around an object develops before active release. At first, release of objects is accomplished by pulling them out of the hook with the sound hand. The child seems to be unaware that he can open and close the hook for release and that this requires the same motions that were used for grasp. It takes a long time and a great deal of practice for a child to become proficient in the use of the prosthesis. He must learn how far to open the hook to accommodate objects of different sizes and shapes, to position the hook accurately, and to properly time the release of an object. The child must also learn to extend the prosthetic arm and still maintain grasp on an object by releasing his sound shoulder so it no longer acts as the reaction point for control. The younger child cannot be expected to learn these more complex skills.</p> <p>Training hints have been offered by many therapists. The most frequent suggestion is the use of toys that require bimanual activity.<a></a> A lengthy list of toys suitable to each age group and each desired activity can be compiled. It was also mentioned that feeding time has been found to be one of the most successful training periods. Drill activities cannot be neglected, but relating them to functional play activities as soon as possible is desirable. <i>The Limb-Deficient Child</i><a></a> contains an excellent and extensive section on prosthetic training.</p> <p>Three prime functions that require prosthetic training are feeding, toilet care, and dressing. Other functional patterns that add to patient independence and satisfaction are: playground, household, and schoolroom activities, sports, musical instruments, card playing, and any other activities commensurate with the child's age. Special assistive devices are available commercially or can be fabricated when necessary.<a></a> Vocational training and preparation is a major consideration as the child grows older. For the unilateral amputee, the prosthesis is a helping or assisting device, and the sound arm is the dominant one in all activities. The part of functional training described in this paper is donning and removing the prosthesis. It is not practical to expect the very young amputee to be able to put on his prosthesis independently from the beginning. This is in contrast to the training procedure in adults, which would begin with this skill. Application is accomplished in the same manner as putting on a coat.<a></a> The socket is grasped with the sound arm and the stump is slipped under the inverted-Y strap. If the prosthesis is raised above the head so that the harness hangs down, the sound arm can reach back through the axilla loop, and the harness then can be properly placed. To remove the prosthesis, the child raises both arms over his head and grasps the socket with his sound arm. He can withdraw the stump while pulling up on the socket and then remove the axilla loop. Although a stump sock is usually worn to absorb perspiration, prevent suction, and allow greater comfort in the socket, it is a matter of individual preference. Some children with below-elbow deficiencies prefer not to wear a stump sock.<a></a> It is recommended that a T-shirt be worn under the harness to decrease local pressure and irritation, especially in the axilla, and to absorb perspiration.</p> <p>Successful training will permit the child to function freely and independently in his environment. Additional training may be required when the needs of the individual change.</p> <p>Follow-up studies of juvenile amputees after long-range treatment from infancy to adulthood have been conducted by Davies, Friz, and Clippinger,<a></a> Hamilton,<a></a> and Lambert, Hamilton, and Pellicore.<a></a> All three indicate the excellent results of long-term prosthetic management as indicated by good social adjustment, excellent prosthetic utilization, high employment rates, and high levels of educational achievement. Increases in these favorable results can be expected as children with congenital limb deformities are referred to prosthetic centers for treatment earlier and earlier.</p> <h3>Conclusion</h3> <p>This paper has discussed the prosthetic management of the congenital amputee with upper-extremity terminal transverse partial hemimelia. Psychological aspects, components of the prosthesis, prescription and fitting, the trend toward early fitting, preprosthetic therapy, and prosthetic training have been considered. A review of the literature and a questionnaire survey were completed. Several questions are raised and areas for further research are suggested as a result of this study.</p> <p>Research concerning the etiology of congenital limb deficiencies is indicated, including the unexplained phenomenon that the highest incidence of these deficiencies involve terminal transverse partial hemimelia of the left upper extremity in females.</p> <p>Information regarding phantom sensation in the congenital amputee is lacking. Study in this area might help to explain the phenomena of phantom pain and sensation in traumatic amputees.</p> <p>Reports regarding peer attitudes toward juvenile amputees show some disagreement. Some authors maintain that the attitude exhibited is one of healthy curiosity easily satisfied by an explanation, while a study by Centers and Centers showed more covert rejecting attitudes toward this group of individuals. It would be interesting to retest this hypothesis of social discrimination in the light of recent changes in attitudes toward many minority groups, since this study was conducted nearly ten years ago.</p> <p>A great deal of research is indicated and is being conducted in the area of prosthetic design. The results of biomechanical and kinesiological studies must be incorporated in the design of components. Analysis of the forces used in prehension and the most frequent types of prehension employed would be beneficial in improving terminal-device design. Further evaluation of the hooks and hands presently available and the voluntary-opening and voluntary-closing mechanisms are needed to determine which is most efficient and to delineate areas for further research. Some work has been done regarding optimum wrist-flexion (palmar) angles for functional activity close to the body. However, no consideration has been made as to the need for dorsiflexion, which is used very frequently in functional activity of the normal hand. The field of plastics offer a great source for improvements in fabrication of prostheses. Durable hooks with improved cosmesis may be a possibility with the new plastic materials available, as it has already aided in light weight and durable socket design and fabrication. The open-ended sockets that permit the use of the sensation at the tip of the stump seem to be an excellent development, especially for the bilateral amputee. Investigation into the advisability of increased use in the United States is indicated.</p> <p>Some disagreement exists concerning the development of prosthetic tolerance by the juvenile upper-extremity amputee. It is not, however, a significant controversy, since the goal of full-time wear is agreed upon, with differing opinions only concerning the rate at which this goal is reached.</p> <p>The results of the questionnaire survey indicate a trend toward earlier prosthetic fitting of the congenital amputee. Among the most interesting and valuable of all the information received was the developmental criteria for fitting. This information should be made available to the clinics participating in the Child Prosthetics Research Program, thereby enabling each of them to re-evaluate their criteria in light of this newly accumulated knowledge. Perhaps this can be accomplished through the <i>Inter-Clinic Information Bulletin.</i>The survey conducted did not consider the important factors of parental attitudes and age at time of referral to the prosthetic center. Any future study should incorporate these factors. Another study might better be able to establish or negate a relationship between the development of the Münster-type socket and the trend toward early fitting.</p> <p>Additional information concerning activation of the terminal device is needed. The proposal by Wendt and Shaperman of allowing natural development of the terminal device control once manual opening occurs, then intervening with formal training if control is not established by two years of age, merits consideration.</p> <p>Prosthetics for congenital amputees is a relatively new area, largely developed since the thalidomide tragedy of a few years ago. It has many areas requiring further research, such as the need for lightweight prostheses that can be operated with the available muscle power and the constant consideration of rapid growth. Research in this specific field of prosthetics for congenital amputees will contribute to and continue to benefit from the ongoing research in prosthetics in general. The goal of this research is improved functional ability for individuals with congenital skeletal limb deficiencies of varying degrees of severity and for all amputees.</p> <h3>Addendum</h3> <p>Three additional responses from the questionnaire survey were received after the statistical analysis had been completed and the article had been prepared. These brought the total return to 53.5%. A summary of the information received is presented here.</p> <p>The results were generally similar to those previously reported, with a number of individuals fitted at each interval except the first (less than three months).</p> <p>The developmental criteria presented were: bilateral gross grasp, beginning to sit, independent sitting, and (not previously mentioned) initiation of hand-eye coordination, as with holding a bottle, blocks, and general grasp for objects.</p> <p>Two of the clinics indicated that they usually fit a first prosthesis at six months of age if the developmental level allows it. Those fitted later in the statistics returned were not referred to the clinics until after that age.</p> <h3>Acknowledgments</h3> <p>I would like to thank Miss Dorothy Page, my advisor, for her help and guidance during this project. I would especially like to thank Miss Mildred C. Ey, O.T.R., Director of Occupational Therapy at Sunnyview Rehabilitation Center Hospital; and Mr. Klaus H. Lohman, C.P., of LaTorre Orthopedics Laboratory. I also extend my appreciation to Dr. Sidney Fishman, Mr. Hector W. Kay, the A. J. Hosmer Corporation, the Dorrance Company, the Otto Bock Company, and the clinics answering the questionnaire.</p> <p><b>References:</b></p> <ol> <li>Aitken, George T., Management of severe bilateral upper limb deficiencies, <i>Clin. Orthop. </i>no. 37:53-60, 1964.</li> <li>Amputations and substitutes for limbs, <i>Brit. Med. J. </i>2:195-196, Apr. 22, 1967.</li> <li>Bates, Marion D., and Joseph C. 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Forum </i>7:411-423, 1968. </li> <li>Stoner, Emery K., Functional evaluation of the upper extremity, in <i>Handbook of Physical Medicine and Rehabilitation, </i>ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </li> <li>Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, <i>Clin. Orthop. </i>no. 37:82-97, Nov.-Dec. 1964. </li> <li>Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, <i>Amer. J. Surg. </i>109:294-299, Mar. 1965. </li> <li>Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, <i>Inter-Clinic Inform. Bull. </i>3:6:1-4, 1964. </li> <li>Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in <i>Selected Articles from Artificial Limbs, </i>Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </li> <li>Taylor, Isabelle Wagner, Psychological needs of the handicapped child, <i>Inter-Clinic Inform. Bull. </i>9:8:9-17, 1970. </li> <li>Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, <i>Amer. J. Occup. Ther. </i>15: 17-18, Jan.-Feb. 1961. </li> <li>Trefler, Elaine, Terminal device activation for infant amputees, <i>Inter-Clinic Inform. Bull. </i>9:9: 11,14, 1970. </li> <li>VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, <i>Inter-Clinic Inform. Bull. </i>3:1:1-3, 1963. </li> <li>Veterans Administration Prosthetics Center, Semiannual report, <i>Bull. Pros. Res. </i>10-3:135-136, Spring 1965. </li> <li>---------, Semiannual report, <i>Bull. Pros. Res.</i> 10-4:157-159, Fall 1965. </li> <li>Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, <i>Inter-Clinic Inform. Bull. </i>2:7:7-12, 1963. </li> <li>Wallace, Maxine T., Group therapy for parents of congenital amputees, <i>Inter-Clinic Inform. Bull. </i>5:2:10-14, 1965. </li> <li>Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, <i>Arch. Phys. Med. Rehabil. </i>43:293-296, June 1962. </li> <li>Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, <i>Neurology </i>11:905-911, Oct. 1961. </li> <li>Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, <i>Amer. J. Occup. Ther. </i>24:393-402, Sept. 1970. </li> <li>Wilson, A. Bennett, Jr., Limb prosthetics— 1967, <i>Artif. Limbs </i>11:1:1-46, Spring 1965. </li> <li>---------, Limb prosthetics —1970, <i>Artif. Limbs</i> 14:1:1-52, Spring 1970. </li> <li>---------, The prosthetics and orthotics program, <i>Artif. Limbs </i>14:2:1-18, Autumn 1970. </li> <li>For an Additional Bibliography, please refer to the PDF at the top of this page.</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>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </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">Hamilton, Robert C, A vocational evaluation of juvenile amputees who have attained the age of twenty-one years: a preliminary report, Inter-Clinic Inform. Bull. 3:7:8-9, 1964. </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"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </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>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Spring, John M., and Charles H. Epps, Jr., The juvenile amputee: some observations and considerations, Clin. Pediat. 7:76-79, Feb. 1968. </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>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </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>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </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">---------, Learning techniques applied to prehension, Amer. J. Occup. Ther. 14:70-74, Mar.-Apr. 1960. </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">Richardson, Geraldine, and Aida Lund, Upper extremity prosthetic training for the young amputee, Amer. J. Occup. Ther. 13:2:57-63, Mar.-Apr. 1959. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </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>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </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>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </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">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </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>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </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>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </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">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </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">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </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>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </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>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </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>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </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">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr><tr><td class="clsTextSmall"><b> 93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </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">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </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>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </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">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </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">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </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">Bates, Marion D., and Joseph C. Honet, Isometric exercises for the upper-extremity stump, Journal of the American Physical Therapy Association 44:1093-1094, Dec. 1964.</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>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </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">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </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">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 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>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 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>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </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>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </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">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </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>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Kyllonen, Ronald R., Body image and reaction to amputations, Conn. Med. 28:19-23, Jan. 1964. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </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>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </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>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </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">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </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>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </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">Knapp, Miland E., Upper-extremity amputations: surgical considerations, Postgrad. Med. 45:2:237-240, Feb. 1969. </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>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </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">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </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">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </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">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </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">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </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>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </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">Martin, J. K., Congenital malformations associated with thalidomide and their management, Amer. Heart J. 67:284-285, Feb. 1964. </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">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </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">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </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>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </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>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </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>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </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">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </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">Jansen, Knud, Amputation: principles and methods, Bull. Pros. Res. 10-4:5-41, Fall 1965. </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">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </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">Caine, Donald, and A. J. Reeder, The problem of the congenital amputee, Med. J. Aust. 50: 1:301-305, Mar. 2, 1963. </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">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </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">Aitken, George T., Management of severe bilateral upper limb deficiencies, Clin. Orthop. no. 37:53-60, 1964.</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>116 .</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </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">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </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">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </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"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </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>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </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">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 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>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </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>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </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>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </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>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </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">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </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">Klopsteg, Paul E., Philip D. Wilson, et al., 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">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </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">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </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">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b> 79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </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">Klopsteg, Paul E., Philip D. Wilson, et al., 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>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </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">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </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">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </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>37.</b> </td><td class="clsTextSmall">Frantz, Charles H., An evolution in the care of the child amputee, Artif. Limbs 10:1:1-4, Spring 1966. </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>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b> 119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </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>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </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>22.</b> </td><td class="clsTextSmall">Daniels, Lucille, Marian Williams, and Catherine Worthingham, Muscle Testing: Techniques of Manual Examination, 2nd ed., W. B. Saunders, Philadelphia, 1956. </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">Epps, Charles H., Jr., Upper extremity limb deficiency with concomitant infantile structural scoliosis, Inter-Clinic Inform. Bull. 5:2:1-9, 1965. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">McGraw, Myrtle B., Neuromuscular Maturation of the Human Infant, Columbia University Press, New York, 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>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Stamp, Warren G., Sharon Mahon, and Harry C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med. Rehabil. 46:354-368, May 1965. </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">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </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">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </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">Jentschura, G., B. Marquardt, and E. M. Ru-del, Inter-Clinic Inform. Bull. 4:9:11-14, 1965. (Reprinted from Behandlung und Vorsorgung bei Fehlbildungen und Amputationen der oberen Extremitdt, Georg Thieme Verlag, Stuttgart, 1963.) </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>68.</b> </td><td class="clsTextSmall">Kuhn, Gotz Gerd, Treatment of the child with severe limb deficiencies, Inter-Clinic Inform. Bull 10:3-S:l-26, 1970. </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">Amputations and substitutes for limbs, Brit. Med. J. 2:195-196, Apr. 22, 1967.</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">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">---------, Malformations of the upper limb, Proc. Roy. Soc. Med. 62:1:55-56, Jan. 1969. </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>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </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">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </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>51.</b> </td><td class="clsTextSmall">---------, Dorrance model 2 hand field study, Inter-Clinic Inform. Bull. 6:8:11-13, 1967. </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">Gazeley, William E., Mildred C. Ey, and William Sampson, Follow-up experiences with Muenster prostheses, Inter-Clinic Inform. Bull. 7:10:7-11, 1968. </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">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </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">Epps, Charles H., Jr., and John H. Hile, Experience with the Muenster-type below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 7:10:1-6, 1968. </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>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hart-mann, and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs 9:2:4-25, Autumn 1965. </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>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </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>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </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>75.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Sammons, Independent-control harnessing in upper-extremity prosthetics, Artif. Limbs 7:1:11-16, Spring 1963. </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">Clarke, Susan, Carole Kral, and Julie Shaperman, Built-in wrist flexion for children's prostheses, Inter-Clinic Inform. Bull. 9:5:1-7, 1970. </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>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </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">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </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">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </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>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </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>77.</b> </td><td class="clsTextSmall">McWilliam, R., and S. R. Montgomery, Artificial arms—are they practical?, Med. Biol. Illus. 19:4:200-201, 1969. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Mitchell, C. Leslie, Amputation and prosthesis: past research and future needs, Clin. Orthop. no. 37:110-112, Nov.-Dec. 1964. </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">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </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>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</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>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </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>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </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">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </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">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </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">Carroll, Leila, Sizing and prehension forces of Dorrance voluntary opening devices, Inter-Clinic Inform. Bull. 2:9:7-10, 1963. </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">Contini, Renato, Engineering in medicine, Bull. Pros. Res. 10-8:4-19, Fall 1967. </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>101.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Veterans Administration Prosthetics Center research report, Bull. Pros. Res. 10-12:331-333, Fall 1969. </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">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </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>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Semiannual report, Bull. Pros. Res. 10-3:135-136, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 113.</b> </td><td class="clsTextSmall">---------, Semiannual report, Bull. Pros. Res. 10-4:157-159, Fall 1965. </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>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </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">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </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>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </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>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </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>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </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>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </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">---------, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-10:270, Fall 1968. </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>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </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>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </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">Ritter, Diane, and Fred Sammons, An interesting terminal device modification, Inter-Clinic Inform. Bull. 4:9:7-10,19, 1965. </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>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </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>121.</b> </td><td class="clsTextSmall">---------, The prosthetics and orthotics program, Artif. Limbs 14:2:1-18, Autumn 1970. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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>84.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The challenge of replacing human parts and functions, Bull. Pros. Res. 10-3:4-19, Spring 1965. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Hile, John, Below-elbow harness without axillary loop, Inter-Clinic Inform. Bull. 6:5:7-8, 1967. </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>86.</b> </td><td class="clsTextSmall">O'Shea, Barbara, A chest strap harness for the below-elbow child amputee, Inter-Clinic Inform. Bull. 6:7:1-4, 18, 1967. </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>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </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>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </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>67.</b> </td><td class="clsTextSmall">Kruger, Leon M., and Nicholas R. Breyan, A study of radial-head dislocation in children with transverse partial hemimelia of the upper limb, Inter-Clinic Inform.Bull.10:1:1-4, 1970. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </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>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </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">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </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>107.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in Selected Articles from Artificial Limbs, Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </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">Finley, F. Ray, Roy W. Wirta, and Kevin A. Cody, Muscle synergies in motor performance, Arch. Phys. Med. Rehabil. 49:655-660, Nov. 1968. </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>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </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>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </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">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., 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>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </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>117.</b> </td><td class="clsTextSmall">Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, Neurology 11:905-911, Oct. 1961. </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">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </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>96.</b> </td><td class="clsTextSmall">Simmel, Marianne L., The absence of phantoms for congenitally missing limbs, Amer. J. Psychol. 74:467-470, Sept. 1961. </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">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </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">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </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">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </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">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </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">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </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>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Hebert, Bernard, the psychological implications of traumatic amputation in children, Inter-Clinic Inform. Bull. 7:4:7-10, 21, 1968. </td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., 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>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </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>108.</b> </td><td class="clsTextSmall">Taylor, Isabelle Wagner, Psychological needs of the handicapped child, Inter-Clinic Inform. Bull. 9:8:9-17, 1970. </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">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">McCollough, Newton C., Interpersonal problems of the handicapped child, Inter-Clinic Inform. Bull. 4:11:1-4, 16, 1965. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </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>49.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Observations and findings concerning upper-extremity prosthesis wearers, Inter-Clinic Inform. Bull. 3:8:1-4, 1964. </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>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </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">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </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">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 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>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</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>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </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>58.</b> </td><td class="clsTextSmall">Janelle, Claire, The role of the social service worker in the rehabilitation of the juvenile amputee, Inter-Clinic Inform. Bull. 7:4:20-21, 1968. </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Cohen, Pauline C, Impact of the handicapped child on the family, Social Casework 43:137-142, Mar. 1962. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </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">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </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>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </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>31.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputation, in Psychological Practices with the Physically Disabled, ed. James F. Garrett and Edna S. Levine, Columbia University Press, New York, 1962. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </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">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </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">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </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>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </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">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </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">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </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>97.</b> </td><td class="clsTextSmall">Sokolow, Jack, Management of the amputee in practice, Med. Clin. N. Amer. 53:3:659-664, May 1969. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </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>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </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">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </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">Gehant, Barbara A., Patient Census at Child Amputee Clinics—1968, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Oct. 1969. </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">Munson, Nancy K., and Clyde M. E. Dolan, Patient Census at Child Amputee Clinics— 1967, Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968. </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">Davies, Elizabeth J., Barbara R. Friz, and Frank W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull. 9:3:6-19, 1969. </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">Bergholtz, Susan G., Patient Census at Child Amputee Clinics—1969, Prosthetics and Orthotics, New York University Post-Gradu-ate Medical School, June 1970.</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">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </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>104.</b> </td><td class="clsTextSmall">Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, Clin. Orthop. no. 37:82-97, Nov.-Dec. 1964. </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">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </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>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </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">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </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">Gingras, G., and C. Corriveau, Modern amputations and prosthetics, Appl. Ther. 9:537, June 1967. </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">Burtch, Robert L., A study of congenital skeletal limb deficiencies, Inter-Clinic Inform. Bull. 2:7:1-6, 1963. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">---------, The classification of congenital skeletal limb deficiencies: a preliminary report, Inter-Clinic Inform. Bull. 3:1:4-9, 1963. </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Frantz, Charles H., and Ronan O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.) 43-A:8:1202-1224, Dec. 1961. </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>Barbara L. Sypniewski </b></td></tr><tr><td class="clsTextSmall">This article was prepared as part of an honors project at Russell Sage College - Albany Medical College SChool of Physical Therapy, Troy, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1972_01_020/1972_01_020-01.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 Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management Creator An entity primarily responsible for making the resource Barbara L. Sypniewski * https://staging.drfop.org/files/original/4c1c2659ace14b6587c3c801d470aa96.pdf dbc48fb2203d6c75e5adce812a9b03de https://staging.drfop.org/files/original/97b98628d90aad9bfbaac84c646fe3fe.jpg 4c4de5849811d644713ec7230d7d0f02 https://staging.drfop.org/files/original/9bf2b7836dee688f0bca62bfc38c7209.jpg 131fef1ae751f64e310d683f6e52c098 https://staging.drfop.org/files/original/27a2d16cac19d4fe68e3aead92053f88.jpg 0ceb64af346708b11b688bc9aec46035 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_005.pdf Text Any textual data included in the document <h2>Vacuum Forming</h2> <h5>Ben Wilson&nbsp;</h5> <p>In an article I wrote in 1974 on vacuum forming of sheet plastics<a></a> I erred in stating that the first reference to vacuum forming of sheet plastics in orthotics and prosthetics was a paper by Gordon Yates in 1968<a></a>. I should have remembered that Dana Street presented this concept in Volume 1 of the Orthopedic Appliances Atlas<a></a> for the fabrication of cervical orthoses. This is certainly an excellent example of how long it takes to get a technological development from the idea stage to fairly widespread application.</p> <p><b><a href="/files/original/97b98628d90aad9bfbaac84c646fe3fe.jpg">Fig. 1</a> Vacuum-forming a shank for a below-knee prosthesis using the hand-drape.</b></p> <p>In the time since my article was published in "Orthotics and Prosthetics" vacuum forming of sheet plastics has been used more and more by private practitioners in both orthotics and prosthetics.</p> <p>Although the educational programs, with a few exceptions, seem to have been very slow in teaching vacuum forming techniques, use of the technique seems to be expanding, owing in part to the several workshops sponsored by the American Academy of Orthotists and Prosthetists.</p> <p>Every process and system has its limitations, and we all recognize that each design in orthotics and prosthetics represents a compromise, but as time goes on the gaps that engender compromise are narrowed as experience is gained.</p> <p>Although the "Orthotics and Prosthetics Clinic Newsletter" has discussed several aspects of vacuum forming in the relatively recent past, in view of what seems to be a rapidly expanding program it seems appropriate that another survey be made concerning the uses of and problems encountered by the private practitioners.</p> <p>A questionnaire on this subject is included in this issue. It will be appreciated greatly if each recipient will complete the enclosed form and add any comments he or she feels that will be helpful in improving service to patients.</p> <p><b><a href="/files/original/9bf2b7836dee688f0bca62bfc38c7209.jpg">Fig. 2</a>. Vacuum-forming thigh section of knee-ankle-foot prosthesis using automatic machinery.<br /><br /><a href="/files/original/27a2d16cac19d4fe68e3aead92053f88.jpg">Fig. 3.</a> Vacuum-forming a below-knee socket with use of a platen and form for holding plastic sheet.<br /></b></p> <h3><b>References:</b></h3> <ol> <li>"Vacuum-Forming of Plastics in Prosthetics and Orthotics," A. Bennett Wilson, Jr., <i>Orthotics and Prosthetics</i>, Vol. 28, No. 1, March 1974.</li> <li>"A Method for the Provision of Lighweight Aesthetic Orthopedic Appliances," Gordon Yates, <i>Orthopaedics</i>, 1:2:153-162, 1968.</li> <li>"Plastic Braces," Dana M. Street; pp. 90-95 in Orthopaedic Appliances Atlas, Edwards Brothers, Ann Arbor, Michigan, 195.</li> </ol> <h3>Additional Bibliography:</h3> <ol> <li> <p>"Fabrication and Application of Transparent Polycarbonate Sockets," Vert Mooney, M.D., Roy Snelson, <i>Orthotics and Prosthetics</i>, Vol. 26, No. 1, March 1972.</p> </li> <li> <p>"Fabrication of Vacuum-Formed Sockets for Limb Prostheses," Roy Snelson, <i>Orthotics and Prosthetics</i>, Vol. 27, No. 3, September 1973.</p> </li> <li> <p>"Report of Workshop on Below-Knee and Above-Knee Prostheses," Hector Kay, June D. Newman, <i>Orthotics and Prosthetics</i>, Vol. 27, No. 4, December 1973.</p> </li> <li> <p>"The Use of Check Sockets in Lower-Limb Prosthetics," Samuel Hammontree, Roy Snelson, <i>Orthotics and Prosthetics</i>, Vol. 27, No. 4, December 1973.</p> </li> <li> <p>"A Thermoplastic Structural and Alignment System for Below-Knee Prostheses," Hans Richard Lehneis, <i>Orthotics and Prosthetics</i>, Vol. 28, No. 4, December 1974.</p> </li> <li> <p>"Development of a Thermoplastic Below-Knee Prosthesis With Quick Disconnect Feature," Charles H. Pritham, <i>Orthotics and Prosthetics</i>, Vol. 28, No. 4, December 1974.</p> </li> <li> <p>"Vacuum-Formed Sockets in Prosthetics Education," Bernard C. Simons, Alan V. Dralle, <i>Orthotics and Prosthetics</i>, Vol. 29, No. 2, June 1975.</p> </li> <li> <p>"Ultralight Prostheses for Below-Knee Amputees," A. Bennett Wilson Jr., Melvin L. Stills, <i>Orthotics and Prosthetics</i>, Vol. 30, No. 1, March 1976.</p> </li> <li> <p>"Use of Thermoplastic Components in Temporary Prostheses," Charles H. Pritham, Ivan E. Letner, David Knighton, <i>Orthotics and Prosthetics</i>, Vol. 30, No. 4, December 1976.</p> </li> <li> <p>"Applications of Transparent Sockets," S.I. Reger, I.E. Letner, CH. H. Pritham, M.D. Schell, and W.G. Stamp, <i>Orthotics and Prosthetics</i>, Vol. 30, No. 4, December 1976.</p> </li> <li> <p>"Above-Knee Polypropylene Pelvic Joint and Band," Erich Fischer, <i>Orthotics and Prosthetics</i>, Vol. 30, No. 4, December 1976.</p> </li> <li> <p>"A Lightweight Above-Knee Prosthesis with an Adjustable Socket," George Irons, Vert Mooney, Sandra Putnam, Michael Quigley, <i>Orthotics and Prosthetics</i>, Vol. 31, No. 1, March 1977.</p> </li> <li> <p>"Welding Plastics," Neil R. Donaldson, Michael J. Quigley, <i>Orthotics and Prosthetics</i>, Vol. 31, No. 1, March 1977.</p> </li> <li> <p>"Functional Partial-Foot Prosthesis," Gustav Rubin, Michael Danisi, <i>Bulletin of Prosthetics Research</i>, BPR 10-16, Fall 1977.</p> </li> <li><a href="http://www.acpoc.org/library/1972_06_003.asp"></a> <p><a href="http://www.acpoc.org/library/1972_06_003.asp">"A Functional Chopart Prosthesis," Gustav Rubin, Michael Danisi, <i>Inter-Clinic Information Bulletin</i>, Vol. 11, No. 6, March 1972.</a></p> <a href="http://www.acpoc.org/library/1972_06_003.asp"></a></li> <li><a href="http://www.acpoc.org/library/1972_10_009.asp"></a> <p><a href="http://www.acpoc.org/library/1972_10_009.asp">"Vacuum-Forming Techniques &amp; Materials in Prosthetics &amp; Orthotics," Alex Artamonov, <i>Inter-Clinic Information Bulletin</i>, Vol. 11, No. 10, July 1972.</a></p> <a href="http://www.acpoc.org/library/1972_10_009.asp"></a></li> <li><a href="http://www.acpoc.org/library/1975_04_011.asp"></a> <p><a href="http://www.acpoc.org/library/1975_04_011.asp">"A Foot Amputation Orthosis-Prosthesis," H.J. Ruben-stein, G.J. Sweeney, P. Strong, G. Durrett, <i>Inter-Clinic Information Bulletin</i>, Vol. 14, No. 4, April 1975.</a></p> <a href="http://www.acpoc.org/library/1975_04_011.asp"></a></li> <li><a href="http://www.acpoc.org/library/1975_04_011.asp"></a> <p><a href="http://www.acpoc.org/library/1975_04_011.asp">"Partial Foot Amputation-A Case Study," Charles H. Pritham, <i>Newsletter. . . Prosthetics and Orthotics Clinics</i>, Vol. 1, No. 3, Summer 1977.</a></p> <a href="http://www.acpoc.org/library/1975_04_011.asp"></a></li> <li> <p><i>Manual for an Ultralight Below-Knee Prosthesis</i>, A. Bennett Wilson, Jr., Charles H. Pritham, Melvin L. Stills, Rehabilitation Engineering Center, Moss Rehabilitation Hospital-Temple University-Drexel University (1977).</p> </li> <li> <p><i>The Rancho Ultralight Below-Knee Prosthesis</i>, Michael Quigley, George Irons, Neal Donaldson, Rehabilitation Engineering Center, Rancho Los Amigos Hospital County of Los Angeles, University of Southern California (1977).</p> </li> </ol> Page Number(s) 5 - 6 Year 1978 Volume 2 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1978_04_005/1978_04_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_04_005/1978_04_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_04_005/1978_04_005-3.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 Vacuum Forming Creator An entity primarily responsible for making the resource Ben Wilson  https://staging.drfop.org/files/original/ea5cb965d7cc12d8d6b0c436964b44d9.pdf e5e3dd0a8d1c47e6d18a93f0e7dde31d https://staging.drfop.org/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg 43dae3e86044e9e9337edfa12f8d523c https://staging.drfop.org/files/original/b99d31ef707acfb4cb39459306f929ae.jpg 1f0a63be299196ddf613145c782f8bb2 https://staging.drfop.org/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg 4f4ff35f2fa8689775893928003e2f4d https://staging.drfop.org/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg b0ffbc512dbf96e101590a70c9834f21 https://staging.drfop.org/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg edc1b0783e1722653e72676e255cecdc https://staging.drfop.org/files/original/f60360f716924225bb6b1b92e24d5971.jpg ccb584ca57daf2499edbf1d0c9c55314 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/1983_04_004.pdf Text Any textual data included in the document <h2>Physical Therapy and Hydraulic Knee Units</h2> <h5>Bernice Kegel R.P.T.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Without a thorough understanding of the principles of operation and functional benefits engineered into the sophisticated hydraulic knee mechanisms, the therapist will be unable to help the amputee gain maximum benefits and use the system effectively. It is important that the prosthetist ascertain that the therapist knows what adjustability is incorporated into the prosthesis. Much of the adjustment will be done during dynamic alignment at the prosthetic facility, but modifications will need to be made as the patient gains confidence and his ambulation pattern improves.</p> <p>An understanding of the fundamental differences between hydraulic control and mechanical friction will help in training the amputee to take full advantage of the flexibility of hydraulic mechanisms. Amputees can walk over a wide range of cadences instead of being limited as with mechanical friction. There are two reasons for this. First, hydraulic friction increases with speed to balance the increase in kinetic energy of the prosthesis while mechanical friction remains essentially constant. The programmed hydraulic characteristics give little frictional resistance during initial extension and flexion but build to a peak at terminal flexion and extension. This helps to provide a natural appearing gait regardless of cadence. The stability of hydraulic systems permits alignment nearer the trigger point and thus results in less energy expenditure required for walking. If a patient has previously used a mechanical knee, he needs to be reminded that no exaggerated residual limb motion is necessary to gain adequate flexion and extension of his hydraulic prosthesis.</p> <p>For purposes of brevity, I will limit my discussion to gait training with one knee unit-the Mauch S-N-S (<b>Fig. 1</b>). The Mauch S-N-S knee unit can be set to provide 3 functions:</p> <strong><a href="/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg">Figure 1</a>. Cutaway diagram of the Mauch Unit</strong><br /> <ol> <li> <p>Swing and Stance phase control.</p> </li> <li> <p>Swing phase control only.</p> </li> <li> <p>Manual knee lock.</p> </li> </ol> <p>A stirrup shaped lever near the top of the piston rod operates as a selector switch. When the lever is in the down position, swing and stance control are both operative. This would be the adjustment chosen for normal walking. The major advantage of stance control is that it offers the patient stumble recovery. If the prosthetic knee buckles, it will give way slowly enough that the patient should be able to regain his balance before falling. When training a patient with a conventional knee unit, he is taught to forcefully contract his hip extensors late in swing phase to accelerate the shank forward (with resulting terminal impact) to ensure extension of the knee at heel strike. Amputees wearing fluid-controlled mechanisms need not do this. The amputee should be instructed to swing his thigh forward, decelerate it, and end the movement with the residual limb pointing to the point on the ground where the heel should strike. The shank, aided by the built-in extension bias will swing forward smoothly, and at heel strike will be in full extension. With the stance phase control engaged, the prosthetic knee will be stable in the initial portion of stance phase without forceful extension of the hip musculature being necessary. The feature makes gait training markedly easier.</p> <p>It is extremely important during the end of stance phase on the prosthetic side that the hip be ahead of the knee and weight on the ball of the foot. This hyperextension moment is necessary to disengage the stance phase control momentarily and allow the knee to bend freely in swing phase. If the amputee does not exert this hyperextension for 1/10th of a second, he might experience difficulty in flexing the knee to begin swing phase. When walking on soft ground, it is even more important to exert this hyperextension moment.</p> <p>The benefits of stance control are also used when walking down stairs and ramps in a step-over-step manner. This ability to walk down steps in a step-over-step manner rather than one step at a time or by jack-knifing is one of the key advantages of the Mauch knee unit. The patient needs to be taught to place his prosthetic heel on the lower step with the forefoot extending beyond the edge of the step (<b>Fig. 2</b>). He is then told to flex his hip forward while simultaneously putting weight on the prosthetic leg. This will cause a controlled bending of the prosthetic knee. As the prosthetic knee yields, the sound leg is brought forward and placed on the lower step. If the patient has to wait for the prosthetic knee to bend, then stance phase resistance is too high and should be reduced. This activity is probably the most difficult to teach an amputee, especially if he has used a conventional knee unit in the past. This same technique is used for going down ramps. When walking up steps and ramps the same techniques are used as in conventional training.</p> <strong><a href="/files/original/b99d31ef707acfb4cb39459306f929ae.jpg">Figure 2</a>. Correct placement of the prosthetic heel</strong><br /> <p>When sitting down in a chair, the patient can either use the weight bearing resistance of the S-N-S unit to control the rate of sitting, or release the stance phase control and use the sound leg to control sitting rate in the same fashion as with a conventional knee unit.</p> <p>How quickly the knee bends under weight is determined by the stance adjustment screw, which is turned with a 22mm Allen wrench (<b>Fig. 3</b>). The adjustment is <i>extremely</i> sensitive with a range of only 120 degrees. Slowest bending and maximum stability is obtained with a full clockwise adjustment. Most patients like to start with a high degree of stability.</p> <strong><a href="/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg">Figure 3.</a> Allen wrench inserted into the stance adjustment screw</strong><br /> <p>To eliminate stance phase control the patient is told to stand with his prosthetic leg behind his sound leg. With weight on the toe of his prosthesis, he pulls the selector switch lever up (<b>Fig. 4</b>). This mode would be used for bicycling and other activities needing a free swinging leg. Swing resistance is adjusted by moving the serrated cap. The verticle black line under the serrated cap is the extension resistance marker. When the black line is all the way to the right (4 o'clock) extension resistance is lowest, and all the way to the left (8 o'clock) is the maximum setting. A good resistance for beginning walking would be at 5 o'clock (<b>Fig. 5</b>).</p> <strong><a href="/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg">Figure 4</a>. Eliminating the stance phase control.</strong><br /><br /><strong><a href="/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg">Figure 5</a>. Good resistance settings for beginning walking.</strong><br /> <p>The same serrated cap that adjusts extension resistance also adjusts flexion resistance. When the "H" in the word HYDRAULIC is over the line marker (regardless of the position of the line marker), flexion resistance is lowest. "K" over the marker indicates maximum resistance. A good resistance for beginning walking is at the "D" position (as shown in <b>Fig. 5</b>).</p> <p>To engage the knee lock, the selector switch is pulled into up position with the knee flexed and bearing no weight (<b>Fig. 6</b>). The knee may now be extended from this flexed position, but increased flexion is not possible.</p> <strong><a href="/files/original/f60360f716924225bb6b1b92e24d5971.jpg">Figure 6</a>. Engaging the knee lock.</strong><br /> <p>A right-legged amputee might choose to lock the prosthetic knee while driving and pressing the pedal by a forward motion of the hip. For standing at work for any length of time or while standing on a bus, the amputee could be taught to lock his knee.</p> <p>The Mauch S-N-S units have also been successfully used by bilateral amputees. The two units are likely to be adjusted differently because different residual limb lengths call for different resistance settings.</p> <p>The patient should be taught that the hydraulic unit may require servicing every one to two years. He should also be told that small amounts of air in the hydraulic system are no reason for concern. An automatic selfbleeding feature will eliminate the air after he walks a few steps, or if he bends the knees several times before applying the prosthesis. The leg should be stored upright with the knee fully extended so that air does not enter the hydraulic spaces.</p> <p><b>References:</b></p> <ol> <li>Kegel, B., Byers, J.L., "Amputee's Manual-Mauch S-N-S Knee." Medic Publishing Co., P.O. Box 1636, Bel-levue, WA 98009, 1977.</li> <li>Lewis, E.A., "Elements of Training with the Mauch S-N-S System for Above-Knee Amputees." Research and Development Division, Prosthetics and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York, New York 10001.</li> <li>Lewis, E.A. and Bernstock, W.M., "Clinical Application Study of the Henschke-Mauch Model A Swing and Stance Control System." <i>Bulletin of Prosthetics Research</i> Fall, 1968.</li> <li>Mauch, H.A., "Stance Control for Above-Knee Artificial Legs-Design Considerations in the S-N-S Knee." <i>Bulletin of Prosthetics Research</i>, Fall 1968.</li> <li>Knee Prostheses, Mauch Laboratories, Inc., 3035 Dryden Road, Dayton, Ohio 45439, January 1974.</li> <li>Murphy, E.F., "The Swing Phase of Walking with Above-Knee Prosthesis." <i>Bulletin of Prosthetics Research</i>, Spring 1964.</li> <li>Staros, A. and Murphy, E.F., "Properties of Fluid Flow Applied to Above Knee Prostheses." <i>Bulletin of Prosthetics Research</i>, Spring 1964.</li> </ol> <em><b>*Bernice Kegel R.P.T. </b> Seattle, Washington<br /><br /><br /></em> Page Number(s) 4 - 7 Year 1983 Volume 7 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-5.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/1983_04_004/1983_04_004-6.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 Physical Therapy and Hydraulic Knee Units Creator An entity primarily responsible for making the resource Bernice Kegel R.P.T. * https://staging.drfop.org/files/original/14e71685d71f779f2e221b6ce3752c7b.pdf 7f5b513db755d91f0fee0e97ce868617 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/1980_01_005.pdf Text Any textual data included in the document <h2>Prosthetic Knee Mechanisms: A Guide for the Prosthetist</h2> <h5>Bert Goralnik, CP&nbsp;</h5> <h3>Introduction</h3> <p>A function of the Veterans Administration Prosthetics Center (VAPC) is to assist VA Clinic Teams nationally in prescribing prosthetic devices, including, of course, prosthetic knees. Prescribing knee mechanisms, however, is a complex task because of the large variety available. Most often these devices differ not that much in function but in size, type of material used for the setup, and additional characteristics related more to assembly and installation processes than prescription rationales.</p> <p>All too often clinicians prescribe either limited numbers or certain types of knee mechanisms found to be reliable in the past. Another inhibitor may be a lack of specific information on the full range and variety of all available systems. The clinician rarely has an opportunity to compare the relative merits of one knee with another.</p> <p>In 1972, the Veterans Administration, through the Department of Medicine and Surgery, Washington, D.C., published a program Guide (M-2, part IX, G7) on "The Selection and Application of Prosthetic Knee Mechanisms." The guide was slightly modified and updated in 1976. A new Program Guide, reflecting developments of recent years and incorporating most commercially available knee mechanisms, will soon be published. This later Program Guide will provide a summary description of the various knee mechanisms thus far evaluated by the VAPC. It is intended to help maximize patient benefits.</p> <h3>Description of Program Guide</h3> <p>The Program Guide comprises six sections: Knee Function, Definitions, Classification, General Requirements, Prescription of Prosthetic Knee Mechanisms, and Catalog of Knee Mechanisms.</p> <ol> <li> <p>Knee Function: Here are described the normal function of the anatomical knee, specifically the relationships of its various parts during the gait cycle, and alignment stability as a key factor in prosthetic fitting. Discussion centers on the TKA line relative to the center of the knee in maintaining stability during the stance phase. Understanding these relationships and utilizing the special features of knee mechanisms for the patient's benefit is an asset for the prosthetist. The Clinic Team thereupon must strive to provide the patient with the specific knee mechanism whose features most closely match his individual needs.</p> </li> <li> <p>Definitions: Reference terms are given to describe the variety of knee functions.</p> </li> <li> <p>Classification: A chart classifying all types of commercially available knee mechanisms is provided. The chart shows functional criteria, specifically swing phase control and stance phase control. Additional topics in this section include extension aids, extension stops, mechanical locks, mechanical friction, and fluid resistance of hydraulic and pneumatic knees.</p> </li> <li> <p>General Requirements: This section consists of a checklist on knee mechanism requirements.</p> </li> <li> <p>Prescription: Prescription rationale is discussed, emphasizing the needs of the individual patient. Although the Program Guide concerns knee mechanisms, socket, shank, foot and suspension are also discussed to achieve the best type of prosthesis available. A chart shows the type of prosthesis best suited for different types of amputees. A classification chart of knee mechanisms is also included. To further assist the clinician, variations of basic prescriptions are given, i.e., for a short residual limb, a very long residual limb, and differences based on level of activity.</p> </li> <li> <p>Catalogue of Knee Mechanisms: this section, the heart of the Program Guide, lists most commercially available knee mechanisms. Illustrations furnished by the manufacturers are included. A chart lists type of knee mechanisms, materials, exact dimensions, and types of control offered.</p> </li> </ol> <h3>Conclusions</h3> <p>The new Program Guide on "The Selection and Application of Prosthetic Knee Mechanisms," will be available on or about June 1, 1980. It should prove to be of significance to all clinic teams. To obtain a copy of this publication, please write to the Veterans Administration Prosthetics Center, Attention: Mr. Bert Goralnik, 252 Seventh Avenue, New York, New York 10001.</p> <p>I wish to thank Mr. Max Nacht, Technical Writer/ Editor, VA Prosthetics Center, for his aid in preparing this article.</p> Page Number(s) 5 - 6 Year 1980 Volume 4 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/. 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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_131.pdf Text Any textual data included in the document <h2>Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation</h2> <h5>Bob Radocy&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The population of upper-extremity amputees, including congenitally limb-deficient persons, in the United States and abroad is placing increased demand upon the profession for improved prosthetic designs and devices which will allow its members to participate competitively in sports and recreation activities.<a></a> Recreation trends indicate that these demands will most likely increase.</p> <p>Until recently, prosthetics did not directly address the needs of the sports-oriented amputee. Prosthetic designs focused on domestic and vocational needs and did not necessarily target the criteria necessary to perform in the vigorous environments of sports or recreation. Over the years, select prosthetists working with individual amputees have developed "one of a kind" sports devices for their patients. These devices sometimes proved adequate, but most were never made available commercially.</p> <p>Two commercially available sports terminal devices have been available for many years: the Baseball Glove Attachment and the Bowling Attachment.<a></a> Recently, other specialized prosthetic devices have become available to meet the sports-minded amputee's needs. These are the SUPER SPORTs,<a></a> Amputee Golf Grip,<a></a> and the Ski Hand.<a></a> Additionally, new variations in the designs of body-powered terminal devices are allowing amputees to participate in many sports activities without the need for specialized aids or radical modifications.<a></a></p> <p>The measure of performance by the amputee in any activity, as always, depends upon proper limb design. Socket design, materials, alignment, and components all play a vital role in any amputee's ability to perform competitively. Another important factor is the amputee's physical condition. The prosthesis, no matter how well designed and constructed, cannot supplement atrophied muscle, limited range of motion, or inadequate strength.</p> <p>Sports prosthetics begins with the evaluation of the need and of the capacity of the amputee being served. A physical therapist and potentially a clinic physician will be important components in the rehabilitation of an amputee wishing to become active in sports and recreation.</p> <p>Exercise and conditioning with or without a prosthesis will be required as a preliminary step for an amputee who wishes to excel without injury in sports. Exercise can take multiple forms. Proven exercise techniques exist. Isometric, isotonic, and passive and active resistance all have specific goals and methods. Education is required so that the amputee is knowledgeable about how to proceed with an exercise program and to determine the objectives, i.e. is muscle hypertrophy (bulk) required for strength or is muscle endurance more appropriate? Additionally, how are flexibility and range of motion impacted?</p> <p>Preprosthetic exercise may be required or desired. Weight harnesses<a></a> (<b>Figs. 1, 2, and 3</b>) rather than strap or cuff weights are a better way to approach exercise without a prosthesis. A properly designed harness will prevent weight slippage during exercise and will enable many variations of upper-extremity conditioning (<b>Figs. 4, 5, and 6</b>).</p> <strong>Figures 1, 2, and 3. Weight harnesses, rather than strap or cuff weights, are a better way to approach exercise without a prosthesis.</strong><br /><br /><strong>Figures 4, 5, and 6. A properly designed harness will prevent slippage during exercise and will enable many variations of upper extremity conditioning.</strong><br /> <p>Bilateral exercise using a dumbbell on the non-affected side is important to maintain muscle balance and reduce spinal stress. A full length mirror aids the amputee in viewing him or herself in order to correct postural deficiencies or extraneous movements to optimize resistance exercise efforts.</p> <p>Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to specific muscle groups (<b>Fig</b><strong>s. 7, 8, 9, and 10</strong>). Complete upper-body conditioning will be most effectively accomplished while wearing a prosthesis. Furthermore, exercise while wearing a prosthesis will help condition the residual limb to the skin stresses and shears a prosthesis will create when under load. Modern exercise equipment systems, such as Nautilus, Hydra-Fitness, and Universal, are available virtually everywhere in YMCAs, community recreation centers, health and sports clubs. A planned program for the amputee can be structured by professional instructors to the amputee's goals. Free weights are another alternative or can complement a weight conditioning program with the convenience of low cost and home use. Equipped with a proper terminal device (<b>Fig. 11</b>), an arm amputee can safely handle dumbbells or barbells in weight training.</p> <strong>Figures 7, 8, 9, (above) and 10 (right). Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to certain muscle groups.</strong><br /><br /><strong>Figure 11. Amputee lifting dumbbell with a terminal device.</strong><br /> <p>Proper conditioning balanced by flexibility achieved through passive stretching, aerobics or any number of alternatives will result in the range of motion and strength an amputee will need for high performance in sports and recreation. A regular conditioning program will especially enhance the use of body-powered prostheses which require activation through body-controlled movements.</p> <p>Sound limb design, mentioned previously, is a major component in an amputee's performance potential. Lightweight yet strong prostheses are ideal, but strength should not be sacrificed just to achieve reduced weight. Socket design is dictated to a certain extent by stump configuration, but it is the author's belief that, if at all possible, a supra-condylar socket should be used.<a></a> Supra-condylar sockets with all their variations (Muenster, Bock, etc.) have evolved rapidly with advances in electromechanical limbs. A supra-condylar socket need not be unduly restrictive, and such a limb allows for less complicated harnessing.</p> <p>Carbon fiber and acrylic resins are two materials which lend well to the lightweight but high strength prosthetic objectives. Socket padding,<a></a> whether fully or partially lined, aids in protecting the condyles, olecranon, and distal residual limb end from trauma. If adequately reinforced, ISNY<a></a> style sockets may prove to be applicable for sports as well, but the published data on below-elbow applications is scarce.</p> <p>In addition to padding, the author recommends a heavy residual limb sock or two regular weight socks for most sports activities. Highly absorbent terry lined socks (designed for athletic footwear) are excellent. A polypropylene sock can be used effectively as a liner if heavy perspiration is a problem.</p> <p>An adjustable excursion harness,<a></a> such as the modified Northwestern (<b>Fig</b>. <strong>9</strong>) which allows for excellent range of motion and terminal device control, can be applied, although other designs will work. Rapidly adjustable excursion is a plus for actuation of voluntary closing terminal device systems and in sports where gross motion of the arms is required, i.e. archery, golf, baseball, etc. Cable efficiency may also be targeted for consideration. Several experienced amputees known to the author wax the stainless steel cables before assembly into the cable housing. The wax is clean and reduces cable to cable housing friction, thus improving efficiency.</p> <p>Alignment of the prosthesis on the residual limb also requires consideration, depending upon the amputee's sports needs. Preextended, as opposed to pre flexed, socket designs have useful applications in sports. They allow for full elbow extension while limiting flexion only slightly and usually not unacceptably. Wrist alignment is also of consequence and affects the manner in which the prosthesis torques on the residual limb when load is applied. It is important to emphasize the need for prosthetists to be concerned with dynamic forces on the prosthesis. A mere static fitting with a check socket will not suffice because it doesn't accurately duplicate what will occur in the definitive prosthesis. A secondary fitting session with a foamed, but unlaminated, prosthesis donned and the chosen wrist unit and terminal device in place can determine the optimum alignment of the components. Changes can be made accordingly and retested so that the definitive prosthesis will fit correctly. Testing the prosthesis in this manner will also determine if undesirable trim lines exist in the socket or whether extended padding is required. A supra-condylar fit socket on short residual limbs can cantilever on the epicondyles and cut in proximal to the olecranon when the prosthesis is loaded distally making it impossible to carry any significant load (<b>Fig. 12</b>). Extending the trim line can direct pressures to the back of the humerus instead of into the joint.</p> <strong>Figure 12. A supra-condylar fit socket with an undesirable trim line.</strong><br /> <p>Two other techniques which can aid in creating a more suitable sports prosthesis are external padding and suspension sleeves. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis (<b>Fig. 13</b>). Thicknesses from 3 mm to 1/4" are available. The material provides a good cushion for contact sports, helps reduce limb trauma during a fall, and the thicker materials have enough bouyancy to float a prosthesis. This technique has satisfied the requirements for a padded prosthesis in several school systems around the country.</p> <strong>Figure 13. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis.</strong><br /> <p>Suspension sleeves can improve a supracondylar fit, especially when using a passive recreational device where the cable is absent or does not play a role in prosthetic suspension. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper-extremity use simply by cutting them down in length (<b>Fig. 14</b>). The advantages of using a commercially available below-knee sleeve is that angulation for a joint is already built in. The author prefers neoprene due to its durability. Both cause increased perspiration within the socket. Designed properly, a neoprene prosthetic cover can function as a suspension sleeve as well.</p> <strong>Figure 14. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper extremity use.</strong><br /> <p>The remainder of this article will focus on modifications for specific sports and recreation to which the author has been exposed either directly or indirectly. In some cases, the solutions are simple; in others, performance dictates a more complex technical solution. Photographs and drawings have been used as often as possible rather than the written descriptions to illustrate a modification, device, or technique. Activities are dealt with alphabetically for convenience sake.</p> <h3>Archery</h3> <p>Modern archery equipment is easily adaptable to certain types of terminal devices. <b>Fig. 15</b> illustrates how a bow riser (handle) can be wrapped with consecutive layers of rubber, foam, and bicycle inner tube to create a durable, functional bow grip.<a></a> A chuck or pin can be used to jam the thumb of the terminal device closed around the riser or the amputee can just "hold on" as illustrated by <b>Fig. 16</b>.<a></a> Performance capabilities are exemplified by the amputee archer in this photo. He is a skilled hunter who has harvested three deer in a four year period.</p> <strong>Figure 15. A bow riser (handle) can be modified to create a functional bow grip.</strong><br /><br /><strong>Figure 16. An amputee can simply hold on to the bow as shown.<br /></strong><br /> <h3>Basketball, Soccer, Volleyball, and Football</h3> <p>Until recently, aids for amputees in ball-sports were limited to padded hooks, cosmetic hands, and custom one-of-a-kind terminal devices. Although these devices were useful, they rarely provided the type of high performance characteristics the sports-minded amputee required to compete successfully.</p> <p>One possible answer or solution is now available. The SUPER SPORTs devices, sized for all ages, are designed specifically for ball-sports and other rigorous recreations in which hand/wrist flexion/extension is needed. Additionally, they absorb shock as well as store and release externally applied energy (<b>Figs. 17, 18, and 19</b>). SUPER SPORTs are passive, not cable activated, but are helpful in catching and ball control when used in opposition to an anatomical hand or another device. SUPER SPORTs combined with padded arm covers create a safe, effective prosthesis for sports, such as football, basketball, and soccer in which interpersonal contact is inevitable.</p> <strong>Figures 17, 18 and 19. The SUPER SPORTs devices sized for all ages, designed specifically for ball sports and other rigorous recreations in which hand/wrist flexion/extension is needed.<br /></strong><br /> <h3>Bicycling, Tricycling, and Motorcycling</h3> <p>Bicycling or tricycling has proven to be an aggravation for amputees equipped with conventional style hooks. Lack of adequate gripping strength and finger shapes have hampered performance. Presently, however, children and adults equipped with newer style voluntary closing terminal devices (<b>Figs. 20 and 21</b>) can control two or three wheeled cycles as well as their two-handed peers. No modifications are required except when hand brakes are present. Front and rear brakes can be actuated from a single hand lever. Brake pressure must be regulated so that braking forces are always applied to the rear wheel first for safe handling. Your local bicycle shop can usually solve hand brake complications.</p> <strong>Figures 20 and 21. Children and adults equipped with newer style voluntary closing devices can control two or three wheeled cycles as well as their two handed peers.</strong><br /> <p>Special adapters have been designed for or by individuals interested in competitive bicycle racing (<b>Fig. 22</b>).<a></a> The prototype illustrated is simple and is designed for safety to "quick disconnect" or "break away" at certain levels of force.</p> <strong>Figure 22. Special adapter for use in bicycle racing.</strong><br /> <p>Motorcycling is a natural extension of bicycling. Again, hand brakes and, in this case, a clutch hand lever complicate the situation. Unilateral amputees missing their left hands can shift and clutch with one hand with practice. Brakes again can be combined. A single foot lever is practical for driving dual master cylinders for hydraulic brakes. The rear wheel braking must occur first however. A local motorcycle mechanic or custom motorcycle shop can provide ideas or adaptations and modifications to standard equipment.</p> <h3>Canoeing and Kayaking</h3> <p>The author's experience with conventional terminal devices proved frustrating during these types of recreation. Split hook finger shapes did not adequately adapt to a paddle or oar. Lack of prehension inhibited the bilateral arm function required for these activities. Locking type terminal devices should never be used in water sports activities. <b>Figs. 23 and 24</b> illustrate how new technology and minor modifications to paddles can overcome problems in canoeing.</p> <strong>Figures 23 and 24. New technology and minor modifications to paddles can overcome problems in canoeing.</strong><br /> <p>Kayaking (<b>Fig. 25</b>) with a double-bladed paddle requires only coordination and practice. Rubber rings on the paddle which are used to keep water off the central shaft work equally well in preventing terminal device slippage.</p> <strong>Figure 25. Kayaking with a double-bladed paddle requires only coordination and practice.</strong><br /> <p>Gross arm movements, such as paddling or rowing, inherently activate voluntary closing devices and keep them closed. Rowing using an oar and oar lock can be enhanced by adding a stop or flange to the oar handle to prevent the terminal device from inadvertently pulling off during a power stroke.</p> <h3>Dance/Floor Exercise and Gymnastics/Tumbling</h3> <p>Activities, such as dance, tumbling and floor exercise gymnastics, have been treated similarly to ball sports in the past due to a lack of specialized terminal devices that were readily available. Padded hooks, cosmetic hands and some custom pedestal style terminal devices have been applied to attempt to satisfy the amputees' needs for balanced bilateral function. <b>Fig. 26</b> illustrates how the SUPER SPORT terminal devices can be applied to satisfy these specialized recreation niches.</p> <strong>Figure 26. SUPER SPORT terminal devices can be applied to satisfy specialized recreation niches.<br /></strong><br /> <h3>Fishing</h3> <p>Fishing is a sport and pastime everyone has access to and should be able to enjoy. Amputees using split hooks who wish to have improved control of reels might want to consider the Ampo Fisher I<a></a> which adapts to their prosthesis and reel (<b>Fig. 27</b>).</p> <strong>Figure 27. Amputees using split hooks may want to consider the Ampo Fisher I which adapts to their prosthesis and reel.</strong><br /> <p>Another alternative for the high level amputee is the Royal Bee Electric Retrieve Fishing Reel system (<b>Fig. 28</b>).<a></a></p> <strong>Figure 28. The Royal Bee Electric Retrieve Fishing Reel systems.</strong><br /> <p>Amputees equipped with voluntary closing terminal devices do not require many modifications to fish. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel, due to the improved prehension of these types of terminal devices (<b>Figs. 29 and 30</b>).</p> <strong>Figures 29 and 30. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel.</strong><br /> <p>Casting with a prosthesis is awkward due to lack of wrist flexibility. Amputees usually control the pole with their natural hand then switch hands to reel or reel with the terminal device. Most reels are available in left and right handed models to suit various physical conditions.</p> <p>Fly fishing poses more of a challenge due to the two-handed dexterity required in handling the fly line. One alternative is the Fly Fishing Reel for Amputees<a></a> (<b>Figs. 31 and 32</b>). This system has been used successfully, although the author feels there is still a need for improved alternatives.</p> <strong>Figures 31 and 32. The Fly Fishing Reel for Amputees.</strong><br /> <p>Automatic fly reels have been experimented with unsuccessfully due to the difficulties involved in "pulling out line" to wind up the return spring in these reels. Additionally, it was discovered that the spring force was only sufficient to pull in slack line, not with line under drag or a fish engaged.</p> <h3>Golf</h3> <p>Due to its popularity, golf has rules (USGA 14-3/15) regarding artificial limbs established by U.S. Golfing Association for tournament play.</p> <p>Variations in golf aids have evolved over the years primarily as individual designs to suit specific amputee's needs. Recently, however, a device called the Amputee Golf Grip (AGG)<a></a> has been introduced. The AGG is a standardized manufactured product which meets the USGA requirements (<b>Figs. 33 and 34</b>). The device is somewhat similar to the Robin-Aids Golfing device<a></a> (<b>Figs. 35 and 36</b>). Both devices utilize a flexible member to attach to the prosthesis and do not require club modification. They allow for <i>complete</i> wrist/club flexion and extension. The Amputee Golf Grip also allows for unrestricted rotation.</p> <strong>Figures 33 and 34. The Amputee Golf Grip is a standardized manufactured product which meets the USGA requirements.</strong><br /><br /><strong>Figures 35 and 36. The Robin-Aids golfing device.</strong><br /> <p>Other attempts to produce a functional aid should also be noted. One custom device is designed to have clubs attach directly to the prosthesis (<b>Fig. 37</b>).<a></a> Similarly, another model, the Atkins Golf Aid,<a></a> also attaches into the end of the club, but uses a ball-socket swivel. The swivel allows for a limited degree of wrist/ club, flexion/extension, and complete rotation.</p> <strong>Figure 37. A custom device designed to have clubs attach directly to the prosthesis.</strong><br /> <p>The author has tried several devices and prefers those that do not require club modification and which provide for total flexion/extension/rotation at the wrist/club interface. This allows for a complete back swing and smooth follow through capability.</p> <p>It is important to note that certain of these designs function more easily with one hand than another and must be played cross-handed for opposite side amputations.</p> <h3>Guns/Hunting</h3> <p>Almost any amputee can redevelop the skills necessary to handle a firearm safely with some simple gun modification. In many cases, a standard military sling can prove useful for handling a rifle. Another technique is to add a ring to a forearm sling mount which can then be grasped or engaged with a terminal device. Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun (<b>Figs. 38 and 39</b>). This modification will even allow for the safe operation of pump style shotguns or rifles. Consult with your local gunsmith for help in this regard as he has the knowledge and the tools to perform the modifications correctly.</p> <strong>Figures 38 (above) and 39 (left). Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun.</strong><br /> <p>Terminal devices can be used to trigger guns as illustrated in <b>Fig. 40</b>, but practice is obviously important.</p> <strong>Figure 40. Terminal devices can be used to trigger guns, but practice is obviously important.</strong><br /> <p>Other modifications/aids like the Blevin's gun yoke (<b>Fig. 41</b>) illustrate what inexpensive devices amputees have designed for themselves to regain access to a favorite recreation.</p> <strong>Figure 41. The Blevin's gun yoke illustrates what inexpensive devices amputees have designed for themselves.</strong><br /> <p>Persons with higher level amputations, multiple leg/arm amputations, strokes, or paralysis resulting in para or quadreplegia can also participate in shooting and hunting. Many states have now legalized hunting from parked vehicles to aid severely disabled sportsmen. Additionally, devices such as the SR-7721 (<b>Fig. 42</b>) or home-made Para-Quad Shooting System<a></a> (<b>Fig. 43</b>) offer capabilities not easily accessed in the past.</p> <strong>Figure 42. The SR-77.</strong><br /><br /><strong>Figure 43. The Para-Quad shooting system.</strong><br /> <p>One final design illustrates how an over and under shotgun can be modified to shoot one handed (<b>Fig. 44</b>).</p> <strong>Figure 44. An over and under shotgun modified to shoot one-handed.<br /></strong><br /> <h3>Hockey</h3> <p>A terminal device for hockey<a></a> (<b>Fig. 45</b>) developed in Canada is an ingenious aid for the hockey enthusiast. It is composed of an adjustable tension ball socket which fits with an adaptor onto the end of a hockey stick. The design allows for the stick to pivot under external force and quick release/flex during a fall. The original model pictured was custom designed for the young hockey player, but if modified with stronger materials, it would be applicable to adults as well.</p> <strong>Figure 45. A terminal device for hockey developed in Canada.<br /></strong><br /> <h3>Mountaineering</h3> <p>Mountaineering is a less accessible, less popular sport for most of the population, but it does attract enthusiasts and disabled persons. <b>Figs. 46 and 47</b> illustrate the author during a technical climbing training session. Voluntary closing devices, because of their ability to grasp rope and control gripping force, have proved useful to mountaineering. Instruction and guidance by professional climbing instructors is a must, and "safety first" procedures are always dictated.</p> <strong>Figures 46 and 47. The author during a technical climbing training session.<br /></strong><br /> <h3>Music</h3> <p>Information and devices to aid amputees playing instruments is scarce. Recently, however, information on a new guitar prosthesis was published in Canada<a></a> (<b>Fig. 48</b>). Dan Roy, the guitarist, in conjunction with specialist Armand Viau have developed a prosthesis which allows Roy to use his shoulder to strum the guitar. The arm is lighter than a conventional prosthesis and can hold a guitar pick.</p> <strong>Figure 48. A new prosthesis which enables guitarists to strum their instrument using their shoulders.</strong><br /> <p>Figures <b>Figs. 49 and 50</b> illustrate how some newer terminal devices, such as the ADEPT,<a></a> have proved to be viable solutions for children wishing to "play" musician.</p> <strong>Figures 49 and 50. Newer terminal devices, such as the ADEPT, have proved to be viable solutions for children wishing to "play" musician.</strong><br /> <h3>Photography</h3> <p>Custom photography and camera adapters have been fabricated for years. Now a device called the Amp-u-Pod<a></a> (<b>Fig. 51</b>) is a standardized, manufactured product which has proved to be an extremely effective aid for the amputee photographer. Designed to replace the amputee's regular terminal device, the Amp-u-Pod mounts directly to the prosthesis and adapts to any 35mm, movie, or video camera equipped to receive a tripod.</p> <strong>Figure 51. The Amp-u-Pod has proven to be extremely effective for amputee photographers.<br /></strong><br /> <h3>Sailing</h3> <p>Amputees are less restricted in this recreation, but handling rope lines and other types of sailing gear can place demands on the sailor to have two-handed capabilities. <b>Fig. 52</b><a></a> illustrates a triple amputee who found a GRIP<a></a> terminal device to be one of his best assets for sailing.</p> <strong>Figure 52. A GRIP terminal device used for sailing.<br /></strong><br /> <h3>Snow Skiing</h3> <p>Amputees have experimented with a number of ways to attach a ski pole to a prosthesis with little functional success. The Ski Hand<a></a> (<b>Fig. 53</b>) is the first standardized manufactured terminal device designed specifically for skiing. Available in varying sizes, the amputee force fits the Ski Hand over a ski pole after removing the standard hand grip. The Ski Hand proved worthwhile for cross-country skiing where upper-body strength is required for propulsion. During downhill skiing, the author found the device of less advantage due to the shallow angle to which the pole enters the hand. The pole basket had a tendency to drag in the snow and was therefore more difficult to control. Novice skiers, however, will find the Ski Hand useful because it enhances maintaining balance and getting up after a tumble.</p> <strong>Figure 53. The Ski Hand.<br /></strong><br /> <h3>Swimming</h3> <p>Swimming for many upper-limb amputees requires no aid whatsoever. However, for those individuals who wish to perform better or compete in the water, several devices have evolved as custom, one-of-a-kind solutions. The Viau-Whiteside Swimming Attachment<a></a> (<b>Fig. 54</b>) and the P.O.S.O.S./Tablada Swimming Hand Prosthesis<a></a> (<b>Figs. 55 and 56</b>) are two with which the author is most familiar, although others may exist.</p> <strong>Figure 54. The Viau-Whiteside swimming attachment.</strong><br /><br /><strong>Figures 55 and 56. The P.O.S.O.S./Tablada Swimming Hand Prosthesis.</strong><br /> <p>The Tablada hand is flat rather than curved to prevent submarining of the prosthesis during pre-stroke arm extension (Australian Crawl) in order to generate greater stroke volume. Additionally, note that the Tablada system uses a prosthesis which is close to actual anatomical arm length, whereas the Viau system has a shortened forearm section. Both utilize a pre-flexed, rigid elbow design. The Viau arm was designed primarily for back stroke swimming and may therefore account for the curved terminal device shape which would not hamper this style of swimming.</p> <p>The author is also aware of the use of SUPER SPORT devices for swimming, especially for children unaccustomed to the water.</p> <p>Pistoning of the prosthesis can be one of the most common occurrences during swimming. A suspension sleeve can aid in eliminating this action. An additional consideration related to swimming and skin or scuba diving is that the prosthesis is not as buoyant as the body and can seem heavier than normal in water and sometimes will impair performance.</p> <h3>Water-Skiing</h3> <p>Water-skiing can be an extremely dangerous recreation if not approached with caution. The author suggests the following rules of good judgment if water-skiing is on an amputee's wish list of recreational pursuits. First, don't ever lock onto a ski rope handle with any terminal device or use a terminal device which requires a cable and harness system. Second, use a ski rope equipped with a single handle. Third, wear a self-suspending, condylar socket that can be twisted free of under stress. A suspension sleeve will aid support but not impair release of the socket due to the flexibility of the material. Fourth, have a neoprene arm cover for the prosthesis which will float the arm in the water if it comes off. Fifth, <i>always</i> wear an approved floatation vest.</p> <p>The Water Ski Hook<a></a> (<b>Fig. 57</b>) is a simple solution to water skiing that has proved safe when set up and used properly. The Ski Hook should be mounted on the prosthesis in a canted position and tightened into place so that it cannot rotate freely. The shallow hook design provides support, yet will twist off a ski rope handle. Should a fall occur where twisting off is impaired, the supra-condylar socket can be "torqued off" the arm and save the amputee's shoulder from potential trauma.</p> <strong>Figure 57. The Water Ski Hand is a simple solution to waterskiing problems.</strong><br /> <p>Another solution to prevent injury is to have the tow rope attached to the boat with a quick release, or equipped with a second handle (for small children only) and always manned by an observer/handler. Should the amputee skier go down, the observer can release the rope instantly, preventing injury.</p> <p>The Ski Seat<a></a> (<b>Fig. 58</b>) and E-Ski<a></a> illustrated in <b>Fig. 59</b> are viable answers for the high level bilateral amputee and the paraplegic or quadraplegic who wishes to enjoy the thrill of skiing. The sled is custom constructed and has two skis. The E-Ski, a newer device, has only one ski and a cage seat.</p> <strong>Figure 58. The Ski Seat.</strong><br /><strong><br /></strong><strong>Figure 59. The E-Ski.<br /></strong><br /> <h3>Wind Surfing</h3> <p>Wind surfing is a relatively new recreation which combines aspects of sailing, surfing, and hang gliding. Load coordination and balance compounded by the need to grasp, maneuver, and rapidly let go of a cylindrical boom as well as uphaul a rope with mast and sail in tow are some of the obstacles the amputee windsurfer faces. A prototype voluntary closing wind surfing terminal device is illustrated in <b>Figs. 60 and 61</b>. Other considerations should include special adjustable harnesses and cable systems for ocean or cold water sailing. Salt accumulation can foul cable function and negate terminal device operation. Wet suits, due to their tight elastic fit, will also interfere with cable function if the cable is worn inside the suit. The harness and cable system must be designed to fit on the outside of the wet suit for unrestricted terminal device operation. Leather on the prosthesis or harness should be avoided, as well as hardware which corrodes. Performance wind surfing is a physically and mentally demanding sport, and the amputee needs to be cautious and prepared to participate safely.</p> <strong>Figures 60 (above) and 61 (right). A prototype voluntary closing wind surfing terminal device.<br /></strong><br /> <h3>Summary</h3> <p>The varied demands of sports and recreation create a multitude of factors which impact the design, construction, and use of a sports prosthesis.</p> <p>Physical fitness and conditioning, prosthetic design and materials, harness styles, and terminal devices all have roles in determining whether an amputee can engage in a sports activity successfully and safely.</p> <p>New improved prosthetic devices and designs will continue to evolve to meet these varying demands. Communication between professionals is important in order to share information on the improvements which are made. Designs for high performance limbs and devices for sports and recreation may well pave the way for improved prosthetic technology as a whole.</p> <p>An open mind, a fresh outlook, an understanding attitude, as well as the patience and willingness to experiment and develop, will inevitably lead to a brighter future for the disabled in sports and recreation.</p> <p><b>References:</b></p> <ol> <li>Chadderton, O.C., C.A.E., "Survey: Consumer Interests," <i>The Fragment</i>, Winter, 1986, Vol. 151, pp. 29-31.</li> <li>Robinson, W.D., B. Pflanz, B. Watkins, and A. Viau "Recreational Limbs AMPUTATION III," <i>The War Amputations of Canada</i>, April, 1986, pp. 19-33.</li> <li><a href="poi/1986_03_129.asp">Mensch, G. and P.E. Ellis, "Running Patterns of Transfemoral Amputees: A Clinical Analysis," <i>Prosthetics and Orthotics International</i>, 1986, Vol. 10, pp. 129-134.</a></li> <li>Products and trade names of Hosmer-Dorrance Corporation, Campbell, California.</li> <li>Products and tradenames of T.R.S., Inc. of Boulder, Colorado.</li> <li>Product and tradename of Recreational Prosthetics, Inc., North Dakota.</li> <li>Radocy, R., "Sports Designs for Upper Extremity Amputees," a symposium presentation at the National Sports Prosthetics and Orthotics Symposium, U.C.L.A. Prosthetics/Orthotics Education Program, October, 1985.</li> <li>"Bow Modifications Serve Amputees," <i>Archery World</i>, February, 1987, p. 22.</li> <li>Weight harnesses designed and tested by Bob Radocy, T.R.S., Boulder, Colorado {not commercially available}.</li> <li>Radocy, B. and Randall D. Brown, "Technical Note: An Alternative Design for a High Performance Below-Elbow Prosthesis," <i>Orthotics and Prosthetics</i>, 1986, Vol. 40, No. 3, pp. 43-47.</li> <li>Billock, John N., "Northwestern University Supracondylar Suspension Technique for Below-Elbow Amputations," <i>Orthotics and Prosthetics</i>, December, 1972, Vol. 26, No. 4, pp. 16-23.</li> <li>Berger, N., et al, "The Application of ISNY Principles to the Below-Elbow Prosthesis," <i>Orthotics and Prosthetics</i>, Winter, 1985/86, Vol. 39, No. 4, pp. 10-20.</li> <li>Radocy, Bob, "The Rapid Adjust Prosthetic Harness," <i>Orthotics and Prosthetics</i>, 1983, Vol. 37, No. 1, pp. 55-56.</li> <li>Courtesy of Bill White, bilateral amputee using two GRIP terminal devices, Waterford, Pennsylvania.</li> <li>Courtesy of Kent Barber &amp; Bill Dalke, Prototype bicycle aid not commercially available. Inquiries to T.R.S. of Boulder, Colorado.</li> <li>Courtesy of Bassamatic, Inc. of Canton, Ohio.</li> <li>Courtesy of Royal Bee Corporation, Pawhuskas, Oklahoma.</li> <li>Courtesy of Robin-Aids Prosthetics of Vallejo, California.</li> <li>Courtesy of The War Amputations of Canada, Ottawa, Ontario.</li> <li>Tradename and product of Innovation Research Corporation, Milwaukie, Oregon.</li> <li>Courtesy of SR-77 Enterprises, Inc. of Chadron, Nebraska.</li> <li>Courtesy of R.F. Meyer's photograph of R. Wityczak, a triple amputee.</li> <li>Courtesy of Carmen Tablada, CP., Professional Orthopedic Systems of Sacramento, California.</li> <li>Ski Seat, Mission Bay Aquatic Center of San Diego, California.</li> <li>E-Ski, Courtesy of E.S.C.I. of Gretna, Louisiana.</li> <li>Courtesy of the Rehabilitation Centre for Children, Winnipeg, Manitoba, Canada.</li> </ol> <em><b>*Bob Radocy </b> Bob Radocy is President, TRS, Inc. 1280 28th St., Suite 3, Boulder, CO. 80303-1797<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 131 - 153 Year 1987 Volume 11 Issue 3 Figure 2 FIGURES 4,5,&6 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-02.jpg Figure 3 FIGURES 7,8,9,& 10 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-03.jpg Figure 4 FIGURE 11 ttp://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-04.jpg Figure 6 FIGURE 13 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-06.jpg Figure 7 FIGURE 14 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision-See Trello Figure 8 FIGURE 15 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-08.jpg Figure 1 FIGURES 1,2,& 3 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-01.jpg Figure 5 FIGURE 12 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-05.jpg Figure 9 FIGURE 16 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-09.jpg Figure 10 FIGURE 17,18,19 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-10.jpg Figure 11 FIGURE 20 & 21 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-11.jpg Figure 12 FIGURE 22 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-12.jpg Figure 13 FIGURE 23 & 24 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-13.jpg Figure 14 FIGURE 25 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-14.jpg Figure 15 FIGURE 26 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-15.jpg Figure 16 FIGURE 27 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-16.jpg Figure 17 FIGURE 28 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-17.jpg Figure 18 FIGURE 29 & 30 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-18.jpg Figure 19 FIGURE 31 & 32 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-19.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 Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation Creator An entity primarily responsible for making the resource Bob Radocy * https://staging.drfop.org/files/original/d73a255fee4b364de1484751b0070bc2.pdf f4268f1f8160ca988e58b8d68c70e4d7 https://staging.drfop.org/files/original/9cd3809f346695203e049ecda06076b9.jpg 4a70f8736bfa8404d75ca3f32d5a0525 https://staging.drfop.org/files/original/fe34c6884c1d4f9cd65bd37a903a8070.jpg b70af2800e997203f2319c46296de5b7 https://staging.drfop.org/files/original/30a3a403da09b29c8a7c41ae21ae5364.jpg 8449acd023022b2f713fc97fc94bb381 https://staging.drfop.org/files/original/a6edecd2ad6203347d70e896ca018d83.jpg 9ce2a9f49884881e3a6ed64718708be7 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_02_082.pdf Text Any textual data included in the document <h2>Voluntary Closing Control: A Successful New Design Approach to an Old Concept</h2> <h5>Bob Radocy, M.S.T.R.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The arrival in early 1980 of the "Prehensile Hand,"<a></a> a new design and concept for terminal devices, sparked a revitalized interest in body power and voluntary closing control. Voluntary closing control and terminal devices are not new to prosthetics, but little interest in this system and technology has existed since the 1950's. Retrospectively, voluntary closing control never achieved dramatic success nor did it have any permanent, positive influence on the direction of upper-extremity prosthetic development until recently, meaning 1980-1985.</p> <p>The acceptance and success of the "GRIP,"<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-1.jpg"><b>Fig. 1</b></a>) and more recently the children's "ADEPT"<a></a> terminal devices, are strong indicators that voluntary closing control is an extremely viable concept. Furthermore, it confirms previous opinions that poor performance characteristics, reliability factors, and the inappropriate design criteria of early volunteer closing control systems and terminal devices<a></a> were responsible for the demise of voluntary closing systems and correspondingly for the dominance of voluntary "opening" control systems and terminal devices in the profession today.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-1.jpg"><strong>Figure 1. (Top to bottom) GRIP I, GRIP II, ADEPT B, ADEPT C, and ADEPT I.</strong></a><br /> <p>This is not to say that voluntary closing devices and systems were not put to excellent use by certain amputees, but that they failed to appeal to the majority of the upper-extremity limb deficient population, i.e. the traumatic or congenitally limb deficient below-elbow unilateral amputee.</p> <p>The standard voluntary opening split hook has continued to be the primary body-powered prescription, while experience now strongly illustrates that correctly designed voluntary closing terminal devices offer superior performance to the limb deficient. Training is no more difficult with voluntary closing; gripping force range is expanded and directly proportional to output, reflex grasping actions are improved, muscles of the affected limb and shoulder are utilized continuously and more effectively, and "feedback" sensations (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-2.jpg"><b>Fig. 2</b></a>) are produced inherently<a style="text-decoration: none;">*</a> and are more easily assimilated, thereby enhancing control, than in voluntary opening systems.</p> <p>The mere fact that children three to six years of age have accepted the concept and have either learned with or converted to voluntary closing control and achieved good to excellent performance should open the minds of even the most conservative in our profession as to the value of the voluntary closing control prescription.</p> <p>Recently, we have seen and heard a great deal about the success of myoelectric devices for children and how a child's performance is improved with myoelectric systems as compared to "body-powered" systems.<a></a> Unfortunately, body power in these comparisons refers only to the voluntary opening split hook systems, and not to voluntary closing systems. It is my firm belief that, if given proper training, limb deficient children will perform as well or better with voluntary closing body powered systems than with myoelectric systems. Furthermore, considering the cost and reliability of externally powered limbs, voluntary closing body powered terminal devices should be prescribed as the primary complements to external powered units, rather than voluntary opening split hook systems.</p> <p>The logic for this assertion is simple. First, muscles of the torso and limb are used more actively with the voluntary closing system, and healthy, strong muscles can only enhance externally powered control and utilization. Second, the new designs in voluntary closing terminal devices offer an opposed thumb and finger gripping configuration, similar to powered hands, enabling the user to incorporate already "learned" patterns of gripping behavior, rather than having to constantly switch patterns of grasp to accommodate "split hook" prehension. Third, children with voluntary closing systems can achieve gripping prehension which equals or exceeds their anatomical capabilities, while voluntary opening systems remain inferior in this area. Comparable prehension bilaterally can only encourage bilateral function and increase prosthetic usage, two primary goals in prosthetic rehabilitation.</p> <p>The success of voluntary closing systems can be related to the design rationale and criteria of the 80's systems. Rationale and criteria are as follows:</p> <ol> <li> <p>Utilize an accepted natural prehension configuration. Previous studies indicate that cylindrical, palmar, and lateral are the most often used gripping patterns.<a></a> Opposed thumb and forefinger prehension satisfies these patterns.</p> </li> <li> <p>Design gripping shapes and surfaces to allow for a wide variety of holding tasks. Complementary curved gripping surfaces enhance cylindrical control and are especially important due to the vast numbers of curved object surfaces we handle daily (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-3.jpg"><b>Fig. 3</b></a>). Additionally, a "clevis" tip configuration imitates the three point chuck of the thumb, index and long finger, important for utensil and implement control (<a href="http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-4.jpg"><b>Fig. 4</b></a>).</p> </li> <li> <p>Emphasize a simple, anesthetic, easily maintained, reliable design that can be understood and accepted by the user- a design with positive psychological connotations, reflecting the capability of the user.</p> </li> <li> <p>Incorporate passive support and suspension capacity (internal hook or bump) for carrying objects with handles or for supporting body weight while climbing or hanging.</p> </li> <li> <p>Require continuous control for grasping and holding to discourage muscle atrophy, enhance muscle development and allow for rapid reflexive grasping. Continuous control also creates an uninterrupted flow of pressure feedback information required for performance handling of objects.</p> </li> <li> <p>Select materials suitable for individualized age groups, rather than a single material for all models. Consider both the needs and the characteristics required for each population and design the model accordingly for each targeted group.</p> </li> <li> <p>Consider weight as a factor, but balance the need for light weight against the strength requirements for the terminal device. Also consider the tolerance the need for light weight against cause variation in age and corresponding tolerances vary.</p> </li> <li> <p>Redesign models as necessary to better answer the needs of the population they serve.</p> </li> </ol> <p>Exclusive of these criteria, a variety of factors exist which have aided the reintroduction of voluntary closing systems and which will increase the use of these systems in the future. Compatibility, harnessing, prosthesis design, proper rehabilitation and weight conditioning are all important if good to excellent prosthetic use is to be achieved.</p> <p>Voluntary closing terminal devices are compatible with all standard prosthetic components. Minor cable modifications or adjustments are usually required to optimize the user's energy output. Unlike previous voluntary closing designs, the user is harnessed under "controlled tension" rather than into a "no tension" system. Accordingly the thumb of the terminal device is not fully open, but pulled partially closed when the arms are relaxed at the user's sides. This tension harnessing allows for improved control of objects, during initial training, and while objects are manipulated close to the medial line of the body.</p> <p>Harnessing should be as simple as possible. A modified Northwestern #9 when possible is excellent, utilizing a ring and "rapid adjust" type buckle.<a></a> This harness system will enhance range of motion control at the shoulder, improve object manipulation overhead, and enable quick excursion adjustments.</p> <p>Prosthesis design should lean towards self suspending (supracondylar) sockets to minimize harnessing. Modified Muenster, Otto Bock, and similar designs can be employed depending on the limb's morphology. New designs such as ISNY or similar flexible sockets may also prove valuable. New patients should be educated in range of motion and pre-prosthetic exercise techniques.<a></a> This is especially important for traumatic limb loss and in instances where complete rehabilitation was lacking and the shoulder girdle and upper limb-musculature is weak and atrophied. Similar atrophication can occur due to disuse of the prosthesis or lack of vigorous bilateral use.</p> <p>Initially, muscle soreness at the shoulder may be experienced by the converting amputee, or the new amputee undergoing rehabilitation. This early soreness is a positive sign of muscle rejuvenation and should be regarded as improved health. However, long term muscle aggravation and soreness may be an indicator that the prosthetic system is not operating optimally.</p> <p>Prior to prosthetic fitting and after initial rehabilitation with the new voluntary closing prosthesis, weight training can be encouraged. Pre-prosthetic training can be accomplished by a knowledgeable therapist and should include a range of motion exercises, dynamic tension, and active bilateral resistance exercises using cuff weights, specialized training equipment, or a simple weight harness in conjunction with dumbbells. Post-prosthetically, the voluntary closing terminal device is capable of handling adjustable resistive weight equipment or free weights, although the former are easier to use, safer, and enable rapid, satisfactory results. An emphasis on strength and endurance conditioning rather than muscle building is suggested due to the needs for adequate range of motion in prosthetic control. This dictates lower resistance loads with more repetitions of exercises.</p> <p>Special applications for voluntary closing systems have also arisen in recent years. Brown<a></a> has achieved excellent success in patients with partial hand amputations. The success, I believe, is due to the common sense simplicity of the prosthesis and harness design, and the utility of the terminal device, which allows prehension in excess of 100 lbs. This amount of gripping force enables the partial hand amputee to be functionally bilateral in a manual working environment. Other terminal devices applied to the case of partial hand amputation cannot offer all the advantages of the new voluntary closing systems. Obviously, the partial hand prosthetic user will not wear the prosthesis all the time, but it is an effective functional tool for many occupations. The increased potential may enable the partial hand amputee to maintain an existing vocation rather than consider retraining for an entirely new occupation.</p> <p>In summary, the new voluntary closing systems offer a great deal of potential for the upper-extremity limb deficient of all ages. They can offer superior performance compared to any other systems, body powered or externally powered, and complement the externally powered prescription, when cosmesis is the primary consideration and function considered only of secondary importance.</p> <p>Voluntary closing systems are not a cure-all for the upper limb deficient individual, and the system is not applicable to everyone, even though all types and levels of amputees including bilaterals have used the technology successfully (excluding shoulder disarticulates). Success also has a lot to do with the attitude of the amputee and the capability of the rehabilitation team, including the prosthetist.</p> <p>Voluntary closing systems will continue to increase in popularity because the technology is reliable, improves performance, and more closely imitates the natural system.</p> <p>The voluntary closing systems will also continue to improve as more innovative research and development in better "total" body powered and hybrid body powered/external powered prosthetic technology evolves.</p> <p><b>References:</b></p> <ol> <li>Trade name of product manufactured by T.R.S., Inc. of Boulder, Colorado.</li> <li>Trade name of product manufactured by T.R.S., Inc. of Boulder, Colorado.</li> <li>Trade name of product manufactured by T.R.S., Inc. of Boulder, Colorado.</li> <li>Klopsteg, Paul E. and Philip Wilson, <i>Human Limbs and Their Substitutes</i>. Hafner Publishing Company; New York. 1964. Reprint of 1954 Edition by McGraw Hill Company.</li> <li>Weaver, S.A. and L.R. Lange, "Myoelectric Prostheses versus Body Powered Prostheses with Unilateral, Congenital, Adolescent, Below-Elbow Amputees," American Orthotic and Prosthetic Association National Assembly Scientific Presentation on October 16, 1985.</li> <li>Mann, R.W., "Evaluation of Energy and Power Requirements for Externally Powered Upper-Extremity Prosthetic and Orthotic Devices," American Society of Mechanical Engineers. Publication No. 62-WA-121, 1962.</li> <li>Radocy, Bob, "The Rapid Adjust Prosthetic Harness," Technical Note, <i>Orthotics and Prosthetics</i>, Volume 37, No. 1, pp. 55-56, 1983.</li> <li>Bates, Marion D. and J.C. Honet, "Isometric Exercises for the Upper-Extremity Stump," <i>Physical Therapy</i>, Volume 44, No. 12, pp. 1093-94, December 1964.</li> <li>Deaver, G.G. and E.H. Daniel, "The Rehabilitation of the Amputee," <i>Archives of Physical Medicine</i>, Volume 30, No. 10, p. 638, October 1949.</li> <li>Gullickson, G. Jr., "Exercises for Amputees," <i>Therapeutic Exercise</i>, 2nd Edition. Sidney Licht, Editor, pp. 581-640.</li> <li>Klopsteg, D.E. and P.D. Wilson, <i>Human Limbs and Their Substitutes</i>, Hafner Publishing Co., pp. 739-756, 1968.</li> <li>Reilly, G.V., "Preprosthetic Exercises for Upper Extremity Amputees," <i>The Physical Therapy Review</i>, Volume 31, No. 5, pp. 183-188, May 1951.</li> <li>Olivett, Bonnie L., "Management and Prosthetic Training of the Adult Amputee," <i>Rehabilitation of the Hand</i>, 2nd Edition, C.V. Mosby, 1984.</li> <li>Brown, Russell D., "An Alternative Approach to Fitting Partial Hand Amputees," <i>Orthotics and Prosthetics</i>, Volume 38, No. 1, pp. 64- 67, Spring 1984.</li> <li>Radocy, Bob and Ronald E. Dick, "A Terminal Question," <i>Orthotics and Prosthetics</i>, Volume 35, No. 1, pp. 1-6, March 1981.</li> </ol> <b><em>*Bob Radocy, M.S.T.R. </em></b><em>Bob Radocy, M.S.T.R. is President of Therapeutic Recreation Systems (TRS), Inc. 1280 28th Street. Suite 3, Boulder, Colorado 80303-1797.</em><b><br /><br />Footnote</b> A major objective of externally powered systems is to develop a reliable 'feedback' system for improved prehension control. Voluntary closing, body-powered systems offer the feedback system inherent in the design. Page Number(s) 82 - 86 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_082/1986_02_082-4.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 Voluntary Closing Control: A Successful New Design Approach to an Old Concept Creator An entity primarily responsible for making the resource Bob Radocy, M.S.T.R. * https://staging.drfop.org/files/original/39661617c0a9eba6b610fe42b024ce94.pdf 80938ab1a7c2213a21e860229c9f5c1c https://staging.drfop.org/files/original/d2190975fcf22aaf4d36cd1f1486eadc.jpg 52102233724241493879e8180f7fe559 https://staging.drfop.org/files/original/c229382fb9182331c340914d8f7e4521.jpg 9c97aed7e57f467d273fe1b5df97c576 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_01_001.pdf Text Any textual data included in the document <h2>Preparatory Prosthetics</h2> <h5>Bruce P. McClellan, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Donald R. Cummings, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The use of preparatory prostheses has for some time been a widely accepted methodology for the immediate or early management of the amputated limb. Burgess, et al., first introduced and popularized the immediate postoperative fitting procedure back in the late 60's.<a></a> Since that time, the use of early weight bearing prostheses has become the norm in fitting centers around the country and indeed in other parts of the world.</p> <p>This paper will deal primarily with preparatory prostheses as they relate to the below-knee amputee. The rationale for such devices will be emphasized in a generalized fashion, as opposed to presenting a different array of commercially available systems or components.</p> <p>The word "preparatory" denotes that these prostheses are used to prepare the amputated limb for definitive fitting with a prosthesis. Within this context, the scope of prostheses which may be considered preparatory in nature ranges from immediate postoperative fitting to the laminated socket with pylon and S ACH foot. In between these two ends of the spectrum are such devices as the pneumatic air cast and Wu early fitting prosthesis. All of these devices have the major purpose of either controlling postoperative swelling or promoting the inevitable atrophy of muscles which were transected during surgery.</p> <h3>Short Term Versus Long Term Devices</h3> <p>The differences between prostheses used for immediate or very early fitting and those used for long term are worth noting. We will clarify the terms "temporary" and "intermediate" to distinguish between the two types of devices. The term "temporary" will be used to describe those prostheses which are intended for relatively short usage; they are applied soon after amputation, and usually are applied directly to the patient using plaster or a plaster substitute. "Intermediate" describes those prostheses which are intended for relatively long-term use; they are generally applied following the use of a temporary prosthesis and are fabricated from plastic over a positive model instead of being formed directly over the patient.</p> <h3>Temporary Prostheses</h3> <p>A temporary prosthesis is primarily used to control postoperative edema and is often the initial step in the residual limb maturation process. But the temporary prosthesis has many additional functions, one of which is early mobilization of the patient. This is especially critical to the physiological well-being of elderly patients. The less time the generally debilitated patient is confined to a bed or a wheelchair, the better the chances for overall recovery and successful long-term prosthetic use.<a></a> Indeed, the early mobilization of any patient can shorten the hospital stay and, therefore, save the patient and the insurance company the costs of increased hospitalization.</p> <p>Another benefit of the temporary prosthesis is the psychological lift it can give the new amputee by reducing phantom pain and permitting early ambulation. Temporary fitting may also help offset some of the anxiety the patient experiences after an amputation.</p> <h3>Temporary Design Concepts</h3> <p>A temporary prosthesis is essentially a rigid dressing with a foot and pylon attached (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg"><b>Fig. 1</b></a>). It is a total contact system, encapsulating the amputated limb, including the patella, and extending to the mid-thigh. The knee is maintained in five to ten degrees of flexion. Suspension is by total contact, with some purchase over the adductor tubercle of the femur, and by a waist belt incorporated into the cast. Padding is provided for the distal end and bony prominences.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg"><strong>Figure 1. Temporary below-knee prosthesis.</strong></a><br /> <p>The standard mid-thigh height of the temporary prosthesis serves some definite purposes. This design assists in sharing weight bearing over a larger surface area, which reduces the load on the amputation site itself. The amputee can also ambulate with less risk of traumatizing the residual limb.</p> <p>Encapsulating the knee also helps prevent knee flexion contractures, which are a very real threat to successful rehabilitation. In spite of the well-documented benefits of early fitting, all too often patients are sent home in an Ace® wrap to languish in a wheelchair for a period of weeks until their "stump toughens up enough" to be fitted with a prosthesis. This is the scenario that results in the elderly patient appearing for prosthetic fitting with hip and knee flexion contractures and an edematous residual limb.</p> <p>Although the knee is fully encapsulated in the traditional temporary prosthesis, knee contractures are rare; partially because the cast is usually changed at weekly or biweekly intervals over the period of use. To enhance knee motion, the patient should be encouraged to flex and extend the knee through its range of motion at the time of each cast change. Intermittent weight bearing in the prosthesis also prevents a knee contracture, much as it does in the case of a long leg weight bearing case used in fracture management.</p> <p>The non-removable nature of the temporary prosthesis has the advantage of continuous control of the tissues. When left to the patient to control via an Ace® wrap or shrinker, the limb is often wrapped intermittently or not at all. Rigid dressings have proven in most cases to be far superior to elastic wrappings in reducing the limb's soft tissue volume, especially in conjunction with controlled weight bearing.<a></a></p> <p>The inclusion of a waist belt, or billet, is essential in maintaining suspension in this type of system. As the residual limb shrinks, the prosthesis will piston on the limb if not supported by this auxiliary suspension.</p> <p>The pylon system is equally important with respect to the success of the temporary prosthesis. Although the patient walks with a stiff knee, appropriate alignment is essential for single limb stance stability.</p> <h3>Intermediate Prostheses</h3> <p>The primary role of the intermediate prosthesis is to act as a preparatory device to reduce the limb to a definitive fitting status. It is generally fit when the postoperative swelling and distal edema have been reduced to a point where the bulbous end can be introduced into a socket. This prosthesis acts as the interim step between the temporary and definitive, thus the term "intermediate." The intermediate differs significantly from a temporary in that it is removable and allows free flexion of the knee. Residual limb shrinkage is accommodated by prosthetic socks as opposed to cast changes. Aside from the obvious advantages of full range of motion and free access to the residual limb, the intermediate prosthesis allows the patient to learn appropriate sock ply management prior to being fitted with a permanent prosthesis.</p> <p>The length of time a patient wears his intermediate prosthesis varies from person to person. Body type, cause of amputation, level of activity, and other considerations all play a part in how rapidly a residual limb will mature to a definitive fitting status. The duration of use can be anywhere from two months to six months, or longer. A general guideline which may be used to determine whether a limb has "plateaued" with regard to shrinkage is when weight bearing and wearing time have stabilized, and the patient has gone approximately three weeks without adding any additional plys of socks.</p> <h3>Intermediate Design Concepts</h3> <p>The design of the intermediate socket is generally consistent with the standard PTB or TSB configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg"><b>Fig. 2</b></a>). A soft liner may or may not be incorporated in the system. In either case, it is appropriate to fit the socket to the patient with as few ply of socks as possible. A one ply or even a nylon sheath fit is preferable in light of the fact that shrinkage, and thus the need for additional plys, is inevitable. As with the temporary, dynamic alignment plays an important role. This importance is now magnified by the fact that the patient is ambulating in essentially the same manner as he will in his definitive prosthesis. Again, it is recommended that the patient be fit with some sort of waist belt suspension to minimize relative motion between the socket and limb as shrinkage continues.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg">Figure 2. Intermediate below-knee prosthesis.</a><br /></strong><br /> <h3>Gait Training</h3> <p>At the time of fitting of the intermediate prosthesis, gait training becomes most significant. This is one of the great advantages of preparatory prostheses: the patient can be monitored and guided by a physical therapist in regard to an appropriate gait pattern while a prosthetist can periodically make alignment modifications as the patient becomes a more proficient ambulator. This advantage is lost, of course, in some of the commercially available systems, which do not allow for fairly precise alignment adjustability.</p> <h3>The Forgotten Limb</h3> <p>One of the least considered aspects of the benefits of preparatory fitting is the contralateral leg. Not only does the preparatory device make it easier for the amputee to maintain his balance, it also allows him to share his weight partially on the prosthesis instead of totally on his remaining limb. In the case of the diabetic or peripheral vascular disease patient, this can be critical, as the remaining leg is usually at risk as well. Any additional trauma, such as prolonged single limb body support or hopping, should be avoided. Preparatory prostheses make this weight sharing possible, and thus prevents overuse or trauma to the remaining leg and foot.</p> <p>It is clear that the role of preparatory prostheses and the management of the new amputee is a necessary and essential component in reaching the fullest rehabilitation potential of the patient.<a></a> The encroachment of non-traditional providers into the prosthetic arena, especially with regard to early fittings, poses a real threat to the realization of these patients' full potentials. It is critical that the prosthetist understand and appreciate the important role of preparatory prostheses in the total regimen of medical and prosthetic care. Success with preparatory fittings depends upon competent management by all members of the rehabilitation team. Temporary and intermediate systems must be applied and managed competently by the prosthetist. Weight bearing, gait training, and residual limb atrophy must be monitored carefully.</p> <p>The term "preparatory" implies that such systems are designed to achieve specific desirable objectives. In this case, the objectives are the maturation of the residual limb and optimum patient readiness for definitive fitting. Comprehensive patient management with preparatory systems produces many advantages, including the provision of maximum early function, improved evaluation of the patient's long-term needs, and reduction of rehabilitation time and expense.<a></a></p> <p><b>References:</b></p> <ol> <li>Burgess, E.M., M.D., "Amputation Surgery and Post-Operative Care," In Bonjeree, Sikhar Nath (ed)., <i>Rehabilitation Management of Amputees</i>, Baltimore/London; Williams &amp; Wilkins, 1982.</li> <li>Burgess, E.M., "Post-Operative Management," <i>Atlas of Limb Prosthetics</i>, St. Louis, The C.V. Mosby Company, 1981.</li> <li>Burgess, E.M. and Zettl, J.H., <i>The Management of Lower Extremity Amputations</i>, Washington, D.C., U.S. Government Printing Office, 1969.</li> <li>Friedmann, Lawrence W., <i>The Surgical Rehabilitation of the Amputee, Springfield</i>, Charles C. Thomas, 1978.</li> <li>Mooney, Vert, M.D., McClellan, Bruce, C.P.O., Cummings, Donald, B.S., and Smith, Patty, R.P.T., "Early Fitting of the Below Knee Amputee," <i>Orthopedics</i>, 8:2, February, 1985, pp. 199-202.</li> </ol> <p><em><b>*Donald R. Cummings, CP. </b> Donald R. Cummings, CP., is Chief Prosthetist at Prosthetic-Orthotic Associates of North Texas, Inc. in Lewisville, Texas.</em></p> <em><b>*Bruce P. McClellan, C.P.O. </b> Bruce P. McClellan, C.P.O., is Director of Orthotics and Prosthetics at the Dallas Rehabilitation Institute in Dallas, Texas.<br /><br /><br /></em> Page Number(s) 1 - 4 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.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 Preparatory Prosthetics Creator An entity primarily responsible for making the resource Bruce P. McClellan, C.P.O. * Donald R. Cummings, CP. * https://staging.drfop.org/files/original/0af497bc37cfab2a9a00a17b1ca6d86f.pdf cf8cb41e194e0ee4499e4051dda5f85e https://staging.drfop.org/files/original/5ea3581f6ee975d42c43106821fad3e2.jpg 313f93afd5728940fede23af77bc8aeb https://staging.drfop.org/files/original/2716c0dfa81b724004f4e14015781792.jpg 6e2dfd49d5e2c1b0b0b628b8a3211b60 https://staging.drfop.org/files/original/576707f40e83237ed35a081d709ab88c.jpg aa88f323501ce5eda2721634bd997f66 https://staging.drfop.org/files/original/581c053fd31ab1f812407ca84373b090.jpg cd646856608dc4c29841ec43ea7d2aa1 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/1984_03_018.pdf Text Any textual data included in the document <h2>The Application of Ionomer Resins in Definitive Below Knee Prostheses: A Limited Study</h2> <h5>Bruce P. McCleUan, CPO&nbsp;<a style="text-decoration: none;">*</a><br />Susan Kapp, CP&nbsp;<a style="text-decoration: none;">*</a><br />Melvin Stills, CO&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>INTRODUCTION</h3> <p>For the past 30 years, polyester resins have been the material of choice for socket fabrication and exoskeletal lamination for all types of prostheses.<a></a> Without question, these thermosetting plastics have proven to be strong, durable, and effective for such application, and, at the time of their introduction, thermosetting plastics provided a quantum leap forward from the age of wood. The advent of plastics allowed for a more hygienic and less bulky prosthesis. More importantly, lamination provided a medium for duplicating a modified replica of the patient's residual limb. Thus, a more intimate fitting socket with greater weight-bearing characteristics was possible. In fact, the use of thermosetting resins continues today as the accepted state-of-the-art.</p> <p>As with any material, the polyester resins have certain characteristics which are not ideally suited for all situations. With this as a basis, the University of Texas Health Science Center at Dallas, in conjunction with the Dallas Rehabilitation Institute, began investigating the use of alternative materials for definitive prosthetic design. One of the most attractive substitutes appeared to be thermoplastics. A clinical study was undertaken to evaluate the group of thermoplastics known as ionomer resins and their role in definitive prosthetic application, as opposed to the polyester resins in use today.</p> <h3>Thermosetting Resins</h3> <p>As indicated, thermosetting-resins such as 4110 laminae have many positive attributes when used in the prosthetic arena. Some of the negative characteristics which prompted the investigation into other materials are equally impressive. The toxicity of the fumes given off during the lamination stage is certainly a matter of concern. The ability to modify a socket fabricated from polyester resin to accommodate residual limb change or pressure on bony prominences is essentially limited to grinding away an area for relief, or adding material to reduce socket dimensions. The cured polyester resin also is fairly rigid in nature—a factor which formed the major emphasis for research into the area of alternative materials.</p> <h3>Ionomer Resins</h3> <p>The thermoplastics which were utilized in this particular study of prosthetic application are classified as ionomer resins. The resins are based on copolymers of ethylene and metha-crylic acid, which are partially reacted with metallic salts to form ionic crosslinks between acid groups of single chain or between neighboring chains.<a></a> The name Surlyn® is the registered trademark of the ionomer resins produced by DuPont and was the material used in the fabrication of the prosthetic sockets. Some of the characteristics which made Surlyn® an attractive option for prosthetic use are as follows:</p> <p><b>Clarity</b></p> <p>Surlyn® is virtually transparent even in thicknesses up to 1/4 inch. This allows the prosthetist to evaluate socket fit visually while the patient is standing with full weight bearing on the residual limb (<b>Fig. 1</b>).</p> <strong><a href="/files/original/5ea3581f6ee975d42c43106821fad3e2.jpg">Figure 1</a>. Symes amputee with clear Surlyn® prosthesis.</strong><br /> <p><b>Adjustability</b></p> <p>The nature of ionomer resins is compatible with heat induced molding which greatly facilitates modifications to the socket. Areas of pressure over bony anatomical structures are simply heated and relieved with no adverse affect on integrity or clarity of material. Surlyn® may also be buffed, sanded, drilled, and riveted in the same manner as the laminates.</p> <p><b>Ease of Fabrication</b></p> <p>Surlyn® comes in a sheet form and is heated and softened in an oven to allow drape vacuum forming. Unlike other thermoplastics, Surlyn® can be formed directly over a wet cast with no need for a lacquer coating or nylon stocking interface. This differs greatly from polycarbonates which require prefabrication dehydration and a dry cast for good results. Additionally, no post-fabrication curing is required to drive off skin irritating styrene gas, as in the case of polyester resin which has a greater than 25 percent flexible resin content. Additional fabrication time is required, however, in the case of long below knee and Symes level amputations because of the need to weld the posterior seam of the Surlyn® socket.</p> <p><b>Flexibility</b></p> <p>This factor has proven to be the most significant advantage of ionomer resins from the patient's standpoint. Sockets fabricated from Surlyn® have much greater flexibility than those fabricated from polyester resin. Patients report that the socket feels more like a part of them and is appreciably more comfortable. The exact deformation occuring in the socket during ambulation has not been quantitatively measured at this point, but clinical trials indicate that anatomical weight-bearing surfaces are not adversely affected by the dimensional changes.</p> <h3>Clinical Applications</h3> <p>Initially, the ionomer resin sockets were used only as "test" sockets prior to fabrication of an intermediate or definitive prosthesis. Later, use broadened to include intermediate prostheses, and eventually definitive application. The move toward definitive use was prompted by the patients themselves. Those who had been wearing intermediate prostheses made of Surlyn® complained of the rigidity of the laminated socket when their permanent prosthesis was delivered. This provided a significant clue as to the direction which should be taken in regard to providing a more comfortable definitive prosthesis.</p> <h3>FABRICATION PROCEDURE</h3> <p>Though the technique is very similar to standard vacuum forming of orthotic devices, some specific steps are employed when making the definitive prostheses. To prepare the Symes cast for vacuum forming, the Symes foot retainer is attached to the modified positive model with plaster, using the vertical fabrication jig for alignment. A small hole is drilled into the popliteal area and the patellar bar of the cast to assure a good vacuum in these depressions. A piece of cotton stockinette is stapled above the trimline and stretched over the cast mandrel and the holes in the hand drape pipe. Pressure sensitive tape is used to hold the stockinette in place on the pipe.</p> <p>The thickness and dimension of the Surlyn® sheet to be used will vary according to type of prosthesis (i.e., Symes or BK) and the size of the patient. Most Symes casts require no more than a 24" x 24" sheet of 3/16" Surlyn® (for the lighter or less active patient 1/8" Surlyn® may be sufficient). The sheet is heated on a teflon rack for approximately seven minutes in a 350°F oven. The heated sheet is draped over the cast and sealed down the posterior side with the vacuum turned on. Excess plastic is cut away and trimmed almost flush with the socket before it is allowed to completely cool, eliminating the need for excessive grinding. Once cool, the posterior seam is grooved in preparation for welding. Three welds are run over the entire seam. The socket is then removed from the cast and trimmed. The foot is attached and the prosthesis is ready for fitting and delivery.</p> <p>The below knee prosthesis is fabricated in the same manner one would fabricate a thermoplastic test socket. It is frame draped with a 12" x 12" sheet of 1/2" Surlyn.® Care must be taken to not create webs below the trimline. It is then formed onto the Berkley alignment fixture for dynamic alignment. The socket may be permanently incorporated into an endo skeletal system or be finished in an exo skeletal manner using acrylic resin for the outside lamination. Using acrylic resin will not impair the flexibility of the socket to the extent that polyester resin will.</p> <h3>CLINICAL RESULTS</h3> <p>The fittings of the ionomer resin sockets for definitive use began in April, 1982. Of the ten patients who were definitively fitted with Surlyn,® eight were Symes level amputees. The remaining two patients were below knee amputees (<b>Fig. 2</b>).</p> <strong><a href="/files/original/2716c0dfa81b724004f4e14015781792.jpg">Figure 2</a>. Below knee type prosthesis with ionomer resin socket.</strong><br /> <p>In the Symes amputee group, five of the eight patients experienced failure of the prosthesis at the ankle/foot juncture (<b>Fig. 3</b>). The shortest use time until breakage was 14 days and the longest was five months, with a mean of 11 weeks for the group experiencing breakage. Two of these patients were refitted with a second Surlyn® definitive, one of which failed again after two months, while the other prosthesis continued to function one year after a modified ankle/foot juncture was devised (<b>Fig. 4</b>). The modification made was one of reinforcing the distal end of the socket with glass cloth adhered with acrylic resin.</p> <strong><a href="/files/original/576707f40e83237ed35a081d709ab88c.jpg">Figure 3</a>.</strong>&nbsp;<strong>Stress fracture at ankle/foot juncture of Symes prosthesis.</strong><br /><br /><strong><a href="/files/original/581c053fd31ab1f812407ca84373b090.jpg">Figure 4</a>. Closed socket design type now being used with reinforced ankle. Suspension is provided by a closed-cell polyethylene shim or pad encompassing the leg proximal of the malleoli and retained in place with a cast sock. Prosthetic socks are worn beneath the shim as usual.</strong><br /> <p>This same method has since been used on two other prostheses in the Symes group. However, over a period of one year, both of these prostheses failed at a level just proximal to where the glass cloth reinforcement stopped. The remaining patient in this group was an elderly lady who is a limited household ambulator and has experienced no known problems to this date.</p> <p>One of the two below knee patients wore his Surlyn® socket prostheses for 11 months before a crack developed. That patient weighed in excess of 230 pounds and participated in sports on a routine basis. His socket developed a crack in the proximal posterio-lateral corner which eventually migrated down the posterior wall. He was subsequently refitted with a polyester laminate socket. The other BK amputee was a 110 pound woman in her twenties who continues to ambulate with her Surlyn® socket prosthesis one year and seven months after fitting.</p> <h3>CONCLUSION</h3> <p>As indicated by Stills and Wilson,<a></a> Surlyn® may not be ideal for applications where high unit stresses are anticipated. Although this seems to have been borne out in this initial group of patients, we still believe that ionomer resins might play an important role in definitive prosthetic fittings. This may be accomplished by reinforcement at crucial stress points, a variation in the ionomer resin itself, or by finding a different material that is better suited to long term stresses. The frame type design being used in the above knee Scandinavian socket may also hold significant promise in a below knee configuration.</p> <p>The potential benefits of ionomer type resins to the amputee population are too great to dismiss without further evaluation and clinical analysis. It is hoped that others in our profession will actively participate in seeking viable materials for definitive socket application.</p> <p><b>References:</b></p> <ol> <li>Aylesworth, R. Dean, ed., <i>Manual of Upper Extremity Prosthetics</i>, Artificial Limbs Project, University of California, Los Angeles, 1952.</li> <li>DuPont, E.I. De Nemours and Company (Inc.), <i>Surlyn® Ionomer Resins Industrial Extrusions Manual</i>, p. 3.</li> <li>Stills, Melvin, and A. Bennett Wilson, Jr., <i>A New Material in Orthotics Prosthetics</i>, Vol. 34, No. 3, pp. 29-37, September 1980.</li> </ol> <div style="width: 400px;"><b>Melvin Stills, CO </b> Melvin Stills, CO, Assistant Director, University of Texas Prosthetics-Orthotics Program.<br /><br /><b>Susan Kapp, CP </b> Susan Kapp, CP, Prosthetic Instructor, University of Texas Prosthetics-Orthotics Program.<br /><br /><b>Bruce P. McCleUan, CPO </b> Bruce P. McClellan, CPO, Assistant Professor and Director, University of Texas Prosthetics-Orthotics Program, School of Allied Health Sciences, Health Science Center at Dallas, 5323 Harry Hines Blvd., Dallas, Texas 75235.<br /><br /><br /></div> Page Number(s) 18 - 21 Year 1984 Volume 8 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-4.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 The Application of Ionomer Resins in Definitive Below Knee Prostheses: A Limited Study Creator An entity primarily responsible for making the resource Bruce P. McCleUan, CPO * Susan Kapp, CP * Melvin Stills, CO *