3 20 371 https://staging.drfop.org/files/original/d6ec4f4cef4fe2b96b5552ee4bba10a9.pdf 8f92cb1131cf047459895a5704ecc878 https://staging.drfop.org/files/original/998b11fabd198c71f6abd4bf6b516e92.jpg 315bfea7ae8512dca9b0928e26cca16c https://staging.drfop.org/files/original/a791344928dd5ce06a9dafb331b696fb.jpg 79ef2482afd24d2c7b2c8dd1b65284ec https://staging.drfop.org/files/original/4134d8561dbb4b9e1a573017e6502b8b.jpg 800248e585502a10a8018e210a065fa7 https://staging.drfop.org/files/original/9954f37265beca7bc0641bc84005faec.jpg a22bede040881a6d70bf53010ced6d35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_020.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 20 - 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/1968_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_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>Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration:none;">*</a><br />John H. Hile <a style="text-decoration:none;">*</a><br /></h5> <p>The Münster technique, an attempt to obviate the traditional problems associated with fitting short and very short below-elbow amputees with split sockets and step-up hinges, has been described in some detail. <a></a> However, individual clinic experience in fitting Münster-type prostheses to patients has not been well documented. Following publication of a manual of instruction for the Münster-type below-elbow prosthesis by New York University in 1965, <a></a> the Juvenile Amputee Clinic of the District of Columbia General Hospital undertook the routine fitting of short below-elbow cases with these prostheses. The principles of construction and fitting outlined in the New York University manual were followed very closely. This article presents an analysis of patients fitted with the Münster-type prosthesis at the Juvenile Amputee Clinic.</p> <h3>Scope of the Study</h3> <p>Fourteen patients were fitted with a total of 24 Münster-type below-elbow prostheses between 1965 and 1967. The group comprised eight female and six male patients. The right upper extremity was involved in eight patients, the left in six. There were no bilateral cases. One ten-year-old boy had an amputation of traumatic etiology; the remaining 13 patients had congenital deficiencies. An 11-month-old infant is not included in the analysis because her family moved to another city shortly after her fitting, and no long-term follow-up data could be obtained. Stump length ranged from 1 1/4 in. to 7 in., with all but two stumps measuring less than 4 in. The distribution was as follows:</p> <table> <tbody><tr> <th> <p>Number of Patients  </p> </th> <th> <p>Stump Length (in.)</p> </th></tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 7/8</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>2 1/2</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>3 1/4</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>3 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>7</p> </td> </tr> <tr> <td> <p><b>Total: 13</b></p> </td> <td> <p> </p> </td> </tr></tbody></table> <p>Seven of the patients had been previously fitted by conventional means, and seven had never worn a prosthesis. It is interesting to note that only one of the previous prostheses had been of the split-socket type, the others being preflexed.</p> <p>During the study period, two patients received three prostheses, six received two prostheses, and six had single fittings. In the multiple fittings, the shortest period before replacement was five months, and the longest 26 months. The average for the entire 13 patients on whom adequate follow-up information was obtained was 11.8 months. The three patients requiring replacement at five to six months gained weight rapidly or experienced spurts in growth.</p> <h3>Fabrication and Fitting Procedures</h3> <p>Taking the wrap cast is one of the most critical steps in the preparation of Münster-type prostheses. Use of a proper molding grip is essential to the success of the technique. It was found that the stump of an infant is more difficult to cast than that of an older child because of the discrepancy between the size of the infant's stump and the hands of the prosthetist. Accentuation of the groove for the patient's ulna formed by the thenar and the hypothenar eminences of the pros-thetist's hand seems to be less critical in casting the infant's stump than in casting the stump of the older child or adult. The difference is probably due to the generous layer of subcutaneous fat so characteristic of infancy. No special efforts were made to relieve the olecranon during casting, but a buildup was added to the positive model of the stump. Important factors during casting are pressure at the posterior distal surface of the humerus above the epicondyle level and the two-fingered pressure on either side of the biceps tendon. On small patients, the prosthetist's middle finger is slightly bent because of the different lengths of the index and middle fingers (<b>Fig. 1</b>). A symmetrical socket brim which provides overall fit is the goal (<b>Fig. 2</b>). Aside from these minor differences, the casting and all the construction procedures followed the Xew York University manual exactly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Molding grip. Note slight flexion of middle finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. End view of symmetrical socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified harness system commonly referred to as the figure-nine harness, with the cable reaction point located on the proximal posterior portion of the socket, was used in the series. For the nine-month-old patient a small triceps pad with conventional figure-eight harness was used, in order to make the prosthesis more secure (<b>Fig. 3</b>). It was believed that the nine-month-old patient might be able to remove the prosthesis without the additional suspension provided by the triceps pad and the anterior forked strap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Nine-month-old female infant (P.M.) with short below-elbow stump fitted with triceps pad and figure-eight harness for additional suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Evaluation</h3> <p>The value of the prosthesis was judged on two bases. First, the reactions of the patient and his parents were considered. Second, patient response and performance were compared with the checkout criteria published in the New York University manual.</p> <p>All patients and parents were pleased with the Minister-type prosthesis. The simplified harness and light weight were consistently mentioned as favorable features. It was interesting to note that the seven patients who had previously worn other types definitely preferred the Münster-type. The patient who had worn the split socket was even more emphatic in his approval, as were his parents.</p> <p>Standard checkout forms were used in the clinic. However, for purposes of this study, special attention was given to certain specific items: range of motion with and without prosthesis, stability, and control-system efficiency. These data are summarized in <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>Terminal-device openings were recorded for all patients within the limits of 30 deg. and 90 deg. of elbow flexion and were considered acceptable. The number of rubber bands varied between one-half a band to three, depending upon the functional requirements of the patients.</p> <p>The recorded ranges of elbow motion without the prosthesis illustrate the hyperextension so characteristic of upper-extremity terminal transverse partial hemimelia. Maximum flexion varied from 80 deg. to 100 deg. with the prostheses for most patients. In all instances, full terminal-device opening was obtained at maximum forearm flexion. The test of full terminal-device opening at the mouth did not apply, because the terminal device could not be brought to the mouth. However, since all the patients were unilateral amputees, the flexion ranges were considered acceptable.</p> <p>Retention of the prosthesis under axial load testing revealed suspension stability to be excellent, as most prostheses tolerated one-third of the child's weight without excursion of the socket. The greatest slippage recorded was one-half in.</p> <p>Control-system efficiency was better than 80 per cent in one-half of the prostheses, and in no instance was the percentage less than the 71 per cent recorded in one case.</p> <p>Perspiration has not been a problem even during humid summer days. All patients used cotton stockinette stump socks for insertion of the stump, with the ends tucked back into the forearm shell after donning. It is believed that the opening provided in the medial socket wall for this purpose may have been a significant factor in heat regulation.</p> <h3>Summary</h3> <p>An analysis of experience in fitting a total of 23 Münster-type prostheses to 13 patients has been presented. The prostheses were fitted, with very minor modifications in casting technique, according to the New York University fabrication manual. Actually, the differences were more quantitative than qualitative.</p> <p>It should be mentioned that the clinic prosthetist attended the pilot course in Münster-type fabrication technique at New York University. This technique is best acquired through firsthand instruction rather than by reading a manual.</p> <p>The results have been gratifying. The parents and patients found the prcsthesis acceptable, and in seven cases preferred it to other types that had been previously worn.</p> <p>Although the range of motion in the prosthesis did not always equal the expected 70 deg. of active flexion, function was acceptable. The stability achieved was excellent. In no case was there more than 1/2-in. displacement of socket on the stump with one-third of body weight in axial pull.</p> <p>The control-system efficiency was within acceptable limits in all cases, with one-half checking out at 80 per cent or better.</p> <p>On the basis of this limited experience, it is believed that the Münster-type prosthesis is the fitting of choice for the child with a unilateral short or very short below-elbow amputation.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>The Münster-type below-elbow socket, an evaluation</i>, Artif. Limbs, Autumn 1964, pp. 4-14.</li> <li>Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, <i>The Münster-type below-elbow socket, a fabrication technique</i>, Artif. Limbs, Autumn 1965, pp. 4-25.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science,<i> A fabrication manual for the "Muenster" type below-elbow prosthesis</i>, April 1965.</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>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 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>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Münster-type below-elbow socket, an evaluation, Artif. Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs, Autumn 1965, pp. 4-25.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 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>John H. Hile </b></td></tr><tr><td class="clsTextSmall">Clinic Prosthetist, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Epps, Jr., M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003; Chief, Division of Orthopaedic Surgery, Howard University College of Medicine, 520 W St., N.W., Washington, D.C. 20001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-04.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 Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * John H. Hile * 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/bc9523cd81a3db7e15e5978454317e7d.pdf 57089e6c60b72cafca746442fcb5429d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_024.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 24 - 27 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_024.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_024.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>Need for Research in Fundamental Biomechanical Studies</h2> <h5>J. Raymond Pearson, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The Subcommittee on Fundamental Studies of the Committee on Prosthetics Research and Development is interested in the promotion of scientific and technological investigations that are fundamental to applied research studies of prosthetic and orthotic devices. Hopefully, the results of the subcommittee's efforts will lead to the establishment and dissemination of knowledge that is of common interest to researchers and clinicians concerned with the design and development of assistive devices.</p> <p>Past experience with such research and its current state of development suggest that future studies should be made in the areas outlined in this article.</p> <h3>Concepts of Methodology</h3> <h4>Systems Analysis</h4> <p>It is believed that the application of modern techniques of systems analysis to discern and clearly define the needs of the disabled could lead to the establishment of appropriate specifications for use in the design of devices.</p> <h4>The Disabled Condition as it Affects Experimentation and Evaluation</h4> <p>Studies of the disabled condition should include investigation of psychological reactions to the use of prosthetic and orthotic devices. Thought should be given to the interplay of psychological and physiological reactions to the application of constraints and restraints. A study of the interactions of physiological systems might prove to be beneficial since it is apparent that there is an interplay of effects from one anatomical system to another.</p> <h4>Disability Evaluations</h4> <p>Corrective assistive devices alter the joint of the musculoskeletal system. Since positions, forces, kinematics, or stresses of the original condition may be changed by the therapeutic device, it is essential that the biomechanics of the normal, abnormal, and treated condition be well understood. This information is necessary for the proper use of such devices and the design of improved devices.</p> <p>The biomechanical analysis of any system must necessarily be preceded by an adequate, accurate description of the system. If forces are involved, it is essential to know the points of application of the forces and the direction of forces applied either by muscles or by constraining passive tissues such as ligaments.</p> <p>The addition of an assistive device to any part of the anatomy results in a hybrid mechanical-anatomical system. Complete understanding of the effect of such assistive devices rests upon the proper analysis of the hybrid system as a whole.</p> <p>Analysis rests upon quantitative data which can be secured only by measurement. Taking</p> <p>such measurements often involves the design and development of the experiment and instruments. This subject in itself is a worthwhile area of investigation.</p> <h3>Specific Research Areas</h3> <h4>Fundamental Physiology Of Muscle</h4> <p>Inconvenience, negative psychological reactions, and the complexity of design of exo-skeletal devices all lead to the hope that one day it may be possible in appropriate cases to stimulate muscles which have been denervated by trauma or disease. Some research in this area has been conducted, but very little is known about the optimum type of stimulation, the response characteristic of stimulated muscle in the disabled condition, and the ultimate possibility of using electromyographic signals of one muscle to control stimulation of another.</p> <p>Since muscles represent the actuators of the musculoskeletal system, it would be helpful to know more about the mechanical characteristics of muscle in terms of its strength, endurance, and efficiency. Hopefully, modern methods of measurements would permit the accumulation of quantitative data <i>in vivo </i>if research were pursued in this direction.</p> <p>While upper and lower motor neuron lesions usually lead to atrophy of associated muscles, it has been shown that exogenous stimulation of muscle counteracts atrophy to some degree. If research should lead to solutions of this type, it will be necessary to know more about stimulative hypertrophy of muscle.</p> <h4>Body and Device Mechanics</h4> <p>Data for proper design of orthotic and prosthetic devices require a knowledge of existing force capacity and range of motion for both normal and various selected abnormal conditions of frequent occurrence. It would be of much benefit to the designers to have such data assembled in a convenient reference volume.</p> <p>More knowledge of the kinematics and kinetics of the upper extremity, comparable to that of the ambulation cycle in the lower extremity, would also represent essential and valuable data for the design of devices. The existence of accelerometers and potentiometers for measurement of inertia forces and position facilitates the gathering of such information by experimental means.</p> <p>Recent advances in the art of simulation of linkages in engineering suggest that the musculoskeletal system of the upper extremity can be treated in a manner that will permit study of the effects of constraints or supplemental power to upper-extremity orthoses. It may prove to be possible to optimize designs with regard to various possible constraints to meet the needs of common motion patterns.</p> <h4>Comparison Of Mechanical Work and Physiological Energy Consumption of Natural As Well As Pathological Movements</h4> <p>Since one of the important criteria of evaluation of assistive and prosthetic devices is the conservation of the energy of the patient, it would be most helpful to devise ways and means of measurement of physiological energy consumption of discrete muscles or muscle systems for a determinable quantity of mechanical work output in the performance of needed tasks. While total oxygen-consumption measurements have been made for subjects with and without assistive devices in ambulation, very little has been done with regard to the upper extremity, particularly for discrete activities.</p> <h4>Control Modes and Locations on Patients</h4> <p>Underlying the problem of control of external power by electromyographic signals is the problem of proper association of biological signal and motion to be executed. In the case of amputation, the existence of the electromyographic signal of a remote muscle might be used as a control signal. However, this involves a retraining procedure for the subject. The improper or irrational selection of a control site may lead to an excessively complex learning procedure that would defeat the purpose of the design. The effects of paralysis may bring about a similar situation where the cause is a pathologic condition other than amputation. In any event, the success of any external power system controlled by electromyographic signals is highly dependent upon the rational selection of the site from which the biological signal is taken. The pursuit of such knowledge is highly important to the success of electromyographic control.</p> <p>Recent investigations of the feasibility of single motor units of muscles as a source of biological signal for controlled purposes indicate the value of pursuing this idea as an eventual method of associating thought processes with limb action. Such solutions should lead to utilizing a portion of the muscle signal without impairing the usefulness of the muscle for its original intended purpose. As this study is in its infancy, considerably more information is needed in order to evaluate its potential.</p> <h4>Rheology of Human Tissue</h4> <p>In the study of the biomechanics of joints, it becomes evident that the forces applied through bones find their reactions in the soft, passive tissues of constraint. Relative displacements of the bones of the joint are then a function of the mechanical characteristics of these tissues. The stress-strain ratio of the collagen tissue of tendon has been shown to be rate dependent for low and moderate rates of loading. Also, strain is a function of time; the tissue shows a recovery capacity when unloaded, demonstrating that viscosity plays a role in the mechanism of response. Investigations of some of the factors of some discrete tissues are examples of what can and should be done in the future by way of establishing factual knowledge of the response of component tissues and joints as a whole to the types of loading brought to bear by corrective devices.</p> <p>Past achievements have demonstrated that this kind of information is also useful in detecting the reasons for certain types of deformities. Such understanding leads to better therapy and to devices designed to counteract the system of forces causing the deformity.</p> <p>It is hoped that future research in this area will bring more knowledge of the factors involved. Investigation of more of the tissues involved is also essential.</p> <p>Further studies of the mechanical characteristics of bone, especially under loadings of the type encountered in orthoses and prostheses, are, of course, part of this picture.</p> <h4>Phyiological and Rheological Characteristics of the Stump</h4> <p>In addition to knowledge of the rheological characteristics of the tissues of the stump, which is needed for the determination of pressure and tension on skin and subcutaneous tissue, knowledge of tissue compartitions and the interplay of effects of forces thereon is also necessary. Interference with the flow of blood brings deleterious effects to the health of the tissue, and faulty distribution of pressure or skin tension can affect nerves and bring pain, Knowledge of the type proposed here would assist in avoiding these dangers.</p> <p>One of the problems encountered in the fitting of prostheses is that of edema. Measurement of the pressure encountered and the deformations involved should permit compensatory procedures providing better design.</p> <p>Since rheological experimentation has shown that the stress-strain ratios are rate dependent and load dependent, it seems that special studies of the properties of compressed and deformed tissues should prove to be beneficial.</p> <h4>Response of Bone and Connective Tissue to External Loads</h4> <p>Knowledge of the nature of the distribution of stress and strain in bone as a response to the implantation of pins in the marrow, such as those encountered in endoprosthetic joints and transcutaneous pylons, will be essential if these experimental methods are to develop into practical, clinical therapies.</p> <p>The tolerance of the tissues to implantation and to the magnitudes and types of loading will also be an important factor in this research.</p> <h4>Implantation of Artificial Organs of the Musculoskeletal System</h4> <p>Another aspect of the possibility of utilizing as much as possible of the natural anatomical system instead of exoskeletal devices is the use of implanted artificial muscles. It is envisioned that plastics capable of contraction excited by external signal will become available. Study of the materials and the tolerance of biological tissues for them will be required to realize this possibility.</p> <p>The effects of implantation on endoprostheses and endoorthoses need more comprehension if materials are to be developed to make approaches practicable. This will include the chemical and physiological reactions as well as the biomechanics of the arrangements.</p> <p>Of vital importance is knowledge of the tissue reactions to implants if methods of this type are to succeed.</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>J. Raymond Pearson, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Professor of Mechanical Engineering, University of Michigan, Ann Arbor, Mich. 48104; Chairman, Subcommittee on Fundamental Studies, Committee on Prosthetics Research and Development. Professor Pearson served as Chairman of the Panel on Fundamental Studies of the Conference on Prosthetics and Orthotics.</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 Need for Research in Fundamental Biomechanical Studies Creator An entity primarily responsible for making the resource J. Raymond Pearson, M.S.M.E. * https://staging.drfop.org/files/original/aee975bd01e173cadb6bd332d9927ed3.pdf d866aabd179e97ad8f259caadfd4f46d https://staging.drfop.org/files/original/cf7e5a1c10865c7a2f6801745802706f.jpg bfb079830381162d6ce2c95f6c3db913 https://staging.drfop.org/files/original/80177bdc2c6d01dcef1002642392393f.jpg b72fa1e2bc643d38e868474976fab946 https://staging.drfop.org/files/original/d61fadd50e79b7203cb643df570abb42.jpg 50e9ab54ca359ad9fdd2b19c36f7ff32 https://staging.drfop.org/files/original/cabb1a4acfdfba520a78a7dc281f59b0.jpg e6d1577d5fee57ef9520df78f3a2e50d https://staging.drfop.org/files/original/fa7e073d9826e1cc48df65128f65c987.jpg 4e64810dc51607824b7edfab6b000dba https://staging.drfop.org/files/original/cb3215048cf3a11c179f71432884353b.jpg 08d1ecaf1034507e7ae1bb4edb00e1dd https://staging.drfop.org/files/original/8cbb68c28d3f97aca81a578e0068b1b6.jpg 160e3c6521c277fc6bbfc22fb411ad60 https://staging.drfop.org/files/original/ed88f8904d06fe0b726da88a744ab157.jpg f6e276d8e77f1ef1a8b4164aea967c37 https://staging.drfop.org/files/original/499b2d14df818927c677e6ab81294bf3.jpg 8832e1d454749fcb34de722dc4763cd4 https://staging.drfop.org/files/original/f0db8d36bc5ab95237bdaf8b3f0774ad.jpg 00a77b4c33e9d587ebfb6657f4b2f634 https://staging.drfop.org/files/original/ffa5c106a3a94dc6f3ffba57275d427b.jpg 505850a92d9a616c370f7071f20a4962 https://staging.drfop.org/files/original/26a9bc87b04573a87b50af221f53a172.jpg 26d44ea9c02e9b1e215d3cc9777cbbe7 https://staging.drfop.org/files/original/83d1441b01dcdb73ab0174906f56b719.jpg f27a354f95c023f556c00e45b7da38c5 https://staging.drfop.org/files/original/f811aafb32502cadbb7ea0672580e37a.jpg 033ffb96764b132c3b786e618d38b8da https://staging.drfop.org/files/original/68652caa9997d995b4fa091cbbaff9f0.jpg fcf7b1acefad733dab4306d7139d21fc https://staging.drfop.org/files/original/6f10c8ec7cab2b8734bacc6b74dacf84.jpg e11fd3ddf35479f9b8a871e27886d182 https://staging.drfop.org/files/original/d8a9c69caa7a722e6c26cc46a47ca86f.jpg b59874d90b7c956ebbbb4b223045572b https://staging.drfop.org/files/original/78f9d8d11382034703a6765a230cd321.jpg 99cc18ad6bf2cc161fd7ec5e42b8b512 https://staging.drfop.org/files/original/557e4cce203fd0edcfa199807c18deef.jpg 6148afe4dbedeaeeeaefae592b2154bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_001.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 1 - 27 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_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_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>Recent Advances in Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, JR.. B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past few years, many innovations have been introduced into the practice of above-knee prosthetics. Most of the literature on the new practices has been provided by the innovators, and therefore the reports and articles on the subject generally are limited to a single approach. It is the purpose of this article to survey past and present practices and to set forth, as accurately as possible, a perspective of procedures and devices available today for the management of the above-knee amputee.</p> <p>Amputation through the thigh results in distinct functional losses. The obvious ones are loss of support by the long bones and loss of joints, resulting in inability to stand and move extensively from place to place. In addition, the appearance of the patient becomes altered from the "normal" in both static and dynamic conditions.</p> <p>Lost support and mobility can be replaced to some extent by the use of a wheelchair or crutches or both, but it has been shown that use of an articulated prosthesis is the most effective means of compensating for these losses. An amputee with a functional prosthesis can negotiate stairs, ramps, and other obstacles and, therefore, can move through areas that would be impracticable if not impossible for a wheelchair. Crutches, properly used, offer a great deal of facility of movement but require the use of considerably more energy than a well-fitted and -aligned above-knee prosthesis, or even a peg leg. <a></a> Also, when crutches are used the hands are not free during ambulation. Another argument for the use of a functional prosthesis is that a fairly normal appearance can be achieved.</p> <p>The basic functional prosthesis for the above-knee amputee consists of a socket, a knee unit, a shank, and a foot-ankle unit. In cases where it is not deemed advisable to keep the socket in place by air pressure (suction socket), suspension must be provided by a belt about the pelvic area or by a shoulder harness.</p> <p>Not so many years ago it was common practice for the prosthetist to make in his shop nearly every part for a prosthesis from basic materials such as wood, steel, and leather. This practice was time-consuming and wasteful. To eliminate as much manual work as possible, the prosthetist today designs and fabricates the socket from basic materials to fit each patient individually, but uses prefabricated components, which he purchases from manufacturers, for the rest of the prosthesis. <a></a></p> <h3>Sockets</h3> <p> Until the introduction of the suction socket in the late 1940's. <a></a> it was common practice to provide the above-knee amputee with a so-called plug-fit socket suspended by a pelvic band connected to the socket by a metal "hip" joint (<b>Fig. 1</b>) <a></a> The plug fit did not provide for a very adequate distribution of forces between stump and socket. There was a tendency for the formation of an adductor roll, and the stability provided between stump and socket left much to be desired. The pelvic belt was heavy. The "hip" joint restricted motion essentially to flexion and extension, and was subject to frequent breakage. Most of the sockets were carved from willow wood and reinforced with rawhide, although sockets formed from aluminum sheet were not uncommon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical prosthesis for above-knee amputees during the 1940's. Note pelvic band, mechanical "hip joint," carved wooden socket with a "plug fit," and pelvic-control knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The primary purpose of the suction socket (<b>Fig. 2</b>) was to provide increased function and comfort by eliminating the mechanical hip joint and pelvic belt. Pressures between the stump and socket were distributed over wider areas; stability and, therefore, control were improved materially. A socket of the quadrilateral shape <a></a> became standard whether or not suction was used for suspension. The waist belt and Silesian bandage were introduced as more comfortable suspension methods to supplant the pelvic belt and hip joint in some cases. Willow wood remained the material of choice, but plastic laminate (usually nylon stockinet impregnated with a polyester resin) replaced rawhide as a reinforcement material.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. An early version of the suction-socket prosthesis <i>(right), </i>shown in comparison to the so-called conventional above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Experience with problem cases, with the early versions of the suction socket in which a certain amount of air space is left below the distal end of the stump, led the University of California, Berkeley, to develop the modification now known as the total-contact above-knee socket (<b>Fig. 3</b>).<a></a> In a certain number of cases, edema developed in spite of most careful fitting with the "open-end" socket. It was found that the edema could be eliminated by providing a small amount of counter-pressure over the distal end. It was also found that the entire stump must be in contact with the socket in order to keep the circulatory system in balance. The introduction of counterpressure also reduced the unit pressures at the proximal region of the stump, and the contact over the end of the stump seemed to enhance proprioception.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. An above-knee prosthesis with a quadrilateral, total-contact socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a well-fitting total-contact socket of wood requires a great deal of skill and is quite time-consuming compared with the use of plastic laminates. Plastic laminates, which had proven so useful in the fabrication and fitting of upper-extremity and below-knee prostheses, had not been used for above-knee sockets because of the difficulty encountered in obtaining an adequate cast for preparation of the positive model needed for molding the laminate. A few highly skilled prosthetists had been known to produce adequately formed casts using only their hands, but this achievement was exceptional. To solve this problem, several devices were developed so that casts of above-knee stumps that required a minimum amount of modification could be achieved.</p> <p>The UC-Berkeley device (<b>Fig. 4</b>) <a></a> uses a series of adjustable brims with which the cast is taken under weight-bearing conditions; the Veterans Administration Prosthetics Center device uses a three-part universal jig for holding the stump in position, also under weight-bearing conditions (<b>Fig. 5</b>); <a></a> the New York University casting fixture is a portable device that holds the cast in position but does not require the patient to be in a weight-bearing position (<b>Fig. 6</b>); <a></a> and Northwestern University has developed a modification of the UC-Berkeley technique in which a cast sock is used to suspend the stump and thus assist in forming the desired contours (<b>Fig. 7</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The fixture for the "brim-fitting" technique developed at the University of California Biomechanics Laboratory (San Francisco and Berkeley). Adjustable, easily interchangeable brims are available in a complete range of sizes. The view on the right shows attitude of patient in fixture; right leg is not shown for clarity. See <b>Fig. 7</b> for still another view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The fixture for casting the impression of an above-knee stump developed at the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anterior view of the New York University casting brim in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. A method, developed at Northwestern University, which uses the University of California casting fixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The object of each of these tools is exactly the same: to provide a cast of the above-knee stump that requires the least modification for the fabrication of a well-fitting, quadrilateral, total-contact socket. Each has its advantages and disadvantages. None is superior to the others in all aspects, and selection is based on the personal preferences of the prosthetist. Many facilities have two or even all three devices available for use as circumstances dictate.</p> <h4>Fitting And Alignment</h4> <p> The basic rationale of alignment as set forth by Radcliffe <a></a> in the early 1950's is essentially unchanged, although proper use of some of the hydraulic knee units demands some variations.</p> <p>In order to make it easier for the prosthetist to achieve optimum alignment, the University of California, Berkeley, developed the adjustable leg (<b>Fig. 8</b>) and alignment duplication jig (<b>Fig. 9</b>). <a></a> Dynamic alignment is obtained during amputee ambulation with the adjustable pylon, and the alignment obtained is transferred to the finished prosthesis during fabrication by use of the alignment duplication jig. This procedure proved to be highly satisfactory for use with single-axis, constant-mechanical-friction knee joints, since the adjustable leg also contained this type of joint. Because the functions of the Hydra-Cadence leg demanded that it be aligned somewhat differently, the STAROS-GARDNER coupling (<b>Fig. 10</b>) was designed. <a></a> When placed between the top of the knee block and the thigh piece or socket, the Staros-Gardner coupling provides all the adjustments permitted by the adjustable leg except mediolateral placement of the foot with respect to the knee axis, an adjustment not often used and, then, only to provide better cosmetic appearance. A technique was developed so that when final alignment was achieved a wooden block could be substituted for the coupling, thereby eliminating the need for the alignment duplication jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The adjustable above-knee leg developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The alignment duplication jig developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley) to be used in conjunction with the adjustable leg shown in <b>Fig. 8</b>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Staros-Gardner coupling being used to achieve alignment in an above-knee prosthesis. When the desired alignment has been achieved the coupling is replaced with a section of wood. A technique has been developed so that alignment can be maintained without need for the alignment duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Components</h3> <p> Components for above-knee prostheses can be obtained from central manufacturers in a number of ways. The most common approach is to purchase "knee-shin set-ups" and foot-ankle units, and to connect these to each other and to the socket in the alignment best suited for the individual patient. The knee-shin set-up usually consists of a wooden knee block, the proximal portion of a hollow wooden shank, and a knee control mechanism (<b>Fig. 11</b>). Excess wood is provided so that the knee and shin can be individually contoured, and in the finished prosthesis the entire unit is reinforced structurally by the application of a plastic laminate over the exterior. Complete wooden set-ups are available, but are seldom used. However, when coordinated motion between knee and ankle is incorporated in the prosthesis, as in the Hydra-Cadence unit, a complete set-up is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical knee-shin wood set-up. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of temporary, or preparatory prostheses, popularly known as "pylons," are available (<b>Fig. 12</b>). Usually these devices are used with an ordinary foot-ankle unit which can be incorporated into the final or definitive prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. "Pylons" for above-knee amputations. <i>Left, </i>U.S. Manufacturing Co.; <i>Center, </i>A. J. Hosmer Corp. unit based on the UCB adjustable leg; <i>Right, </i>VAPC unit designed to accommodate a variety of knee-control devices. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Knee Units</h3> <p> Probably no other component of artificial limbs has received as much attention from designers and "gadgeteers" as the knee joint. Several hundred patents have been issued for knee designs, and many types have been produced and offered to the public, but relatively few designs have been used widely.</p> <p>The primary functions of a knee unit for above-knee prostheses are control of the leg during standing and the stance phase of walking, and control of the shank during the swing phase of walking.</p> <p><i>Swing-Phase Control</i></p> <p>The articulated above-knee prosthesis functions as a compound pendulum. As the thigh stump is brought forward during the latter stages of stance phase, the knee begins to flex and the foot is lifted from the ground because of the effects of inertia. The force propelling the shank acts more or less horizontally through the knee joint, while the center of gravity of the shank is well below this level; thus a moment is created, resulting in rotation of the shank about the knee joint in a backward direction (<b>Fig. 13</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Forces developed during rotation of the shank about the knee joint during forward swing of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The less friction there is in the joint, the higher will be the rise of the heel for any given acceleration. Therefore, when a nearly frictionless joint is used, the amputee must use very short steps at a low cadence, so that the shank and foot will return to the proper fully extended position to support him as stance phase is begun. If friction, or some other form of resistance, is introduced, rise of the heel is restrained and shank motion toward full extension is retarded, so that longer steps at higher cadences are possible. When the amount of friction is constant, only one best speed is available to the patient. To overcome this limitation, designers have turned to hydraulic and pneumatic devices to obtain desirable resistance.</p> <p>To guide the design of swing-phase control units, the University of California has plotted knee moments against time for the ideal prosthesis during swing phase (<b>Fig. 14</b>). <a></a> This diagram is based on data accumulated from four normal young males, allowances being made for weight and weight distribution between normal and artificial limbs. The values, of course, will change as cadence is varied and as the height and weight distribution are changed. However, the general pattern should not change.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Knee-moment pattern required for natural swing of an artificial leg. This curve was developed by the University of California Biomechanics Laboratory based on data collected during the study of human locomotion. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Constant Friction (Mechanical)</i></p> <p>Constant friction in a way is a misnomer, because the amount of friction or restraint can be controlled or set, but does not vary in accordance with the needs of the amputee during a given cycle. The amount of friction can be controlled in a number of ways, the most common being the application of a braking surface to the peripheral area of the knee bolt (<b>Fig. 15</b>). The typical knee-moment diagram for a constant-friction knee unit is shown in <b>Fig. 16</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. One type of constant-friction single-axis knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Knee-moment patterns of various swing-phase units in comparison with the ideal curve of <b>Fig. 14</b>. Data were taken at the Veterans Administration Prosthetics Center. The knee units were adjusted for intermediate resistance, and were subjected to 43 cycles per min. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Intermittent Friction</i></p> <p>To more closely approximate the ideal knee-moment diagram, several designs have been made to vary the amount of mechanical friction applied at predetermined points during the swing phase. The Northwestern University Intermittent-Friction Knee Unit (<b>Fig. 17</b>) is one such device that is available commercially. Mechanical friction is provided by pressure between three disks mounted concentrically with the long axis of the knee bolt. The resistance offered by each individual disk is brought into play at varying intervals during the swing phase. The knee-moment diagram of the Northwestern University unit is shown in <b>Fig. 16</b>. The unit is available in a wood set-up, and is delivered with three disks installed. Two additional disks of different configurations are provided for interchange with the regular disks, so that the pattern of resistance about the knee can be changed to suit the amputee on an individualized basis. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Intermittent-Friction Knee Unit developed at Northwestern University, installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hydraulic Swing-Phase Control Units</i></p> <p>Because the resistance offered by an orifice to the flow of a fluid increases at a greater rate than the increase in velocity of the fluid, hydraulic systems are ideally suited for control of the shank during swing phase. Thus, heel rise and terminal deceleration can be controlled automatically over a wide range of cadences, giving the amputee much more flexibility in speed of ambulation. <a></a> The value to be obtained by applying these principles has been recognized for many years, but a good deal of engineering was required to develop units that met the exacting demands of limb prosthetics. <a></a></p> <p>The Henschke-Mauch Model "B" unit (<b>Fig. 18</b>) is a very sophisticated device available in a wood set-up to make its use compatible with standard components and practices. A number of orifices are so incorporated into the cylinder wall that the moving piston successively blocks off escape of the fluid and thus varies the resistance throughout the swing phase in order to approximate the ideal moment curve (<b>Fig. 16</b>). Resistance to flexion and to extension may be adjusted independently of each other by the wearer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The Henschke-Mauch "Hydraulik" Knee Unit. <i>Left, </i>Unit installed in a wood set-up; <i>Right, </i>cross-section of the Model "B" (Swing-Phase) Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a clinical evaluation program conducted by the Veterans Administration, involving more than 30 test subjects, the results were overwhelmingly in favor of the Henschke-Mauch unit in comparison with mechanical friction devices previously worn by the amputees in the study. <a></a></p> <p>The ability to vary gait easily and a reduction in effort required and fatigue produced were the advantages most frequently cited. The last two advantages are particularly noteworthy, since the experimental prostheses were heavier than the prostheses worn previously.</p> <p>The DuPaCo "Hermes" Knee (<b>Fig. 19</b>) is quite similar in design and function to the Henschke-Mauch Model "B" unit and is also available in a wood set-up. Resistance to flexion and to extension may be adjusted independently of each other by the amputee. A clinical study of the DuPaCo knee by the Veterans Administration resulted in very positive reactions, strikingly similar to those obtained in the study with the Henschke-Mauch Model "B" unit. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. DuPaCo "Hermes" Hydraulic Swing-Phase Control Unit mounted in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unlike the Henschke-Mauch and DuPaCo units, the "Hydra-Cadence" hydraulic leg (<b>Fig. 20</b>) is an integrated system incorporating some ankle control as well as swing-phase control. This system is available only in a metal frame, with a specially designed foot-ankle assembly. For appearance, the metal frame that constitutes the shank is covered with a cosmetic cover of a relatively thin, semirigid plastic cast to resemble an average normal shank. The swing-phase unit is a relatively simple piston type and does not offer quite as precise control of function as the more sophisticated units. In addition to control of the shank during swing phase, resistance to plantar flexion is controlled hy-draulically, and motion between the ankle and knee are coordinated so that dorsi-flexion of the ankle takes place after the knee has been flexed 20 deg. The object of the coordinated motion feature was to provide additional toe clearance during the swing phase, but unfortunately the motion does not take place at the time when it is needed most. Nevertheless, as in many other instances, the side effects are highly useful. One advantage of coordinated motion appreciated by amputees is that during sitting dorsiflexion of the foot allows the wearer to draw his artificial foot comfortably under his knee, thus keeping it out of the way when he is seated in a theater or bus. In clinical tests conducted by the Veterans Administration, the overwhelming majority of test subjects preferred the "Hydra-Cadence" unit to their conventional limbs. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. "Hydra-Cadence" Artificial Leg with cosmetic cover removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The swing-phase control system of the "Hydra-Cadence" unit is offered in a wood set-up or separately for use in a pylon as the "Hydra-Knee" (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. "Hydra-Knee" installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the problems of leakage and high maintenance costs have been overcome to a point where hydraulic devices are practical, pneumatic systems also have appeal since manufacturing costs should be materially lower. Pneumatic systems are not apt to produce a knee-moment curve as smooth as those obtained with hydraulic units, but many feel that they offer an excellent compromise suitable for many amputees.</p> <p>One such device nearly ready for commercial distribution is the University of California Pneumatic Swing-Phase Unit. <a></a> Like the Henschke-Mauch and DuPaCo units, the UCB device consists essentially of a moving piston in a cylinder (<b>Fig. 22</b>). It will be available initially in a pylon-type shank and wooden knee block.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pneumatic Swing-Control Unit developed at the Biomechanics Laboratory, University of California (San Francisco and Berkeley). <i>Left, </i>Cutaway view; <i>Center, </i>complete unit; <i>Right, </i>pylon and cosmetic cover designed especially for the pneumatic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stance-phase Units</h3> <p>Increased understanding of fitting and alignment has alleviated many of the former problems of stability control of the leg during stance phase, especially for those patients with relatively strong stumps. Nevertheless, there appears to be a real need for knee units that provide assurance against buckling yet do not interfere with other functions of the leg. The increase in the number of "geriatric" patients in recent years has tended to highlight this need. Patents have been granted for many ways of stabilizing the knee, but few have been found practical. Doubtless the most widespread stance-phase control device in use today is the Otto Bock knee (<b>Fig. 23</b>). Purely mechanical in action, the Bock knee provides resistance to flexion by a friction braking action effected by weight-bearing. When weight is placed on the prosthesis, the knee block moves slightly toward the shank to engage a "V"-type brake. Swing-phase control consists of constant friction and a spring-biased extensor mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The Otto Bock Safety Knee Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch Model "A" unit (<b>Fig. 24</b>), currently in an advanced experimental stage, consists essentially of the Model "B" unit (<b>Fig. 18</b>) with provisions for stance-phase control added. Braking of the knee joint is controlled by the complex interaction of a pendulum and a counterweight suspended in hydraulic fluid. <a></a> The braking action is brought into play whenever required to arrest buckling action, and is removed only by the prolonged hyperextension moment typical of late stance phase, so theoretically there should be a smoother transition between stance phase and swing phase than that provided by other units. Moreover, for special tasks, the amputee can set the knee either in "freewheeling" or almost fully locked position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Henschke-Mauch "Hydraulik" Model "A" (Swing and Stance Control) Unit. <i>1, </i>Cylinder; <i>2. </i>piston; <i>3, </i>piston rod; <i>4, </i>hydraulic fluid; 5<i>, </i>accumulator piston; <i>6, </i>dashpot; 7, dashpot piston; <i>8, </i>control bushing; <i>9, </i>swing adjustment screw; <i>10 </i>and <i>11</i>. check valves; <i>12 </i>and <i>13. </i>channels: <i>14, </i>pendulum; <i>15, </i>valve; <i>16, </i>counterweight; <i>17, </i>spring; <i>18, </i>stance adjustment screw; <i>19, </i>selector switch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A clinical evaluation by the Veterans Administration involving 50 units has nearly been completed. It is expected that the Henschke-Mauch Model "A" unit will be available for general use in the near future.</p> <h3>Foot-ankle Units</h3> <p> Many attempts have been made to develop foot-ankle units that offer more than the minimum function required, which is controlled plantar flexion. Through the years several designs have been manufactured and made available, but none has found widespread use, usually because the maintenance requirements of the units have outweighed any functional gain they offered. Thus, today, nearly every artificial leg (except the "Hydra-Cadence") incorporates either a SACH (solid-ankle cushion-heel) foot (<b>Fig. 25</b>) or a so-called conventional foot (<b>Fig. 26</b>). Both designs provide controlled resistance to plantar flexion, firm resistance to dorsi-flexion, and limited toe motion, but little else. Resistance to plantar flexion can be adjusted more easily in the conventional foot by introducing rubber bumpers of different densities. The absence of parts in the SACH foot which rotate or rub and its resistance to moisture make its use attractive. Since its introduction in 1958, the design of the SACH foot has been refined in a number of ways. Initially the SACH foot was made by laminating layers of foam rubber around a wooden keel. Later, techniques for molding the rubber were developed and most units are manufactured in this manner. However, the laminated type is available for special applications where shaping to unusual sizes and configurations is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. The SACH (solid-ankle, cushion-heel) Foot. <i>Upper, </i>Laminated type; <i>Lower, </i>molded type. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Cross-section of a typical "conventional" foot-ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very recently, a special SACH foot has been made available by Kingsley Manufacturing Co. for use in immediate postsurgical fitting procedures (<b>Fig. 27</b>). This version has a flat, wide sole designed for use without a shoe while the patient is in the hospital. This permits equal leg length when the natural foot of the patient is bare or is covered simply with a sock or slipper. It is also about 20 per cent lighter than the conventional SACH foot, and resistance to toe break is less.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Special SACH foot for use in immediate postsurgical fitting procedures. <i>Courtesy Kingsley Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center is responsible for updating the specifications for the SACH foot, and makes periodic checks of mass-produced units on a random basis.</p> <p>At the present time, development of a more functional foot-ankle unit using hydraulic principles is under way.</p> <table> <tbody><tr><td> <h3><i>Definitions</i></h3></td> </tr> <tr><td> <p><i>Preparatory Prosthesis</i></p> </td> </tr> <tr><td> <p>A cosmetically unfinished functional replacement for an amputated extremity, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to expedite prosthetic wear and use and to aid in the evaluation of amputee adjustment.</p> </td> </tr> <tr><td> <p><i>Pylon</i></p> </td> </tr> <tr><td> <p>A rigid supporting member, usually tubular, that is attached to the socket or knee unit of a prosthesis. The lower end of the pylon should be connected to a foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Rigid Dressing</i></p> </td> </tr> <tr><td> <p>A plaster stump wrap, usually applied in the operating or recovery room immediately following operation, for the purpose of controlling edema and pain. It is preferably shaped in accordance with the basic patellar-tendon-bearing (PTB) or quadrilateral designs, but is not necessarily so.</p> </td> </tr> <tr><td> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a functional socket, designed for weight bearing and walking, is fitted to the patient immediately after operation in the operating or recovery room, or at some time prior to removal of sutures. As distinct from the rigid dressing, referred to above, this socket should be shaped in accordance with the basic PTB or quadrilateral design; it incorporates provision for easy attachment and detachment of a pylon and foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Early Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> </td> </tr> <tr><td> <p><i>Permanent Prosthesis</i></p> </td> </tr> <tr><td> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> </td> </tr> </tbody></table> <h3>Pylons</h3> <p> Recently a number of devices known as pylons have been developed to meet the requirements imposed by immediate and early postsurgical fitting, namely, functional devices that contain built-in alignment features but are light enough for use throughout the day. Also, devices used in fitting immediately postoperatively should be easily removable from the socket so that the device may be disconnected when the patient is sleeping. Provision for locking the knee joint manually is desirable for use with infirm patients.</p> <p>The Hosmer Above-Knee Temporary Leg (<b>Fig. 28</b>) is a modification of the adjustable leg originally designed by the University of California Biomechanics Laboratory for alignment adjustment during walking trials.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. The Hosmer Above-Knee Temporary Leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. above-knee constant-friction pylon (<b>Fig. 29</b>) is simple, is light in weight, and provides all adjustments necessary in aligning a leg. However, the wedge disks used to change the adduction-abduction and flexion-extension attitudes of the socket require compensatory adjustments to maintain position in one while the other is changed. Hence some degree of skill in using this unit is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. The U.S. Manufacturing Co. Above-Knee Constant-Friction Pylon. The expanded metal straps at the top are provided for use with plaster-of-Paris sockets. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. also provides an above-knee temporary prosthesis with the "Hydra-Knee" unit installed (<b>Fig. 30</b>). Alignment adjustment is provided in the same manner as in the above-knee unit shown in <b>Fig. 29</b>. Cosmetic covers similar to those used with "Hydra-Cadence" units are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. The Hydra-Knee Pylon. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide for independent adjustment in the adduction-abduction and flexion-extension planes, the Veterans Administration Prosthetics Center designed a unit (<b>Fig. 31</b>) in which threaded "disks" are used to provide a wedging action between two conical surfaces placed apex to apex. This device is incorporated in the VAPC "Standard" above-knee pylon which permits the interchange of several knee mechanisms including various constant friction knees, the DuPaCo swing-control unit, both of the Henschke-Mauch knee units, and the UCB pneumatic device. This very desirable interchangeability feature permits the patient to try out a number of swing-control devices at a minimum cost.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Pylon developed at the Veterans Administration Prosthetics Center. This unit will accommodate a number of different standard mechanisms for control of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is feasible and practical to use any of these prostheses for indefinite periods. Thus, changes in alignment can be made if they are needed. A comparison of the major features and characteristics of the various pylons is given in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Use of the Prosthetics Research Study (Seattle) casting fixture to form socket in fitting above-knee case with prosthesis immediately after operation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p> From time to time through the years, a few clinicians have argued for fitting new amputees with temporary or "training" limbs, either for acceleration of the rehabilitation process or to evaluate the patient's potential for use of a prosthesis if there is doubt about his ability to use one. No one argued against this approach provided the temporary limb was properly fitted and aligned. However, when fitting was done before the stump had stabilized the frequent socket changes that were necessary resulted in high costs. If poorly fitted and aligned prostheses were used, more harm than good could result.</p> <p>The introduction of improved casting methods, improved fabrication techniques, and adjustable pylons led the Orthopaedic Department at Duke University to conduct a series of experiments, beginning about 1960, in which it was demonstrated that it is feasible and, indeed, desirable to fit amputees as soon as the wound has healed. <a></a> In 1963, several groups in the United States began experimenting with the concept of fitting the patient immediately after operation and allowing some degree of ambulation very soon thereafter, a technique that had achieved some success in a rather crude way in France and Poland.<a></a></p> <p>By 1967 the technique had been developed in sufficient detail at the Prosthetics Research Study, Seattle, Washington, and experience with experimental cases was such that it seemed warranted to offer special courses in the Prosthetics Education Program in immediate postsurgical fitting of prostheses. The technique applies to all levels of lower-extremity amputation. Experience has shown that the formation of edema is materially reduced, postoperative pain is reduced, development of contractures is avoided, stump bandaging is unnecessary, and the general well-being of the patient is better than when he is treated in the conventional manner. The procedure obviously reduces both time of hospitalization and time required for rehabilitation, and it is appropriate for use in virtually all types of cases except where an open amputation is indicated. More time is required by the surgeon and prosthetist in the management of the patient during the first two weeks, but substantial savings are effected in the over-all treatment program.</p> <p>For the above-knee case, immediate postsurgical fitting consists essentially of providing the patient with a quadrilateral total-contact socket of plaster-of-Paris bandage (<b>Fig. 32</b>) and an easily detachable functional pylon, allowing him to begin weight-bearing about 24 hours after amputation (<b>Fig. 33</b>). No special surgical techniques are needed. Myoplasty, consisting of some method to ensure reattachment of the cut muscles about the thigh, is recommended in any case. <a></a> The cast-socket is left in place for 8 to 12 days, at which time the sutures can usually be removed. A new cast socket is applied immediately and is kept in place until measurements and a cast can be made for the definitive prosthesis, usually 10 to 12 days later. If some other condition precludes the patient from walking, a rigid dressing of plaster of Paris should be used, rather than conventional dressings, to keep formation of edema to a minimum and thus provide a stump that will cause the pros-thetist less trouble.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Above-knee amputation patient fitted with a prosthesis immediately after amputation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Immediate postsurgical fitting and early fitting have been very successful in the hands of competent surgeon-prosthetist teams, and are routine procedures in many centers today. Research in this area is continuing in order to refine the methods still further.</p> <h3>Above-Knee Prosthetics for Children</h3> <p> Amputation in children can be classified as either acquired or congenital. The acquired amputation is the result of trauma or of disease, usually a malignant tumor. The congenital type is the result of a malformation occurring during embryonic development.</p> <p>Management of the acquired amputation in children is essentially the same as that for the adult. Because wounds in children tend to heal faster than they do in adults, immediate postsurgical fitting and early fitting techniques are most appropriate. Usually care must be taken to keep the child patient from being too active. The quadrilateral, total-contact, plastic, suction socket is nearly always indicated. A Silesian bandage may be used, but is usually not needed. For patients below the age of puberty, the only knee unit available is the constant-friction type. SACH and conventional feet are available in sizes suitable for children of all ages.</p> <p>Children with congenital malformations of the lower extremities usually offer a greater challenge. Many times the stump and proximal anatomy are abnormal in structure, and these features must be taken into account in design of the socket and suspension. For guidelines and suggestions for treatment of unusual and bizarre cases, the reader is referred to <i>The Limb-Deficient Child</i>. <a></a></p> <p>For the high, bilateral above-knee case where conventional above-knee or knee-disarticulation prostheses are not suitable, <i>i.e., </i>the patient is unable to use crutches, the use of the swivel walker is recommended (<b>Fig. 34</b> and <b>Fig. 35</b>). <a></a> Designed at the Ontario Crippled Children's Centre for use by patients with severe involvement of all four limbs, the swivel walker has met with success wherever it has been used. Motion is effected by displacement of the center of gravity of the body. Although movement is restricted to smooth, level surfaces, the swivel walker offers an effective means of mobility, and the psychological benefits to be gained from it are quite rewarding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Principle of the "Swivel Walker" developed at the Ontario Crippled Children's Centre, Toronto, Canada, for very high, bilateral, lower-extremity cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. The OCCC swivel walker with articulated joints that permit a sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Above-Knee Prosthetics for Geriatric Cases</h3> <p> At one time it was an almost universal rule to amputate through the thigh in cases of peripheral vascular disease when limb ablation was indicated. However, since it has been shown that many knee joints can be saved in spite of what appear to be overwhelming odds, the ratio of above-knee to below-knee amputations is decreasing. Unfortunately, however, there will always be a certain number of above-knee cases.</p> <p>Immediate postsurgical and early fitting practices should be used whenever possible. Proper use of these procedures reduces the mortality rate drastically and permits the fitting of definitive prostheses considered impossible, or at least impractical, only a few years ago. The use of provisional prostheses permits the clinic team to determine, without question, whether or not a definitive prosthesis is indicated. The VAPC "Standard" AK Pylon permits experimentation with several hydraulic units as well as with mechanical friction knee control.</p> <p>In spite of the many useful innovations that have been introduced into the practice of above-knee prosthetics through the years, there is still room for further improvement. Among the developments needed are more foolproof methods of obtaining optimum fit and alignment. Sockets that can be adjusted to meet the constantly changing cyclical demands of the amputee are certainly desirable and possible. Indeed, it might be feasible to provide a socket that is adjusted automatically to meet the needs of the patient constantly throughout the day. In any event, studies of the effect of pressure on human tissues must lead eventually to a better application of limb prostheses.</p> <p>Needed also are methods for fitting and fabrication of limbs in even less time than is presently required. Materials that can be formed at temperatures safe to human tissues are now becoming available, and it is hoped that a useful socket can be molded over the stump, eliminating the need for plaster of Paris in taking impressions and making models of the stump. Such a technique, when used with adjustable pylons that are cheap enough and light enough to leave as the "permanent" prosthesis, should permit fast, economical service.</p> <p>Concurrently with studies designed to point the way to more functional prostheses and more efficient service, a number of surgeons are studying and trying to devise methods for providing more functional stumps. In recent years the techniques of amputation have taken on more significance in the minds of surgeons and, consequently, prosthetists have been seeing stumps that are more functional than has been the case in the past. Further research and a continuation of educational programs should result in even more improvement.</p> <h3>Acknowledgment</h3> <p>Special appreciation is due the Prosthetic and Sensory Aids Service of the Veterans Administration for providing nearly all of the illustrations for this article.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessy,<i>The construction and fitting of lower-extremity prostheses</i>, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</li> <li>Bard, Gregory, and H. J. Ralston, <i>The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40:415-420, October 1959.</li> <li>Blakeslee, Berton, ed.,<i>The limb-deficient child</i>, University of California Press, Berkeley and San Francisco, 1963.</li> <li>Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Veterans Administration, Washington, D.C., 1967.</li> <li>Foort, J.,<i> Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</li> <li>Foort, J., and N. C. Johnson, <i>Edema in lower-extremity amputees</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1962.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand,<i> Immediate postsurgical fitting and early ambulation</i>, Clin. Orth., 56:119-131, 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project 1363 to (U.S.)</li> <li>Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas,<i> Status of the above-knee suction socket in the United States</i>, Artif. Limbs, 1:2:29-39, May 1954.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hanger, H. B.,<i>Above-knee socket shape and clinical considerations</i>, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</li> <li>Kay, Hector W., K. A. Cody, and H. E. Kramer, <i>Total contact above-knee socket studies</i>, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</li> <li>Lewis, Earl A., <i>Fluid controlled knee mechanisms, clinical considerations</i>, Bull. Pros. Res., 10:3:24-56, Spring 1965.</li> <li>Motloch, W. M., and Jane Elliott, <i>Fitting and training children with swivel walkers</i>, Artif. Limbs, 10:2:27-38, Autumn 1966.</li> <li>Murphy, E. F., <i>The swing phase of walking with above-knee prostheses</i>, Bull. Pros. Res., 10:1:5-39, Spring 1964.</li> <li>Murphy, Eugene F., <i>Lower-extremity components</i>, Chap. 5 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</li> <li>Radcliffe, C. W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, C. W.,<i> Biomechanical design of an improved leg prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</li> <li>Radcliffe, C. W., and H. J. Ralston, <i>Performance characteristics of fluid-controlled prosthetic knee mechanisms</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artif. Limbs, 7:1:31-43, Spring 1963.</li> <li>Staros, Anthony, and Eugene F. Murphy, <i>Properties of fluid flow applied to above-knee prostheses</i>, Bull. Pros. Res., 10:1:40-65, Spring 1964.</li> <li>Staros, Anthony, and Edward Peizer, <i>Northwestern University intermittent mechanical friction system (disk-type)</i>, Artif. Limbs, 9:1:45-52, Spring 1965.</li> <li>Thomas, Atha, and C. C. Haddan, <i>Amputation prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Hydra-cadence above-knee prosthesis</i>, TR-2, Nov. 1, 1963.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Henschke-Mauch "Hydraulik" swing control system</i>, TR-3, Dec. 1, 1964.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the DuPaCo "Hermes" hydraulic control unit</i>, TR-4, Jan. 4,1965.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, 11:1:47-50, Spring 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>14.</b> </td><td class="clsTextSmall">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, 10:2:27-38, Autumn 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>3.</b> </td><td class="clsTextSmall">Blakeslee, Berton, ed.,The limb-deficient child, University of California Press, Berkeley and San Francisco, 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>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 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>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Golbranson, F. L., Charles Asbelle, and Donald Strand, Immediate postsurgical fitting and early ambulation, Clin. Orth., 56:119-131, 1968.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, 11:1:47-50, Spring 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">Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project 1363 to (U.S.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, 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>24.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Hydra-cadence above-knee prosthesis, TR-2, Nov. 1, 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">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the DuPaCo 'Hermes' hydraulic control unit, TR-4, Jan. 4,1965.</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>25.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Henschke-Mauch 'Hydraulik' swing control system, TR-3, Dec. 1, 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>13.</b> </td><td class="clsTextSmall">Lewis, Earl A., Fluid controlled knee mechanisms, clinical considerations, Bull. Pros. Res., 10:3:24-56, Spring 1965.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, 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>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 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>22.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Northwestern University intermittent mechanical friction system (disk-type), Artif. Limbs, 9:1:45-52, 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>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 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">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 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>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, 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>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, 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>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 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">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, 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">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, 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>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, 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>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 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>11.</b> </td><td class="clsTextSmall">Hanger, H. B.,Above-knee socket shape and clinical considerations, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Thomas, Atha, and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artif. Limbs, 1:2:29-39, May 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>1.</b> </td><td class="clsTextSmall">Anderson, M. H., J. J. Bray, and C. A. Hennessy,The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Bard, Gregory, and H. J. Ralston, The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40:415-420, October 1959.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 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>A. Bennett Wilson, JR.. B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-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 Recent Advances in Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, JR.. B.S.M.E. * https://staging.drfop.org/files/original/fc94390daaecbf5fe0e515d25844a562.pdf addcea0ef5d054afe2d97b8b2ed7d402 https://staging.drfop.org/files/original/b63e79eeb63c71071d4e658053cf7453.jpg 7033f3a9ae76997cae29ba015bdf6e1a https://staging.drfop.org/files/original/c916255036e94916ce3f90294984788f.jpg ed7c60521a368679fe0866091d1ba7c5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_017.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 17 - 19 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_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_017.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 of a Bilateral, Below-Elbow Amputee, a Report</h2> <h5>Edward Loughlin, M.D. <a style="text-decoration:none;">*</a><br />James W. Stanford, III, C.P. <a style="text-decoration:none;">*</a><br />Marcus Phelps, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The application of immediate postsurgical prosthetics fitting procedures in the management of lower-extremity amputees has been reported as providing a number of advantages, notably control of postsurgical edema, a marked reduction in pain, and a material reduction of the period of hospitalization. <a></a></p> <p>Although somewhat different considerations are involved in upper-extremity cases, immediate postsurgical prosthetics fitting of upper-extremity amputees is a logical progression in the application of these procedures. Upper-extremity amputations are considerably less frequent and are usually in a younger age group. Adequate wound healing is usually not a problem, local factors being the most important determinant. Still the application of a rigid dressing is a sound surgical concept.</p> <p>Unilateral amputees have a high rejection rate for actual use of their prostheses. It is believed that immediate postsurgical fitting of prostheses to upper-extremity amputees permits rehabilitation from the earliest possible moment and, hopefully, a higher acceptance rate. As used in this report, the term "immediate fitting" means the application of a rigid surgical dressing with terminal device at the time of surgery or in the immediate postoperative period. This is in contrast with "early fitting," which is applied at some time after the removal of sutures.</p> <p>During the past two years, the authors have had the opportunity to apply immediate prosthetics fittings to three patients, with four upper-extremity amputations. The case reported here is that of a bilateral, below-elbow amputee.</p> <h3>Case History</h3> <p>LMW, a 26-year-old employee of an electric power company, sustained electrical burns of both upper extremities on March 7, 1967, the result of receiving 19,000 volts of current through both wrists. One month later he was seen in the hospital by a consulting group (general surgeon, plastic surgeon, and orthopaedic surgeon) for consideration of possible reconstructive measures. It was the consensus of the group that no useful hand or part thereof could be salvaged (<b>Fig. 1</b>). As a result, on April 17, 1967, bilateral midforearm amputations were carried out. At the time of surgery extensive muscle necrosis was found-as expected- proximal to the apparent skin defect. This required loose closure of the amputations. Drains were placed in the wounds and compression dressings were applied. On April 20, 1967, the patient was returned to the operating room so that the wounds could be viewed, and they appeared to be clean. At this time rigid surgical dressings with terminal devices and harnessing were applied. From that time on, a marked improvement in the emotional status of the patient was noted (<b>Fig. 2</b>). The patient wore his temporary prostheses until May 26, 1967, when he was fitted with permanent prostheses. The patient made an excellent recovery, returning to full-time work in November 1967.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Neither the left nor the right hand was considered salvageable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. From the time of the application of the rigid dressings and temporary prostheses, there was an upturn in the patient's emotional status. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Temporary Prostheses</h3> <p>Some details in the application of the rigid dressings and temporary prostheses may be of interest.</p> <p>Autoclaved lamb's wool was applied over the suture lines, and Orion Spandex socks were then rolled into place and held under tension.</p> <p>To satisfy two somewhat conflicting considerations-that is, to ensure that the rigid surgical dressing would not be displaced when the patient flexed and extended his elbows, and to avoid immobilization of the elbow joint with plaster-Ace bandages were applied about 3 in. below the elbow and continued proximally to encase the elbow joint. Elastic plaster bandages were then applied, and the Ace bandages were incorporated into the plaster wrap. The plaster wrap extended to a point just below the condyles of the joint. Thus the rigid dressing was held in contact, and at the same time limited movement was permitted to the joint.</p> <p>Steel straps attached to WE-500 wrist units were then applied to the rigid dressing with regular plaster for reinforcement.</p> <p>A retainer plate riveted to an anchor plate was attached to the socket for cable attachment.</p> <p>A standard bilateral ring harness with plastic triceps pad and flexible leather hinges completed the setup.</p> <p>Two 5XA hooks were applied with one rubber band each.</p> <p>On April 25, 1967, sufficient atrophy had occurred to warrant new rigid dressings. The foregoing procedure was repeated. At this time, extra rubber bands were added to the terminal devices, and the patient demonstrated proficiency at a number of activities.</p> <p>On May 9, 1967, the second cast change was made, and a wrist-flexion unit was applied to the right side. Again, more rubber bands were applied.</p> <h3>Permanent Prostheses</h3> <p>"Definite prostheses" were prescribed for the patient on May 18, 1967. The prostheses were fabricated and subsequently fitted on May 26, 1967. The prescription included:</p> <ul> <li>Bilateral below-elbow plastic prostheses.</li> <li>Double-wall sockets.</li> <li>Flexible joints.</li> <li>5XA hooks.</li> <li>Dorrance No. 4 hands.</li> <li>Two wrist-flexion units.</li> <li>One driving ring.</li> <li>One button hook.</li> </ul> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de V 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>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Management of lower-extremity amputees using immediate postsurgical fitting 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 V 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">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</td></tr><tr><td class="clsTextSmall"><b>3.</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>4.</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>Marcus Phelps, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James W. Stanford, III, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 Loughlin, M.D. </b></td></tr><tr><td class="clsTextSmall">Peachtree Orthopaedic Clinic, Atlanta, Ga. 30301</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-02.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 of a Bilateral, Below-Elbow Amputee, a Report Creator An entity primarily responsible for making the resource Edward Loughlin, M.D. * James W. Stanford, III, C.P. * Marcus Phelps, C.P. * https://staging.drfop.org/files/original/7b8252c8f883f24af6692bb69c37688d.pdf 295a867a36ca94a6cf7d56daa6aa3e46 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_022.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 22 - 23 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_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_022.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>Need for Research in Surgical and Medical Considerations Dealing with Prosthetics and Orthotics</h2> <h5>George T. Aitken, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The discussion of the Panel on Surgical and Medical Considerations at a Conference on Prosthetics and Orthotics sponsored by the Committee on Prosthetics Research and Development was divided into two parts-those considerations dealing with prosthetics and those dealing with orthotics.</p> <h3>Prosthetics</h3> <p>Much fundamental work in the area of amputation surgery remains to be done, as briefly outlined in this article.</p> <h4>Indicators For Amputation</h4> <p>It is believed that the modern methods of amputee management may have made amputation a more desirable procedure now than some reconstructive procedures currently in use, and the entire field needs a comprehensive review.</p> <h4>Selection Of Level Of Amputation, Especially In Cases With Vascular Insufficiency</h4> <p>No reliable test for measurement of circulation in the extremities exists. As a result, it is the practice in many centers to amputate above the knee in virtually all cases with peripheral vascular disease. However, it has been shown that many times the knee joint can be saved even when standard tests indicate that the blood supply is apt to be insufficient. Objective tests of circulation coupled with surgical studies should result in more below-knee amputations and fewer above-knee amputations.</p> <h4>Sites Of Election Of Amputation</h4> <p>Although it is generally agreed that all length possible should be saved, a study should be made in which length of stump is correlated with function and comfort when current fitting practices are used.</p> <h4>Surgical Techniques</h4> <p>A comprehensive review of surgical techniques should be made. This should include special attention to the care of transected muscles.</p> <p>The advantages of end-bearing and how much should be carefully reviewed in order to determine whether different techniques, such as myoplasty, osteoplasty and nonviable implants, should be vigorously tested in order to obtain varying degrees of end-bearing. Muscles that must be transected may eventually be control points for externally powered devices and careful attention must be focused on the preservation of their optimal ability to provide control sources such as myoelectric signals or pure biomechanical motion.</p> <h4>Postsurgical Procedures</h4> <p><i>Rigid Postsurgical Dressing</i></p> <p>There was agreement that the application of a rigid dressing postsurgically is desirable. To achieve the best results consistently it is necessary to determine the range and distribution of pressures that bring about the best results. Techniques for achieving and maintaining proper pressure will then need to be developed. Included in this study, of course, will be the problems of suspension of the cast.</p> <p><i>Ambulation</i></p> <p>Studies of the effect of ambulation should be made. Included in such studies would be such factors as time to begin ambulation, the amount of weight-bearing that should be taken, and alignment.</p> <p><i>Effect of Immediate Postsurgical Fitting on Cases with Vascular Problems</i></p> <p>In the opinion of some, immediate postsurgical fitting permits amputation at a lower level than is the case with conventional procedures, but no data have been accumulated to substantiate this opinion. This should be investigated, because the presence of the "normal" knee joint permits meaningful function that cannot be approached with an artificial limb and provides a much better chance for rehabilitation measures to succeed.</p> <p><i>Immobilization of the Next Proximal Joint</i></p> <p>Although it is recognized that a study of the effect of immobilization of the next joint in the early stage of immediate postsurgical fitting is a part of the overall suspension problem, it was recommended that attention be given this matter.</p> <h4>The Phantom Sensation</h4> <p>Although a good deal of work has been carried out in the study of the phantom sensation, especially in reference to phantom pain, very little is understood about these phenomena. It is felt that attention should be continued in this area.</p> <h3>Orthotics</h3> <p>Out of a general discussion of the surgical and medical considerations in orthotics, three broad recommendations developed.</p> <ol> <li>There is an urgent need for the development of criteria for the design of bracing based on the biomechanical needs of patients. Perhaps a system of classification of disability based on biomechanics is not only the proper approach to criteria development but, when brace components are related to it, a sounder basis for prescription can be developed.</li><li>Little is known about the response of human tissues to the application of pressure, yet every function of an orthopaedic brace involves the application of pressure. Studies on the effect of pressure are needed before it is possible to determine the efficacy of certain treatment procedures, especially some of those for children.</li><li>Studies involving buried and partially buried implants for facilitating control of externally powered devices should be continued.</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>George T. Aitken, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopaedic surgeon, College Avenue Medical Building, 50 College Ave., S.E., Grand Rapids, Mich. 49503; Chairman, Subcommittee on Child Prosthetics Problems, Committee on Prosthetics Research and Development. Dr. Aitken served as Chairman of the Panel on Surgical and Medical Considerations of the Conference on Prosthetics and Orthotics.</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 Need for Research in Surgical and Medical Considerations Dealing with Prosthetics and Orthotics Creator An entity primarily responsible for making the resource George T. Aitken, M.D. * 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/f922814d211b608a697466e29490333b.pdf e5a35d98b2c617e7f9ded283ff5dafa7 https://staging.drfop.org/files/original/48cf7ac67e217521f3acb7e40d6b2a38.jpg f5a6cea41ca17f732cb253daf7918897 https://staging.drfop.org/files/original/16410b5f62b683ff0be5f6a0ef4730a6.jpg d8aa785829781cb0896ecc82863c789c https://staging.drfop.org/files/original/433b014b1a43a6614856053945b2243c.jpg 2b4c04387bc7f8a8bdc413c6109662d3 https://staging.drfop.org/files/original/843d131b77b5dc6c8f18d58702881340.jpg 5f4eff514a08be3ae5daaa303dc0cf7d https://staging.drfop.org/files/original/e575b525f13cc42d25f865c4db4ecb9e.jpg fc78601c78357e69128fc5a5290b83fd https://staging.drfop.org/files/original/e6ca2fa5bfd699bce64bf63899c6d86a.jpg ce75e70e35780221d326a363fc1dc05e https://staging.drfop.org/files/original/d803b3cc574d377eee5137bfd10f9db9.jpg 29d55e95bcb3a6b15f4a6b98f2c189e0 https://staging.drfop.org/files/original/5bc2ecf5e9ba7ac10a96388a62f09100.jpg e82f3d9d247bb7790f21711a8885532f https://staging.drfop.org/files/original/4de87b8d2e769e4c1287a208354fc8dc.jpg 70855f2c86c26331cc6fba80045e7553 https://staging.drfop.org/files/original/197022ec795072639ae32d2c689f1dc8.jpg 3cfec86e35d1b3315dafa497908e73ac https://staging.drfop.org/files/original/b4962dbe7236d6656d2297e42960d167.jpg 0970a72bbd0016a1fd49b37ead35272e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_005.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 5 - 21 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_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>External Power in Prosthetics and Orthotics, an Overview</h2> <h5>James B. Reswick, Sc.D. <a style="text-decoration:none;">*</a><br />Lojze Vodovnik, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>The large number of persons who could be materially helped if highly developed orthotics and prosthetics systems were available is not generally appreciated. The conquest of infectious diseases has increased life expectancy to the point where disability caused by the failure of physiological systems is common in old age. The ever-increasing rate of injuries resulting from vehicle accidents adds to the numbers of paralyzed and maimed, and at the present time the Vietnam conflict is adding its toll.</p> <p>Detailed statistics are difficult to obtain, but it has been estimated that there are 25,000 to 30,000 amputations per year in the United States from all causes. The Veterans Administration reported 25,000 lower-extremity and 6,000 upper-extremity service-connected cases treated during 1967 (incomplete figures), resulting from several wars. There are no immediately available statistics related to the Vietnam conflict.</p> <p>Dr. Virginia Badger <a style="text-decoration:none;">*</a> has estimated the numbers of patients in the United States with various types of rheumatic, arthritic, and neurological disorders, including quadriplegia, as follows: <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>Of these patients, Dr. Badger estimates that <i>2</i> million could benefit markedly from orthotic devices, provided that the difficult problems of patient acceptance could be overcome.</p> <p>Unfortunately, much remains to be done in defining the need more precisely. Many persons suffering from neurological disorders are not recorded in hospital statistics; and, if they are, the nature of their disability is not. The specific types and numbers of disabilities need to be codified in a way which could lead to the development of engineering specifications and decisions on priorities of effort and specific engineering designs.</p> <h3>The Man-Machine System</h3> <p>The human being and his assistive device comprise a man-machine system. When the orthotics or prosthetics system uses external power and is operated by means of feedback control, the result is a cybernetic system in the true sense of the term. <b>Fig. 1</b> illustrates the possible information paths of an orthotics or a prosthetics system. The following important elements are depicted: I. Signal Sources; II. Transducers; III. Signal Processors; IV. Output Systems; V. Feedback Receptors; and VI. Local Feedback. In addition to these physically identifiable elements, an important element in the performance of the system is the capability of man to learn to use a complex assistive device (VII. Adaptive Learning). Here, age and motivation are important; for example, "thalidomide children" show tremendous learning capacity with complex prostheses, while many geriatric lower-extremity amputees are not able, or are not motivated, to use an artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Elements of a prosthetics or an orthotics system. I. Signal Sources: muscle motion, electromyographic, electroneurographic, electroencephalographic, eyeball motion, sound. II . Transducers: direct connections, switches, valves, proportional analog, proportional digital, electrodes, radio transmitters. III. Signal Processors: on-off, electromyographic, coupled function devices, proportional or velocity control systems, adaptive computer. IV. Output Systems: communication devices, environment and tools designed to work with the orthotics or prosthetics system, vehicles controlled by the orthotics or prosthetics system. IV. A. Prosthetic: terminal devices, upper-extremity components, lower-extremity components. IV. B. Orthotic: splints and casts, implant bone supports, body-powered splints, externally controlled splints, externally powered splints, functional electrical stimulation. V. Feedback Receptors: vision, hearing, proprioception, touch, "stereo" vibration, "stereo" electrical stimulation. VI. Local Feedback: Pressure sensors, slippage sensors, position, velocity, force. VII. Adaptive Learning. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article will discuss each of the elements of the prosthetics or orthotics system depicted in <b>Fig. 1</b>, briefly indicating the present levels of research activity and future possibilities.</p> <h4>I. Signal Sources</h4> <p>The human desire to initiate movement of an orthotics or a prosthetics system originates at some conscious level in the central nervous system, but it must take the form of some voluntary physical action if a result is to be achieved. This action may be, for example, a simple muscle movement resulting in the closing of a switch, the pressing of a key, or the very sophisticated use of the tongue (<b>Fig. 2</b>) to activate a keyboard of miniature switches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Rancho Los Amigos Hospital electric arm orthosis. The various degrees of freedom are actuated by a series of bidirectional microswitches placed in front of the patient's mouth and operated by his tongue. A number of these devices are in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Recently, electrical signals associated with muscle and neuron activity have been explored for use as control signals. Although electro-neurographic (ENG) signals seem attractive because of their proximity to the central nervous system<a></a>, the practical difficulty of maintaining electrodes proximal to nerves in human subjects over extended periods of time has not been overcome. Instead, the more accessible electromyographic (EMG) signals have been used as sources of control signals. Most practical to date has been the use of so-called surface EMG signals obtained by means of electrodes resting on the surface of the skin near a muscle whose electrical activity is to be detected.</p> <p>A number of prosthetic hands and some hand orthoses have been developed to operate from EMG signals picked up through surface skin electrodes.<a></a> More recently, interest has grown in obtaining EMG signals from within a muscle. Such intramuscular EMG signals exhibit a wider range (from single motor unit pulses to signals of many asynchronous pulse combinations) and are more free from "cross talk" resulting from the activity of neighboring muscles.<a></a> Practical use of intramuscular EMG signals requires either wire electrodes which penetrate the skin and which can exist for long periods of time without breaking or promoting infection (<b>Fig. 3</b>), or the development of implantable radio transmitters capable of long-term operation (<b>Fig. 4</b> and <b>Fig. 5</b>) <i>(35,37.) </i>Future research will undoubtedly press in both of these directions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A monopolar, helically wound, percutaneous electrode. It is used to detect electrical activity within a muscle. The electrode is inserted into the proper muscle by a hypodermic needle which, when withdrawn, leaves the electrode comfortably implanted. A surface connector protects the electrode-skin interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Miniature FM radio transmitter used to obtain electromyographic signals by complete implantation. The signals are received externally and, after processing, can be used as control inputs in a control system. The transmitter shown will be encapsulated in epoxy and coated with medical grade silicone rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transmitters implanted in a human and attached to the trapezius muscles. The electromyographic signal obtained by lifting the shoulder ( a motion possessed by many quadriplegics) was used to drive a variable-speed motor, a bidirectional prehensile hand splint, and a multilevel selector. The transmitter was turned on by changing the state of a magnetic switch influenced by an external magnetic field. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Many other sources for voluntary signals from the human being have been suggested from time to time. The electroencephalogram (EEG) signal is often mentioned, but, to date, it has been used only as an on-off switch responding to the presence or absence of the alpha rhythm <i>. </i><a></a> Enticing as the idea may be, many years must pass before thoughts will will be transformed directly into meaningful electrical signals.</p> <p>The human voice, including whistles and the like, has been proposed and used as a signal source. Much research at present is devoted to machine recognition of human speech for voice-operated typewriters and for speaking directly to a computer <i>. </i><a></a> These efforts show promise, but they are probably far too complicated at present to be considered for use in a prosthetics or an orthotics system. The human eye has also been used to switch devices by means of ultrasonic and infrared reflections <i>. </i><a></a> Unfortunately, many such promising sources of control signals are involved in the normal activities of living, such as eating, looking around, speaking, and the like. This could be a disadvantage when the patient desired to control his orthotics or prosthetics system with a signal such as sound while he was talking or eating <i>.</i><a></a> </p> <h4>II. Transducers</h4> <p>Transducers are the devices used to change physiological phenomena into engineering signals that provide inputs to signal processors and output systems. A transducer may be as simple as an on-off switch or as complicated as an implantable FM radio transmitter. Some elements of orthotics and prosthetics systems are difficult to classify. Bowden cables used to transmit shoulder movements to an amputee's terminal device are an example. More recently, hydraulic systems which function as a wire cable have been demonstrated <i>. </i><a></a> Such systems combine the roles of transducer and actuator in a single unit.</p> <p>Electric switches and pneumatic-hydraulic control valves which convert body movements into changes in electric current or fluid flow are highly developed. Many types of reliable, very small electric switches have been easily adapted to prosthetics and orthotics systems, but, in the case of hydraulic and pneumatic control valves, it has been necessary to develop a number of appropriate special valves.</p> <p>Not so widely used in prosthetics and orthotics systems, but highly developed for general instrumentation purposes, is a wide range of proportional analog and digital transducers capable of converting pressure or movement into voltage or current changes. These devices range from analog potentiometers and capacitive and inductive devices which convert motion to smooth voltage changes, to linear transducers which produce pulse-coded signals proportional to incremental changes or absolute position. Also available are the very ingenious accelerometers and other motion transducers developed for space research and guidance control systems. Accelerometers have been used in at least one head-motion-activated control system <i>.</i><a></a> </p> <p>Generally speaking, the mechanical-to-electric transducers have been highly developed, but only limited use has been made of their capabilities in prosthetics and orthotics systems. This does not imply, however, that a number of mechanical - to - electric transducers are immediately available for use in prosthetics and orthotics systems. An actual application often requires either a major redesign or a new design to take into account the unique problems inherent in physiological-data transduction. It is appropriate to mention here the National Aeronautics and Space Administration's Space Technology Utilization Program, in which NASA is actively searching for ways to apply transducers developed for space applications in orthotics and prosthetics systems.</p> <p>The recent interest in electrophysiological signals for control of orthotics and prosthetics systems has focused attention on the development of electrodes. A large variety of surface electrodes used in electrocardiographic diagnosis and long-term monitoring systems is already available. From space technology come the "spray-on" electrodes and other surface electrodes used in telemetry and in obtaining physiological data from astronauts.</p> <p>Two main approaches exist for obtaining EMG signals from within a muscle, namely: percutaneous wires inserted by means of hypodermic needles; and surgically implanted radio-transmitting devices. In the first method, wires leading through the surface of the skin from inside the muscle must be capable of flexing as the muscle moves and maintaining contact with motor units for many months. Present indications are that tissue-reaction and infection at the point of exit from the skin are minimal. Some newly developed silastic-im-pregnated spiral electrodes show promise of solving the problem of mechanical reliability <i>. </i><a></a> Similar problems exist for the electrodes of surgically implanted devices. In fact, the electrodes may well prove to be the weakest link in a biotransmitting system. It is well known that electrode failures in heart pacers continue to be a vexing problem. Research will continue to find ways to prevent metal fatigue and to discover contact materials which produce no body-tissue reaction, and which do not corrode and weaken.</p> <p>In the foregoing paragraph, electrodes were discussed in the context of signal-sensing devices. Their importance is much more critical in transducers used for the electrical stimulation of muscle, as in the case of functional electrical stimulation to be described later on in this article, and in heart pacemakers and bladder stimulators, which have been excluded from this discussion of orthotics and prosthetics systems. The relatively higher currents associated with electrical stimulation, as compared with detection of electrophysiological signals, create problems. It is believed that the material, corrosion, and tissue-reaction problems associated with electrodes for picking up signals are not severe and can be easily overcome through present technology.</p> <p>Electrical powering, long-term body acceptance, and sealing of the package are the issues around the active transmitters used for detecting electrophysiological signals from within the body and the passive and active implantable transducers for electrical stimulation of muscles. At present, all such experimental devices are powered by mercury cell batteries. Much effort is being devoted to minimize total electrical power requirements and to obtain electrical energy from within the body through mechanical and chemical transformers.<a></a> Battery-powered biotransmitters of a total size of 0.1 cu. in. have operated continuously for 200 hr. and, intermittently, over a three-month period in dogs. An EMG transmitter was first implanted in a human being in Sweden in 1966 <i>. </i><a></a> More recently, one was implanted in a subject in Cleveland, Ohio <i>. </i><a></a> Many problems remain to be overcome before such transmitters can be used routinely in the clinical situation, but progress with packaging techniques which produce no tissue-reaction in animals over long periods of time, and with electrode designs which can survive mechanical and electrolytic effects, indicates that prototype systems will be evaluated in human subjects within the year.</p> <h4>III. Signal Processors</h4> <p>This discussion of signal processors is concerned primarily with the special electronic and computer-type systems used for converting low-level control signals containing noise and artifacts to useful, high-level input for orthotic or prosthetic devices.</p> <p>Although not specifically designed for signal processing, the mechanical and hydraulic characteristics of many systems may be viewed as signal processors. For example, the speed of response of a gas-powered orthotics or prosthetics system is often limited by the size of the valve openings and tubing used in the system. In this way, the on-off characteristic of the valve is converted inherently into a velocity output and is so observed by the patient. In fact, subjects are often very much aware of the noises and speeds of response associated with their control devices, and improve their skills with practice and knowledge of how the system will perform for given input operations.</p> <p>Signal processors designed specifically to alter electrical wave forms include a wide range of circuits used for processing EMG information. Most such circuits involve rectification, integration, and various nonlinear components used to reject noise and provide the smoothest possible electrical systems for operating the orthotic or prosthetic device. Since the EMG signal, especially when detected from within the muscle, consists of an asynchronous train of pulses, signal conditioners based upon digital - signal - handling theory are being developed. Some of these systems would "clean up" the pulse signals from within a muscle to the point where they might be used as direct signals into a digital computer.</p> <p>Under another kind of theory for signal processing, combined or patterned functions are produced from one or more inputs. Among body-powered orthotic devices, the linkage feeders widely used by quadriplegics are an example.<a></a> These mechanical linkage systems support the forearm and allow the patient to convert shoulder and trunk movement into controlled movement of his hand. When given a controlled prehensile function, patients often learn to feed themselves and perform many other useful tasks. Externally powered arm prostheses have been designed for children, with coupled movements such that the programmed movement of an eating implement is obtained by the child through a single input action.<a></a> The conversion of a single input action to interrelated movements of each part of the prosthesis may be regarded as a type of signal processing, especially when one considers the possibility of using an elecrical computer to do the same sort of thing. The sophisticated prosthetic hands built in France and, more recently, in Yugoslavia and Japan,<a></a> in which a simple set of input signals is mechanically converted to a smoothly closing movement of all fingers, constitute a type of signal processing.</p> <p>Another type of signal processing is found in the automatic control systems used in some orthotic and prosthetic devices (<b>Fig. 6</b>). Recently, interest has developed in systems possessing automatic proportional and velocity control. Such systems differ from so-called "open-loop" systems in that feedback position or force signals are fed back to the control system itself rather than the patient. The patient provides command signals, such as a new position, to which the control system automatically responds. Such techniques have not been widely used in orthotics and prosthetics systems to date, but they have been demonstrated in research prototypes and will probably find increasing application <i>.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A prototype automatic prehension system developed at the Army Medical Biomechanical Research Laboratory. It includes miniaturized electronics, a motor-driven No. 4 hand, and a thumb sensor. A cosmetic glove is worn over the assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Most human motor activity is a combination of direct conscious control and patterned movements which are coordinated at levels below the conscious nervous system. Many research projects are now concerned with using computers or high-speed data processors to perform for an advanced prosthetics or orthotics system what the lower motor neuron system does for the human being. The problem is essentially one of information-channel capacity, wherein much information may be required to control a complex device but only limited channels are available for converting the desires of the patient into electrical command signals.<a></a> </p> <p>One approach to this problem was the Case Research Arm Aid, Mark I (<b>Fig. 7</b>), <a></a> which used a computer with pre-programmed tapes for a number of activities of daily living. The quadriplegic patient was required to select the portion of tape appropriate for the action he wished to accomplish, but he did not need to be actively involved once the action had started. More recently, proposals have been made for using computers adaptively to learn to provide patterned functions. The idea would be to store within the computer patterns or subroutines for elementary body movements which combine to produce walking or upper-extremity movement. The subject would then provide only "coarse" information about where he wanted his limb to go, and the computer would calculate according to some pre-programmed strategy how best to move his limb most efficiently from one place to another. The tremendous progress in machine computation has opened unlimited possibilities for research in such systems which can be reduced practically to patient needs. One can visualize, for example, a paralyzed leg being electrically stimulated according to a patterned program stored in a solid-state, micrologic computer worn on the belt. Although such a system can be imagined, it will be many years before it is technically and economically feasible.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The Case Research Arm Aid, Mark I. The pneumatic system shown allowed five degrees of freedom through the shoulder, arm, and wrist. Modifications being made include conversion from a pre-programmed tape control to computer-calculated trajectories by means of myoelectric input control signals. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>IV. Output Systems</h4> <p>In the past, most of the research, development, and clinical application of orthotics and prosthetics systems has been concerned with the output systems, for these are the hardware devices which perform the functions required by the handicapped person. Through intuition, designers have shown awareness of control and feedback, but their attention has been primarily directed toward the powering and fitting of devices to improve the function of the handicapped.</p> <p>Almost all the elements in the man-machine systems are applicable to both orthotics and prosthetics; but, when output systems are considered, it is necessary to discuss orthoses and prostheses independently, except for certain communication devices which apply to both. For example, much effort has been devoted to modifying telephone, recorder, typewriter, radio and television equipment for easier use by handicapped persons. Touch dialing, alone, is an important asset. Tape-recording and typewriters operated through coded signals from the tongue or voice make it possible for the paralyzed person to carry on a business and communicate with friends.</p> <p>In addition to communication devices, attention has also been given to the development of special tools and machines so that the handicapped can perform useful work. Interestingly, much of the philosophy in the development of such tools is common with the development of special tools for astronauts to use in space. This occurs because the normal man in an alien environment is similar in many respects to the handicapped man in a normal environment. Vehicles for the transportation of handicapped persons, including powered wheelchairs (<b>Fig. 8</b>) and modified automobiles, must also be included in output systems for the handicapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ampersand Research, Highland View Hospital, three-level electromyographic control of wheelchair and flexorhinge splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prosthetics</i></p> <p>The term "prosthesis" brings to mind artificial hands, arms, and legs. The historical development of these artificial limbs is an extensive and fascinating study in itself. Although seemingly simple and perhaps crude, the cable-controlled, rubber-band hooks commonly used by below-elbow amputees are, in fact, quite sophisticated, and many amputees have developed remarkable dexterity with them. Probably many years will elapse before the users of EMG-controlled, electrically powered hands achieve the same level of reliability and dexterity now found in thousands of skilled hook-users around the world.</p> <p>The problem is much more severe for the above - elbow and shoulder - disarticulation amputee, especially the bilateral case. It is a fact that when a patient has one good arm the margin of increase in function provided by a prosthetic second arm is often too small to make it worth his while to learn to use it. Much effort is now under way to provide improved functions for high-level amputees, especially bilateral cases. The most successful systems to date are powered by gas or electricity.<a></a> Each clinical application represents a major engineering achievement, and each one is usually somewhat different from all others. This is the real limitation in the development of sophisticated upper-extremity systems, for the problem of fitting and the nature of disability are so different among the relatively limited numbers of amputee patients and congenitally deformed children that the sophisticated engineering required is often economically unjustified. However, the obvious challenge presented by the creation of an artificial human limb continues to fire the imagination of engineers throughout the world, and one may expect continued progress.</p> <p>The case for the lower-extremity prostheses is somewhat different, because a man cannot walk with just one leg. Much effort has been devoted to developing lower-extremity prostheses for both above-knee and below-knee amputees. A successful prosthetic application requires close collaboration between the orthopaedic surgeon and the prosthetist. Thoughtful planning concerning the nature of the stump to be produced can make a great difference in the effectiveness of the final prosthesis. Walking is one of the most sophisticated patterned functions in man. Many muscles are interrelated in producing a gait of minimum energy expenditure. One area of intensive research has been the study of human gait in order to improve the design of lower-extremity prosthetic and orthotic devices. Although considerable data have been gained through cinematography and EMG studies, there is still much to be learned, and one can expect continuing research in this area.<a></a> </p> <p>Lower-extremity prostheses are more complicated than one might imagine. The acceleration sequences required for normal human gait are not produced by a simple pendulum swing. Instead, one must build nonlinear damping devices into a lower-extremity prosthesis to control the swing phase so that it will approximate that of a normal human being. In the simplest versions, disks of leather are used to provide this friction. Recently, nonlinear and hydraulic devices have been built into artificial limbs. These hydraulic devices still suffer occasionally from seal and other failures, but they have been successfully used by amputees under a Veterans Administration evaluation program.</p> <p>The problem of socket design and fitting is still under investigation, for one must transfer considerable forces to the limb, both in direct compression and in torsion. Sockets providing total-surface contact, air cushions, "breathing effect" and special types of support have been developed. For a number of years, researchers have attempted to measure the pressure distributions occurring under dynamic conditions within lower-extremity sockets. In general, these attempts have not been successful, and this remains a challenging area for future research. Such pressure-distribution data are urgently needed for the intelligent design of lower-extremity prostheses and, in some cases, for upper-extremity devices.</p> <p><i>Orthotics</i></p> <p>The first orthoses were the splints used to support a fractured limb and the canes and crutches used by early man. Bracing of weakened limbs due to neurological disorders and the therapeutic appliances used to overcome deformities have been widely applied by the orthopaedic surgeon and his collaborating orthotist. Through surgical reconstruction and tendon transplants, the orthopaedic surgeon can provide concepts for rehabilitation which complement improved engineering systems.<a></a> The future possibilities of such combined surgical intervention and engineering systems development have been only hinted at and much research undoubtedly will be carried on between the engineer and the surgeon in this area.</p> <p>A number of new, externally powered, and controlled splint systems are being made available to paralyzed patients. A kind of race is now occurring between the proponents of gas-powered orthotics systems and electrically powered systems. Actually, these systems are highly competitive when one considers the energy-storage capacity and weight of motors and batteries as compared to gas actuators and storage containers. The gas-powered systems still provide the best force-to-weight capability, but electric motors are being improved continuously and the overall simplicity of an all-electric system has many advantages.<a></a> </p> <p>A number of prehensile splints to provide grasp to paralyzed patients have been applied routinely, and many new multiaxis powered splints are being applied.<a></a> As in the case of the complex prosthesis, the need for many different approaches to meet the many different types of disability in paralysis or neurological disorders has slowed down the broad development of externally powered orthotic systems. We believe, however, that engineering developments will soon reach the point where such systems will be widely applied to the very large number of patients who can benefit from increased functions, especially in old age. Expanded research and development in externally powered orthoses for both upper and lower extremities is certainly going to occur.</p> <p>A promising new approach is being investigated throughout the world. This approach suggests the use of electrical stimulation of muscles for functional activity. <a></a> While electrical stimulation of muscles has been used extensively for a number of years in diagnosis and in therapy, its use for functional action has only recently been studied. The increased sophistication of electronic systems and the possibility of passive and active implants suggest the realization of controlled muscle activity. Such systems would certainly operate in parallel with some sort of external functional bracing, for in the foreseeable future one can imagine only a limited number of agonist and antagonist muscles being functionally stimulated.</p> <p>There is much to be learned about whether denervated muscles can be kept in an active stimulatable condition for long periods of time and whether intact lower motor systems will respond to controlled stimulation without inducing spasticity and other aberrations. The progress to date, however, is exciting and it is urged that serious consideration be given to programs of electrical stimulation of the muscles of recent victims of neuron lesions so that the atrophy of involved muscles can be retarded awaiting the day that functional stimulation can be made available.</p> <p>Expanded research around the understanding of the process of functional stimulation and physiologic factors in muscle stimulation, both from a physiological and an engineering point of view, is to be expected.</p> <h4>V. and VI. Feedback Receptors and Local Feedback</h4> <p>A human being controlling either the most simple or the most complex assistive device must have feedback information. In normal human motor activity, feedback comes via sight, sound, touch (pressure), and proprioceptive senses. These normal feedback channels are always impaired to some degree in handicapped persons and may be altogether missing. The visual path is still the most important for control in most orthotics and prosthetics systems, but much research has been undertaken recently to relieve the patient of the need to keep his eyes consciously fastened on each part of an output task. The sounds of electric motors and gas-operated systems provide many cues for feedback control, some of which may not be consciously appreciated by the subject. Many amputees learn to interpret reflected forces and motions through Bowden cables and other body-powered components.</p> <p>Much interest in sensory feedback research has been shown throughout the world, but only minimal progress has been made to date. Stereo effects are also being investigated, including transducers which produce vibration of varying phase and intensity at two points on the surface of the skin from which a sensation of spatial position proportional to an actual position can be produced <i>. </i><a></a> The possibility of producing a similar spatial position sense through "stereo" electrical stimulation at two different points on the surface of the skin is also being investigated.</p> <p>Recently proposed orthotics and prosthetics systems, using data processes, may require local feedback which is not processed by the human. <b>Fig. 1</b> indicates some paths which are analogous to some afferent paths in lower motor neuron systems in the human. Systems to select the grasping pressure in terminal devices have been developed. A recent approach to the problem at the Army Medical Biomechanical Research Laboratory uses a sound pickup to detect incipient slip in lieu of pressure to modulate the force applied in an artificial hand <i>.</i><a></a> </p> <p>To date, feedback control of orthotics and prosthetics systems has been severely limited by the inability to provide effective artificial sensory feedback, and will constitute a major barrier to overall system effectiveness for some years to come. It seems clear that a maximum research effort should be made to develop effective pseudosensory feedback signals, not only for orthotics and prosthetics systems, but also for sensory aids to the blind and deaf- areas which are, of course, closely related.</p> <h4>VII. Adaptive Learning</h4> <p>The success of any orthotics or prosthetics system or device must depend on acceptance by a patient and his abilty to learn to use it effectively. If the device proves to be more trouble than it is worth, it will be rejected. Thousands of rejected devices now rest in closets and dark corners.</p> <p>An important element of an orthotics or prosthetics system is the capability of a patient, whether young or old, to learn to employ his device skillfully <i>.</i><a></a> </p> <p>As new systems become ever more complex with many degrees of freedom (moving elements), the problem of control becomes more difficult.<a></a> One may visualize a multi-axis orthosis controlled by EMG signals from six or more voluntarily excited muscles (<b>Fig. 9</b>). An unanswered question remains as to how well the patient can train the six or more muscles to perform the functions required, especially when the functions may be very different from those for which the muscle was naturally used. The authors have discussed this difference between so-called naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC) (<b>Fig. 10</b>) <i>. </i><a></a> It appears intuitively correct to use the naturally conditioned channels wherever possible as signal sources for natural functions. The EMG-controlled artificial hands previously referred to use signals obtained from the prehensile extensors and flexors so that the amputee may open and close his artificial hand with the same muscles he would have used prior to the amputation. However, as degrees of freedom increase and the nature of the disability precludes naturally conditioned sources, one is forced to employ other muscles, such as the auriculares muscles behind the ears<a></a> or the trapezius muscles in the shoulders, as signal sources.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. A test of the feasibility of exercising three degrees of freedom by means of myoelectric control. Six muscle sites received percutaneous electrodes, all in the forearm. The six sites were then connected to a model hand trainer possessing three degrees of freedom. The motions of the trainer could be controlled to correspond with those of the control muscles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic representation of naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that much research on these issues remains to be done. Age is certainly an important factor, for it is known that young children adapt very much more easily to orthotic and prosthetic devices than do older persons. Learning capability is closely related to the amount of information being received by the patient through his feedback channels and to the amount of patterning and programming that can be done at the signal-processing level. No doubt the future will bring clarification of these matters.</p> <h3>Evaluation</h3> <p>Before closing, a major problem which continues to face the American orthotics and proshetics research, development, and clinical application program should be mentioned. This is the important issue of effective <i>evaluation. </i>Evaluation does not stand alone as a specific activity. The theory that a prototype developed by one group can be taken over by a separate evaluation agency to determine if it "works," and if it works can then be taken over by a manufacturer for production, just does not often succeed in practice. Problems in the medical engineering field of prosthetics and orthotics development are immensely complicated, and often the true nature of the problem to be solved is not undertood until one or two attempts have been made at solution. A constant interplay between the needs of the patient, the requirements of the physician, and the technical development by the engineer must be maintained. It is the rule, rather than the exception, that most new developments brought to the prototype stage require continued research and redesign. It seldom happens that a first-prototype development can be picked up and replicated in quantity for the field.</p> <p>The implication of the foregoing remarks is that the evaluation process is a continuing and integral part of the overall design-development process and is perhaps the hardest and most expensive part. To date, inadequate funds have been allocated for its accomplishment in grant programs. The result has been that not nearly so many fruits have accrued from the research and development programs as might otherwise have been the case.</p> <p>The specific need could be met by providing an overall systems-management function for the broad spectrum of activities throughout the nation. This systems-management function would be a cooperative effort authorized by federal government agencies and their advising groups. The lessons learned by the National Aeronautics and Space Administration in the management of the space effort seem applicable here, and it is the strong recommendation of these authors that the need for systems management in the broad field of orthotics and prosthetics research and development be recognized.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</li> <li>Allen, J. R., A. Karchak, V. L. 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Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</li> <li>Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</li> <li>Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</li> <li>Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</li> <li>Highland View Hospital, Ampersand report, Cleve-and, September 1966.</li> <li>Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 1966.</li> <li>Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</li> <li>Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</li> <li>Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</li> <li>Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kestenback, H. 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Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</li> <li>Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 1964.</li> <li>National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 1961.</li> <li>National Academy of Sciences-National Researchouncil, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</li> <li>Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 1964.</li> <li>Pearson, J. 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McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 1966.</li> <li>Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, September-October 1966.</li> <li>Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</li> <li>Vodovnik, L., C. Long, J. B. Reswick, A. Lippay,nd D. Starbuck, Myoelectric control of paralyzed muscles, IEEE Trans., BME-12, pp. 169-172, 1965.</li> <li>Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</li> <li>Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 1965.</li> <li>Wasserman, W. L., Human amplifiers, Sci. and Technol., October 1964.</li> <li>Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>45.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 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>72.</b> </td><td class="clsTextSmall">Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, September-October 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">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 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>68.</b> </td><td class="clsTextSmall">Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75r July 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>15.</b> </td><td class="clsTextSmall">Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</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>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 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>22.</b> </td><td class="clsTextSmall">Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 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>1.</b> </td><td class="clsTextSmall">Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 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>References</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 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>47.</b> </td><td class="clsTextSmall">McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 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>20.</b> </td><td class="clsTextSmall">Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 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>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 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>44.</b> </td><td class="clsTextSmall">Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 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>48.</b> </td><td class="clsTextSmall">McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., 47B: 448, 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>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>25.</b> </td><td class="clsTextSmall">Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 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>31.</b> </td><td class="clsTextSmall">Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</td></tr><tr><td class="clsTextSmall"><b> 51.</b> </td><td class="clsTextSmall">Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>65.</b> </td><td class="clsTextSmall">Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, 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>54.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 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>67.</b> </td><td class="clsTextSmall">Spaco, Inc., The sight switch, Huntsville, Ala.,pril 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>56.</b> </td><td class="clsTextSmall">Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 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">Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., November 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>4.</b> </td><td class="clsTextSmall">Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Highland View Hospital, Ampersand report, Cleve-and, September 1966.</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 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>5.</b> </td><td class="clsTextSmall">Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</td></tr><tr><td class="clsTextSmall"><b> 66.</b> </td><td class="clsTextSmall">Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 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>3.</b> </td><td class="clsTextSmall">Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Instructor in Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Mo. Data has estimated the numbers of patients in the United States with presented at combined meeting of the Panel on Control of External Power and the Panel on Upper-Extremity Orthotics of the Subcommittee on Design and Development, Committee on Prosthetics Research and Development, in New York, N.Y., May 15-17, 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>Lojze Vodovnik, D.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106, and Associate Professor of Electrical Engineering, University of Ljubljana, Yugoslavia.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James B. Reswick, Sc.D. </b></td></tr><tr><td class="clsTextSmall">Leonard Case Professor of Engineering and Director of the Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_005/aut67t-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_005/aut67-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_005/aut67-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_005/aut67-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_005/aut67-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_02_005/aut67-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_02_005/aut67-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_02_005/aut67-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_02_005/aut67-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_02_005/aut67-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_02_005/aut67-10.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 External Power in Prosthetics and Orthotics, an Overview Creator An entity primarily responsible for making the resource James B. Reswick, Sc.D. * Lojze Vodovnik, D.Sc. * https://staging.drfop.org/files/original/1af135b4046fb2db501ded967f727ab2.pdf a4ca54acbda5984b15304cd6f7f016f5 https://staging.drfop.org/files/original/228e86e9452aa08be3bd9351e6c31dd0.jpg 5ccce9aaa2c5fa279985a74d639717be https://staging.drfop.org/files/original/c3df5a9743aed351dd319f2fb7e5112b.jpg a6f33c8ff187dab14eaff25dfafeecc3 https://staging.drfop.org/files/original/d5917e7f85a5a4c742cd2881c5d8c622.jpg 7b428b86fa69aeaa6a00da502d9b8c5b https://staging.drfop.org/files/original/d7d878173bbf5ec95e330af715e05b3a.jpg 3fc75ef8e1cadc253917ec7678b04d21 https://staging.drfop.org/files/original/da2a87a3ffef9f0eaf6e00bce461aede.jpg b746ec00689aa36b9d45c21f1587efca https://staging.drfop.org/files/original/54cbbe5693ea9e29ee0aab4eeb74d355.jpg f68af07a7951cc4830b6396717efbbcb https://staging.drfop.org/files/original/c865c0387c4ee04978be8c5707188774.jpg b2accc827111018a5ac53834cf59ac5a https://staging.drfop.org/files/original/ec3a3830c510a3a5beeeceb61f8ec202.jpg 9ef1d7fba1b6d89801277060612ca699 https://staging.drfop.org/files/original/85aee9dd4f8c9ffb71f4f4f600f45426.jpg 3ba2d1b34f53dbd76ad7069fbc2847d3 https://staging.drfop.org/files/original/e9760a32a1177547755bd80d61b859d0.jpg 0e658181df75e5a68bafb70e7e89cb7a https://staging.drfop.org/files/original/e83bead762c305b477ce5472b0c2c660.jpg cfe681da6e99338852c5c85b9aa8a8cf https://staging.drfop.org/files/original/efcb14dbaa8a3571f79a5c522cbfc587.jpg b7a17d0b20c308b84db4cb71383ed647 https://staging.drfop.org/files/original/063f9cc82fc0b22d33d5afc3b26ab2f8.jpg c0c7f6254ff24cb2489895ad919e66c5 https://staging.drfop.org/files/original/d9aef5c99b9e68a90850d61c434ee8fb.jpg 302927b6d2390d85826ddc3c38ea28fc https://staging.drfop.org/files/original/d1a8faaf3cedc688656a9fdf13e1d6b1.jpg e86b096968e144fb105e347fca51cc98 https://staging.drfop.org/files/original/bae29461b9316b470b68481ef53c0e67.jpg 3a177550c19df8561c721d998a50b471 https://staging.drfop.org/files/original/cf3f68b62ba311b841de515c0ad9727c.jpg 378c97c7ad10e652d2a03009da51411b https://staging.drfop.org/files/original/1739de25d66a546b4f81d95b07a9cd81.jpg 74e052d9003c72e4bb39645dfb2f587f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_001.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 1 - 13 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_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities</h2> <h5>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. <a style="text-decoration:none;">*</a><br />E. E. Rogers, M.A.O.T. <a style="text-decoration:none;">*</a><br />M. S. Clark, M.A.O.T. <a style="text-decoration:none;">*</a><br />W. G. Stamp, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Children with severe multiple congenital limb deformities associated with thalidomide are numerically few. <a></a> Because of the severity of this disability, the associated deformities, and the psychological trauma to both parents and child, the thalidomide tragedy has served as a catalyst to study the congenital amputee in depth. There is still controversy concerning the appropriate prosthetic and rehabilitation program for these children, but the attention this tragedy has focused on other less-involved children perhaps will reap benefits far beyond our expectations. <a></a></p> <p>The possible factors associated with acceptance or rejection of appliances may be inherent in the appliance, or they may arise from the child's own frustration, the parental reaction, <a></a> or other environmental factors. Retrospective studies of children who attend the Nuffield Orthopaedic Centre for prosthetic management and a review of the relevant literature have been carried out in an effort to establish a pattern of management and to delineate topics for future research.</p> <h3>Scope of the Study</h3> <p>During the past four years, 50 children with congenital amputations and limb deformities have attended the Disabled Living Research Unit at the Nuffield Orthopaedic Centre. Approximately half were deemed not to need prostheses or appliances at this time.</p> <p>This article reviews 21 children with multiple congenital limb deformities who have been under continuous care for prosthetic management and general rehabilitation for four years. All the deformities were presumed to be due to thalidomide, and the lesions were characteristically bilateral (<b>Table 1</b>). Thirteen of the children have been fitted with upper-limb prostheses only, four with lower-limb appliances only, and four with both upper-and lower-limb appliances (<b>Table 2</b>). Henkel's classification <a></a> was used; other classifications are used in various parts of the world. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each child has been fitted with appliances on more than one occasion. In considering acceptance or rejection of prostheses, attention has been focused on the type of prosthesis provided rather than actual numbers. A satisfactory design may well be repeated in different sizes or, after rejection of one type, a different pattern may be tried. On average, each child has passed through three stages of prosthetic management, but the number of prostheses made and supplied is in considerable excess of this (<b>Table 2</b>). The classification of type of prosthesis fitted is given in <b>Table 3</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>Some children had only conventional prostheses, and others only powered upper-limb appliances. The majority, however, started with conventional appliances and then "graduated" to the powered ones.</p> <h3>Criteria for Prosthetic Management</h3> <h4>Upper-Limb Appliances</h4> <p>The fitting of upper-limb prostheses at the Disabled Living Research Unit was governed by various factors. In the early stages, the demands of the parents and the availability of materials and appliances were the most dominant factors. As this was a disability incurred by a man-made drug, the parents felt that they had the right to have the best treatment available. For the first year or so the Unit was dependent upon the availability of material and parts from within the United Kingdom, those imported from Germany, or what could be made locally.</p> <p>When the children's rudimentary arms were long enough to grasp objects bilaterally, to reach the mouth, and to be within the child's vision, then an appliance was not considered appropriate. <a></a> But when both arms were absent, or the rudimentary arms were so short that they could not achieve the basic function of feeding, artificial arms were fitted. However, these children were also deliberately encouraged to use their feet to enable them to acquire sensory perception of texture, temperature, etc., as well as dexterity in movement and achievement of toilet management. <a></a></p> <p>The fitting of the upper-limb appliances attempted to follow the normal behavioral patterns. A cosmetic appliance fitted during the first few months of life helped them to get used to wearing such appliances and learn sitting balance.</p> <p>In order to give the child some form of bilateral grasp, "pat-a-cake" appliances were fitted when the child was approximately one year old. These were the first type of appliances to be powered by compressed carbon dioxide, and were actuated bv body movement (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The first powered upper-limb appliances known as "pat-a-cakes" were fitted at the age of about one year. These are no longer issued. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The next stage was the introduction of wrist rotation and externally powered hooks or hands, fitted as the materials became available and the needs of the child demanded (<b>Fig. 2</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Child with bilateral amelia who was issued an appliance giving powered prehension and wrist rotation with passive elbow and shoulder movements. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Limb Appliances</h4> <p>A child's development is directly dependent on the vertical positioning of spine. Sitting, standing, and walking at the normal age are important for the child's normal development. Therefore, it is important that babies with amelia or short dysmelia of the lower extremity sit up at the normal age of sitting; that is, at the age of six months in a "flowerpot" (<b>Fig. 3</b>), and at about one year they should be given some form of legs for mobility (<b>Fig. 4</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Child with lower-extremity amelias placed in a "flower-pot" at the normal age of sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Some form of mobility should be provided during the child's second year. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The type and height of the lower-limb appliances issued to the children depended on the degree of competence and confidence in balance (<b>Fig. 5</b>). The children were supplied appliances with "shoes" as soon as was practicable; in any case, before they commenced formal schooling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The type and height of a lower-limb appliance depend upon the child's competence and balance. Whenever possible, the height should be kept within the lower limits of normal growth. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Coping with appliances for all four limbs imposes a considerable physical and intellectual strain on small children. The physical maneuvers necessary to walk with bilateral lower-limb appliances are often considerably restricted by the presence of upper-limb appliances. The children's activities and needs should be balanced and the training program phased to allow the children to obtain practice with both sets of appliances separately and together. For some children, upper-limb appliances are an aid to balance, whereas for others these appliances are an impediment.</p> <h3>Method</h3> <p>The children and parents were interviewed, schools were visited, and all available records and reports were reviewed. These records include functional activities of daily living, simple objective tests of skill, and school reports. The extent of the activities covered included those featured in other simple follow-up studies. <a></a> All children were seen by a clinical psychologist.</p> <p>In the analysis, notation was made of:</p> <ol> <li>The children's preferences.</li><li>The parents' preferences.</li><li>The amount of cooperation from the child.</li><li>The amount of cooperation from the parent.</li><li>The amount of cooperation from the school and teachers.</li></ol> <p>Concerning mechanical aspects, comments were recorded concerning:</p> <ol> <li>The weight of the appliance.</li><li>Delay in supply of the appliance.</li><li>Delay in supply of spare parts.</li><li>Speed of response of the appliance.</li><li>Limitation of reach.</li><li>Limitation of other movements.</li></ol> <p>Physical reactions noted included heavy perspiration (associated with the weight of the appliance), skin rashes, soreness from the harness, and restriction of the child's body movement.</p> <h3>Definitions</h3> <h4>Appliances</h4> <p>The appliances have been grouped into: conventional upper limbs; powered upper limbs; lower limbs; and then classified according to their functional features (<b>Table 2</b> and <b>Table 3</b>).</p> <h4>Acceptance And Rejection</h4> <p>"Acceptance" of prostheses by children is often more passive than active. "Acceptance" of an appliance in this study means that the child uses the appliance for most of the day for various activities; for example, feeding, writing, or playing. "Acceptance" in this context does not necessarily indicate that the child prefers the appliance to his own limbs. Almost invariably, the children prefer to use their own body and residual limbs for most manipulative activities.</p> <p>"Total rejection" implies complete refusal to wear the appliance. Some children have to be persuaded to wear the appliances even for short periods each day, but will do so with encouragement; this usually means periods of half an hour. This condition is termed "partial rejection"; it could equally well be termed "partial acceptance."</p> <h3>Results</h3> <h4>Acceptance And Rejection Of Conventional Upper-limb Appliances</h4> <p>Undoubtedly, conventional appliances for this group of children have a poor record of acceptance. Of those fitted before the age of two years, 14 children fitted with 14 bilateral appliances rejected the appliances on nine occasions (64 per cent), whereas acceptance was recorded in five cases (36 per cent) (<b>Table 4</b>). But it is difficult to assess correctly whether a child of this age has accepted or rejected an appliance, as the observer's judgment is likely to be very subjective.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was noted, however, that after the age of two years conventional appliances were totally rejected.</p> <h4>Acceptance And Rejection Of Powered Upper Limbs</h4> <p>Thirty-nine powered upper-limb appliances were fitted on 13 children, and were rejected on 27 occasions.</p> <p>The acceptance of the powered upper-limb appliances in this series is 25 per cent in children under four years of age and 38 per cent in those over four years (<b>Table 5</b>). Acceptance increased considerably when the powered hand was introduced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>However, partial rejection (or partial acceptance) occurs for 50 per cent of appliances, and total rejection of powered appliances has not occurred in children over four years of age.</p> <h4>Acceptance And Rejection Of Lower-limb Appliances</h4> <p>Seventeen lower-limb prosthetic appliances have been fitted on eight children; 13 of these were accepted, one partially rejected, and only three totally rejected. Ultimately, <i>all </i>lower-extremity prostheses were accepted.</p> <p>One child rejected appliances during her second year, because any type of appliance restricted her mobility and she was able to progress well by crawling. One child rejected, when, at the age of five years, he was fitted with appliances and he found them cumbersome and restrictive. This child has now accepted caliper appliances. Another child preferred the ski-type of appliance rather than those with shoes, because the latter kept on breaking and she had little confidence in them.</p> <p>The swivel walkers were made according to the design principles described by Motloch and Elliott <a></a> (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Swivel walkers are a distinct improvement over previous lower-limb appliances. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>None of the swivel walkers fitted has been rejected. They are a distinct improvement over any previous appliance. The full details are given in <b>Table 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Acceptance And Rejection Of Appliances According To Age</h4> <p>Acceptance and partial acceptance are clearly related to increasing age (<b>Table 7</b> and <b>Table 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Major Reasons For Rejection Of Upper-limb Appliances</h4> <p>There were many recorded reasons for rejection or partial rejection, and for each child there were usually several contributory reasons.</p> <p>When these were grouped together and all the different appliances were considered, it was found that the commonest cause for rejection was the mechanical inefficiency of the prostheses (76 per cent); the next most common cause of rejection was the child's preference for using his or her own residual limbs. In a relatively few cases, the lack of cooperation of parents or child was a major reason for rejection (<b>Table 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Change From Rejection To Acceptance</h4> <p>It is even more interesting to analyze the major factors that lead from a rejection to an acceptance (<b>Table 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Family Environment</h4> <p>The problem of parental cooperation is partly reflected in the families' general environmental background. Although the numbers are small, the review indicates that the better-educated, middle-class families are more likely to help their children accept appliances (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Clinical Psychologists' Assessment</h4> <p>All the children in this series were of at least average intelligence, with three being distinctly above average. Two children of average intelligence developed aggressive tendencies and for a period would use their artificial arms almost entirely as weapons. Their aggression finally diminished after starting at normal primary schools.</p> <p>Psychological testing was unable to delineate specific features helpful in predicting acceptance or rejection of appliances. Perhaps if the testing had been more comprehensive and more frequent, trends might have been exposed. However, the simple clinical psychological appraisal reflected the acknowledged situation rather than helping to elucidate the underlying motivation toward acceptance or rejection of prostheses. <a></a></p> <h4>School</h4> <p>In this series, 13 children attended normal state schools, five attended day schools for the physically handicapped, and two were at residential schools for the physically disabled. One child was undergoing orthopaedic treatment during the period covered by this survey. From this small series, acceptance for upper-limb appliances was higher for children attending normal state schools than for children at special schools for the physically handicapped (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>The birth of a child with a congenital limb deformity is a domestic crisis and the parents need urgent help and advice on the total management of the child. The crisis intervention <a></a> is a critical function of the management team, but the personal approach and careful handling are also essential. <a></a></p> <p>That there should be complex factors interacting to produce acceptance or rejection of the appliances is understandable. Goldner and Titus <a></a> noted that they have been uniformly unsuccessful in the upper-extremity amelia and phocomelia, particularly when the condition occurred bilaterally. It was only when external power was added that they were able to make significant progress. This experience has been true of other authors. <a></a></p> <p>The outstanding findings in this study are that therapists, parents, and children partake in a mutual learning process, and very close cooperation between all concerned is essential for good rehabilitation. <a></a> Brooks <a></a> emphasizes the importance of recognizing situations which are known to produce adverse reaction and aptly refers to this as "crisis intervention." Each stage of the child's development must be watched, <a></a> and the value of the appliances should be frequently reassessed.</p> <p>Many children have deformities which at first do not seem to need surgical or prosthetic intervention. However, as the child develops, function and environmental features change, and there is a need for continuity of supervision and repeated clinical and functional reappraisal. The need for aids to daily living, special aids, or, indeed, surgical management may become relevant at any stage of the child's development. <a></a> Although surgery of the upper limbs should be approached with caution during infancy, arteriograms indicate that the blood supply, even in single-digit phocomelia, is likely to be adequate for major reconstructive surgery to be contemplated in later life. <a></a></p> <p>Objective records of activity, writing, and performing other prearranged tasks which can be timed, or for which some degree of accuracy can be charted, are of more value than a "clinical impression" or answers to a questionnaire. <a></a> This study has employed simple tests which can be timed, and from which "learning curves" can be constructed. <a></a></p> <p>The assessment of a child's function is more than simple assessment of activities of daily living in a therapeutic environment. Assessment must be in "real life" terms, and the children, the teachers, and the parents need to be integrated into the assessment and therapeutic team. This is well illustrated by the comprehensive evaluation of a functional cosmetic hand carried out by New York University. <a></a></p> <p>The teacher does not need to be particularly orientated toward the physically handicapped. The children in this study often appear to do better at normal schools than at special schools for the physically handicapped, unless they have all four limbs severely involved; and very often a normal school near home would seem to be more appropriate than a school for the physically handicapped that is located further away. Estimation of intelligence should be an accepted method of evaluation of all children prior to entrance into school, and psychological evaluation may be of significant help. <a></a></p> <p>However, it may be necessary to adapt the child's physical environment, so that he is not penalized by unsuitable classroom furniture or unduly physically fatigued. This can usually be overcome by relatively simple devices.</p> <p>Gouin-Decarie <a></a> compared thalidomide children to the average population and found the mean I.Q. to be 98. Along with a delay in speech, there was retardation in development of the child's perceptual concept of space and movement.</p> <p>The design and fitting of prosthetic devices for children with multiple limb deformities and the subsequent training and resettlement of the children at home and school are complex activities involving engineers, technicians, prosthetists, therapists, school teachers, social workers, and, not the least, the children and their parents. The establishment of objective and valid criteria for evaluating patient performance in the very young is difficult. The fact that the children are constantly changing as they grow and develop should emphasize the importance of reassessing goals of achievement as well as anticipated attainment.</p> <p>There are three major factors of influence: the personality of the child, the parental influences, and the therapeutic unit managing the child. <a></a></p> <p>Brooks and Shaperman <a></a> devised a "Prosthesis Adjustment Scale" based on the child's use of the prosthesis-the applied use, maintenance, and acceptance. In their experience with the below-elbow congenital amputee, acceptance was interrelated with wearing, use, and skill of applied use. Although they emphasize that the fitting of a unilateral congenital below-elbow amputee before the age of two tends to result in full-time wearing and good acceptance of the prostheses, they also note that the category most closely related to early fitting is full-time wearing. Although indoctrination for full-time wearing is possible for single amputees, it is much more difficult to accomplish for multiple amputees.</p> <p>The almost complete acceptance of lower-limb appliances from an early age reflects the point that if the appliance fulfills a real need, even if inefficiently, the appliance will be accepted.</p> <p>In the case of upper-extremity appliances, there is a definite improvement in partial acceptance and a dramatic improvement with the development of more reliable appliances, less subject to mechanical failure (note the change from P.3. to P.4. in <b>Table 5</b>).</p> <p>In this review, no differentiation has been made between mechanical failure, troubles with control mechanisms, or power packs. Interestingly enough, in this series there was no particular problem relating to the supply and recharging of the gas cylinders. As more function is derived from gas-powered appliances, the supply problem will increase and probably limit the use of this type of appliance. <a></a></p> <p>Brooks and Shaperman <a></a> also note that the acceptance of a prosthesis is closely related to the ability to communicate, and that good communication between parents and child (that is, good family relationships) is probably the major factor in establishing acceptance of appropriate prostheses. Thus the home environment is critical, and in certain circumstances this may be the determining factor. <a></a> In this series, the age of four appeared to be the "watershed." At this age, children can begin to understand the reasons for continuing to use appliances and become at least partially cooperative. They also tend to start to attend nursery school at this age. Children with severe multiple limb deformities may be educated in normal schools or special schools for the physically handicapped, depending upon their clinical or their social needs. <a></a></p> <p>The decision to remove the child to a residential school for the physically handicapped is a major one, and not necessarily associated with improvement in physical function or acceptance of suitable appliances. In this study, it has been noted that normal state schools have accepted these severely disabled children as a personal challenge and have usually gone to great lengths to encourage the children in their rehabilitation, collaborating closely with the hospital therapists and prosthetics departments. By treating the children in this way, they have been permitted, indeed encouraged, to face up to many of the normal challenges and experiences of school life. This seems to have helped the children to be integrated into community living.</p> <p>In this series, a small number of children with limb deformities in special schools for the physically handicapped are not so adapted to their disability as those at normal schools, and prosthesis acceptance is relatively poor. The atmosphere of the schools for the physically handicapped is often more protective and necessarily geared to the most incapacitated. Furthermore, some of these schools have many children who are on the borderline of being educationally subnormal. Appliance training in these schools is usually the responsibility of the physical therapist and not the teachers, and the teachers are reluctant to divert individual attention to appliance training in the presence of more disabled children who are unable to use appliances, for example, victims of cerebral palsy. However, children with severe mobility problems, as well as severe upper-limb dysmelia, may find the special equipment, adapted environment, slower tempo, and special staff of particular help.</p> <p>As a group, these children achieve remarkable levels of manipulative skills using their residual upper limbs, chin, shoulder tips, feet, and mouth. The wearing of an upper-limb prosthesis frequently hampers these skills while only providing a much cruder form of function. However, there has been no experience here in fitting a single multifunctional arm balanced with a cosmetic prosthesis, and there are certain advantages in this approach. <a></a> For children with absent or deformed legs, almost any form of lower-limb appliance gives them an immediate advantage in standing, achieving reasonable height, and—as a bonus—walking short distances.</p> <p>As a general experience, it can be said that patients must obtain an immediate advantage from the appliance for it to be accepted. It is the immediate postfitting phase which appears to be of greatest importance. If the appliance looks unfinished, if the technicians have to make numerous adjustments in the fittings, if it is uncomfortable or scratchy, if mother's face registers horror at the appearance—all these factors have a long-term effect out of proportion to their immediate import. If the antagonistic features even slightly outweigh the advantages, then acceptance is unlikely, or at best partial, and becomes more a matter of deference to authority, or, for children, part of a game rather than a true integration of the appliance into the body image. The immediate advantage gained must outweigh all the antagonistic factors. If this occurs, the patient will persist through further stages of fitting, training, and redevelopment.</p> <p>The swivel walkers are a striking example. These appliances were used experimentally at first because earlier caliper-type lower-limb appliances were breaking so frequently that the children were continually frustrated. The swivel walkers were both more reliable and more immediately efficient, and acceptance was immediate and universal.</p> <p>Cosmesis is often a motivating force in acceptance of any appliance. <a></a> In this series, there was a marked improvement in acceptance on the introduction of a powered hand in preference to a hook (<b>Table 5</b>) even though function might be less. The change from 25 per cent to 75 per cent acceptance associated with the use of a powered hand accentuates the urgent need for a sophisticated, cosmetically acceptable, functional terminal device. This confirms the experience of New York University. <a></a> Children were also pleased when ordinary shoes could be fitted to their lower-limb appliances.</p> <p>Frequently, however, it is the mothers' dominant influences which lead to cosmetic acceptance overriding function, whereas fathers are often more likely to be interested in function. In one instance, a powered prosthesis was frequently returned nonoperational because a father repeatedly attempted to improve its functions. Another father, often at home because of shift work or lack of work, spent many hours training his son to use his upper-limb prostheses.</p> <p>However, acceptance associated with cosmesis might occasionally extend to a pathological acceptance, and there is one child with bilateral upper-limb, unequal-length phocomelia, who insists on wearing a single upper-limb prosthesis in spite of the fact that it prevents him from undertaking many functions he could perform with his two phocomelic limbs. The initial supply was largely at the insistence of the parents, and in retrospect probably should have been refused.</p> <p>One problem that was very unsettling for both child and parents was the involvement of more than one clinical center. Usually, this was due to geographical circumstances. The clinicians near the child's home were unable to provide certain facilities; for example, experienced training, or appropriate surgery or prosthetic devices. Furthermore, in some instances, there was a separation between the provision of upper-limb appliances and lower-limb appliances. In all instances, this diversification of clinical control and lack of unified approach led to difficulties in management and was, not infrequently, a contributory factor in rejection of appliances.</p> <h3>Conclusions</h3> <p>The object of any critical reappraisal of clinical management is to improve the treatment of patients in the future. On the basis of this study, it is possible to lay down some broad general principles for the management of children with congenital limb deformities.</p> <p>In the initial stages, the parents' attitudes are dominant; therefore, early confident collaboration is essential. The parents should have faith in the doctors and should have a clear understanding of the individual responsibilities of the members of the pediatric and prosthetics team, which may vary according to local facilities. The child should be under frequent review by the same clinical team. Each member of the team—pediatrician, prosthetics consultant, therapist, technician, social worker, and psychologist-has contributions to make at all stages.</p> <p>For severely disabled children, introduction to adapted clothing, aids to daily living, and training activities must be tailored to fit the individual child's expected development, and independent activities should, wherever possible, match the accepted "stepping stones" of child development.</p> <p>Lower-limb deformities should be treated by appropriate surgery and prosthetics so that independent mobility is achieved as early and as efficiently as can be matched with normal progress. The size of the appliance should match natural growth as nearly as possible.</p> <p>Upper-limb appliances present a more complex problem. Most children will alternate between accepting and rejecting appliances, depending on their development and needs.</p> <p>Early fitting, at perhaps 12 to 18 months (or even earlier), has some relevance in that it accustoms the child to a somewhat uncomfortable appliance. But the child is unlikely to accept formal training in the use of a sophisticated appliance until more than four years of age. Once schooling starts, training in the use of an appropriate appliance should be part of formalized education, and this demands close collaboration between therapists and teachers, particularly in the school surroundings.</p> <p>The prosthetists and technicians must be prepared to adapt and redesign frequently as the child's needs change. They must accept the need for adequate cosmesis even at an early age. Rejection of appliances must never be regarded as "naughty" or "ungrateful," but as part of natural development. Gentle insistence on regular training sessions may well tide a child over until in later years he understands and appreciates the need for the appliance and can make a reasonable personal decision regarding design and use.</p> <p>There is an urgent need for the development of mechanically reliable, cosmetically acceptable, and functionally sophisticated upper-limb appliances.</p> <p>This development of an awareness of the most suitable design and the appropriate uses of upper-limb prostheses should be the outcome of close understanding between the child, parents, doctors, teachers, and therapists.</p> <h3>Summary</h3> <p>A group of 21 children with multiple limb deformities associated with thalidomide who have been supplied with various upper- and lower-limb prostheses is described. The acceptance and rejection of the appliances are analyzed according to age, family background, and the type of appliance.</p> <h3>Acknowledgments</h3> <p>The powered upper-limb appliances and the swivel walkers were designed and made in the Research Workshops at Mary Marlborough Lodge.</p> <p>Other appliances were made in the Orthopaedic Workshops of the Nuffield Orthopaedic Centre or supplied by the Ministry of Health in various limb-fitting centers.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>Management of the child amputee</i>, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</li> <li>Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, <i>Crisis intervention</i>, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</li> <li>Brooks, M. B., and J. Shaperman, <i>Infant prosthetic fitting</i>, Amer. J. Occup. Ther., 19:6, November and December 1965.</li> <li>Burtch, R. L., <i>A study of congenital skeletal limb deficiencies</i>, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</li> <li>Buttrup, E., <i>Parents of child amputees</i>, Prosthetics International, Vol. 2, No. 1, 1964.</li> <li>Campbell, E. I., and J. C. Bansavage,<i> The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study</i>, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</li> <li>Fishman, Sidney,<i> Studies of the upper-extremity amputee; VIII. Research implications</i>, Artif. Limbs, Autumn 1958, pp. 117-127.</li> <li>Fishman, Sidney,<i> Amputee needs, frustration and behavior</i>, Rehab. Lit., Vol. 20, 1959.</li> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, Part 1</i>, Artif. Limbs, Spring 1964, pp. 28-43.</li> <li>Frantz, C. H., and R. O'Rahilly,<i> Congenital skeletal limb deficiencies</i>, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</li> <li>Friedmann, L.,<i> Special equipment and aids for the young bilateral upper-extremity amputee</i>, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</li> <li>Gesell, Arnold L., et al.,<i> Infant and child in the culture of today; the guidance of development in home and nursery school</i>, Harper, New York, 1943.</li> <li>Gillis, Leon,<i> Thalidomide babies; management of limb defects</i>, Brit. Med. J., September 8, 1962.</li> <li>Goldner, J. L., and Bert R. Titus,<i> An experience with externally powered prostheses for children</i>, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</li> <li>Gouin-Decarie, T., <i>The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers</i>, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</li> <li>Hall, C. B., M. B. Brooks, and M. F. Dennis, <i>Congenital skeletal deficiencies of the extremities</i>, J.A.M.A., 181:590 599, August 1962.</li> <li>Hall, C. B., <i>Corrective surgery for infant hands</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hall, C. B., <i>Recent concepts in the treatment of the limb-deficient child</i>, Artif. Limbs, Spring 1966, pp. 36-51.</li> <li>Haslam, E. T., Joan Hayden, and Jean Dutro, <i>The habituation of a congenital quadruple amputee</i>, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</li> <li>Hebert, B., <i>The psychologist and congenital physical anomalies, Inter-Clinic Information Bull.</i>, Vol. VI, No. 4, January 1967.</li> <li>Henkel, L.,<i> Das Fehlbildungsmuster der Dysmelie</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> <li>Her Majesty's Stationery Office Publication, <i>Deformities caused by thalidomide</i>, 1964.</li> <li>Hunter, J. M., David Subin, and A. J. Plank, <i>Some observations on upper extremity prosthesis applications</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hutt, S., Private communication.</li> <li>Kay, Hector W., and Edward Peizer, <i>Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance</i>, Artif. Limbs, Autumn 1958, pp. 31-87.</li> <li>Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker,<i> The management of upper limb deficiencies in the thalidomide-type syndrome</i>, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</li> <li>McKenzie, D. S., <i>The clinical application of ex- ternally powered artificial arms</i>, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</li> <li>McLaurin, C. A., <i>External power in upper-extremity prosthetics and orthotics</i>, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</li> <li>MacNaughton, A., <i>The role of the occupational therapist in the training of the child arm amputee</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Maier, W. A.,<i> Thalidomide embryopathy and limb defects</i>, Orth. Dis. Child, Vol. 40, 1965.</li> <li>Marquardt, E., <i>The Heidelberg pneumatic arm prostheses</i>, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</li> <li>Mendez, M. A., <i>Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton</i>, Occup. Therapy, Vol. 30, No. 5, May 1967.</li> <li>Motloch, W. M., and Jane Elliott,<i> Fitting and training children with swivel walkers</i>, Artif. Limbs, Autumn 1966, pp. 27-38.</li> <li>Nichols, P. J. R., <i>The development of powered limbs, Special Education</i>, Vol. 44, Winter Issue 1965.</li> <li>Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, <i>Aids to daily living for children with severe multiple congenital limb deformities</i>, in preparation, 1968.</li> <li>Nickel, V. L., and Worden Waring, <i>Future develop- ments in externally powered orthotic and prosthetic devices</i>, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</li> <li>Pearson, F. A., and B. W. Spiers, <i>Teamwork in the management of dysmelic children</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</li> <li>Scott, Stevenson M., <i>Providing for their education</i>, Special Education, Vol. 44, Winter Issue 1965.</li> <li>Sheridan, M., <i>The developmental progress of infants and young children</i>, Ministry of Health Report No. 102, 1960.</li> <li>Siller, Jerome, and Sydelle Silverman, <i>Studies of the upper-extremity amputee; VII. Psychological factor</i>s, Artif. Limbs, Autumn 1958, pp. 88-116.</li> <li>Simpson, D. C, and D. W. Lamb,<i> A system of powered prostheses for severe bilateral upper limb deficiency</i>, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</li> <li>Spock, B., and M. O. Lerrigo, <i>Caring for your handicapped child</i>, Macmillan Co., New York, 1965.</li> <li>Stamp, W. G., S. Mahon, and H. C. Morgan, <i>Problems of management of the child with multiple amputations</i>, Arch. Phys. Med., Vol. 46, May 1965.</li> <li>Swanson, A. B., <i>The Krukenberg procedure in the juvenile amputee</i>, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</li> <li>Swanson, A. B., <i>Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement</i>, Amer. J. Surg., 109, March 1965.</li> <li>Swanson, A. B., <i>Classification of limb malformations on the basis of embryological failures</i>, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</li> <li>Taussig, Helen B., <i>The thalidomide syndrome</i>, Sci. Amer., Vol. 207, No. 2, August 1962.</li> <li>University of California at Los Angeles Staff, <i>Cosmesis: can it be defined?</i> Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</li> <li>Weiss, S. A., <i>Integrating the handicapped child into the community center</i>, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</li> <li>Willert, H. G, <i>Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</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>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">University of California at Los Angeles Staff, Cosmesis: can it be defined? Inter-Clinic Information Bull., Vol. V, No. 10, July 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>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 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>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 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>50.</b> </td><td class="clsTextSmall">Weiss, S. A., Integrating the handicapped child into the community center, Inter-Clinic Information Bull., Vol. V, No. 8, May 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>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 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">McLaurin, C. A., External power in upper-extremity prosthetics and orthotics, Inter-Clinic Information Bull., Vol. VI, No. 1, October 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>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 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>8.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputee needs, frustration and behavior, Rehab. Lit., Vol. 20, 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>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 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>6.</b> </td><td class="clsTextSmall">Campbell, E. I., and J. C. Bansavage, The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Siller, Jerome, and Sydelle Silverman, Studies of the upper-extremity amputee; VII. Psychological factors, Artif. Limbs, Autumn 1958, pp. 88-116.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>24.</b> </td><td class="clsTextSmall">Hutt, S., Private communication.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 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>25.</b> </td><td class="clsTextSmall">Kay, Hector W., and Edward Peizer, Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance, Artif. Limbs, Autumn 1958, pp. 31-87.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 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>11.</b> </td><td class="clsTextSmall">Friedmann, L., Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Hall, C. B., Corrective surgery for infant hands, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, Aids to daily living for children with severe multiple congenital limb deformities, in preparation, 1968.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Swanson, A. B., The Krukenberg procedure in the juvenile amputee, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Swanson, A. B., Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement, Amer. J. Surg., 109, March 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>12.</b> </td><td class="clsTextSmall">Gesell, Arnold L., et al., Infant and child in the culture of today; the guidance of development in home and nursery school, Harper, New York, 1943.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Sheridan, M., The developmental progress of infants and young children, Ministry of Health Report No. 102, 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>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 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>29.</b> </td><td class="clsTextSmall">MacNaughton, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Pearson, F. A., and B. W. Spiers, Teamwork in the management of dysmelic children, Physiotherapy, Vol. 52, No. 6, 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>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Haslam, E. T., Joan Hayden, and Jean Dutro, The habituation of a congenital quadruple amputee, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">McKenzie, D. S., The clinical application of ex- ternally powered artificial arms, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Stamp, W. G., S. Mahon, and H. C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med., Vol. 46, 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>14.</b> </td><td class="clsTextSmall">Goldner, J. L., and Bert R. Titus, An experience with externally powered prostheses for children, Inter-Clinic Information Bull., Vol. VII, No. 2, November 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>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 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>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 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">Fishman, Sidney, Studies of the upper-extremity amputee; VIII. Research implications, Artif. Limbs, Autumn 1958, pp. 117-127.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, Autumn 1966, pp. 27-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Mendez, M. A., Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton, Occup. Therapy, Vol. 30, No. 5, May 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>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 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>34.</b> </td><td class="clsTextSmall">Nichols, P. J. R., The development of powered limbs, Special Education, Vol. 44, Winter Issue 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>31.</b> </td><td class="clsTextSmall">Marquardt, E., The Heidelberg pneumatic arm prostheses, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 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>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 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>4.</b> </td><td class="clsTextSmall">Burtch, R. L., A study of congenital skeletal limb deficiencies, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and M. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., 181:590 599, August 1962.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Swanson, A. B., Classification of limb malformations on the basis of embryological failures, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Willert, H. G, Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 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>21.</b> </td><td class="clsTextSmall">Henkel, L., Das Fehlbildungsmuster der Dysmelie, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 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>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Hebert, B., The psychologist and congenital physical anomalies, Inter-Clinic Information Bull., Vol. VI, No. 4, January 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Spock, B., and M. O. Lerrigo, Caring for your handicapped child, Macmillan Co., New York, 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>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, Management of the child amputee, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies; management of limb defects, Brit. Med. J., September 8, 1962.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Hall, C. B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs, Spring 1966, pp. 36-51.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Hunter, J. M., David Subin, and A. J. Plank, Some observations on upper extremity prosthesis applications, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker, The management of upper limb deficiencies in the thalidomide-type syndrome, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 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>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Taussig, Helen B., The thalidomide syndrome, Sci. Amer., Vol. 207, No. 2, August 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>W. G. Stamp, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Department of Orthopaedics, University of Virginia School of Medicine, Charlottesville, Va. 22901; Visiting Professor to the Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>M. S. Clark, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>E. E. Rogers, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Research Assistant, Department of Engineering Science, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. </b></td></tr><tr><td class="clsTextSmall">Director, Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-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 The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities Creator An entity primarily responsible for making the resource P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. * E. E. Rogers, M.A.O.T. * M. S. Clark, M.A.O.T. * W. G. Stamp, M.D. * https://staging.drfop.org/files/original/db74232ff919eba50ae953fc5d8e15df.pdf 4106376d5c34e536f4d1f88cbe77c124 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_001.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 1 - 4 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_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_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>Still a Long Way to Go</h2> <h5>D. S. McKenzie, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is probably a common experience to those of us who work in the field of artificial limbs to receive odious comparison between the relatively primitive prostheses and the sophisticated hardware deriving from space technology, nuclear physics, and the like. The implication usually is that, if similar expenditure on research were made in our field, similar dramatic advances would be made. I do not think that the problem is as simple as this reasoning would imply, and there is some evidence to support my view. I am told that, once upon a time, a great American aviation company undertook to develop an artificial arm and that, some years and a million or two dollars later, they reverted with relief to the relatively simple matter of designing aircraft.</p> <p>And yet we must acknowledge that the externally powered upper-extremity prostheses of today are poor things. It is very doubtful indeed whether the unilateral arm amputee can obtain from them any functional or emotional gain over that deriving from the conventional body-powered prosthesis; indeed, in some respects there may be a loss. It is even doubtful whether any bilateral amputee with measurable humeral stumps would be improved, except perhaps by making it possible to superimpose an additional degree of freedom such as pronation-supination on the existing body-powered prostheses. Indeed, I would go so far as to say that the amelics and bilateral shoulder-disarticulation patients would be better off functionally if they only had sufficient sites available for harnessing with sufficient power and excursion for body-powered control. Currently available externally powered limbs are acceptable to these patients only because a little function is better than none at all. How little that is, is exemplified by the readiness with which the children with upper-extremity amelia and normal lower limbs revert to using their feet for prehension and manipulation.</p> <p>It is of more than passing interest to attempt to analyze why these things should be so, and I think there are a number of reasons.</p> <p>First, the power-weight ratio of available actuators and power storage components is still not advantageous enough for us to provide truly acceptable responses.</p> <p>Second, we have not yet discovered enough control sites capable of providing a sufficient number of degrees of freedom to position the hand or terminal device in space, to put it in the optimum attitude in relation to each task to be performed, and still leave an adequate reserve for prehension.</p> <p>The problem of simulating normal prehension has not been solved, nor, in my opinion, has a truly acceptable compromise been attained. Most writers agree that a well-designed hook is more functional than any of the many so-called functional hands, and yet few would claim that the hook contributes anything to cosmetic restoration or that it is likely to be emotionally satisfying to more than a small proportion of patients. Various ingenious hands purport to provide a selection of different types of grasp, such as the power grasp, precision grasp, "three-jaw chuck," and so forth, and some even achieve this. But none of them, nor of the hooks for that matter, is capable of manipulation within the grasp. This results in the exasperating experience for the user that any object he picks up is seldom immediately in a position of function; he is unable to manipulate it into such a position and has to resort to inelegant procedures such as transferring the object to the mouth and back to the hand again. Furthermore, many tasks that we do are achieved by manipulation-screwing, modeling, squeezing, and a host of others--which, for the amputee, have to be done by energy-consuming gross arm movements or even gross body movements, and he cannot feel what he is doing. It is not surprising that the unilateral amputee elects to use his remaining hand, and the amelic his toes.</p> <p>The foregoing difficulties apply in the main both to externally powered and body-powered prostheses, and I have said little about sensory feedback, a degree of which is available to the users of the latter systems. The control cable offers a built-in position servo, while a great deal of information about the forces applied at the output can be derived from the reactions of the harness against the body and those of the socket on the stump. When external power is used, these afferent channels either cease to exist or are severely attenuated, and it becomes necessary to consider the provision of artificial sensory loops which in their turn introduce difficulties in interpretation.</p> <p>We are thus confronted with what I believe to be the main barrier to progress in externally powered prostheses-the man-machine interface. This should be taken to mean not only the physical attachment of the prosthesis to the wearer, but also the boundary through which all command signals from the biological system of the wearer must pass to the mechanical system of the prosthesis and through which all information relating to the output of the prosthesis must return to the biological system if the wearer is to make the best use of such information to modulate performance.</p> <p>It is on these channels of communication that the effective control of externally powered devices depends. I am quite certain that we do not know enough about their mechanism to exploit them to best advantage. No one has yet attempted to measure the "goodness" of the channels-for example, in terms of communication theory-and yet I believe that effective systems design would follow on such data as surely as night after day.</p> <p>One of the greatest virtues of biological systems is that they are highly adaptive. The human control system-and in particular the computer as represented by the central nervous system-is no exception to this. The pattern of manual activity which we require in order to enjoy a full life is so infinitely variable that I have very serious doubts whether any form of programmed operation within the prosthetic system will satisfy a user for any length of time. The concept of programming the trajectory of the terminal device so as to limit the decision-making demand upon the user to commanding the system to move it from <i>A </i>to <i>B </i>is open to this criticism. Even if provision were made for the user to override the program and revert to voluntary control, I suspect that the switch would soon be left permanently in the override position. In any event, the case for this sort of programming seems to me to be accepting that the interface is inevitably poor in a communications sense. It may be that a better understanding of the interface will make this an unduly pessimistic view.</p> <p>Reverting to the adaptive properties of the biological system in general, and of the central nervous system in particular, it seems to me that significant progress in externally powered limbs will be made only when it becomes possible to link the central nervous system "on line" with the prosthetic control system. Servo loops crossing the interface would make an integrated and adaptive system. It might be said that a start had already been made on this by exploiting the myoelectric discharges for control. In such an integrated system, however, the command signal is being derived by tapping the middle of the efferent loop. Such sensory information as returns by afferent channels is derived from the muscles and their tendons. Essentially, this is a backwater of the main stream of the afferent channel of the man-machine complex. It follows that information about the output of the man-machine system can only be inferred rather than known. In my view, Simpson's position-controlled servos and Bottomley's pressure-demand pneumatic valve have more prospects of achieving a truly adaptive output and might be regarded as among the first breaches in the man-machine interface.</p> <p>Taking all these matters into consideration, besides many other difficulties which I will not discuss for reasons of space, we are in no position to be complacent about externally powered arms. Indeed, the state of the art is so relatively primitive that the only overriding indication for prescribing them at this time is bilateral high-level amputation or the equivalent-only a handful of patients out of the total upper-extremity case load of any prosthetic service and an even smaller proportion of the total case load. The difficulties are so great, and the amount of fundamental information lacking is so formidable, that one is continually surprised at the surge of interest in the field and the amount of effort that is going into it. Indeed the budget for prosthetics research and development in Great Britain for next year envisages that over 30 per cent of the total expenditure will go to work on external power. From what I saw when I visited the United States in May 1967, I would think that a similar proportional expenditure is being made there. Taking into account the tiny number of immediate beneficiaries-although admittedly they are among the most severely disabled-it is proper to take stock and consider whether this level of expenditure of money and effort is justified. Have we got our priorities right? Of course, there is much common ground in the orthotics field, and many developments arising from purely prosthetics requirements would have direct application here. This would increase the number of potential beneficiaries, but they would still be a small proportion of the total disabled population. I think the justification as well as the reason for the interest in the subject is the fact that we believe the possibility of introducing a new order of function to <i>all </i>upper-extremity amputees lies in external power and possibly to lower-limb amputees as well.</p> <p>May I use these pages to make a plea, if not that hardware development should cease, at least that some of the effort should be put into fundamental research into problems such as those I have indicated? Indeed, all of us already engaged in such work should devote sufficient time to discovering what the patient really needs, rather than to providing him with what we think he ought to need.</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>D. S. McKenzie, M.D. </b></td></tr><tr><td class="clsTextSmall">Director, Ministry of Health, Biomechanical Research and Development Unit, Roehamp-ton, London, S.W. 15, England.</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 Still a Long Way to Go Creator An entity primarily responsible for making the resource D. S. McKenzie, M.D. * https://staging.drfop.org/files/original/7904e0df9f82ca12c7c4e5cd88f6db97.pdf 28eeacacfe9b1b5e4ac2b081f46ce305 https://staging.drfop.org/files/original/82e7e39858aab0ffb26247e4ac66f8ff.jpg 9f927c763f3c0a435205f628539e33fd https://staging.drfop.org/files/original/959f68367f7cae905c928c179c005a3f.jpg 53b45497795ecaf6b411058791a39c7b https://staging.drfop.org/files/original/7b0e5455441dc18eff98d48d86415fb7.jpg bd46345d3be76766394dec62eb977ef7 https://staging.drfop.org/files/original/6c178a7d49b2ae565c5fdd88f9b45441.jpg dca58414c4ca42c275c9827d838c88d0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_051.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 51 - 57 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_01_051.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_051.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>Experiences with the Total-Contact Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>At the request of the Finnish Disabled Ex-Servicemen's Association, New York University arranged for a series of lectures on the fabrication of total-contact, above-knee sockets to be given in Helsinki in 1963. The lectures were intended for prosthetists and other interested persons. Since then some 300 prostheses of this type have been fabricated in Finland.</p> <p>The total-contact socket <a></a> is a further development of the conventional open-end socket. The proximal portion of a total-contact socket has the same contours as the corresponding portion of an open-end socket. The ischial seat, the relatively high anterior and lateral walls, the bulge into the femoral triangle, and the reliefs for the rectus femoris, for the adductor longus, and for the hamstring tendons are similar in both the open-end socket and the total-contact socket. The main difference is that the total-contact socket completely encases the stump, while the open-end socket, as its name implies, is open distally.</p> <p>This means that, in the total-contact socket, the stump end is surrounded by a vacuum which keeps the prosthesis in position without a pelvic joint and belt. The total-contact socket is kept in place by its intimate fit around the stump. There is a moderate vacuum during swing phase. The intimate fit of the total-contact socket, which is made of plastic, has been designed with a view toward imitating the mechanism of the physiological pumping action performed by the muscles while walking. the patellar-tendon-bearing (PTB) prosthesis acts in a similar fashion. The pumping effect is accomplished by the amputee as he walks. In fact, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, improves circulation and reduces edema in the stump.</p> <p>The total-contact socket is designed to reduce pressure on the stump proximally and increase the pressure distally. In cases where the diaphysis has been cut, the stump end never tolerates strong pressure. Therefore, pressure must be very carefully modified in each case.</p> <p>Distally, the plastic socket is joined to a wooden knee. The shank, too, is made of wood, to which a SACH foot is attached. Plastic has certain advantages over other materials. It is readily washed with soap and water. The surface can be made very smooth and free from pores. The chief drawback is airtightness. Plastic does not permit an exchange of air. The result is perspiration, particularly in the summer. Sweat gradually breaks down the plastic. In winter plastic is cold. Sometimes there are allergic reactions to plastic.</p> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with total-contact prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. Some four to six weeks later the patients and their prostheses are examined at the Department of the State Supervisor, where the prostheses are approved or some modification or correction is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their prostheses a questionnaire is sent to them, which they accomplish and return.</p> <p>Record cards are kept for all amputees on which are entered notations concerning new prostheses, repairs, and modifications.</p> <p>The present study covers 150 amputees fitted with total-contact prostheses. Of the amputees, 143 (95.3 per cent) were ex-servicemen and 7 (4.7 per cent) were insured civilians.</p> <p><b>Fig. 1</b>, which shows the ages of the amputees, indicates that the age group of 40 to 54 years is the largest. The high mean age of the ex-servicemen is accounted for by the time that has elapsed since World War II. The series includes two cases from the Finnish civil war of 1918. The youngest amputee was 24, the oldest 67. Only one was a recent amputee. In principle, every above-knee amputee should be fitted with a total-contact prosthesis from the outset in order to become used to it as soon as possible. This would accelerate the remodeling of the stump. Still, the stump of a recent amputee is often tender and swollen for some time. The total-contact prosthesis demands much of the stump. Consequently, a recent amputee may need a new socket at frequent intervals.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Ages of the amputees when they were fitted with total-contact prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. It is of major interest to ascertain whether the total-contact prosthesis can be worn while performing heavy labor of different kinds, particularly outdoors and at low temperatures. In northern Finland temperatures may be as low as -40 deg. C. Therefore, the occupations have been precisely specified. Whenever possible, amputees will usually choose labor that is not too heavy. The series includes 23 farmers (15.3 per cent), 1 lumberman, and 11 fitters. After World War II, retraining of invalids was arranged in the form of courses for watchmakers, storekeepers, fitters, shoemakers, etc. These occupations appear in the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 2</b> shows the lengths of the amputation stumps. The total-contact prosthesis has been worn successfully by amputees whose stumps measured only 10 cm to 15 cm. This series includes 10 such cases, but in two of these cases it became necessary to abandon the total-contact prosthesis. One of these patients received a conventional, wooden, open-end prosthesis; the other was fitted with a leather prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These cases (No. 8 and No. 9 in <b>Table 2</b>) will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. Amputees Who Could Not Wear the Total-Contact Prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn itf </i>According to the replies, 108 (72 per cent) had worn their prostheses regularly, while 42 (28 per cent) had not been able to do so for a variety of reasons.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>The replies were compared with the record cards, and causes were elicited as follows: <ul> <li>The knee joint in the prosthesis was too stiff.</li> <li>In eight cases there was profuse perspiration and a repulsive odor.</li> <li>In one case the prosthesis was too warm in the summer and too cold in the winter.</li> <li>In one case the prosthesis was too cold in the winter.</li> <li>In five cases the socket did not fit.</li> <li>The amputee put on weight and the socket became too tight.</li> <li>The inner surface of the socket became granular.</li> <li>The stump swelled.</li> <li>There were pains in the stump.</li> <li>Walking was difficult because of a heart condition.</li> <li>In two cases the socket split.</li> <li>There was a jarring sound from the knee joint of the prosthesis.</li> <li>In one case the amputee was so used to his old prosthesis that he preferred it.</li> <li>The SACH foot became loose, the socket was tight, and the knee mechanism functioned differently from what it did in the old prosthesis.</li> <li>In three cases the skin became irritated.</li> <li>In one case the stump was operated upon after the prosthesis had been finished.</li> <li>The socket became too wide.</li> <li>The stiffness of the knee mechanism was a hindrance while fishing.</li> <li>The socket became too tight.</li> <li>In many cases modification and repair of the prosthesis put an end to the trouble.</li> </ul></li><li><i>Have you worn your prosthesis (a) when working indoors, </i>(b) <i>when working outdoors, (c) when working outdoors in very cold weather? </i>Of those replying to the questionnaire, 128 (85.3 per cent) had worn their prostheses while working indoors, 100 (66.7 per cent) had worn their prostheses while working outdoors, and 72 (48.0 per cent) had worn them outdoors in very cold weather. Some amputees had been in a position to wear the prosthesis only during the warm season at the time of the questionnaire.</li><li><i>Have you worn your prosthesis in some additional</i>-<i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only eight amputees indicated that they had such activities: fishing in one case, gardening in one case, agricultural work and lumbering in two, work as a doorkeeper in one case, two cases in which the patients had built their own cottages, and one case in which the amputee participated in ball games.</li><li><i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>Conventional prostheses of wood had been worn by 147 amputees (98 per cent), one (0.7 per cent) had worn a leather prosthesis, and one (0.7 per cent) had worn a prosthesis of light metal. One patient (0.7 per cent) was a recent amputee and had been fitted with his first prosthesis.</li><li><i>Have you been satisfied with your prosthesis? </i>There were 112 (74.5 per cent) satisfied wearers and 38 (25.5 per cent) who were dissatisfied.</li><li><i>Do you think this prosthesis is (a) better than, (b) just as good as, </i>(<i>c</i>) <i>not as good as your previous limb? </i>The replies were as follows: <br /> <table> <tbody><tr><td> <p>Better</p> </td> <td> <p>   81 (54.0 per cent)</p> </td> </tr> <tr><td> <p>Just as good</p> </td> <td> <p>   36 (24.0 per cent)</p> </td> </tr> <tr><td> <p>Not as good</p> </td> <td> <p>   33 (22.0 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>What defects or drawbacks have you observed in your total-contact prosthesis? </i>Listed below are the complaints of 39 patients (26 per cent). In 32 cases the stump had caused trouble and in seven cases there was something wrong with the prosthesis. But no sharp distinction can be drawn between these two groups. Quite frequently, the prosthesis is the ultimate source of the discomfort.<br /> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p></p> </td> </tr> <tr> <td> <p>The skin did not tolerate the prosthesis</p> </td> <td> <p>   12</p> </td> </tr> <tr> <td> <p>Perspiration from the stump and an unpleasant odor</p> </td> <td> <p>   15</p> </td> </tr> <tr> <td> <p>Cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Stump end became discolored</p> </td> <td> <p>   1</p> </td> </tr> <tr> <td> <p>Warm in summer, cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Totals</p> </td> <td> <p>   32</p> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <p><b>Prosthesis</b></p> </td> <td> <p></p> </td> </tr> <tr><td> <p>Plastic socket split</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket was too closed</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket did not fit</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Socket too tight</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Totals</p> </td> <td> <p>   7</p> </td> </tr> </tbody></table><br /> </li><li><i>Has perspiration of the stump constituted a problem? </i>In 33 cases (22 per cent) perspiration had been profuse, in 99 cases (66 per cent) moderate, and in 17 (11.3 per cent) it had caused no trouble. Only one patient (0.7 per cent) stated that perspiration gradually became less of a problem. As a rule, summer was the worst season from this standpoint.</li><li><i>Has perspiration caused any repulsive odorf </i>The replies of 113 amputees (74.7 per cent) were in the affirmative, while 37 patients (25.3 per cent) replied in the negative. When the odor of the sweat in the closed socket mingled with the odor of the plastic, which is particularly strong in new sockets still containing traces of the solvents used in the fabrication, the effect is extremely disagreeable to both the amputee and his environment. The plastic socket can be washed with soap and water, but personal hygiene varies widely. Many patients have stated that perspiration is not a major problem, if the stump and the prosthesis are washed regularly.</li><li><i>Has the skin on the stump tolerated the total-contact prosthesis? </i>In 118 cases (79.0 per cent) the skin on the stump had shown no symptoms, while in 32 cases (21.0 per cent) it had not tolerated the strain of the intimate fit of the socket.</li><li><i>Have reddening of the skin and eczema occurred? </i>In 51 cases (34 per cent) there had been reddening, which may be a transient phenomenon of no significance, but 23 amputees (15.3 per cent) had had eczema, and ulceration had occurred in 18 cases (12 per cent).</li><li><i>Has the end of the stump become discolored after adoption of the new prosthesis? </i>Discoloration of the end of the stump had occurred in 34 cases (22.7 per cent). This phenomenon is the result of circulatory disturbances in the end of the stump. The most frequent cause is that pressure on the blood vessels is too strong.</li><li><i>Did reddening, eczema, or ulceration of the stump occur before you started wearing a total-contact prosthesis? </i>Reddening had occurred in 60 cases (40 per cent), eczema in 45 (20 per cent), and ulceration in 5 <i>(3.3 </i>per cent). These replies do not differ greatly from those to question No. 12. But it must be remembered that the previous, conventional prosthesis of wood, leather, or light metal had been worn for a long time, while the total-contact prosthesis had been worn only one-half year to one year. Therefore, the two groups cannot be directly compared.</li><li><i>What are your experiences with the new prosthesis outdoors in cold weather? </i>Thirty-two patients (35.1 per cent) had not experienced discomfort during the winter, while 61 (64.9 per cent) had found their prostheses very cold.</li><li><i>Have you skied with the new prosthesis? </i>Only 23 (15.3 per cent) patients answered in the affirmative. As a rule, above-knee amputees are not likely to participate in this sport. The below-knee amputees found on skis are much more numerous.</li><li><i>If you experienced phantom pains previously, have they been aggravated or alleviated after adoption of the new prosthesis? </i>The replies were as follows:<br /> <table> <tbody><tr> <td> <p>No previous phantom pains</p> </td> <td> <p>   32 (22 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains aggravated</p> </td> <td> <p>   15 (10 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains unchanged</p> </td> <td> <p>   94 (62.3 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains alleviated</p> </td> <td> <p>   8 (5.3 per cent)</p> </td> </tr> <tr> <td> <p>Total</p> </td> <td> <p>   149 (99.6 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>Have you had pains in the amputation stump (a) after adoption of the new prosthesis, (b) with the old prosthesis? </i>Sixty-six patients (44 per cent) had experienced pain after adoption of the new prosthesis, and 66 (44 per cent) had had pains while wearing their old limb. In this respect the type of prosthesis seemed to make no difference. But it should be noted that no direct comparison is possible because the total-contact prosthesis had been worn for a shorter period than the old one. In nine cases the total-contact prosthesis was abandoned in favor of the open-end prosthesis previously worn. These cases were subjected to a more detailed study, presented in <b>Table 2</b>.</li></ol> <p>The table discloses that the occupations of the patients had little to do with the failure. The ages of the patients did not differ from the mean age of the series as a whole. In two cases the stump was short, 12 cm and 15 cm, respectively. In the entire series there were 10 stumps measuring 10 cm to 15 cm, three measuring 16 cm, six measuring 17 cm, and five measuring 18 cm. In all cases except the two mentioned at first, fitting with a total-contact prosthesis proved successful. In general, short stumps constitute a problem to the prosthetist. No. 8 in <b>Table 2</b> was one of a number of amputees who had not been able to wear any prosthesis without complications. No. 9 was the only patient who was tested for allergy.</p> <p>As appears from the replies to the questionnaire, perspiration and skin changes constituted problems in the wearing of total-contact prostheses. These troubles arose from the properties of the socket: its intimate fit around the stump, and the airtightness of the plastic material. Partly because of the solvents used in the fabrication, the plastic socket sometimes has an irritating effect on the skin, especially when it is new. This irritation is increased by the decomposition of the sweat caused by the heat of the closed socket. In a considerable number of cases, however, the difficulties may have been caused by inadequate curing of the plastic laminate. Also, prostheses made of wood or leather are not free from perspiration.</p> <p>The possible occurrence of allergic reactions is another problem. In Finland, amputees suspected of allergy are remitted to the Dermatological Department of the Helsinki University Central Hospital. The present series includes only one such case. Perhaps the question of allergy has not been sufficiently taken into account.</p> <p>The majority of the remaining troubles were readily dealt with in the prosthetist's shop.</p> <p>It should be emphasized, however, that the view of the total-contact prosthesis derived from the replies that have been reported may be too unfavorable. To the amputee, it is a great advantage to be able to walk with greater ease than with a conventional prosthesis, because of the firm adherence of the total-contact socket to the stump. No pelvic joint and belt are needed. As mentioned earlier in this article, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, assists circulation. Some of the cases with derma-tologic problems had poor fits, usually as the result of stump changes. In a number of cases, the difficulties may well have been caused by inadequate curing of the plastic laminate. Also, a number of the problems did not relate to the principle of the total-contact socket as such but would have occurred with other designs.</p> <h3>Summary</h3> <p>This study was performed on 150 amputees fitted with total-contact prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans constitute the majority (96.3 per cent of the series).</p> <p>Seventy-two per cent had worn their prostheses regularly from the outset, and 74.5 per cent were satisfied with them. The airtightness of the socket elicited unfavorable reactions from the skin of a number of the patients (21 per cent). Twenty-two per cent of the amputees complained of profuse, and 66 per cent of moderate, perspiration of the stump. Some of the cases with dermatological problems had poorly fitting sockets, usually as the result of stump changes. In a considerable number of the cases, the difficulties may well have resulted from inadequate curing of the plastic laminate. The majority of the problems were readily dealt with in the prosthetist's shop.</p> <p>The skin requires meticulous hygiene. In contrast to leather and wood, the plastic socket is readily washed. Conventional prostheses are not free from dermatological problems.</p> <p>The total-contact prosthesis has been used in the performance of heavy labor and while outdoors in cold weather.</p> <p>Some of the problems of the patients did not relate to the principle of the total-contact socket and would have occurred with other designs.</p> <p>The gentle, alternating, positive and negative pressure afforded by the total-contact socket to the patient as he walks improves the circulation of the stump and constitutes one of the socket's main advantages.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</li> <li>Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1962.</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">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 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>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-4.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 Experiences with the Total-Contact Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/43d2e80bb7287060417ad2e656a4a222.pdf 1e835407f00822f0f13ceb8823bc60bb https://staging.drfop.org/files/original/4883a90da6034c4c1b32440d97b3755d.jpg 6be8ba96a52feee7928cfa58d70a9cb1 https://staging.drfop.org/files/original/30087b0ad704d400a5301996e194aa1b.jpg 03b421194ff589844bf70b4d3b6137c3 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_047.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 47 - 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/1967_01_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_047.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>New Concepts in the Management of Lower-Extremity Amputees</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>For many years the acceptable practice in management of lower-extremity amputation after wound closure consisted of the application of a reinforced gauze dressing and the confinement of the patient to bed until the wound was healed. Fitting of a prosthesis was seldom attempted until edema was reduced to a more or less stable point by means of elastic bandages which had to be removed and reapplied at regular intervals during the day. Elaborate precautions had to be taken so that muscle contractures would not occur. With this method of treatment it was rare for a patient to be fitted less than six weeks after surgery, most patients requiring a much longer period.<a></a></p> <p>The reluctance to fit patients before the stump was "stabilized" was, in a large part, due to the need for one or more socket replacements shortly after the initial fitting. A number of physicians advocated the use of temporary prostheses usually consisting of a plaster-of-Paris socket and a peg leg to hasten stabilization of the stump, but this practice never became widespread, probably because no adequate documentation was made of the various series that were reported, and many physicians realized that it was extremely difficult to obtain adequate fit and alignment with the techniques existing then.</p> <p>The introduction of the patellar-tendon-bearing socket, total-contact sockets, new stump-casting techniques, adjustable legs, and plastic-laminate sockets led the Department of Orthopaedic Surgery, Duke University, to embark on a study to determine the earliest practical time for fitting. The project has demonstrated clearly that successful application of prostheses can be made as soon as it is safe to remove the sutures.</p> <p>In the late fifties Berlemont of France <a></a> began providing patients with leg prostheses immediately upon completion of surgery and initiating ambulation training the following day. Berlemont's technique was modified somewhat by Weiss of Poland <a></a>, who brought it to the attention of Americans in a lecture given at the Sixth International Prosthetics Course in Copenhagen in July 1963. A tour of the United States by Weiss later that year, sponsored by the Vocational Rehabilitation Administration and the Committee on Prosthetics Research and Development, stimulated sufficient interest at the University of California, San Francisco, and the U.S. Naval Hospital, Oakland, for these groups to experiment with the concepts reported by Weiss.</p> <p>Initial results led the Veterans Administration to support an experimental program proposed by the Prosthetics Research Study of Seattle, Washington. Other groups, notably Duke University, the University of Miami, Marquette University, and a group in New York City centered around the Hospital for Joint Diseases, became interested and embarked on modest experimental programs.</p> <p>Because there was not available any written or visual material covering European experience, each group approached the problem along somewhat different lines. From time to time through the efforts of the Committee on Prosthetics Research and Development and the University Council on Orthotic-Prosthetic Education, these groups were brought together for the purpose of exchanging ideas and coordinating the efforts of all involved. Meanwhile, the Vocational Rehabilitation Administration made it possible for a number of the research teams to visit Weiss. Experience with more than 400 cases has now been accumulated.</p> <p>At its meeting January 20, 1967, which was preceded by a conference of research teams involved in immediate postsurgical fitting, UCOPE decided to offer courses in the technique to qualified teams.</p> <p>The basic technique consists of the application of a nonadherent silk mesh dressing and fluffed gauze over the wound and a sterile stump sock and plaster-of-Paris cast (which is also the socket for the prosthesis) over the stump (<b>Fig. 1</b>). To the socket is attached an adjustable pylon-type prosthesis suitable for the level of amputation. Provisions are made for easy removal and reattachment of the prosthetic unit to prevent the prosthesis from being wrapped in the bedclothes and causing undue stresses on the stump. A drain is usually used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An example of immediate postsurgical fitting of prosthesis to a below-knee amputee. Note the waist-belt suspension, the cast-socket carried above the knee, the pylon, and the foot. See also Figure 18 in Limb Prosthetics-1967, the preceding article in this issue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is encouraged to stand <i>between parallel bars or with the aid of a "walker" </i>about 24 hours after surgery if there are no physical or medical contraindications. The amount of weight-bearing and ambulation is increased daily and the patient is graduated to crutches, to canes, and to unaided walking as his physical condition permits. The drain is removed 48 hours after surgery, and the cast-socket is kept in place until time for removal of the stitches- some 10 to 14 days after surgery.</p> <p>A new cast-socket is applied immediately, and the pylon-type prosthesis is replaced. The second cast is removed 8 to 10 days later when it is generally possible to make a cast for fabrication of a plastic socket.</p> <p>The advantages of treating patients in this manner are a reduction in the formation of edema, a reduction in the incidence of pain, elimination of the formation of contraction, decreased hospitalization time, and less time lost from work. The technique appears to permit improved wound healing, and a number of investigators feel that in cases of amputations because of vascular disorders many more knee joints may be preserved than when conventional methods of treatment are used. In one series of a hundred cases, the average time between surgery and delivery of the "permanent" prosthesis was 28 days. The shortest time was 17 days <a></a>. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Progress of 80-year-old patient whose leg was amputated because of vascular disease and diabetes. A, First day postoperative; B, seventh day postoperative; C, seventeenth day postoperative; D, twenty-sixth day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Patients of all types and all ages have been treated successfully by fitting prostheses immediately after surgery. However, success depends upon many factors, and the technique should not be undertaken unless the team has a thorough understanding of proven methods. For this reason, courses are being offered at Northwestern University, the University of California, Los Angeles, and New York University.</p> <p>In spite of the success achieved by the research teams and others that have been trained by them, it is not clear why certain of the advantages accrue, and to what degree the various factors that enter into success are critical. Continued research is expected to answer these questions.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., The principles of amputation surgery, Chap. 10 in Orthopaedic Appliances Atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Berlemont, M., Notre experience de l'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.</li> <li>Berlemont, M., L'appareillage des amputes des membres inferieurs sur le table d''operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</li> <li>Weiss, Marian, The prosthesis on the operating table from the neurophysiologies point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</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>4.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 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>5.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiologies point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 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>2.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de l'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>3.</b> </td><td class="clsTextSmall">Berlemont, M., L'appareillage des amputes des membres inferieurs sur le table d''operations, paper given at the International Congress of Physical Medicine, Paris, 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>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The principles of amputation surgery, Chap. 10 in Orthopaedic Appliances Atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 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>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development. National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_047/1967_01_047-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_047/1967_01_047-2.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 New Concepts in the Management of Lower-Extremity Amputees Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/13483799eeef6de665c9bbb9af7b9faa.pdf c58980d044e592784ff92c261572cb70 https://staging.drfop.org/files/original/88328052220571e0fc20a864a6829964.jpg 66cafb6c0ae410559da88d3c6d548b21 https://staging.drfop.org/files/original/96e82ff7eea90594d484b9bd33e81c7e.jpg 1434282fa08d69ba185572ba4a1fcd1b https://staging.drfop.org/files/original/b6d5144215bb3dbbd723c4b8bb3a62a5.jpg e5382c2d9f7afecf74fe925fff7e28a5 https://staging.drfop.org/files/original/9cb7c3ebdffb95d6682116b73f94baa3.jpg 3208b240ca5b9271e98a68e4b09db6d0 https://staging.drfop.org/files/original/79695db2e584586503cc226686d16e5d.jpg 15434912daba69219d4e20745bd20a2a https://staging.drfop.org/files/original/32ad6c8f31a40cf8768910f1f71a1e86.jpg 9ad57bb3f90aece39e7c67bc4ef9a9e7 https://staging.drfop.org/files/original/2dd6ac18d6245c9d29236c6c620a12ad.jpg 6b452113afc75f8a732e203232711048 https://staging.drfop.org/files/original/5b0cbe7e09c8a178d30df13f69f31b97.jpg a90dab8ec34461f8015b8160e1c757a3 https://staging.drfop.org/files/original/aa411e9c0d94b09ee34d8dfe6cd61643.jpg fc2fc8ec437f8c653cbf5204e56de2b5 https://staging.drfop.org/files/original/edc114da52e28e0c0b6b7232ac00385e.jpg 724e3a1f505bb49024a7dfd947aeb382 https://staging.drfop.org/files/original/0c3ce7981d1ba2ffd57a31f9b99441cb.jpg 394e213d7b1c2193df215ac99c04fe37 https://staging.drfop.org/files/original/ad3b7233a6cabfff6c8399230b2a134d.jpg 4d44106fab8c1b1165d4b3fac0937598 https://staging.drfop.org/files/original/88fa3fd1d2928a71d8d8e0999736376b.jpg c2bea47e140174bc3875689af1a1b991 https://staging.drfop.org/files/original/ee51beb02fd85067cd1d579fac60ba28.jpg af3799f1f630e053b0fd5fe9480fb8bd https://staging.drfop.org/files/original/ac4030ee6c7df699fe7d75382c651bdf.jpg 7116e89a6c7eb72b5f55206c520ef96d https://staging.drfop.org/files/original/945bda9a12449fb3635d9974f819b027.jpg ba18513057ab53a915cf3129a30346a8 https://staging.drfop.org/files/original/739f04652820548143db4fa58b496a59.jpg 5030742e0bfdb6beb718ef64ecac8ea0 https://staging.drfop.org/files/original/1737d62016b57b8b2823cb05b2d0c4a0.jpg fd477e4cae07b389d7b5be19e0705ebc https://staging.drfop.org/files/original/3fd18dbb5eab5745097f327f368b2b8b.jpg 1f4f074ccae5fda0c472b769bf69f07a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_001.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 1 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limb Prosthetics-1967</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p><i>Because of the large demand for reprints of </i>"Limb Prosthetics Today" <i>which originally appeared in the Autumn 1963 issue of ARTIFICIAL LIMBS, the article has been revised to reflect the numerous advances that have been introduced into limb prosthetics since 1963. To distinguish this revision from the original we have chosen the title </i>"Limb Prosthetics-1967."</p> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>"History" </i>written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stib-bert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses. Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A., Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H., Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan <i>, </i><a></a> a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of The Surgeon General of the Army, initiated a research program in prosthetics.<a></a> The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made <i><a></a>. </i>Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Academy of Engineering.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roehampton, London, by the Ministry of Health, and a new program was initiated in West Germany by the government. Also, a program was started in Russia. The so-called "Thalidomide Tragedy" of 1959-1960 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480 the United States supports prosthetics research in India, Israel, Poland, and Yugoslavia.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and ortho-tists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 5,787 physicians, 3,962 therapists, and 2,000 prosthetists have been enrolled in these courses during the period 1953 through 1967.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In July 1965 the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled by use of antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>).<a></a> The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disar-ticulation case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump-Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p><i>A </i>true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the resuit is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many pros-thetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through The Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation At The Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disar-ticulation cases.</p> <p><i>Shoulder Disarticulation And Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare, the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963 it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted, limb as soon as the sutures were removed some two to three weeks after surgery. In 1963 Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day after.<a></a>Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Results with over 400 patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated, postsurgical pain is greatly alleviated, contractures are prevented from developing, phantom pain seems to be virtually nonexistent, less psychological problems seem to ensue, and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days during which ambulation is encouraged. At the end of this time the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematic cross section showing most of the elements of the application of a prosthesis to a below-knee amputee immediately after surgery. The suture line, silk dressing, and drain are not shown for the sake of clarity. View "A" is an enlarged schematic section of the cast socket, prosthetic unit attachment straps, stump sock, and fluffed gauze at the distal portion of the stump. The fluffed gauze does not extend beyond the area indicated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>Contractures</h4> <p>When immediate postsurgical fitting is employed there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily but it is most difficult, and sometimes impossible, to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.<a></a> </p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>). A number of devices have been introduced in recent years to aid the prosthetist in obtaining accurate casts rapidly <i><a></a>. </i>Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administraton Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>).<a></a> Not only is the need for the alignment jig eliminated but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses For Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed.</p> <p>Most Syme prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 25</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 26</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 27</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses For Below-Knee A mputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 28</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by-means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 29</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cutaway view of the patellar-tendon-bear-ing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 30</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Trial below -knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p>Several simplified adjustable shanks have been made available recently expressly for use in the immediate postsurgical fitting technique (<b>Fig. 31</b>). Straps are provided for lamination into the plaster cast-socket. Provisions are incorporated for adjustability in all planes. The shank and foot can be connected to and disconnected from the socket easily and quickly. Although these units were designed for temporary use, they are sturdy enough for use on a permanent basis. A natural appearance can be obtained by using plastic cosmetic covers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Prosthetic unit designed especially for fitting below-knee cases immediately after surgery. The stainless steel straps are laminated into the plaster socket. All parts below the top plate are easily removed without affecting alignment. A sach foot is normally used with this device. Although designed for temporary use, this device can form part of a "permanent" prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Knee-Disarticulation And Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 32</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists have installed commercially available piston-type hydraulic swing-phase control units, but this requires extreme care to achieve the proper result.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Model <i>"B" </i>(<b>Fig. 33</b>), and the Hydra-Knee. These units are all of the piston-cylinder-type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 34</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The Henschke-Mauch "HYDRAULIK" set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 35</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used. A promising stance-phase control unit currently being evaluated is the Henschke-Mauch Model "A" hydraulic unit. The Model "A" unit contains the same swing-phase control device as the Model "B" and provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The Model "A" and Model "B" units are interchangeable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 36</b>A) has generally been the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 36</b>B),a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 36</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 36</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket.<a></a></p> <p>(<b>Fig. 36</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischium area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs (<b>Fig. 37</b> and <b>Fig. 38</b>) are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. The same principles used in the below-knee device (Fig. 31.) are incorporated. In addition, mechanical friction about the "knee" axis and a mechanical "knee" lock are provided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. This is essentially the same unit shown in Fig. 37. except that hydraulic resistance instead of mechanical friction is provided about the knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Hip-Disarticulation And Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 39</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses<a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles has been developed in Russia for below-elbow amputees. Versions of the Russian design are available in England and Canada. Similar devices have also been developed in Austria and Italy. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore less in need of sophisticated devices. The devices are expensive and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for patients with amputations above the elbow and higher. Efforts to develop useful externally powered arms, both electrical and pneumatic, are being made in both the United States and abroad, especially in reference to severely handicapped children <a></a>.</p> <p><i>Hand Substitutes - Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanism have been developed for terminal-device operation-voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 40</b> and <b>Fig. 41</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dor-rance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-8, ring-type harness is most generally used. Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses For The Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses For The Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of prerlexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 44</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figureeight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 45</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Typical prosthesis for the above-elbow case. The figure-8 harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 46</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 47</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is begun usually on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and use of canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 49</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 50</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechan-ical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations For Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these, procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging The Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 52</b>, <b>Fig. 53</b>, and <b>Fig. 54</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees <a></a></h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 55</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects-and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases.</p> <p>It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 37-39 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty <a></a></h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis.</p> <p>Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h4>Agencies That Assist Amputees</h4> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, 828 Davis Street, Evanston, Ill. 60201.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, Autumn 1957.</li> <li>Artificial Limbs, April 1961.</li> <li>Artificial Limbs, June 1962.</li> <li>Bechtol, Charles O., and George T. Aitken, <i>Cineplasty</i>, Chap. 12 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Blakeslee, Berton, <i>The limb-deficient child</i>, University of California Press, 1963.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower-extremity amputees</i>, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs</i>, covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>, Chap. 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees</i>, a review of technique and criteria, Artificial Limbs, Spring 1965.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artificial Limbs, Autumn 1966.</li> <li>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council</i>, J. Bone and Joint Surg., 29: 538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation</i>, Publication 1352, 1966.</li> <li>Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, <i>A new surgical-prosthetic approach to Syme's amputation, a preliminary report</i>, Artificial Limbs, Spring 1966.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial limbs with the adjustable coupling</i>, Artificial Limbs, Spring 1963.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty</i>, Chap. 12 in <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. <i>Haddan, Amputa- tion prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees</i>, Chap. 7 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>The prosthesis on the operating table from the neurophysiological point of view</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</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>4.</b> </td><td class="clsTextSmall">Bechtol, Charles O., and George T. Aitken, Cineplasty, Chap. 12 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 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>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton, The limb-deficient child, University of California Press, 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>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 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>18.</b> </td><td class="clsTextSmall">Vultee, Frederick E., Physical treatment and training of amputees, Chap. 7 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 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>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 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>16.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chap. 12 in 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>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 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>3.</b> </td><td class="clsTextSmall">Artificial Limbs, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artificial Limbs, 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>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 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>15.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial limbs with the adjustable coupling, Artificial Limbs, 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>11.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artificial Limbs, Autumn 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>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chap. 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 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>19.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiological point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 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>1.</b> </td><td class="clsTextSmall">Artificial Limbs, Autumn 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, A new surgical-prosthetic approach to Syme's amputation, a preliminary report, Artificial Limbs, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone and Joint Surg., 29: 538-540, 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>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 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>17.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputa- tion prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-34.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-52.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-53.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-54.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-55.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-02.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-03.jpg Figure 12 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-04.jpg Figure 13 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-05.jpg Figure 14 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-06.jpg Figure 15 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-07.jpg Figure 16 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-08.jpg Figure 17 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-09.jpg Figure 18 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-10.jpg Figure 19 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-11.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 Limb Prosthetics-1967 Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/4a1d647a65001ac401d87d1ff0a502dc.pdf be21d355bbb7726b48257560f38ffcc1 https://staging.drfop.org/files/original/ade75bbe682d095fafd8dc98e0bdeebc.jpg cb33bea6982578ca9f1ac897d024b8aa https://staging.drfop.org/files/original/f53916b68ed1a9091e5b7dfd3280019f.jpg e427877188e0e0d0e8f2b3055d5f8df4 https://staging.drfop.org/files/original/1dd8550b2936a7b9cdcc9b23c89e287c.jpg 04f2643b57c264bf37196de0ec256397 https://staging.drfop.org/files/original/e6dab0edff7c7c4249c3192ca924704f.jpg c979896054406fa7bbaa56c9b9bb2d45 https://staging.drfop.org/files/original/3e28fdce00199c50876c4dea728fcd3d.jpg 5fdcfa70023ebdf6bbe368c413721e11 https://staging.drfop.org/files/original/f43c68108152e6a1e1c805a301451b93.jpg 0d3fa2972071447fad21b77828e0dde6 https://staging.drfop.org/files/original/c1607df85b443b92c33b9062283f89f9.jpg ed20251e138d78199b81805f9b773f8e https://staging.drfop.org/files/original/7c2db4f48c70105bc7bf7a49a36f693d.jpg 69d9387960fd1c5c46cf6fd1945e043b https://staging.drfop.org/files/original/a1504fa035cb6baf568bc21f4e6032ae.jpg d2ee96370904fedccfdd586158fc8106 https://staging.drfop.org/files/original/a75b7b94908e32a9a415c6af0859c4d1.jpg 4777a991370a82177c1ba45d1885294f https://staging.drfop.org/files/original/5137c3276e634e3a7a07c361d89615f6.jpg fba588d37b02c32d343d6047401bbf78 https://staging.drfop.org/files/original/2b8e10f3ccd57901d0685024fa54fe16.jpg 4993250f15bf97bab4d79615df1bcda1 https://staging.drfop.org/files/original/0de013a315001679feaee2a5fb2512ec.jpg f62d2caa4a29bf71c555be9f20eeb071 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_027.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 27 - 38 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_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>Fitting and Training Children with Swivel Walkers</h2> <h5>W. M. Motloch <a style="text-decoration:none;">*</a><br />Jane Elliott <a style="text-decoration:none;">*</a><br /></h5> <p><i>Mobility can be provided fairly successfully for the bilateral hip-disarticulation patient when his arms can be used in connection with crutches and canes, but when the patient cannot use crutches a most difficult problem is presented to the clinic team. The most effective means of treating patients who have complete or essentially complete absence of all four limbs has been to provide them with a socket encasing the pelvic region mounted on a three- or four-wheeled platform (<b>Fig. i</b>), or to provide them with motorized carts with special controls. The unpowered vehicles permit the patient to be upright but generally they must be moved from place to place by an attendant, and the motorized carts are expensive.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. i. Three-wheeled cart built by Child Amputee Prosthetics Project, University of California, Los Angeles, for patient with congenital bilateral above-elbow amputations and bilateral lower-extremity amelias. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experiments at the Child Amputee Prosthetics Project, University of California, Los Angeles, with pylons mounted on rockers, and hinged at a point anterior to the anatomical hip joint, proved to be very disappointing mainly because the effort required in their use exceeded the functional gain (<b>Fig. ii</b>) <a></a>.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. ii. Same child who appears in Figure i shown on pylons mounted on rockers and hinged at a point anterior to the anatomical hip joint. Although the child learned to ambulate with this device, her progress was slow and the energy expenditure extremely high. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>To overcome some of the deficiencies presented by previous approaches, Richard E. Spielrein, <a></a> Senior Engineer, Repatriation Department, Commonwealth of Australia, suggested a pylon arrangement to capitalize on side-to-side oscillations of the man-machine combination (<b>Fig. iii</b>) and built a prototype, based on mathematical computations, which was used successfully by a 16-year-old girl.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iii. Swivel walker developed by Richard E. Spielrein, Senior Engineer, Repatriation Department, Commonwealth of Australia. From Spielrein, R. E., A Simple Walking Aid for Legless People. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Ontario Crippled Children's Centre, Toronto, Canada, has successfully utilized the principles set forth by Spielrein and presents herewith instructions for fabrication and use of the so-called swivel walker (<b>Fig. iv</b>).</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iv. Swivel walker developed by the Ontario Crippled Children's Centre, Toronto, Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experience has been limited to young children, but the walker should prove successful with older persons. It has been suggested that the principle of the swivel walker might also be applied in the case of paraplegia.</i></p> <p><i>A. Bennett Wilson, Jr.</i><a style="text-decoration:none;">*</a></p> <p>The swivel walker in its simplest form (<b>Fig. 1</b>) consists of two pylons attached in a vertical position to a pelvic socket, and two foot pieces which are attached to the pylons so that each may rotate about the vertical axis of the appropriate pylon. Stops are provided to limit rotation of the feet in each direction, and a spring returns the feet to a neutral position when no force is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Principle of the swivel walker. The child can transfer his weight to one foot by leaning sideways and then swivel forward about this foot, using only the force of gravity. Stops are provided to limit forward or backward swing, with springs returning the foot to the neutral position when it has been returned to the floor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The soles of the feet are canted in relation to the floor, and the pylons are positioned with their center lines falling posterior to the center of gravity of the patient and prosthesis so that tilting of the body on one side will cause rotation of the socket about the long axis of the pylon on the tilting side. The contralateral pylon is raised initially and swings forward due to gravity until it strikes the floor ahead. Backward motion can be obtained by tilting sideways and leaning backward so that the center of gravity falls posterior to the center lines of the pylons. Of course, to manipulate the swivel walker, the patient must have a mobile trunk.</p> <p>The type of walker suggested for initial use is shown in <b>Fig. 2</b>. Later, a more cosmetic device can be used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic dimensions of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is essentially the same as that for a conventional bilateral hip-disarticulation prosthesis <a></a> and is mounted on a platform which, in turn, is mounted on two aluminum tubes. In the bottom end of each pylon is mounted an ankle joint, or rotation unit, which in turn is attached to a foot piece mounted so that the inner edge rests on the floor when the appliance is at rest (<b>Fig. 2</b>). The foot pieces should have rubber soles to prevent slipping.</p> <h3>Measurements</h3> <ul> <li>Measurements that need to be recorded (<b>Fig. 3</b>) are:</li> <li>Crown-rump length Waist width</li> <li>Crest of ilium to ischial tuberosities</li> <li>Distance between ischial tuberosities</li> <li>Maximum distance across pelvis</li> </ul> <p>The "normal" height of the child with pylons on can be estimated by multiplying the crown-rump length by two or a little less.</p> <h3>Taking the Cast</h3> <p>Taking the cast usually requires the services of two people. A length of large-diameter stockinette is sewn closed at one end, with openings for existing limbs if present. Straps or webbing are used to suspend the stockinette from an overhead hook. This arrangement ensures firm contours and supports the child. The lower trunk, excluding the limbs, is then wrapped with plaster bandages up to the rib cage.</p> <p>If the child is not toilet trained, the cast is made over the diapers. If diapers are not worn, the ischial tuberosity, pubic tubercle, crests and anterior spine of the ilium, and the rib cage are marked as shown in <b>Fig. 4</b>. For use in alignment, vertical lines indicating the lateral and sagittal planes are drawn on the cast before it is removed from the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fabrication</h3> <h4>Socket</h4> <p>The original socket is usually made so that it extends a little higher than the waist, both front and back, for early training. As ability to balance improves and proficiency increases, the height can be reduced to approximately waist level. It is important that forward, backward, and side-to-side motions of the torso are not restricted.</p> <p>The original socket fabricated for testing the first model of the swivel walker was heat-formed out of acrylic sheet, but all later models have been of polyester laminate. Two complete layers of Dacron felt, two partial layers of Dacron felt, and two partial layers of glass cloth are used, as shown in <b>Fig. 5</b>. The lay-up is completed with four layers of nylon stockinette before impregnation with a mixture of 70 per cent rigid and 30 per cent flexible polyester resin. The laminate should be formed under a vacuum in order to prevent unnecessary bulk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Recommended socket configuration. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing and removal from the plaster cast, the socket is trimmed approximately as shown in <b>Fig. 5</b> and all edges are rounded and smoothed. Ease of entry and exit is facilitated by an anterior hinge.</p> <p>A plastic hinge with the trade name of Polyhinge is satisfactory and may be fastened with flat-head wood screws. Either polyester or epoxy paste can be applied to the screw heads to prevent corrosion if necessary.</p> <p>Wooden blocks are screwed to the base of the socket to provide a level surface for mounting the socket on top of the pylon walker.</p> <p>The pylons are aluminum tubing, 2-in. outside diameter, 1/16-in. wall thickness. The top ends are fitted with wooden plugs; the bottom ends are fitted over the ankle joints.</p> <p>The dimensions of the pylon and its placement are based on the "normal" height of the child and are indicated in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Measurements required for fabrication of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An adequate method for fastening the pylons is to slit the ends and use hose clamps (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Assembly of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Ankle Joint</h4> <p>The ankle joint (<b>Fig. 7</b>), mounted between the pylon and the foot piece, permits rotation of the foot piece about a vertical axis to allow forward and backward swing. As can be seen in <b>Fig. 7</b>, the foot piece is returned to a neutral position by a spring-loaded roller. Built-in stops restrict rotation to approximately 39 deg. forward and 11 deg. backward. (It is planned that a simpler, less expensive version of the ankle joint will be available commercially in the near future.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Foot Pieces</h4> <p>The foot piece (<b>Fig. 2</b> and <b>Fig. 6</b>) consists of a block of wood, a platform sole, and a rubber undersole. The rubber is glued to the wooden platform, which is fastened to the block of wood with glue and screws. The block is bored to receive the lower part of the ankle unit, which is held in place with epoxy resin or paste.</p> <h3>Alignment</h3> <p>The main considerations in alignment are (<b>Fig. 2</b>):</p> <ul> <li>The center lines of the ankle joints should fall approximately 1 1/2 in. behind the center of gravity of the child's body.</li> <li>When the walker is at rest, the pylons should be vertical.</li> <li>The foot platform should tilt about 6 deg. and rest on the medial edge.</li> <li>When viewed from above, the foot pieces are rotated out about 10 deg. (This adjustment is made by reaching down inside the pylon with an extension wrench and slackening off the bolt. This releases a tapered shaft, enabling the foot piece and lower ankle housing to be rotated to the desired position.)</li> </ul> <h3>The Cosmetic Swivel Walker</h3> <p>To improve appearance and to permit the patient to assume a sitting position, the pylons can be replaced with articulated limbs (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Swivel walker equipped with articulated limbs to permit sitting, and fabricated to improve cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The knee joints and hip joints are those used in a Canadian-type hip-disarticulation prosthesis, and they are aligned in a similar manner. For purposes of stability, the hip joints are placed well forward and the knee joints well back. It is imperative that the alignment between the socket and the foot pieces be identical to that used with the pylon type.</p> <p>The lateral straps are 1-in. elastic webbing installed with sufficient tension to prevent hip or knee flexion when the limb is lifted clear of the floor. Each strap is attached to the socket and to the lower limb in such a manner that in the standing position the direction of pull is behind the hip joint and in front of the knee joint. In the sitting position, the straps pass in front of the hip joint and behind the knee joint.</p> <p>The foot is carved from solid wood, bored out to receive the lower housing of the ankle joint. Foot pieces, used for training, are at-</p> <p>tached by screws through the soles of the shoes into the wooden feet. When the child has progressed to a point where foot pieces can be removed, screws are used to secure the soles of the shoes to the wooden feet. The shoe soles should be flat, with the same 6 deg. tilt from the medial edge.</p> <p>The shank sections must be hollow so that a wrench may be inserted from the top to adjust the vertical shank bolt.</p> <h3>Training</h3> <p>It is recommended that training for young children be commenced by using a lateral rocker as shown in <b>Fig. 9</b> to enable the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. When the child feels secure in this arrangement, he is transferred to the swivel walker with short pylons and encouraged to go through the same rocking motion. At this point it is necessary to demonstrate to the child the forward swing by placing the hands on the trunk and guiding the child through the side-to-side motion coupled with a forward tilt. This support is gradually decreased until the child can manage unaided.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Device for training patient to use the swivel walker. The lateral rocker enables the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As proficiency in the use of the swivel walker increases, the height of the pylons is raised in 1-in. increments until a "normal" height is attained. The rate of increase will vary according to the child's capability. Experience at the Ontario Crippled Children's Centre has been that the height can be increased one inch about every two days.</p> <p>At low heights body sway above the waist is required to operate the walker. As the height is increased, the child's movement alters to a lateral displacement of the hips such that the body moves sideways while remaining vertical.</p> <p>When patients become proficient in the use of the walker, they do not swing the walker to the limits of the stops.</p> <p>The ability to walk backward is attained with little more difficulty than walking forward, but smaller steps are generally used. One child was able to walk very well in either direction within a period of two weeks. Walking backward is important because it permits the child to back out of corners or similar situations.</p> <p>Great care must be taken with the child during training, since it is possible that a few falls will occur until his sense of balance is perfected. Falls from being pushed by other children are likely to be far greater in number than those resulting from overbalancing. It is recommended that some form of protective head covering (such as an ice hockey head guard) be worn during this stage of training.</p> <p>One child was fitted with the swivel walker shown in <b>Fig. 8</b> after she became proficient with the pylon type. Initially, the foot pieces were larger than the shoes. As proficiency developed, they were gradually trimmed in size and finally removed, leaving the shoes tilted at the same angle.</p> <p>With both types of walker it was found that the children averaged approximately 120 steps per minute, each step being approximately three inches when walking forward.</p> <p>Each child had to be treated individually according to his own temperament. One child was extremely nervous and frightened, and so training had to be carried on more slowly than with another child who accepted alterations readily.</p> <p>From experience gained so far, it is suggested that a child who is nervous and cautious be given a period of at least one week to become used to major adjustments and alignment changes.</p> <p><b>References:</b></p> <ol> <li>Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</li> <li>McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</li> <li>Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</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">McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 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>3.</b> </td><td class="clsTextSmall">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 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>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (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>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (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>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (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>Jane Elliott </b></td></tr><tr><td class="clsTextSmall">Physiotherapist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-09.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-13.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 Fitting and Training Children with Swivel Walkers Creator An entity primarily responsible for making the resource W. M. Motloch * Jane Elliott * https://staging.drfop.org/files/original/bce63a5f984a2b7e266ad41c794457eb.pdf 3336381361b926e881b5e08b4d5a104f https://staging.drfop.org/files/original/8984ef005962175cd2cd9ca4c67dd953.jpg 27b4bfe13ac727d78e188ef5c0b67354 https://staging.drfop.org/files/original/abfa246572131fe9dd3cdcbd55538f20.jpg a393b0f058bc54700d9c3ab34b65c9f4 https://staging.drfop.org/files/original/b1236f8892840de73e07786a00477f27.jpg 17ad3bcf73e9cc611c2f726000e15585 https://staging.drfop.org/files/original/f423924d489cce78f8517b42ebf79aae.jpg da4e43f799a904dc23d6620dc6553989 https://staging.drfop.org/files/original/1605ed8928919d3ac2b4a9755e041d30.jpg 36995fceb11605d7162400a6c40443e0 https://staging.drfop.org/files/original/999e0f60cb6a02c2a0115145cf515482.jpg 1dad4baf20341bf6baeb1f03138e9898 https://staging.drfop.org/files/original/f6b705039b55b6defd8e13b6e9c13e02.jpg abe2f39e1bd4137970fc50bef98c633e https://staging.drfop.org/files/original/59c9f866e0c4115b40694ac727ab58e3.jpg 22142ed910fdea4adda64f3b92d3480d https://staging.drfop.org/files/original/c807f2e8e367587163feae6926ca1b81.jpg 5f9b6c07208aad1b7d1c8f17934ec314 https://staging.drfop.org/files/original/74e60652660a7f2fade6c3f7f604d916.jpg 4c8a84c66cf97e3b930c25c10fce434a https://staging.drfop.org/files/original/0422d5a84c721d8228bef8e3651da68e.jpg 4c29f85936b1ff8d7fde5e8a6c90e7a8 https://staging.drfop.org/files/original/9a2d677825dd94e876b15c4dd04e83bc.jpg e5ef2eba763449d1d7606f322f5ae139 https://staging.drfop.org/files/original/07ea344764325dbc83c30b93217adcb4.jpg a579c5f3e92ff8e9ead1a6975eb28f55 https://staging.drfop.org/files/original/a4abcb85f4dca41eb258db103a1b6758.jpg 33f7ded8889906f86c4011008830c2f7 https://staging.drfop.org/files/original/b37d8f6126d94e2d7899983c1a474c0f.jpg 1fe5f44a5993f642ec0619a7eab4ef46 https://staging.drfop.org/files/original/3af334d9f215fbfc19ea5de010c1cd7c.jpg f585c5ed5d6d36c905cf9769833bd923 https://staging.drfop.org/files/original/a4a20ebdca1ecd21eaae49d233d5ce56.jpg 63ada1bca5d0c342a0eb4a5ac485ec14 https://staging.drfop.org/files/original/766e46411ccd23ec701dab020f5f81ba.jpg 80998bfac3aa008d9f07c6c5a820fa6b https://staging.drfop.org/files/original/137b1d7a083dea7f124c935af402eed6.jpg 19c2b24e6295de60f62d98abb36ee83e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_005.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 5 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The suspension casting technique permits the casting of an amputee's lower-extremity stump while it is being held in an attitude simulating stance-phase weight-bearing in a prosthesis. This is accomplished through application of the principle of the Chinese finger trap; namely, when a cloth cylinder of suitable weave is stretched longitudinally, the circumference of the cylinder is decreased.</p> <h3>Suspension Casting of the Below-Knee Stump</h3> <p>In casting below-knee stumps, a cast sock clamped in a ring is the cloth cylinder. As the amputee bears weight on the suspended sock, the sock stretches longitudinally and constricts circumferentially, thereby firming the tissues of the stump during the application of the plaster wrap. The amputee is properly oriented in an upright position for casting and for producing accurate alignment lines on the cast. The tissues are firmly contained, edema is restricted, and bony prominences are emphasized. Distal redundancy is held firmly in the correct position by the suspension sock. While the stump is suspended, areas requiring relief can be definitively outlined and, if necessary, build-ups of appropriate thickness can be applied to the suspension sock prior to wrapping. <b>Fig. 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>Equipment required includes:</p> <ol> <li>A ring, approximately 6 1/2-in. inside diameter.</li><li>A rubber gasket.</li><li>A hose clamp.</li><li>A VA or a Berkeley casting stand with vertical adjustment.</li><li>Bathroom scale and platform.</li></ol> <p><b>Fig. 2</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>Data to be obtained and recorded are:</p> <ol> <li>The length of the normal leg from the medial tibial plateau to the floor, with the shoe off.</li><li>The shoe size.</li><li>The anteroposterior dimension of the stump, measured with a VA caliper while the stump is fully relaxed and supported by the prosthetist.</li><li>The mediolateral dimension of the stump just proximal to the tibial plateau, measured with a VA caliper.</li><li>The length of the stump, measured from the end of the stump to the level of the midpatellar tendon. A small square is used to obtain this measurement; the blade of the square should contact the crest of the tibia.</li></ol> <p><b>Fig. 3</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><b>PREPARATION OF MEDIAL TEMPLATE.</b> Because the medial flare of the tibial condyle is a particularly good weight-bearing area, it is desirable to construct a medium-weight cardboard template of the medial aspect of the stump for use as a guide in checking and maintaining the contours of the positive model in this important area. A cast sock is pulled over the stump and held with moderate tension by the amputee. To prevent bulging of the gastrocnemius during the tracing, the weight of the stump is supported by the prosthetist. The pencil is held vertically and slight pressure is exerted against the stump as the outline is drawn. The outline should extend from the proximal border of the femoral condyle to the midline of the distal aspect of the stump. After the medial tibial plateau is marked on the outline as an important landmark, the template is cut out and checked against the stump. <b>Fig. 4</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><b>PREPARATION OR RELIEF PATCHES.</b> Relief patches should be prepared prior to suspension of the amputee in the ring. Various materials may be used for the patches, such as 1/8-in. Kemblo rubber, 1/8-in. adhesive-backed felt, or any foam material 1/8-in. thick and of sufficient density for dimensional stability. Areas usually requiring relief are the tibial tubercle, the tibial crest, the distal end of the tibia, the leading edge of the lateral tibial condyle, and the head and distal end of the fibula.</p> <p>The patch for the head of the fibula should extend at least 1/4 in. beyond the bone area. If the head of the fibula is prominent, a double patch is sometimes indicated.</p> <p>The patch for the tibial crest should be 1-in. wide. This will allow 1/4 in. of plaster on each side for blending the edges of the positive stump model. The actual relief remaining is 1/2-in. wide, sufficient to cover the lateral edge of the tibial crest and blend into the medial tibial surface. <b>Fig. 5</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><b>SIZING THE CAST.</b> The dimensions of the negative cast produced are dependent upon the stump, the number and weight of the socks used, and the tension with which the plaster bandages are applied. One heavy cast sock is used to accommodate the fit of a stump wearing a three-ply wool sock in a hard socket. For a mature stump, two heavy cotton cast socks are used to accommodate a five-ply wool-sock fit in a hard socket. For a socket incorporating an insert, one light-weight cotton cast sock is used. Both socks and relief patches are removed from the negative cast before the plaster is poured to form the positive stump model. <b>Fig. 6</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><b>ASSEMBLY OF EQUIPMENT AND SUSPENSION OF AMPUTEE.</b> Preparatory to taking the negative cast of the stump, the distance from the end of the stump to a point 4 in. above the proximal edge of the patella is marked on a heavy cast sock, the ring is mounted horizontally on the vertical stand, and the cast sock is centered in the ring with the mark showing. The gasket is then applied over the sock and secured with the hose clamp.</p> <p>Next, the ring is lowered on the easting stand to facilitate entry of the stump into the sock. Then the ring is raised until one-half of the body weight is borne by the stump sock, as indicated by the scale. Under these conditions, the suspension sock should contain the thigh to a point 3 in. above the superior border of the patella. The height of the ring should be adjusted until the amputated side is slightly high,so that further stretching of the suspension sock will be accommodated during the wrapping process.</p> <p>The amputee should be positioned so as to obtain a correct base of support and so that his thigh is vertically centered in the ring. The knee should be flexed so that the stump is approximately 12 deg. from the vertical, measured along the crest of the tibia. Excessive flexion will result in loss of support or cause bridging of the sock along the posterior aspect of the stump. The stump is palpated, and areas requiring relief are outlined. The relief patches are glued to the appropriate areas. and the flexion angle of the knee is checked. <b>Fig. 7</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><b>WRAPPING THE STUMP.</b> Starting from a level just proximal to the top edge of the patella, four wraps of 4-in. plaster bandage are firmly applied. As noted previously, the medial flare of the tibial condyle is a good weight-bearing area. For emphasis, the plaster bandage is applied with firm tension diagonally upward in this area. The plaster bandage is then spiraled downward until the remainder of the stump is completely covered.</p> <p>Before the plaster begins to set, it is worked by hand to ensure an intimate contact between the wrap and the stump, to emphasize bony areas including the patella, to enhance the texture of the plaster, and to assist in obtaining a smooth inner surface in the cast.</p> <p>Several techniques and devices may be used when casting a below-knee stump to locate and define the patellar tendon and the support area posteriorly. Later in this article some of the variations will be presented.</p> <p>When the suspension casting technique was used initially, no attempt was made to deform the cast permanently at the patellar tendon or in the popliteal area. The patellar tendon was defined by a light massaging action on the cast, using the web of the hand between the thumb and index finger, and by applying a light counter-pressure posteriorly with the other hand. The hands were removed after the contouring, and the plaster was allowed to set. This method kept distortion of the tissues to a minimum and preserved the contours of the medial flare of the tibia.</p> <p>This technique has been modified to the extent that the hands are held in such a manner as to deform the cast permanently, producing a patellar-tendon bar anteriorly and a flattening of the popliteal area posteriorly. Any distortion of the contours of the medial flare of the tibia is corrected later by use of the template (previously discussed) when modifying the positive model of the stump. <b>Fig. 8</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><b>ALIGNMENT LINES.</b> After the plaster has set, two vertical alignment lines are scribed on the cast with the use of a plumb bob while the amputee is standing in a position simulating stance phase in a prosthesis. Half of his weight should be borne on the amputated side. The pelvis should be level and at right angles to the line of progression. One line, scribed on the anterior aspect of the cast, will be used as a reference for the correct adduction or abduction angle of the socket during bench alignment. The other line, scribed on the lateral aspect of the cast, will serve as a reference for the flexion angle of the socket.</p> <p>In order to remove the cast, the hose clamp is released to allow rotation of the ring in the stand. After the ring has been lowered sufficiently to permit the amputee to sit down, the hose clamp, gasket, and ring are removed. Care must be taken to avoid distortion of the cast during its removal.</p> <p>Before plaster is poured to form the positive model of the stump, the cast socks and relief patches are removed from the negative cast, and the cast is oriented with the reference lines vertical. Orientation can be accomplished by setting the distal end of the cast in plaster and using a square to obtain the correct alignment. A Milmo vertical transfer jig is a useful device for this procedure and also provides a means for holding the pipe vertically in the cast until the plaster hardens. <b>Fig. 9</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><b>MODIFICATION OF THE POSITIVE MODEL.</b> Modifications of the plaster model of the stump are made in accordance with the principles developed at the University of California Biomechanics Laboratory, Berkeley and San Francisco. <a></a></p> <p>An essential prerequisite to the modification of the plaster model is a complete examination and evaluation of the stump by the prosthetist. Variations in modification will necessarily be based upon this evaluation.</p> <p>An outline of the socket is drawn on the plaster model of the stump. This outline extends from the midpatellar level anteriorly to 2 1/2 in. to 3 in. above the midpatellar tendon level on the medial and lateral aspects of the model, down to a point 1/2 in. above the midpatellar-tendon level on the posterior aspect of the model.</p> <p>The anteroposterior dimension of the positive model will be determined by the type of socket to be fabricated. For a socket with a soft insert, the anteroposterior dimension of the model should be modified to that of the stump. For a hard socket, the anteroposterior dimension of the model should be 1/4 in. greater than the measured anteroposterior dimension of the stump; for example, if the anteroposterior dimension of the stump is 3 in., the anteroposterior dimension of the model should be 3 1/4 in.</p> <p>The following example is offered for guidance in determining the amount of plaster to be removed from the patellar-tendon area of the stump model as opposed to the amount to be removed from the popliteal area. Assuming that the anteroposterior dimension of the stump is 3 in. (to which 1/4 in. must be added for a hard socket) and that the anteroposterior dimension of the slump model is 4 in., it follows that 3/4 in. of plaster should be removed (that is, 4 in. less 3 1/4 in. equals 3/4 in.). Two-thirds of this amount, or 1/2 in., is removed from the patellar-tendon area (that is, 2/3 of 3/4 in. equals 1/2 in.). The remainder, or 1/4 in., is removed from the popliteal area (that is, 3/4 in. less 1/2 in. equals 1/4 in.).</p> <p>To prevent restriction of circulation in the stump, the plaster is removed posteriorly to produce a flattened surface rather than a bulge. The deepest removal of plaster is opposite from and just distal to the midpatellar-tendon level-thus creating the start of a radius proximally-and is continued downward to blend in toward the distal aspect of the stump model. <b>Fig. 10</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><b>MODIFICATION OR THE POSITIVE MODEL.</b> Starting approximately 1/4 in. from the edge, plaster is removed from the reliefs to blend the edges into the contours of the stump model. Plaster is removed from the area of the medial shaft of the tibia to within 1 in. of the end. The angulation of the shaft must be maintained. The amount of plaster removed is dependent upon the amount of tissue covering the shaft. Approximately 1/8 in. to 1/4 in. of plaster is removed from the anterolateral aspect of the model, starting at the distal border of the relief for the leading edge of the flare of the lateral tibial condyle and continuing to within 1 in. of the end of the tibia. The template made from the stump is used as a guide in modifying the flare of the tibial condyle. The mediolateral dimension of the model should be reduced to within 1/8 in. to 3/16 in. of the measured mediolateral dimension of the stump. Usually, smoothing this area of the model with wire screening is all that is necessary.</p> <p>If warranted, 1/8 in. of plaster may be added to the relief of the anterodistal aspect of the tibia. The patella is smoothed by a wash of plaster rather than removal of plaster. Along the previously drawn posterior trim line of the socket, a build-up of plaster is applied to a height, of about 3/4 in. The build-up should be given a generous flare, and the distal border of the liare should be blended into the contours of the model, especially in the area of the hamstrings. Plaster should be added to eliminate any groove between the junction of the posterior plaster build-up and the medial or lateral side of the model. A piece of plastic screen or line sandpaper should be used to smooth the entire surface of the model. <b>Fig. 11</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><b>BUILD-UP FOR RTV PAD.</b> When a Silastic RTV pad is to be used in the socket of the finished prosthesis, an additional plaster build-up about 3/4 in. high is formed on the distal aspect of the model. A piece of cardboard is applied to the cast to serve as a form for the plaster to be added. The form is sloped away from the distal anterior aspect of the tibia to provide any additional relief required. If the pipe is held vertically when the plaster is poured, a flat distal surface incorporating the correct angular alignment will result. All edges should be feathered into the contours of the model, especially in the tibial area.</p> <h3>Variations in Suspension Casting of the Below-Knee Stump</h3> <p>Since the introduction of the suspension casting concept, many variations have evolved in its use. These variations are mainly in the wrapping, the forming of the patellar-tendon bar, the modification of the wrap cast, and the modification of the positive model of the stump. <b>Fig. 12</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><b>CALDWELL PROCEDURE.</b> In the procedure followed by Mr. Jack L. Caldwell,<a style="text-decoration:none;">*</a> gypsona plaster bandage is used in place of standard plaster bandage, a clamp (the Caldwell clamp) is used to measure the anteroposterior dimension of the stump and to contour the patellar-tendon bar and the popliteal area into the wrap cast, one heavy-cast sock is used during the wrapping procedure, the flare for the posterior proximal edge of the socket is formed in the wrap cast prior to pouring the plaster to form the positive model of the stump, and the distal portion of the stump is wrapped first for contouring purposes.</p> <p>In the Caldwell procedure, measurements are taken and recorded on a measurement chart before casting is begun. The patellar-tendon bar of the Caldwell clamp is pressed gently against the amputee's patellar tendon, and the reading made on the clamp scale is recorded. After the stump has been wrapped, the dimension should be approximately 1/8 in. greater than the measurement made on bare skin. Before the contouring clamp is applied to the gypsona-wrapped stump, the popliteal pad and the patellar-tendon bar should be greased with vaseline, since gypsona has an adhesive property not present in the ordinary plaster of Paris or elastic plaster. <b>Fig. 13</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><b>CALDWELL PROCEDURE.</b> As soon as the wrap is completed, the clamp should be slipped onto the amputee's stump and the popliteal pad pressed into the proper area gently and correctly. With the contouring clamp in place, the wet plaster is worked into the medial tibial condylar shelf.</p> <p>A line is drawn circumscribing the wrap cast at the midpatellar-tendon level, also the socket trim line. <b>Fig. 14</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><b>CALDWELL PROCEDURE.</b> After the cast has been trimmed along the proximal trim line, several longitudinal cuts about 1/2 in. in length are made downward from the trim line in the area above the popliteal fossa. The cut area is reinforced with small strips of wet gypsona plaster. The use of warm water will reduce the time required to handle the plaster. The inside of the cast where the cuts were made is smoothed with a paste of warm water and plaster-of-Paris powder. <b>Fig. 15</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><b>FOORT PROCEDURE.</b> In a procedure developed by Mr. James Foort,<a style="text-decoration:none;">*</a> one heavy cast sock is used routinely, no relief patches are applied to the suspension sock prior to wrapping, plaster is used to provide reliefs during modification of the positive model of the stump, the distance between the hamstrings is measured and used as a control for the posterior outline of the socket, the modification of the positive model under the flare of the medial tibial condyle is extended posteriorly to include the hamstring tendons, and the position of the posterior flare on the plaster model of the stump is located at the midpatellar-tendon level.</p> <p>A fixed ring holds the casting sock at the top, a clamp ring binds the sock against the fixed ring, a clamping screw is used to force the clamp ring out against the fixed ring, and a pin connects the ring assembly to the UCB stand.</p> <p>The distance between the outer edges of the tensed hamstring tendons is measured and recorded.</p> <p>After the plaster wrap has been applied to the stump, the patellar tendon is defined by pressing the thumb tips on either side of it. At the same time, light counterpres-sure is exerted with the fingers across the back of the stump. This procedure is similar to the technique described in <i>The Patellar-Tendon-Bearing Prosthesis </i><a></a> and subsequently modified as reported in <i>Air-Cushion Socket for Patellar-Tendon-Bearing Below-Knee Prosthesis. <a></a> - <b>Fig. 16</b></i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FOORT PROCEDURE.</b> When the plaster stump model has been cast, plaster is removed from the sloping surface of the medial flare with a curved l 1/2-in. rasp. The purpose here is to prepare the surfaces for supporting weight. Coupled with pressures from lateral surfaces, the medial flare helps to stabilize the stump mediolaterally in the socket. But very little adjustment of this surface is required. A 1/4-in. adjustment at the deepest part of the shelf, tapering off to nothing along the vertical portions, would be the greatest amount removed. If the model is of a seasoned stump, it is sufficient merely to work this area smooth with wire screening. The screening should be swept around the natural contours of the flare, into the posterior area, and over the hamstring tendons.</p> <p>Plaster is added to the stump model in bony areas to provide relief. In addition, a posterior flare is constructed on the model by means of a plaster build-up. This is done by pouring plaster over the posterior surface above the circumscribed mid-patellar-level line until the addition is 1-in. thick. The plaster is spread with a wet spatula, and the flare is formed with wet fingers and thumb. The back flare is not grooved for the hamstring tendons. Instead, a broad surface is provided against which the tendons can rest when the amputee is seated. The build-up for the posterior flare should be trimmed to about 3/4 in. with a flat rasp. <a></a> - <b>Fig. 17</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><b>VARIATION USED AT NUPRC.</b> Another slightly different procedure sometimes used at the Northwestern University Prosthetics Research Center incorporates a patellar-tendon pad and a popliteal pad into the wrap during suspension casting. The pads used were developed at the Veterans Administration Prosthetics Center in conjunction with a pneumatic casting svstem. These pads define the patellar-tendon bar and the popliteal depression, and their use results in a positive stump model with an anteroposterior dimension that is within 1/16 in. of the measured anteroposterior dimension of the stump. <b>Fig. 18</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><b>VARIATION USED AT NUPRC.</b> Two wraps of standard plaster bandage are applied to the proximal aspect of the stump, covering the patellar-tendon area. The protuberance of the pad is positioned over the patellar tendon and covered with two additional wraps of bandage applied with firm tension to hold the pad in place.</p> <p>The popliteal area is then covered with two wraps of plaster bandage, and the pad is placed so that its top edge is approximately 1/2 in. above the top of the proximal border of the head of the fibula. The lateral edge of the pad should be placed 1/2 in. medial to the medial border of the head of the fibula. The pad is covered with two additional wraps of plaster bandage, and firm tension is applied during the wrapping. The wrap is then spiraled down to include the rest of the stump, and the plaster is worked by hand to emphasize bony areas.</p> <p>If the resulting stump model has a depression in the popliteal area, some plaster is removed from the medial and lateral border of the depression so as to prese nt a flatter posterior surface. A slight screening is usually all that is necessary to finish the patellar-tendon bar. The medial template should be used when modifying the cast to arrive at a true contour of the medial flare of the tibial condyle.</p> <h3>Suspension Casting of the Above-Knee Stump</h3> <p>Suspension casting of above-knee stumps may be used in conjunction with a UCB casting stand and brims. The technique permits the firming of stump tissues that are not in contact with the brim. It is also a means of controlling bulges at the distal end of the brim and the adduction angle of the femur. The technique results in a smooth interior to the negative cast of the stump. <b>Fig. 19</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><b>CASTING THE ABOVE-KNEE STUMP</b>. The major equipment required is a UCB stand, a set of brims, and a roll of 4-in. tubular gauze.</p> <p>Initially, the stump is correctly fitted into the brim, in accordance with the instructions contained in <i>Adjustable-Brim Fitting of the Total-Contact Socket</i>. <a></a> The brim is set in the stand horizontally. When all the necessary conditions-such as, the correct anteroposterior and mediolateral dimensions and the circumference of the brim-are satisfied, a piece of tubular gauze approximately 1-yd. long is applied to the brim. The tubular gauze is held to the outside of the brim with adhesive tape and is then draped down through the brim. A stump sock is then applied to the amputee's stump. The distal end of the stump sock is pulled down through the tubular gauze, and the stump sock is removed entirely while pulling the stump into the brim.</p> <p>Pulling the stump into the brim in this manner results in a bulging of the stump around the distal edge of the brim. To alleviate this situation, the amputee is instructed to flex his trunk over the brim as far as possible, thereby easing the gluteal muscles proximally. As the amputee straightens up in the brim, the tissues should be gently eased proximally in the anterior area of the brim. When the amputee bears weight on the brim, some of the bulging will have been eliminated. <b>Fig. 20</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><b>CASTING THE ABOVE-KNEE STUMP.</b> The tubular gauze distal to the brim is grasped and pulled downward, causing the tubular gauze to stretch longitudinally and reduce circumferentially, thereby compressing the stump tissues. With one hand, the prosthetist maintains tension on the distal end of the gauze as he grasps the gauze at the distal end of the stump with his other hand. The amputee is instructed to remove some weight-bearing from the brim, and the gauze is tied with string at the distal end of the stump. Weight-bearing should be reapplied to equal approximately one-half of the amputee's weight. A piece of 1-in. elastic webbing is tied to the distal end of the gauze and passed under the arch of the amputee's foot, usually from the lateral to the medial side. Sufficient force is applied to the elastic to maintain the correct adduction attitude of the femur. <b>Fig. 21</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><b>CASTING THE ABOVE-KNEE STUMP.</b> A firm, even wrap of standard plaster bandage is applied, enclosing the stump completely. While the plaster is still wet, the prosthetist palpates the stump to locate the distal end of the femur. He then applies gentle pressure approximately 1 in. above the end of the femur until the plaster sets.</p> <p>Before the plaster is poured to form the positive model of the stump, the tubular gauze is removed from the brim area down to its contact with the plaster wrap.</p> <h3>Suspension Casting for the Syme's Amputation</h3> <p>The suspension casting technique provides a means of wrapping a Syme's stump with plaster bandages under weight-bearing conditions. It is an excellent means of holding an unstable heel flap or supporting redundant tissue in the correct position during the casting procedure. It firms tissues, resulting in a smooth interior to the wrap cast, and it provides a means for checking the size of the medial opening prior to laminating the socket. <b>Fig. 22</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><b>CASTING THE SYME'S STUMP.</b> The equipment used is the same as that used for casting below-knee stumps; namely, an adjustable vertical stand, a ring, a gasket, a hose clamp, a cast sock, and a scale.</p> <p>A light-weight cast sock is used because it has more stretch than a heavy cast sock and can conform intimately to the contours of the stump. The sock should contact the thigh approximately 3 in. above the patella, with one-half of the amputee's weight borne by the sock.</p> <p>With the amputee supported in a level position, blocks are placed under the stump to contact its distal surface. Areas requiring relief are located by palpation and outlined. An outline of the medial opening is planned and drawn on the suspension sock, as described in <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening</i>. <a></a></p> <p>The largest circumference at the bulbous end of the stump is measured, and a horizontal line is drawn just proximal to this. The stump is then measured proxi-mally until the same circumference is obtained, and another horizontal line is drawn at this level. A line is drawn along the crest of the tibia. Just 3/4 in. medially from the tibial line another line is drawn parallel so as to intersect the two horizontal lines. The width of the cut-out is usually equal to 1/4 of the circumference measured. This remaining vertical line is drawn following the posterior contour of the stump to complete the medial opening. Relief patches 1/8-in<i>. </i>thick are prepared and applied to the areas previously outlined on the suspension sock. <b>Fig. 23</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><b>CASTING THE SYME'S STUMP.</b> The blocks are slid from under the stump, and the amputee retains weight-bearing on the sock. Plaster bandages are contoured to the distal end of the stump, and the bulbous end is wrapped up to the distal horizontal line of the medial panel. The plaster bandage is applied vertically to cover the stump to the anteromedial and posteromedial vertical outlines of the panel, and horizontally to include the top edge of the patella down to the top line for the medial opening. After wetting his hands, the prosthetist works the plaster to ensure an intimate contact of the wrap, especially in the area just proximal to the bulbous end. If necessary, one wrap of plaster bandage can be applied in this area to prevent possible bridging.</p> <p>The wooden blocks are then slid back under the plaster wrap of the distal stump. Slight contact pressure is all that is required to provide a flattened surface to the distal end of the cast. If too much weight is borne on the blocks, the amputee should be raised slightly by vertical adjustment of the casting stand. <b>Fig. 24</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><b>CASTING THE SYME'S STUMP.</b> The plaster is worked along the stump and around the proximal aspect of the wrap. The prosthetist locates and defines the patellar tendon and flattens the wrap cast posteriorly just below the midpatellar-tendon level. After the plaster has set, the remaining area to be covered is evident. Vaseline is applied to the uncovered portion of the sock and 1 in. to 1 1/2 in. along the plaster cast bordering the area. A splint of plaster bandages is made, large enough to cover the opening but not so large as to extend beyond the lubricated areas of the wrap cast. The splint is applied to cover the medial opening and worked well by hand to obtain an intimate mating along all the edges. <b>Fig. 25</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><b>CASTING THE SYME'S STUMP.</b> After the panel covering the opening has set, alignment lines are drawn on the cast to be used later for bench alignment. The amputee is oriented so that his pelvis is level, with half of his weight borne on the amputated side. Using a plumb bob, the prosthetist draws a vertical line on the anterior aspect of the wrap cast to determine the adduction angle of the socket and another vertical line on the lateral aspect of the cast to determine the flexion angle of the socket. Before removing the panel, the prosthetist draws two horizontal lines on the panel extending onto the body of the cast for positioning purposes.</p> <p>The clamp on the casting stand is loosened to permit the amputee to be seated. The clamp and ring holding the cast sock are removed. The prosthetist slides a knife under the edges of the medial panel and exercises care to avoid distortion during removal. The exposed cast sock is cut, and the stump is withdrawn from the cast.</p> <p>The cast sock and relief patches are removed from the interior of the wrap cast, and the medial panel is replaced and held in position with additional strips of plaster bandage.</p> <p>The positive stump model is then poured into the wrap cast, with the wrap cast held so that the alignment lines are vertical. The holding pipe is inserted vertically and should be invested into the plaster to within 1/2 in. of the end of the cast.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</li> <li>Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</li> <li>Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</li> <li>Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</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>3.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 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>1.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 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>2.</b> </td><td class="clsTextSmall">Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 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>4.</b> </td><td class="clsTextSmall">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 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">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Manager, J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla. 32806.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 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>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center, 401 East Ohio St., Chicago, Ill. 60611. The work of the Center is supported by U. S. Veterans Administration Research Contract V1005M-1079.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-19.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 Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/4dd6d94c1daa2cb68cd4f392331932db.pdf 259046e83e06f18b250ccc9220f4934a https://staging.drfop.org/files/original/2d3c637c51e5be4ea4a9b4f22c646846.jpg 11fee075823dd0fa5b865a8e747525dc https://staging.drfop.org/files/original/71f334ea18c694ea04b3d9b1f08a2253.jpg f7ec0a39eb5bbe47b310aa1f57a3d155 https://staging.drfop.org/files/original/6a0443994001a210b073e6923907b80a.jpg f8dcbc9d4224aa5e9cbb3f44145131fb https://staging.drfop.org/files/original/9263685d4481876c0d4e9272dd4ebeea.jpg d0d533d69cdfefbd4d631caee28aa13c https://staging.drfop.org/files/original/98f2d20450ad3768fbb296aef6b3bf20.jpg 74771fdcfdd89388647e71b2b29d843c https://staging.drfop.org/files/original/c55b28bda436388da75e3eee453c6c75.jpg 722fd6cb26bbb613bcdda96faad136a5 https://staging.drfop.org/files/original/46575d89fa490b67fd583a23dbb0eba1.jpg 1d6a709393590127cca18e095b03d7c1 https://staging.drfop.org/files/original/03efb5bd9a7aa0a4e0c7536b11d81944.jpg b8ab156ee418e2e7f14c6f781ad91ddc https://staging.drfop.org/files/original/9b3dd80c9f94cac1f8d03173ac09fa29.jpg 2cc8730d37d1046df4e01ae577b08e1a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_024.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 24 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_024.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_024.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>Nomenclature for Congenital Skeletal Limb Deficiencies, a Revision of the Frantz and O'Rahilly Classification</h2> <h5></h5> <!--Page 24--><!--====NEW ARTICLE====--> <p><i>Report of the Consultants to the Subcommittee on Child Prosthetics - Problems of the Committee on Prosthetics Research and Development:</i></p> <p><i>Cameron B. Hall, M.D., Los Angeles, Calif.<br /> Claude N. Lambert, M.D., Chicago, Ill.<br /> Ronan O'Rahilly, M.D., St. Louis, Mo.<br /> Chester A. Swinyard, M.D., Ph.D., New York, N.Y.</i></p> <p><i>Prepared by Robert L. Burtch, M.A.,<a style="text-decoration:none;">*</a> Research Scientist, Prosthetic and Orthotic Studies, New York University Post-Graduate Medical School, under the supervision of Sidney Fishman, Ph.D., Project Director, and Hector W. Kay, M.Ed.,<a style="text-decoration:none;">*</a> Associate Project Director, Prosthetic and Orthotic Studies, New York University Post-Graduate Medical School.</i></p> <p>At the request of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, Child Prosthetic Studies, New York University, initiated a study of congenital skeletal limb deficiencies during March 1963<a></a>. The primary purpose of this initial effort was to determine the adequacy of the classification nomenclature for congenital skeletal limb deficiencies proposed by Drs. Charles H. Frantz and Ronan O'Rahilly<a></a> and of a description-classification form developed by NYU Child Prosthetic Studies. The results of the evaluation<a></a> indicated that 471 of 577 limbs (85 per cent) were classifiable within the framework of the Frantz-O'Rahilly system.</p> <p>In the light of these generally favorable results, the Subcommittee on Child Prosthetics Problems appointed a group of consultants (Drs. Cameron B. Hall, Claude N. Lambert, Ronan O'Rahilly, and Chester A. Swinyard) to consider possible ways and means by which the Frantz-O'Rahilly plan might be modified to provide an even more comprehensive system for classifying limb deficiencies.</p> <p>In the course of several joint meetings of the consultants and the NYU staff, a revised system was developed. The revised system generally follows the basic principles proposed by Drs. Frantz and O'Rahilly, in that: <i>first</i>, it is based on a description of <i>absent </i>skeletal parts; <i>second, </i>deficiencies are classified under the two basic headings, Terminal and Intercalary, with subgroups of Transverse and Longitudinal under each of these headings. However, the use of anatomical terms has been extended significantly and is included in the classification of all deficiencies. Thus the use of such clinical descriptive terms as hemimelia, peromelia, ectromelia, phocomelia, dysmelia, etc., has been eliminated. Only two basic descriptive <!--Page 25--> terms are now proposed: Amelia, or <i>complete </i>absence of a free limb, and meromelia, or <i>partial </i>absence of a free limb. The latter term is a derivative of the Greek <i>meros </i>(part or partial) and <i>melos </i>(limb).</p> <p>The use of the revised nomenclature adheres to procedures set forth in the <i>Standard Nomenclature of Diseases and Operations </i><a></a>. The classification of a given deficiency, therefore, proceeds from the general to the specific, citing absent skeletal elements for definitive identification. For example, Meromelia: Terminal Longitudinal; Metacarpal: I, II, III describes a terminal longitudinal deficiency of the hand involving absence of digital rays I, II, and III. To provide a basis for possible international consideration, the anatomical terminology utilized in this system is consistent with <i>Nomina Anatomica.</i><a></a> Since x-rays and the resulting classification may be expected to change depending on the degree of maturation (for example, tarsals and carpals), cases where ossification is continuing must be reclassified periodically.</p> <p>The material related to the revised classification system is presented in five parts:</p> <blockquote> <ol> <li>A definition of the terms and symbols employed.</li><li>Two charts (II. a. and II. b.) adapted from articles by Dr. Hall <i>et al. </i><a></a> and Dr. O'Rahilly<a></a> to facilitate understanding of the basic principles involved.</li><li>A detailed, illustrated description of the classification plan.</li><li>A description-classification form used for recording purposes.</li><li>Instructions for use of the description-classification form.</li></ol> </blockquote> <ol> <li>TERMS AND SYMBOLS <ul> <li>TERMS <ul> <li>Amelia - <i>Complete </i>absence of a free limb (exclusive of girdle).</li> <li>Meromelia - <i>Partial </i>absence of a free limb (exclu- sive of girdle).</li> <li>Terminal - Absence of all skeletal elements distal Deficiency to the proximal limit of the defi- ciency, along the designated axis (longitudinal or transverse).</li> <li>Intercalary Deficiency - Absence of middle part(s) lying between a proximal-distal series of limb components; elements proximal to and distal to the absent part(s) are present.</li> <li>Transverse - Absence extending across the width of the limb.</li> <li>Longitudinal - Absence extending parallel with the long axis of the limb (forearm and/or hand, or leg and/or foot), either pre-axial, postaxial, or (as in the hand or foot) central in nature.</li> <li>Pre-axial Absence of the portion of the fore- arm and/or hand, or leg and/or foot on the thumb or the great-toe side of the limb (radial or tibial portion).</li> <li>Postaxial - Absence of the portion of the fore- arm and/or hand, or leg and/or foot on the side of the limb opposite the thumb or the great toe (ulnar or fibular portion).</li> <li>Central - Absence of one or more of the intermediate digital rays (for example, Ray III).</li> <li>Rudimentary - A remnant of an osseous element. If the remnant is identifiable (for example, the humerus), the term "rudimentary humerus" would be applicable. If the remnant cannot be identified, the symbol "X" (unknown) would be cited (for example, "rudimentary X").</li> <li>Ray - A digit.</li> </ul></li> <li>SYMBOLS <ul> <li>I - Intercalary.</li> <li>T - Terminal.</li> <li>- - Transverse.</li> <li>/ - Longitudinal</li> <li>Pre - Pre-axial.</li> <li>Post - Postaxial.</li> <li>? - Questionable identity of element cited (for example, radius <b>?</b>).</li> <li>X - Unknown (unidentifiable).</li> <li>:I, II, III, IV, or V - Digital ray(s) involved, starting from pre-axial to postaxial side of limb.</li> </ul></li> <li>SKELETAL ELEMENTS<br />Capital letters are used to identify skeletal elements that are <i>completely </i>absent; small (lower case) letters are used to identify skeletal elements that are <i>partially </i>absent. If the word identifying the skeletal element is written out, the first letter of the word is capitalized when the element is completely absent (for example, Humeral), and in lower case when only partially absent (for example, humeral). <ul> <li>HU or hu - Humeral.</li> <li>U or u - Ulnar.</li> <li>R or r - Radial.</li> <li>CA or ca - Carpal.</li> <li>TI or ti - Tibial.</li> <li>FI or fi - Fibular.</li> <li>TA or ta - Tarsal.</li> <li>MT or mt - Metatarsal.</li> <!--Page 26--> <li>MC or mc - Metacarpal.</li> <li>PH or ph - Phalangeal.</li> <li>FE or fe - Femoral.</li> <li>PP or pp - Phalanx Proximal.</li> <li>PM or pm - Phalanx Middle.</li> <li>PD or pd - Phalanx Distal.</li> </ul></li> <li>SKELETAL SEGMENTS <ul> <li>P - Proximal third of element cited.</li> <li>M - Middle third of element cited.</li> <li>D - Distal third of element cited.</li> <li>The symbols P, M, and D are used to indicate thirds of the skeletal elements cited, which may be completely or partially absent. Utilization of the three symbols requires the following clarification:</li> </ul></li> <li>TERMINAL TRANSVERSE (T-) DEFICIENCIES <ul> <li>P - absence of <i>part </i>of the proximal third of the skeletal element cited <i>and everything distal to it.</i></li> <li>M - absence of <i>all or part </i>of the middle third of the skeletal element cited <i>and everything distal to it.</i></li> <li>D - absence of <i>all or part </i>of the distal third of the skeletal element cited <i>and everything distal to it.</i></li> </ul></li> <li>TERMINAL LONGITUDINAL (T/) DEFICIENCIES <ul> <li>P - absence of <i>part </i>of the proximal third of the skeletal element cited and everything distal to it <i>parallel with the same axis. </i></li> <li>M - absence of <i>all or part </i>of the middle third of the skeletal element cited and everything distal to it <i>parallel with the same axis. </i></li> <li>D - absence of <i>all or part </i>of the distal third of the skeletal element cited and everything distal to it <i>parallel with the same axis.</i></li> </ul></li> <li>INTERCALARY TRANSVERSE (I-) DEFICIENCIES AND LONGITUDINAL (I/) DEFICIENCIES <ul> <li>P - absence of <i>all or part </i>of the proximal third of the skeletal element cited.</li> <li>M - absence of <i>all or part </i>of the middle third of the skeletal element cited.</li> <li>D - absence of <i>all or part </i>of the distal third of the skeletal element cited.</li> </ul></li> </ul></li><li> <ol> <li>BASIC SCHEMA FOR CLASSIFICATION OF CONGENITAL SKELETAL LIMB DEFICIENCIES - <b>Fig. 1</b> presents a basic schema for the classification of congenital skeletal limb deficiencies which has been adapted from one originally presented by Dr. Cameron B. Hall <i>et al. </i>.<a></a></li><li>BASIC SCHEMA FOR CLASSIFICATION OF CONGENITAL SKELETAL LIMB DEFICIENCIES - <b>Fig. 2</b> presents a basic schema for the classification of congenital skeletal limb deficiencies which has been adapted from one originally presented by Dr. Ronan O'Rahilly.<a></a></li></ol> </li><li>CLASSIFICATION NOMENCLATURE <ol> <li>Terminal Transverse (T-) Deficiencies ( <b>Fig. 3</b> and <b>Fig. 4</b>)</li><li>Amelia - complete absence of a free limb (exclusive of girdle). (For example, Amelia: T-; Upper Right.)</li><li>Meromelia - partial absence of a free limb (exclusive of girdle). <ol> <li>Humeral or Femoral (P, M, or D) - Partial absence of the humerus or femur and all distal elements.(For example, Meromelia: T-; humeral D (distal third above-elbow-type stump).)</li><li>Radio-Ulnar or Tibio-Fibular <ol> <li>Complete absence of the Radius and Ulna or Tibia and Fibula, and all distal elements. (For example, Meromelia: T-; Radio-Ulnar (elbow-disarticulation-type stump).)</li><li>Partial absence of the radius and ulna or tibia and fibula, and all distal elements. Use P, M, or D, as appropriate.(For example, Meromelia: T-; radio-ulnar M (short below-elbow-type stump).)</li><li>Complete absence of <i>one </i>of the forearm or leg elements, and all distal elements. (For example, Meromelia: T-; Radius (wrist-disarticulation-type stump).)</li></ol> </li><li>Carpal or Tarsalol - Complete absence of all hand or foot elements. (For example, Meromelia: T-; Tarsal (ankle-disarticulation-type stump).)</li><li>Carpal or Tarsal, Distal - Absence of the distal row of carpals or tarsals, and all other hand or foot elements distal to this level.(For example, Meromelia: T-; carpal, Distal (mid-carpal-type stump).) <ol> <li>Carpal or tarsal, Pre- or Postaxial - Absence of either the pre- or postaxial carpal or tarsal bones, <i>and all other hand or foot elements. </i>(For example, Meromelia: T-; carpal, Pre-axial (carpal-metacarpal-type stump).)</li><li>Metacarpal or Metatarsal <ol> <li>Absence of all metacarpals or metatarsals and all hand or foot elements distal to this level. (For example, Meromelia: T-; Metatarsal (tarsal-metatarsal-type stump).)</li><li>Absence of a portion of metacarpals or metatarsals and all hand or foot elements distal to this level. Use P, M, or D to indicate absent segment(s) of each metacarpal or metatarsal. (For example, Meromelia: T-; metacarpal: I D, II D, III D, IV M, V M (trans-meta-carpal-type stump).)</li></ol> </li><li>Phalangeal <ol> <li>Absence of all phalanges from all five digits. (For example, Meromelia: T-; Phalangeal, Upper Right (metacarpo-phalangeal-type stump).)</li><li>Complete or partial absence of <i>one or more phalanges from all five digits </i>(but not all phalanges from all five digits).(For example, Meromelia: T-; phalangeal, Upper Right: I, II; III PM, IV PM, D; V PD (trans-phalangeal-type stump).)</li></ol> </li></ol> </li><li>Terminal Longitudinal (T/) Deficiencies (<b>Fig. 5</b>) <ol> <li>Major Long Bones <ol> <li>Complete absence of one of the forearm or leg elements and of the corresponding portion of the hand or foot. The skeleto-anatomical terms Radial (R), Ulnar (U), Tibial (TI), or Fibular (FI) are used to indicate the absent long bone. In order to provide greater precision, the identifying number of each absent ray is included in the nomenclature. (For example, Meromelia: T/; Radial: I, II.) If all but one unidentifiable ray or rudimentary <!--Page 28--> ray is absent, the symbol "X" (unknown) or term "rudimentary X" is used.</li><li>Partial absence of one of the forearm or leg elements and absence of the corresponding portion of the hand or foot. P, M, or D is used to indicate the absent segment (s) of the long bone. Lower case letters are used, and the absent ray(s) is cited. (For example, Meromelia: T/; fibular M: IV, V.)</li></ol> </li><li>Carpal or tarsal, Pre- or Postaxial - Absence of <i>either </i>the pre- or postaxial carpal or tarsal bones, <i>and </i>corresponding digital rays.(For example, Meromelia: T/; carpal, Pre-axial: I, II.)</li><li>Metacarpal or metatarsal (P, M, or D) <ol> <li>Absence of all phalanges of one to four digits <i>and </i>complete or partial absence of their respective metacarpals or metatarsals.(For example, Meromelia: T/; metacarpal: I, II, III, V.)</li><li>In the case of partial absence of a specific metacarpal or metatarsal, P, M, or D is used to indicate the absent segment (s).(For example, Meromelia: T/; metatarsal: I, II; III D; V M.)</li></ol> </li><li>Phalangeal Absence of all or part of one or more phalanges from one to four digits.(For example, Meromelia: T/; phalangeal, Upper Right: I, II, III.)</li></ol> </li><li>Intercalary Transverse (I-) Deficiencies (<b>Fig. 6</b> and <b>Fig. 7</b>)<br /> A minimum of at least two digital rays (two metacarpals or metatarsals and their associated phalanges) must be present to permit classification as an Intercalary Transverse (I-) deficiency of the major long bones. In such cases, the hand or foot deficiencies (if any) are classified separately. Where there are fewer than two complete digital rays, the deficiency is classified as Terminal Transverse (T-), with a description of the distal digital elements that are absent (for example, "all but one ray absent"). <ol> <li>Major Long Bones <ol> <li>Humeral, Radio-Ulnar; or Femoral, Tibio-Fibular - Complete absence of all three major long bones in the limb with hand or foot elements attached directly to the trunk. (For example, Meromelia: I-; Humeral, Radio-Ulnar.)Concomitant hand or foot deficiencies are classified independently of the major long bone deficit. (For example, Meromelia: I-; Humeral, Radio-Ulnar; plus T/; metacarpal: I, II, V.)</li><li>Humeral or Femoral - Complete or partial absence of the long bone cited. (For example, Meromelia: I-; Humeral.) <!--Page 30--> If a partial absence exists, P, M, or D is added to indicate the absent segment (s) of the bone cited.(For example, Meromelia: I-; humeral M, D.)</li><li>Radio-Ulnar or Tibio-Fibular - Complete or partial absence of the long bone cited.(For example, Meromelia: I-; Radio-Ulnar.)If a partial absence exists, P, M, or D is used to indicate the absent segment (s) of each bone.(For example, Meromelia: I-; tibio-fibular P, M.)</li><li>Humeral, radio-ulnar; or femoral, tibio-fibular - Partial absence of <i>all three major long bones </i>in the upper or lower limb. P, M, or D is used to indicate the absent segment (s) of each long bone.(For example, Meromelia: I-; humeral D; radio-ulnar M, D.)</li></ol> </li><li>Carpal or Tarsal - Complete absence of the carpal or tarsal bones, with proximal and distal skeletal elements present.(For example, Meromelia: I-; Carpal.)</li><li>Metacarpal or Metatarsal - Complete absence of the metacarpals or metatarsals, with proximal and distal skeletal elements present. (For example, Meromelia: I-; Metacarpal.)</li><li>Phalangeal - Absence of all or part of the proximal and/or middle phalanx from all <i>five </i>digits. (For example, Meromelia: I-; phalangeal, Lower Right: I PP; II PP; III PM; IV PM; V PP.)</li></ol> </li><li>Intercalary Longitudinal (I/) Deficiencies (<b>Fig. 8</b>) <ol> <li>Major Long Bones <ol> <li>Complete absence of one of the forearm (R or U) or leg (TI or FI) elements with hand or foot elements intact along the same axis as the deficient long bone. (For example, Meromelia: I/; Fibular.)</li><li>Similar to above except that <i>only part </i>of the long bone cited is absent. P, M, or D is used to indicate the absent segment(s).(For example, Meromelia: I/; radial P, M.)</li></ol> </li><li>Carpal or tarsal, Pre- or Postaxial - Absence of <i>either </i>the pre- or postaxial carpal or tarsal bones with all other hand or foot elements present. (For example, Meromelia: I/; tarsal, Pre-axial.)</li><li>Metacarpal or metatarsal - Absence of <i>all or part </i>of one to four metacarpals or metatarsals.(For example, Meromelia: I/; metatarsal: I, II.) If only part of a metacarpal or metatarsal is absent, P, M, or D is used to indicate the absent segment(s) of the involved ray.(For example, Meromelia: I/; metatarsal: I D; II M, D.)</li><li>Phalangeal - Absence of <i>all or part </i>of the proximal and/or middle phalanx of from one to four digits. (For example, Meromelia: I/; phalangeal, Upper Left: I PP; II PM; IV PP.)</li></ol> </li></ol> </li><li>DESCRIPTION-CLASSIFICATION FORM <b>Fig. 9</b> presents the description-classification form developed by NYU Child Prosthetic Studies for recording congenital skeletal limb deficiencies.</li><li>CLASSIFICATION OF CONGENITAL SKELETAL LIMB DEFICIENCIES The following instructions were developed by NYU Child Prosthetic Studies to accompany the description-classification form: <ol> <li>Fill in the identification items at the top of the page.</li><li>Indicate in the space provided the presence or history of congenital visceral, soft-tissue or skeletal anomalies other than those of the limbs; that is, cardiac, pulmonary, gastrointestinal (esophageal and/or duodenal atresia, imperforated anus, etc.); genito-urinary, for example, cryptorchidism; cleft palate, hare lip, congenital and/or structural scoliosis, spina bifida, etc.</li><li>Using a <i>black </i>pencil or pen, shade in all <i>absent </i>skeletal elements or parts of elements. If an anomaly has been converted to an amputation, describe and classify the <i>original </i>anomaly. Care should be taken to retain the approximate length and girth proportions when shading in partial elements. Using a <i>red </i>pencil or pen, also indicate on the appropriate limb the approximate <i>site </i>and <i>date </i>of the surgical conversion (s).</li><li>In cases where prosthetic restoration is appropriate, indicate the analogous functional level of amputation for prosthetic purposes (for example, short above-elbow, short below-elbow, long above-knee, etc.) in the space provided. Consult <i>Upper </i>and <i>Lower Extremity Manual(s) </i>for functional amputation levels.</li><li>Indicate next to the appropriate skeletal part on the diagram any of the following conditions that exist. Also, include any unlisted conditions present, as well as any additional information that will enhance the completeness of the description. <ul> <li>Synostosis - Contracture</li> <li>Hypoplasia - Pseudoarthrosis</li> <li>Bifurcation</li> <li>Valgus - Dislocation</li> <li>Varus - Subluxation</li> <li>Syndactylism - Supernumerary digit(s)</li> <li>Torsion - Soft-tissue nubbin(s)</li> </ul></li><li>After completing the description of each affected<!--Page 34-->limb, insert in the appropriate space the appropriate classification nomenclature.</li></ol> </li></ol> </li></ol> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Basic schema adapted from Dr. Cameron B. Hall <i>et al. </i>(5). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic schema adapted from Dr. Ronan O'Rahilly <i>(6). </i>The term "meromelia," denoting <i>partial </i>absence of a free limb, is applicable to all examples in the schema with the exception of the transverse deficiency of the <i>complete </i>limb which has been denoted as "amelia." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Terminal transverse (T-) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Terminal transverse (T-) deficiencies (continued). The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Terminal longitudinal (T/) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Intercalary transverse (I-) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Intercalary transverse (I-) deficiencies (continued). The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Intercalary longitudinal (I/) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Description-classification form for recording congenital skeletal limb deficiencies. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Burtch, Robert L., <i>A study of congenital skeletal limbdeficiencies, </i>Inter-Clinic Information Bulletin, May 1963, pp. 1-6.</li> <li>Burtch, Robert L., <i>The classification of congenitallimb deficiencies: A preliminary report, </i>Inter-Clinic Information Bulletin, October 1963, pp. 4-9.</li> <li>Excerpta Medica Foundation (Amsterdam, London,ilan, New York), <i>Nomina anatomica, </i>2nd ed., 1961.</li> <li>Frantz, C. H., and Ronan O'Rahilly, <i>Congenitalskeletal limb deficiencies, </i>J. Bone &amp; Joint Surg., Boston, 43A:1202-1224, December 1961.</li> <li>Hall, C. B., M. B. Brooks, and J. F. Dennis, <i>Congenital skeletal deficiencies of the extremities, </i>J.A.M.A., Chicago, 181:590-599, August 1962.</li> <li>O'Rahilly, Ronan, <i>Morphological patterns in limbdeficiencies and duplications, </i>Am. J. Anat., Philadelphia, 89:155-187, September 1951.</li> <li>Thompson, Edward T., ed., <i>Standard nomenclatureof diseases and operations, </i>McGraw-Hill, New York, 1961.</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>6.</b> </td><td class="clsTextSmall">O'Rahilly, Ronan, Morphological patterns in limbdeficiencies and duplications, Am. J. Anat., Philadelphia, 89:155-187, September 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and J. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., Chicago, 181:590-599, August 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>6.</b> </td><td class="clsTextSmall">O'Rahilly, Ronan, Morphological patterns in limbdeficiencies and duplications, Am. J. Anat., Philadelphia, 89:155-187, September 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and J. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., Chicago, 181:590-599, August 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">Excerpta Medica Foundation (Amsterdam, London,ilan, New York), Nomina anatomica, 2nd ed., 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>7.</b> </td><td class="clsTextSmall">Thompson, Edward T., ed., Standard nomenclatureof diseases and operations, McGraw-Hill, New York, 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>2.</b> </td><td class="clsTextSmall">Burtch, Robert L., The classification of congenitallimb deficiencies: A preliminary report, Inter-Clinic Information Bulletin, October 1963, pp. 4-9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Frantz, C. H., and Ronan O'Rahilly, Congenitalskeletal limb deficiencies, J. Bone &amp;Joint Surg., Boston, 43A:1202-1224, December 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>1.</b> </td><td class="clsTextSmall">Burtch, Robert L., A study of congenital skeletal limbdeficiencies, Inter-Clinic Information Bulletin, May 1963, pp. 1-6.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Since April 1, 1965, Mr. Kay has been serving as Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences—National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Since September 1, 1965, Mr. Burtch has been serving as Coordinator of the Physical Medicine and Rehabilitation Service, Maimonides Hospital—Coney Island Division, Ocean and Shore Parkways, Brooklyn, N.Y. 11235.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-009.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 Nomenclature for Congenital Skeletal Limb Deficiencies, a Revision of the Frantz and O'Rahilly Classification https://staging.drfop.org/files/original/854528621eb80bd8a9b4f7349f5d48a6.pdf e7ecf8eb166fd1de014a65d9a4e19c54 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_020.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 20 - 23 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_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>Conclusions of a Conference on Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>Following the preparation of the <i>Preliminary Design Analysis of Linkage Feeders </i>by Prosthetic and Orthotic Studies of New York University,<a></a> it seemed desirable to explore the significance of the design similarities and differences identified in the NYU report.</p> <p>Accordingly, a Workshop on Linkage Feeders was organized and conducted under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development. Participants in the workshop conference, which was held at the University of Michigan, Ann Arbor, Mich., July 26-27, 1965, included representatives from the five centers whose feeder designs were discussed in the NYU analysis, plus unattached engineering and other consultants.<a style="text-decoration:none;">*</a></p> <p>At the conference, the design and applications of linkage feeders were discussed in considerable detail, both with respect to the major components (chair-attachment assemblies, proximal and distal links, rocker-arm assemblies, and troughs) and the device as a whole. In the following presentation of major points emerging from the discussions, it will be noted that while there were areas of disagreement, a community of agreement on many considerations was evident.</p> <h4>Adjustment</h4> <h4><i>Availability to the Patient</i></h4> <p>A characteristic of the University of Michigan and the Rancho Los Amigos Hospital systems is that provisions for adjustment are retained throughout the life of the orthoses. At the other centers, apparently, a temporary feeder is used initially, with adjustments made during the course of training by physician, therapist, or orthotist. Before the patient leaves the center, the optimal adjustments are frozen, so to speak, in a permanent unit.</p> <p>A basic difference in philosophy is evident here. The belief at the University of Michigan is that the patient's family can be taught to adjust the feeder and should have the privilege of doing so; for example, to accommodate changes in the status of the patient's muscular torques with time. The belief at the other centers is that the optimal feeder geometry established during training may be lost with patient-family manipulation.</p> <p>Since proponents of both approaches are apparently satisfied with the results achieved, no categorical rule would appear to apply. To the impartial observer, retention of adjustability would seem desirable with, perhaps, provision for locking the adjustment features, if this restriction were found necessary.</p> <h4><i>Precision</i></h4> <p>Theoretically-and perhaps actually-the threaded-screw adjustments of the University of <!--Page 21--> Michigan model provide the means for securing more precise adjustments than any of the other units.</p> <p>There appears to be no question that the provision of an efficient system of balances and biases is critical to the patient's performance and increases in importance with the extent of disability.</p> <p>There is, however, considerable question concerning the degree of precision achieved or required in these units. Since motion of the forearm in the trough shifts the center of gravity of the forearm in relation to its axis of rotation, as do objects of different weights held in the hand, optimal adjustment would seem to be dynamic rather than static. Moreover, desired adjustments are in relation to a particular configuration of trough and rocker-arm assembly, for example, and this configuration itself may not represent the optimal design. It is noteworthy, though, that all the systems reviewed appeared to be very useful devices, despite these lacks.</p> <h4>Extent of Use</h4> <p>Texas Rehabilitation Center apparently applies linkage feeders primarily or solely for use with lapboards. Most of the other institutions plan more extensive use, particularly that involving activities at tables or desks, with a strong bias toward vocational rehabilitation or an approximation of normalcy. This difference in approach obviously influences feeder design and application, particularly with respect to the "reach" provided and provisions for securing adequate trough height to avoid disturbing objects on the table or desk. Total linkage length, the use of drop rather than straight swivel arms, and curved rather than straight distal links, may all be affected by these considerations.</p> <p>On this question of limited <i>vs. </i>extended feeder usage, the latter approach (maximum function and use) seems preferable unless the goals are unrealizable.</p> <h4>Link Lengths and Ratios</h4> <p>In mechanical terms, the maximum feeder reach is the sum of the lengths of the proximal and distal links, while the minimum reach is the difference between the two lengths. Kinematically, the two links should be of equal length.</p> <p>A considerable variety of link lengths and ratios was evident in the five feeders reviewed, each apparently representing a compromise between kinematic and practical considerations, that is, the need to reduce the length of the proximal links to permit passage through doorways without interference by the projecting joint between the proximal and distal link. All compromises apparently worked satisfactorily. However, the maximum length for the proximal link commensurate with noninterference would appear desirable to reduce the stress on bearings.</p> <h4>Bearings and Friction</h4> <p>Four of the feeders reviewed incorporated ball bearings to reduce joint friction while only one (Texas Institute for Rehabilitation and Research) used needle bearings. However, since these latter were said to be strong and durable and result in smaller joints, they may well be the bearings of choice.</p> <p>There was some difference of opinion concerning the need for antifriction bearings at the rocker-arm assembly (for trough function). Some conferees deemed a small amount of friction (for dampening) desirable here (for some patients); others disagreed. An obvious solution to meet both contingencies would be the incorporation of antifriction bearings, with nylon washers available for insertion if friction were desired.</p> <h4>Distal Links</h4> <p>Straight, angled, and curved distal links were represented in the feeders reviewed. Functionally (reduced interference between distal link and trough) and aesthetically, the curved links appeared to be superior.</p> <h4>Trough Pivots and Forearm Position</h4> <p>Despite the variety of rocker-arm assembly designs and trough-pivot positions (offset, below the trough, and forked to each side of the trough), the function of all designs appeared to be reasonably satisfactory. Independent engineering opinion tended to favor a forked pivot supporting the trough halfway through the thickness of the forearm rather than below it.</p> <!--Page 22--> <p>Forearm motion (sliding) within the trough was considered. The value of the typical elbow disk (dial) in stabilizing the forearm was questioned by the engineering consultants at the workshop. A strap that pivots on an axis passing through the anatomical axis of the elbow (as in the University of Michigan design) was considered to be more satisfactory. Velcro was suggested as a possible means for retaining the forearm in the trough.</p> <h4>Cosmesis</h4> <p>Feeders are rather conspicuous, mechanical, utilitarian devices. Hence the stress placed on cosmetic considerations by the conferees was all the more noteworthy. Two factors are apparently involved: <i>first, </i>the appearance of the feeder itself, that is, graceful lines, lack of obtrusiveness, etc.; <i>second, </i>the simulation of normalcy in use, for example, sitting at the table to eat a meal rather than using a lap-board.</p> <h4>An Appropriate Name</h4> <p>So-called linkage or ball-bearing feeders are obviously more than this name connotes. A less awkward term that would more appropriately define the characteristics and function of the device would be very desirable. Numerous suggestions were made by the conferees, including the term "balanced forearm orthesis" developed by Dr. Robert L. Bennett at the Georgia Warm Springs Foundation. However, none of the suggestions aroused any enthusiasm.</p> <h4>Potential Users</h4> <p>An attempt was made by the workshop participants to estimate the number of persons who would derive benefit from the use of a feeder.</p> <p>It was mentioned that a large but unspecified number of postpoliomyelitis patients would require such devices for the remainder of their lives.</p> <p>As far as new cases were concerned, the five centers represented at the workshop fitted a total of approximately 150 cases per year. It was estimated that an equal number of patients who might benefit from feeders were not being fitted because of lack of publicity concerning their value or lack of knowledge concerning applications. The conferees were also of the opinion that although new poliomyelitis patients are rare, survivors of automobile, diving, trampoline, and other accidents resulting in high spinal-cord injuries are increasing. In general, these patients require more sophisticated feeders than those developed originally for victims of poliomyelitis.</p> <h4>Need for Further Research</h4> <p>All the feeders reviewed appeared to be of fairly adequate design, and all appeared to be fairly useful devices. Presumably, each device could be improved by incorporating features in other designs, or by taking cognizance of suggestions advanced during the workshop. However, further research to develop a new design-a "super feeder"-does not seem indicated at the present time.</p> <h4>Need for Education</h4> <p>If, as postulated at the workshop, numerous patients with high spinal-cord injuries (who could benefit from the use of a feeder) are not being provided with the device, an obvious educational need exists. To meet this need, two elements are involved: <i>first, </i>information concerning the existence and usefulness of linkage feeders should be brought to the attention of physicians and institutions treating appropriate patients; <i>second, </i>hospital and rehabilitation personnel should be trained in the application and adjustment of the device.</p> <p>To these ends, it was considered that:</p> <ol> <li>Publicity might profitably be given to the NYU review and to the deliberations of the workshop conference.</li><li>Announcement should be made that commercially made feeders closely resembling the Rancho Los Amigos Hospital model described in the NYU report are available.<a style="text-decoration:none;">*</a> </li><li>Announcement should be made that instructional material dealing with the application and adjustment of feeders has been prepared by the Georgia Warm Springs Foundation<a></a> and Rancho Los Amigos Hospital<a></a>, and that reports on design principles have been published by the University of Michigan.<a></a></li><li>Based on available experience, information concerning feeder design principles and applications might well be included in one or more courses offered by the Prosthetics and Orthotics Education Program.</li></ol> <p><b>References:</b></p> <ol> <li>Georgia Warm Springs Foundation, <i>Instructions forbalanced forearm orthesis and research kit.</i></li> <li>Georgia Warm Springs Foundation, <i>Instructions foruse of balanced forearm orthesis kit.</i></li> <li>New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, <i>Preliminary design analysis of linkage feeders, </i>May 1965.</li> <li>Rancho Los Amigo Hospital, <i>How to fit and adjust aball bearing feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>How to fit and adjust asuspension feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>Uses and limitationsof mobile arm supports.</i></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Theory of"feeder" mechanics, </i>Am. J. Phys. Med., <b>42:3, June </b>1963, pp. <b>113-139.</b></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Designrefinement of the linkage feeder, </i>Arch. Phys. Med., 44, November 1963, pp. 609-615.</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>7.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Theory of'feeder' mechanics, Am. J. Phys. Med., 42:3, June 1963, pp. 113-139.</td></tr><tr><td class="clsTextSmall"><b> 8.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Designrefinement of the linkage feeder, Arch. Phys. Med., 44, November 1963, pp. 609-615.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>4.</b> </td><td class="clsTextSmall">Rancho Los Amigo Hospital, How to fit and adjust aball bearing feeder.</td></tr><tr><td class="clsTextSmall"><b> 5.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, How to fit and adjust asuspension feeder.</td></tr><tr><td class="clsTextSmall"><b> 6.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, Uses and limitationsof mobile arm supports.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Georgia Warm Springs Foundation, Instructions forbalanced forearm orthesis and research kit.</td></tr><tr><td class="clsTextSmall"><b> 2.</b> </td><td class="clsTextSmall">Georgia Warm Springs Foundation, Instructions foruse of balanced forearm orthesis kit.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Jaeco Orthopedic Specialties, Box 616 M-R5, Hot Springs, Ark. 71919; J. A. Preston Corp., 71 5th Ave., New York, N.Y.; Orthopaedic Supplies Co., Inc., 9126 East Firestone Blvd., Bldg. R, Downey, Calif.; Rehabilitation Equipment, Inc., 175 E. 83rd St., New York, N. Y. 10028.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Persons attending the workshop were: Herbert Elftman, Sidney Fishman, as co-chairmen; Edward Haak, James Poulson, of the Georgia Warm Springs Foundation; Robert C. Juvinall, James W. Rae, Jr., Edwin M. Smith, of the University of Michigan; G. Hartmann, Nancy Verdon (Appoldt), of New York University; Alice Garrett, Patrick Marer, Betty Yerxa, of Rancho Los Amigos Hospital; Thorkild Engen, of Texas Institute of Rehabilitation and Research; Linda Parker, Randolph Witt, of Texas Rehabilitation Center; Hans A. Mauch, Colin A. McLaurin, Eugene F. Murphy, as engineering consultants; Hector W. Kay, James R. Kingham, A. Bennett Wilson, Jr., of the staff of the Committee on Prosthetics Research and Development. (Mr. Wilson also served as an engineering consultant.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, Preliminary design analysis of linkage feeders, 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>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</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 Conclusions of a Conference on Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/8697a8f963d8891708f7146a8800f1fa.pdf 49a4a04ffbca3021f555d7b987e35685 https://staging.drfop.org/files/original/4caa47c2d021f88d058ca6724b453a4c.jpg 87d9e4145cc6305c442954af03851d1a https://staging.drfop.org/files/original/db019b84f1068a9dd8b7a17c9f3c82f5.jpg 4b54d9acd0a32a50d47ca3a3315312b8 https://staging.drfop.org/files/original/daf8c596c8eb7e9d49656325de183a55.jpg abe05f2d30dae891020dbda823205d85 https://staging.drfop.org/files/original/2cf7234b28f3f375fd1f6ba2eb438cba.jpg 5007228a1cc68268e5171f413d39e00f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_001.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_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>Aging and Amputation</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a part of a lower extremity due to peripheral vascular disease (PVD) incident to the effects of arteriosclerosis with or without the presence of diabetes is today the predominant type of amputation that is being performed in peacetime in the Western World; <i>i.e., </i>the United States and Europe. These ischemic amputations begin to make their appearance in the late forties of life and their incidence increases rapidly in succeeding decades. Lower-extremity PVD cases constituted 85 per cent of all amputations performed at the Massachusetts General Hospital during the period 1962-1964 and the average age of these patients was 70 years.</p> <p>This predominance of PVD lower-extremity cases in the field of amputation surgery is a development of quite recent origin. A survey of lower-extremity amputations by Doctor Jan Hansson in Sweden for the period 1947-1962 documents this fact. During this period, the incidence of lower-extremity amputations in individuals under 60 years of age remained constant at an annual rate of 4 to 5 per 100,000 population. In males over 60, the rate rose from 34 per 100,000 in 1947 to 129 in 1962. In females over 60 years of age, the amputation rate increased from 24 to 62 per 100,000 during this period. Doctor Hansson expressed the opinion that these rates would continue to rise over the coming years.</p> <p>One cannot but surmise that these rapidly increasing rates of lower-extremity amputations in individuals over 60 years of age are but a reflection of the change in the character of our older aged population that has occurred over the past four decades as a result of the dramatic advances that have been made in the prevention, care, and management of disease. Before the advent of insulin, it is doubtful that many diabetics lived long enough to develop gangrene of a lower extremity. Countless numbers of people are now reaching the age of 65 or older with medical conditions which, forty years ago, would have been fatal at a much earlier age.</p> <p>Ischemic amputations of the lower extremity formed an insignificant part of the workload of prosthetic facilities forty years ago. This is borne out by Doctor Hansson's Swedish study. In 1926, only 2 per cent of fitted lower-extremity cases were due to PVD amputations, whereas by 1955, they had increased to 57 per cent. Older prosthetists in the United States, whose professional experience dates back to the 1920's, have unanimously stated that this Swedish study accurately reflects their own experience in that forty years ago they rarely fitted a PVD amputee, whereas today these cases form the major part of their workload. The incidence of ischemic amputations was relatively low in 1926 and at that time the mortality rate for these operations was extremely high in view of the fact that no means were available to control infection. Furthermore, it appears that forty years ago very few of these cases were considered as candidates for prosthetic rehabilitation.</p> <p>Potentially, the Medicare Act for the Aged which became effective in July 1966 can relieve a serious national inequity that in the past has involved the older aged amputees in this country. Over the years federal and state programs have been available to provide financial assistance for needy amputees from birth until they reached the 60 to 65 year age period. The Children's Bureau and the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare have conducted these assistance programs through their support of corresponding state agencies. Until the Medicare Act, amputees and other handicapped individuals over 65 years of age who needed assistance, except for beneficiaries of the Veterans Administration, have been dependent upon local welfare programs that varied widely in their character throughout the country. The 1964 annual VRA report revealed that only 1.7 per cent of their rehabilitated cases for that year were over 65 years of age. Yet this older aged segment of our population is characterized by multiple disabilities and, as a group, does not have the financial resources to take advantage of the rehabilitation opportunities that are available in most sections of this country. A bulletin of the National Health Survey of the Public Health Service, Series 10, Number 32, reports that 50 per cent of citizens 65 years or older have incomes of less than $3,000 per year and that 50 per cent have disabilities that limit materially their daily activities.</p> <p><b>Table 1</b> compares, in terms of their ages, a study of 12,000 new, fitted amputees that were collected during the two-year period 1961-1963 in the United States with all new cases that were furnished prostheses in Great Britain in 1962. No unfitted or old amputee cases provided with a new replacement device are included in these two groups of amputees.</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 basis for this wide disparity between Great Britain and the United States with respect to the fitting of older aged amputees is economic. Any amputee in Great Britain, regardless of his age, can receive a prosthesis at government expense if he demonstrates that he has some useful prosthetic rehabilitation potential.</p> <p><b>Table 2</b> presents the sources of payment for prostheses of the 12,000 new, fitted cases cited in <b>Table 1</b> above. Cases assisted by welfare agencies are almost exclusively geriatric since the state programs subsidized by the Children's Bureau and VRA are available to younger amputees.</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 data presented in <b>Table 2</b> apply to the United States as a whole and vary widely between individual states. This is illustrated by <b>Table 3</b> that compares the percentage of new, fitted cases over 65 years of age in two states that have, roughly, the same numerical population. The relatively higher economic status of state A and its well-developed welfare programs, as compared with state B, form the basis for the very wide disparity in the fitting of older aged amputees in these two states. The Medicare Act is now available to provide the geriatric amputees in state B with the prosthetic rehabilitation services that have been denied them in the past.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Individuals with peripheral vascular disease of their lower extremities of a severity requiring amputation have, as a group, multiple disabilities that can abridge and even reduce to zero their prosthetic rehabilitation potential. The prosthetic evaluation of these cases, therefore, is critical. They have widely varying rehabilitation goals. Recent studies of these geriatric amputees indicate that, under present management concepts, only about 30 per cent will ever be able to obtain any use of their prostheses. This percentage could be significantly increased if the surgical community would adopt a conservative philosophy in its management of PVD amputations with respect to the original level of amputation and the indications for reamputation in cases of delayed wound healing.</p> <p>The study of PVD amputations at the Massachusetts General Hospital, referred to above, documents the fact that the preservation of the knee joint is all important in determining the rehabilitation potentials of these cases. Percentage-wise, twice as many below-knee cases will be able to use effectively a replacement device as those with above-knee amputations. That there are today widely divergent views concerning the level of amputation in PVD cases is indicated by the fact that, in one large metropolitan area, two-thirds of these cases were amputated above the knee and, in another large city, two-thirds were amputated below the knee. A study of all ischemic amputations performed in 1964 at 14 Veterans Administration hospitals reveals this same disparity in surgical philosophy as regards the level of amputation. The two extremes among these hospitals is shown in <b>Table 4</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>The study of 12,000 new, fitted cases cited earlier reveals that the reamputation rate in successfully fitted, below-knee cases is almost zero. The reamputation of a BK is nearly always due to wound complications at the time of amputation. Pedersen and others have shown that a high percentage of these cases of delayed wound healing following amputation below the knee will successfully respond to conservative management and, because of the preservation of the knee joint, will become effective users of prostheses.</p> <p>The percentage of geriatric amputees that can achieve some useful degree of prosthetic rehabilitation would be increased by early fitting and ambulation. There is today an undue time lag between amputation and the fitting of these cases. A recent spot check revealed that this interval averages seven and one-half months. During this period, many of these older amputees will have developed contractures that may preclude prosthetic restoration, or they may become wedded to a wheelchair existence.</p> <p>It is hoped that orthopedic surgeons who are knowledgeable in the field of amputee rehabilitation will endeavor to inform the general surgeons in their respective communities with regard to modern concepts in the care and management of this form of disability.</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>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-04.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 Aging and Amputation Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/f73009e86594dcca75541df0a12e99d0.pdf 1889f60a10577651577742fa073f3c95 https://staging.drfop.org/files/original/290830ff921d3225c71b7da047de3c91.jpg 604673b43d699b8dd0e4e40b2ebc2915 https://staging.drfop.org/files/original/a35ba394e727d7f97890d44e3b4bc8f8.jpg d1d8235db6501bdc2e847d0aa6325edc https://staging.drfop.org/files/original/64c3f030f117136789588247cc666446.jpg 4f2e2336c57ccb9972606fa34fc39784 https://staging.drfop.org/files/original/80a7da92cda87b5b46d4629f021c8c94.jpg dbe15132b2e8b0856e434023c45cafd3 https://staging.drfop.org/files/original/5c1001c8613c3cdbbbeaec4168327017.jpg a0568a7d77d908e3e116118e815c1508 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_010.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 10 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_010.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_010.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>Preliminary Design Analysis of Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Nancy V. Appoldt, B.A. <a style="text-decoration:none;">*</a><br /></h5> <!-- <sup Note="1">*Based upon a report entitled <i>Preliminary Design Analysis of Linkage Feeders, </i>published by Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, New York, N. Y., in May 1965. The report was prepared under the general supervision of Sidney Fishman, Ph.D., Project Director, Prosthetic and Orthotic Studies, New York University. The study reported upon was supported by funds from the Vocational Rehabilitation Administration, Department of Health, Education, and Welfare.</sup> --> <p>In 1962 the Committee on Prosthetics Research and Development authorized a survey of current orthotics research and development in a number of selected centers as an initial step in a proposed orthotics evaluation program. A prime purpose of the survey was the identification of orthotic devices and procedures as suitable subject matter for the evaluation program.</p> <p>One of the devices selected as meeting the requirements for inclusion in the evaluation process was the linkage feeder designed at the University of Michigan. However, it was apparent that this device, plus a number of others, was essentially a variant of the ballbearing feeder designed and developed two decades ago by the Georgia Warm Springs Foundation. Hence, a review of existing feeder designs was undertaken as a prelude to any formal evaluation program.</p> <p>The systems involved were those currently in use at the Georgia Warm Springs Foundation, Rancho Los Amigos Hospital, the University of Michigan, the Texas Rehabilitation Center, and the Texas Institute for Rehabilitation and Research. Two prefabricated units that were available commercially were also reviewed, but these units resemble the Rancho Los Amigos Hospital feeder so closely that separate consideration is not warranted.</p> <p>Ideally, a feeder supports the weight of the arm and permits the patient with severely weakened or paralyzed upper extremities to position the hand with a minimum of muscular effort. The extent of a patient's performance with a feeder and his method of performance are, of course, contingent on the nature and extent of his disability.</p> <p>The feeders considered in this article have numerous structural features and operational principles in common. An aluminum forearm trough and two stainless-steel swivel arms that rotate on ball or needle bearings support the weight of the upper extremity and provide useful motion when activated by a slight residual motor power in the head, neck, trunk, or arms. The joint cylinders may be rotated to bring the feeder assembly into an inclined plane which provides gravity assistance to the horizontal motions of the extremity. The trough pivot may be positioned to give a bias to both vertical motions of the forearm, namely, raising the hand to the head or lowering it to the table top.</p> <p>A number of accessory components may be attached to a feeder to adapt the equipment to individual requirements without modifying the basic design. Among these are metal clips, straps, and foam-rubber liners to prevent slippage <!--Page 11--> of the forearm; horizontal and vertical stops to restrict feeder motions to a controllable range; elastic-band and supinator assists to aid motion; and double T-bars to support the hand and provide attachments for self-help devices.</p> <p>The basic principles of the various feeders being the same, a matter of interest is the significance of the points on which they differ. In Appendix A the distinctive features of each of these systems are identified and illustrated in detail. The Georgia Warm Springs Foundation model is presented as the basic design, with its apparent advantages and disadvantages. The other four designs are then compared with the Georgia Warm Springs Foundation item.</p> <h3>SUMMARY AND CONCLUSIONS</h3> <p>Linkage feeders were received from the Georgia Warm Springs Foundation, the University of Michigan, Texas Rehabilitation Center, the Texas Institute for Rehabilitation and Research, and Rancho Los Amigos Hospital. With the Georgia Warm Springs Foundation balanced forearm orthesis as the frame of reference, the design and operational features of each feeder were subjected to critical examination. In summarizing the findings of the examination, two points must be emphasized:</p> <ol> <li>All feeders are in current and apparently successful use at the centers from which they were obtained.</li><li>The feeders were not applied to <i>bona fide </i>patients, but were analyzed in relation to use by a normal adult.</li></ol> <p>Thus the validity of the advantages and disadvantages cited in this report might require further verification.</p> <p>It is of value, however, to identify the <i>apparent </i>strengths and weaknesses of each feeder in relation to the Georgia Warm Springs Foundation balanced forearm orthesis. This feeder was the first of its kind, and its basic design served as a model for the subsequent feeders. The question that this review attempts to answer is: In what respects do the features of the other feeders appear to be superior or inferior to those of the Georgia Warm Springs Foundation Feeder?</p> <h3>UNIVERSITY OF MICHIGAN</h3> <p>The multiple adjustment features of the University of Michigan feeder appear to make it the most versatile of those reviewed. Moreover, this adjustment capability is maintained throughout the life of the feeder, in contrast to the reduced adjustability of the "permanent" feeder which is the end product in some of the other designs.</p> <p>The significant additional adjustment involves the rocker-arm assembly and allows the trough, and consequently the forearm, to be raised or lowered with respect to the trough pivot. The fore-and-aft adjustment found in other feeders is also available. Thus the forearm may be balanced against gravity in two dimensions, permitting maximum control of the forces acting about the trough pivot in horizontal, vertical, and intermediate positions of the forearm. The use of ball bearings in the distal link and trough pivot, as well as in the first and second joints, minimizes frictional forces in the system. The screw-adjustment system permits precise adjustment without the use of tools. The lateral location of the rocker-arm assembly, combined with the use of a triceps strap, permits a closer relationship between table top and trough, while the lateral space required for feeder operation is reduced by the use of a relatively short proximal link.</p> <p>The prime limitations of the University of Michigan feeder are:</p> <ol> <li>It is bulky and has a nonaesthetic appearance.</li><li>The nondetachable proximal link imposes the necessity for removing the entire feeder from the wheelchair when it is to be collapsed, transported, or stored.</li><li>The triceps strap may bind, reducing or eliminating elbow support.</li></ol> <h3>TEXAS REHABILITATION CENTER</h3> <p>The outstanding characteristic of the Texas Rehabilitation Center feeder is its simplicity. The adjustability of link lengths should also be useful for applications to children during the growth years.</p> <p>The absence of ball bearings in the proximal joint makes this feeder more difficult to maneuver in horizontal motions. The short swivel arms and stationary elbow dial restrict extension of the arm and thereby limit function to a reduced zone of motion. Contact of the elbow dial with the distal link obstructs lateral trough motion, while the rocker-arm assembly restricts the upward tilt of the trough. Because the trough is offset from the distal link vertically, <!--Page 12--> placement with relation to a table top is more distant than with the Georgia Warm Springs Foundation, University of Michigan, or the Rancho Los Amigos Hospital system, each of which has horizontally offset troughs. In order to change tilts at the first and second joints, the device must be returned to the orthotics shop.</p> <h3>TEXAS INSTITUTE FOR REHABILITATION AND RESEARCH</h3> <p>The Texas Institute for Rehabilitation and Research model is notably streamlined in appearance. Frictional resistance is minimized in horizontal feeder motions by the use of needle bearings at the end of the distal link.</p> <p>As with the Texas Rehabilitation Center feeder, an orthotist must make any tilt adjustments. This lack of ready adjustment might tend to hinder a patient's performance if his wheelchair were on uneven terrain. It might also delay accommodation to improvement or regression of his disability. The trough's vertical offset from the distal link and relatively long vertical rod limit the closeness of trough placement to the table top. Moreover, to bring the trough as close as possible to the table top, clearance of the distal link is minimized (1/2 to 1 in.) and the link may strike objects on the table.</p> <h3>RANCHO LOS AMIGOS HOSPITAL</h3> <p>In the Rancho Los Amigos Hospital feeder a unique tilt adjustment is provided at the distal end of the proximal link. Adjustment of the second joint, therefore, is easier and more precise. The rocker-arm assemblies permit greater ranges of motion at the trough pivot than those of the Georgia Warm Springs Foundation model. The outside rocker-arm assembly, which has a ball-bearing unit at the trough pivot similar to that of the University of Michigan feeder, minimizes friction in vertical motions and permits two-dimensional adjustment of the pivot relative to the forearm. A ball-bearing unit may also be added to the joint at the end of the distal link to minimize friction in horizontal feeder motions.</p> <p>Each of the feeders, when compared with the Georgia Warm Springs Foundation system, appears to have both positive and negative features. On the basis of the available data, resolution of the various pros and cons as to which feeder is the best is not feasible. Certainly the thought that the most advantageous characteristics of the five feeders might be combined in one superior system has appeal.</p> <p>However, selection of the optimal feeder for a particular patient depends primarily on the purpose for which the device is prescribed. Purposes may range from support of the arms in a comfortable position for the most severely disabled to increased functional independence and participation in vocational activities for others. Thus a single feeder, even one incorporating the best elements of the various designs, may not serve the needs of all patients.</p> <p>Nevertheless, the similarities and differences of the five feeders identified in this review, and particularly the significance of the differences, are worthy of further study. If patients' needs in relation to the functions offered by the various components could be precisely defined, an individual's requirements might best be met by using selected components from one or more of the available feeders.</p> <!--Page 13--> <h3>Appendix A</h3> <h3><i>A Detailed Comparison of Five Feeders</i></h3> <h4>GWSF Balanced Forearm Orthesis</h4> <p><b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Georgia Warm Springs Foundation (GWSF) balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>attaches to the chair upright <i>2. </i>Two screws <i>3 and 4 </i>extend from the clamp to provide attachment for, and anteroposterior angular adjustment of, a ball-bearing tube 5.</p> <p><i>Advantages - </i>The proximal joint may be independently tilted anteroposteriorly and rotated mediolaterally to provide a gravity assist or to compensate for an inclined chair upright or for slopes. There is minimal joint friction.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable swivel arm 6 terminates distally in a ball-bearing tube <i>7. </i>Length of proximal link is adjustable during fitting, nonadjustable in the finished unit. The proximal link is either a drop-type <i>6 </i>or straight (not shown). Accessory collars (not shown) may be used to raise the proximal link. The distal link 8, curved approximately 90 deg., terminates in a vertical tube or post <i>9, </i>the height of which may be increased by height extenders (not shown).</p> <p><i>Advantages - </i>The feeder may be removed from the chair upright without disturbing the base assembly. Minimal friction is present between proximal and distal links. Drop-type proximal link is useful in obtaining proper feeder height for short patients (without clamp adjustment). The straight proximal link may be used with collars to provide elevation of the feeder for taller patients. The curved distal link reduces interference between elbow and distal link. Height extenders are useful for gaining additional trough height and increasing elbow-distal link clearance.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A drop <i>10 </i>or straight (not shown) offset rod inserted in the tube permits rotation of the trough. Accessory collars <i>11 </i>increase rod height. The distal end of the rod fits into two sleeves <i>12 </i>which rotate on the rod. The sleeves are brazed to a 1-in. flat bar with threaded holes for attachment to the underside of the trough <i>13. </i>An L-shaped bar <i>14 </i>soldered to the rod between the sleeves holds the movable sleeve unit on the rod.</p> <p><i>Advantages - </i>The offset rod provides additional trough-link clearance. Additional height adjustment is useful in accommodating tall patients.</p> <p><i>Disadvantages - </i>The L-shaped bar imposes a "down" stop on trough motion.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>15 </i>has prepunched holes interiorly for anteroposterior adjustment on the sleeve bar. The elbow dial is stationary (not shown) or hinged <i>16 </i>to the stem of the cradle and connected to the rocker-arm assembly by a linkage rod <i>17.</i></p> <p><i>Advantages - </i>The hinged dial permits full elbow extension.</p> <p><i>Disadvantages - </i>The stationary dial restricts elbow extension.</p> <!--Page 14--> <h4>The University of Michigan feeder.</h4> <p><b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The University of Michigan (U of M) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>similar to the GWSF item attaches to the chair upright <i>2. </i>An adjustment assembly connects the clamp with a ball-bearing cylinder <i>3 </i>and allows positioning anteroposteriorly by screw <i>4 </i>and mediolaterally by screw 5. Feeder height may be regulated by an adjusting nut <i>6 </i>incorporated into the ball-bearing tube.</p> <p><i>Advantages - </i>Greater precision in mediolateral, anteroposterior,and height adjustments than the GWSF feeder. No tools are required for adjustments. Minimal joint friction.</p> <p><i>Disadvantages - </i>Bulky, conspicuous. Weight of unit must be supported when attaching clamp to wheelchair.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The vertical portion <i>7 </i>of a straight swivel arm is threaded to accommodate the height-adjusting nut. The proximal link, which terminates distally in a ball-bearing tube <i>8, </i>is relatively shorter than the GWSF item. The distal link is angled distally 90 deg. and has a ball-bearing tube <i>10 </i>attached. The distal link is proportionally longer than the GWSF item.</p> <p><i>Advantages - </i>Short proximal link decreases space required (laterally) for feeder excursion. Minimal friction present at second ballbearing joint. Angled distal link provides trough-link clearance. Minimal friction present between distal link and rocker-arm assembly.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint. Linkage is not readily detachable from the wheelchair assembly.</p> <!--Page 15--> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A short vertical rod fits into the ball-bearing tube to permit horizontal rotation of the trough. Affixed to the superior end of the rod is a U-shaped housing <i>11 </i>which supports a ballbearing unit <i>12. </i>Extending from this unit is a threaded shaft which is mounted by a grooved block and adjusting screw <i>13. </i>Affixed to the block is a curved supporting arm <i>14 </i>which extends under the trough and attaches to another grooved block and screw assembly on the inferior lateral aspect of the trough <i>15.</i></p> <p><i>Advantages - </i>Minimal friction present in vertical motions of the trough. Screw-type adjustments permit finer control of elbow-hand balance. Balance of the feeder may be adjusted in two planes, vertical as well as anteroposterior. No tools are required for adjustments.</p> <p><i>Disadvantages - </i>Conspicuous, crude appearance.</p> <p><b>Trough</b></p> <p><i>Description - </i>A triceps strap <i>16 </i>has hinged attachments to two outriggers <i>17 </i>and <i>18 </i>which are riveted to the inferior and lateral aspects of the forearm cradle <i>19.</i></p> <p><i>Advantages - </i>Triceps strap permits full elbow extension. Posterior protrusion of elbow is less with triceps strap than with elbow dial.</p> <p><i>Disadvantages - </i>Triceps strap may be displaced from support position with repetitive motion.</p> <!--Page 16--> <h4>The TRC Feeder</h4> <p><b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Texas Rehabilitation Center (TRC) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly One arm of a U-shaped rod <i>1 </i>inserts into the round clamp <i>2. </i>The other end is brazed to a vertical tube <i>3 </i>so that bending of the U-rod tilts the tube anteroposte-riorly. Rotating the rod within the clamp tilts the joint mediolaterally.</p> <p><i>Advantages - </i>Simple and inconspicuous. The effect of increased friction from absence of ball bearings in the proximal joint is uncertain. Some friction at this point may be advantageous, for example, to lend stability at the shoulder so that motion imparted to the feeder will occur at the elbow first. It may, however, be disadvantageous if the impedence cannot be readily overcome, particularly in the zone of hand motions about the head.</p> <p><i>Disadvantages - </i>Benders must be used to obtain anteroposterior tilt adjustments.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>A detachable straight swivel arm <i>4 </i>is adjustable in length from 4 3/4 to 8 in. and terminates in a ballbearing tube 5. The distal link <i>6 </i>is a straight swivel arm, adjustable in length from 4 3/4 to 8 in., and terminates in a vertical tube <i>7.</i></p> <p><i>Advantages - </i>Feeder can be removed from chair without disturbing the base assembly. Ball bearings reduce joint friction. Short proximal link reduces lateral space required for feeder excursion.</p> <p><i>Disadvantages - </i>Short linkage lengths limit reach and permit joint toggle. As with the GWSF unit, benders must be used on the proximal link to obtain tilts at the second joint without affecting the plane of motion of the first joint. When the forearm is inclined vertically, the distal link interferes with horizontal excursion of the dial.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A rod, Y-shaped distally <i>8, </i>swivels within the tube and articulates with pre-drilled holes in the trough fenders <i>9 </i>to form the trough pivot.</p> <p><i>Advantages - </i>Pivot joints are easily adjusted on the trough without tools. The location of the trough pivot, being higher with respect to the trough than that of the GWSF feeder, more closely approximates the center of gravity of the forearm.</p> <p><i>Disadvantages - </i>Y-shaped rod imposes "up" stop on trough.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>10 </i>has anteroposterior adjustment on pre-drilled holes. Forearm cradle as stationary dial <i>11.</i></p> <p><i>Disadvantages - </i>As with the GWSF stationary dial assembly, elbow extension is limited.</p> <!--Page 17--> <h4>The TIRR Feeder</h4> <p><b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The Texas Institute for Rehabilitation and Research (TIRR) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly A round clamp <i>1 </i>is attached to the chair upright. An offset plate <i>2 </i>affixed to the clamp provides the mounting for the needle-bearing tube <i>3, </i>which is adjustable anter-oposteriorly in the trial feeder, nonadjustable in the permanent model (not shown). The tube is tilted mediolaterally by rotation of the round clamp.</p> <p><i>Advantages - </i>Smaller tube with needle bearings reduces bulk of unit and provides an unobtrusive appearance. Minimal joint friction.</p> <p><i>Disadvantages - </i>In the permanent feeder, mediolateral adjustments cannot be made without affecting anteroposterior tilt which has been established.</p> <!--Page 18--> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The proximal and distal links are straight and terminate in needle-bearing tubes 5 and <i>6. </i>The proximal link is detachable and the length of the links is adjustable in the trial model, nonadjustable in the permanent model.</p> <p><i>Advantages - </i>Feeder may be removed from the chair without disturbing the base assembly. Minimal joint friction.</p> <p><i>Disadvantages - </i>As in the GWSF unit, benders must be used to effect tilts at the second joint without altering the base assembly.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A relatively long vertical rod <i>7 </i>terminates superiorly in a clevis hinge <i>8. </i>A rectangular bar <i>9 </i>bearing two threaded holes for trough attachment is brazed to the movable portion of the hinge.</p> <p><i>Disadvantages - </i>The length of the vertical rod is not sufficient to prevent interference of the distal link with the lateral excursion of the elbow dial when the trough is in the "up" position. This means of offsetting the trough from the distal link positions the terminal end of the link approximately 1/2 in. above the table top. The path of feeder motion is obstructed by objects on the table.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>10 </i>and hinged elbow dial <i>11 </i>are similar to the GWSF unit's trough. The linkage rod <i>12, </i>which is adjustable for fitting purposes, is nonadjustable in the permanent feeder (not shown).</p> <p><i>Advantages - </i>Permits full elbow extension.</p> <!--Page 19--> <h4>The RLAH Feeder</h4> <p><b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The Rancho Los Amigos Hospital (RLAH) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>As in the GWSF unit, a round clamp <i>1 </i>attaches to the chair upright. An L-shaped bracket <i>2 </i>extends from the clamp to provide attachment for and anteroposterior angulation of an adjusting plate <i>3. </i>A ball-bearing tube <i>4 </i>is soldered to the posterior lateral aspect of the plate.</p> <p><i>Advantages - </i>As with the GWSF unit, the proximal joint may be tilted mediolaterally by rotating the wheelchair clamp and anteroposte-riorly by a separate adjustment. The plate simplifies anteroposterior adjustment.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable drop swivel proximal link 5 is similar to the GWSF item and terminates distally in an adjustable ball-bearing tube <i>6. </i>A small hinge unit <i>7 </i>permits anteroposterior tilting of the tube. The selected tilt position is maintained by set screws <i>8. </i>The distal link, similar to the GWSF item, is curved 90 deg. and terminates in a vertical tube <i>9. </i>An alternate unit (not shown) for patients with limited motion in the horizontal plane replaces the vertical tube with a ball-bearing unit. Post height extenders, like those of the GWSF system, may be fitted into the vertical tube to elevate the trough.</p> <p><i>Advantages - </i>The tilt adjustment for the second joint permits greater ease and precision in providing assistance to horizontal motions of the forearm. As with the GWSF distal link, the curved offset permits adequate horizontal rotation of the rocker-arm assembly when the trough is in the "up" position. Ball bearings used at the end of the distal link reduce friction between the distal link and the rocker-arm assembly. Additional feeder height may be desirable for tall patients or for specific activities (for example, combing the hair).</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>The standard assembly consists of a vertical rod which swivels within the tube and is surmounted by a U-shaped hinge unit <i>10. </i>Fixed to the movable portion of the hinge is a 1-in. rectangular bar <i>11. </i>Threaded holes in the bar can be aligned with drill holes in the underside of the trough for attachment and anteroposterior adjustment. The outside rocker-arm assembly incorporates a height-adjusting collar <i>12 </i>on a longer vertical rod and a ball-bearing trough pivot <i>13. </i>A clamp anchored to the hinge axis medially, attaches to an offset rod <i>14 </i>to permit vertical adjustment of the trough with respect to the hinge.</p> <p><i>Advantages - </i>The outside rocker-arm assembly reduces friction in vertical motions and permits greater control of elbow-hand balance by means of placing the trough pivot closer to the center of gravity of the forearm.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>15 </i>and dial <i>16 </i>are similar to but not identical with the GWSF forearm cradle and stationary dial.</p> <p><i>Disadvantages - </i>Stationary dial restricts elbow extension.</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>Nancy V. Appoldt, B.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-005.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 Preliminary Design Analysis of Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Nancy V. Appoldt, B.A. * https://staging.drfop.org/files/original/09ae6273b7efa1eca6cc0322ff308dd3.pdf c37e010a6efb7da15ebc3041aebdd09c https://staging.drfop.org/files/original/0e3e1220253af6aa4b191462f1226ca4.jpg b0082ad957d997d1c0132891b476d3b6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_044.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 44 - 45 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_02_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>L'Attelle Monotubulaire, a Review</h2> <h5>Ralph Lusskin, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>L'Attelle Monotubulaire is the second fascicle, or increment, of the Atlas d'Appareillage Prothetique et Orthopedique (Atlas of Prosthetic and Orthopaedic Appliances) being published under the direction of Professor Louis Pierquin of the Faculty of Medicine of Nancy {Artificial Limbs, Spring 1964). L'Attelle Monotubulaire describes a lower-extremity brace of novel design and function-the monotubular brace. This interesting departure in French orthotics utilizes a single straight tubular upright to provide lightness and strength. The conventional medial upright is eliminated.</p> <p>Additional departures include a round caliper shoe attachment placed anterior to the ankle joint as well as below it. Geometry is accommodated during ankle movement and spring action is added to the joint by the use of a telescoping lower leg piece which inserts into an upper tube below the calf band. Stops and additional springs can be attached to the stirrup piece.</p> <p>Thus there has been developed a brace that uses a straight upright anterior to the axis of the leg, which has a moderate posterior offset of the knee joint, which varies in length with ankle motion and is easily adjusted to the torsional alignment of the leg. Patellar-tendonbearing-type leg bands and quadrilateral sockets can be utilized in place of narrow leg and thigh bands. Wide, contoured plastic bands are attached by metal bands soldered to the brace.</p> <p>To evaluate such a novel device, one must determine whether construction would present significant problems, whether fitting and alignment procedures can be standardized, and whether utilization corroborates the claimed attributes. Unfortunately, the publication does not provide sufficiently detailed information to answer these questions. This work is presented in broad terms for the general information of the physician-therapist-orthotist team. It does introduce the device but does not describe the metals used or the fabrication methods. Alignment procedures are not discussed, although two errors-improper depth of the thigh and leg bands and improper rotational alignment due to faulty positioning of the shoe piece-are demonstrated. No analysis of failure rates or comparison of the effectiveness of this brace versus that of standard braces is given. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "When viewed laterally, the monotubular brace is traight; it does not show even the slightest curve at the level of the knee. It rests on a forward pin; that is, on a pin located in front of the axis of the limb." From L'Attelle Monotubulaire </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable thought and work have obviously been expended to bring this device to its present state. Thus it is unfortunate that one can only speculate concerning possible limitations or advantages that might be inherent in its design.</p> <h4>Possible Limitations</h4> <p>Difficulties in using this brace might be encountered if deformities of the knee in the frontal plane, for example, genu valgum or genu varum, are present. In addition, the management of any flexion contracture of the knee would apparently be most difficult.</p> <p>Ankle instability would not be controlled by this device. While drop foot could be managed, varus and valgus deformities, both fixed and functional, might exceed the capacities of the brace. It is not apparent whether or not a calcaneal deformity could be adequately stabilized.</p> <p>The report notes the critical nature of the depth of the leg band, indicating that proper alignment and fit are vital factors in the application of this orthosis and that careful supervision by the physician would be required.</p> <h4>Possible Advantages</h4> <p>Certain advantages of the monotubular brace are apparent. The simplicity of the single-bar fabrication, the lightness of the device, and its potential for control of bilateral disorder without clearance problems are all positive values.</p> <h4>Conclusions</h4> <p>Since the monotubular brace appears to have potential value and its limitations can be only assumed, the device should be the subject of a controlled evaluation to identify problem areas and to demonstrate the usefulness of the device. This evaluation should include the training of others in fabrication, alignment, and fitting of the brace, and its utilization by a representative group of patients under controlled conditions.</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>Ralph Lusskin, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Clinical Professor of Orthopaedic Surgery, School of Medicine and Post-Graduate Medical School, New York University, 550 First Ave., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_044/1965_02_044.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 L'Attelle Monotubulaire, a Review Creator An entity primarily responsible for making the resource Ralph Lusskin, M.D. *