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Clinical Prosthetics & Orthotics
Description
An account of the resource
The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2).
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The American Academy of Orthotists and Prosthetists
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<h2>Technical Note: Rigid A.F.O. - Another Choice</h2>
<h5>Robert E. Doran, C.P.O. <a style="text-decoration: none;">*</a></h5>
<p>When an orthotic prescription calls for an ankle/foot orthosis to provide rigid ankle/foot stabilization, the two basic choices have been (1) a double bar metal orthosis or (2) a thick and/or reinforced thermoplastic orthosis. We are all familiar with the advantages and disadvantages each has to offer.</p>
<p>It was this author's goal to design a rigid A.F.O. that would combine the advantages of both. The features of such an orthosis should include light-weight construction; provide rigid ankle stabilization; provide adjustable plantar and dorsiflexion in order to dynamically align the orthosis; fit inside the shoe; be cosmetically acceptable; be easily donned; and maintain alignment while changing heel heights.</p>
<p>With the above in mind, the following orthosis was designed. The orthosis consists of "pre-preg" (the resin is impregnated in the matrix in an uncatalyzed form prior to lay-up, generally at the factory. Once the desired lay-up is achieved, the structure is exposed to a catalyzing agent so that it hardens), carbon-fiber and fiberglass fabric. Epoxy and polyester resin have been used as bonding agents and the orthosis is formed over a plaster model of the patient's leg. Such pressure applying agents as vacuum bags and pressure wraps have been used. The carbon fiber and fiberglass fabric are properly oriented to resist the stresses imposed upon the orthosis and comprise a structure that provides a high strength to weight ratio.</p>
<p>The orthosis has a foot section which begins on the plantar aspect of the foot and extends proximally on the medial and lateral sides of the leg. The "uprights" are connected by adjustable velcro-closing calf straps. Plantar and dorsiflexion adjustments are independently achieved by adjusting the anterior and posterior velcro-closing calf straps.</p>
<p>In some cases, donning is simplified by removing the posterior strap, thus allowing for a posterior entry of the foot and leg into the orthosis and shoe.</p>
<p>Over the past eighteen months, nine patients with diagnoses that include low level paraplegic, C.V.A., and neuromuscular disease have been fitted with the graphite composite A.F.O. as a successful alternative to "traditional" orthoses.</p>
<p>Orthotists now have another choice when designing a rigid ankle foot orthosis for their patients. The graphite composite A.F.O. combines some of the advantages of the standard metal and thermoplastic constructed A.F.O.</p>
<b>Robert E. Doran, C.P.O. </b> Thousand Oaks Prosthetic Orthotics, 253 Lombard Street, Suite C, Thousand Oaks, California 91360.<br /><br /><br />
<div style="width: 400px;"></div>
Page Number(s)
28 - 28
Year
1984
Volume
8
Issue
4
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Technical Note: Rigid A.F.O. - Another Choice
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Robert E. Doran, C.P.O. *
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Title
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Clinical Prosthetics & Orthotics
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An account of the resource
The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2).
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The American Academy of Orthotists and Prosthetists
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English
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<h2>Orthotic Pelvis Control in Spina Bifida</h2>
<h5>H.R. Lehneis, Ph.D., C.P.O. </h5>
<p>Control of the pelvis has been typically problematic in high level spina bifida patients due to the imbalance of motor power around the hip joint. This can be readily appreciated when one considers the differential innervation particularly of the hip flexors versus the hip extensors (<b>Table 1</b>). Note that the hip flexors are at least partially innervated at the L2 and L3 level, whereas the hip extensors are innervated below the L3 level. Such imbalance at the L2 and L3 level of involvement is the cause of lordosis so often seen in these patients, which is often aggravated by hip flexion contractures. Control of the pelvis and thus lordosis has been difficult with conventional designs.</p>
<strong>Table 1. Innervation of the Lower Limb</strong><br /><img src="/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg" p="" width="469" height="684" /><br />In analyzing the force system required to prevent hip flexion and thus lordosis, it becomes clear that the rigid portion of the pelvic band needs to be reversed from the conventional location (<a href="/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg"><b>Fig. 1</b></a>). It should be noted that this consists of a plastic molded Subortholen panel which extends superiorly to the level of the xyphoid process. The uprights of the hip joints are attached to this panel. An anteriorly directed force is provided by a leather hammock covering the buttocks (<a href="/files/original/4af954f59f49c76eabdab685dc5eab40.jpg"><b>Fig. 2</b></a>). Straps attached on each of the four corners of the hammock run through D rings, attached equi-distant above and below the orthotic hip joint center. This system has worked quite effectively in controlling lordosis since first initiated approximately five years ago.
<p>In cases where the patient presents a relatively severe hip flexion contracture, the hip joint uprights are attached to the panel by means of a single pivot placed approximately 5 cm. below the lateral trim line of the panel. By gradually tightening the straps of the buttock pad, some correction can often be achieved. The pivot allows the anterior panel to adapt to the changing angulation as correction is attempted.</p>
<p>It should also be noted that in our practice, patients up to the age of approximately six years old are provided with solid ankles and knees since their legs are still short enough to sit through hip flexion without obstructing much of the space in front of the chair. The purpose of this is to provide the patient with maximum stability and lightweight orthoses. As the patient gains upper limb strength and mobility, knee joints with drop locks are added, usually of the lateral single bar type. Double bars are only used when the patient is relatively heavy and when there is a torsional problem in the orthosis. The ankle-foot portion of the orthosis remains of the solid ankle type to provide the largest possible base of support over which the patient's center of gravity can be maintained with a greater degree of latitude than is possible if orthotic ankle joints were to be used.</p>
<h3>Acknowledgment</h3>
<p>The assistance of Barry Gosthnian, CPO in developing the system described is gratefully acknowledged.</p>
Page Number(s)
26 - 28
Year
1984
Volume
8
Issue
4
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Figure 3
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Orthotic Pelvis Control in Spina Bifida
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H.R. Lehneis, Ph.D., C.P.O.
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Clinical Prosthetics & Orthotics
Description
An account of the resource
The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2).
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The American Academy of Orthotists and Prosthetists
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English
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<h2>Rochester Parapodium</h2>
<h5>Edwin Kinnen, Ph.D. <a style="text-decoration: none;">*</a><br />Martha Gram, P.T. <a style="text-decoration: none;">*</a><br />Kenneth V. Jackman, Ph.D. <a style="text-decoration: none;">*</a><br />Franklin V. Peale, M.D., P.C. <a style="text-decoration: none;">*</a><br />P.W. Haake, M.D. <a style="text-decoration: none;">*</a><br />Gerald A. Tindali, C.P.O. <a style="text-decoration: none;">*</a><br />James A. Brown, O.P.A. <a style="text-decoration: none;">*</a></h5>
<p>The Biomechanics Team at the University of Rochester Medical Center has been developing and testing design modifications to the Toronto parapodium since 1975. Early in 1983, these design modifications had stabilized, and prototypes of the new design were offered to medical centers and orthopedic laboratories in the United States and Canada. The Rochester parapodium has now been fitted to over 80 young children of ages 17 months to 14 years. Most of these children have flaccid paralysis due to spina bifida or spinal injury from L5 to T12.</p>
<p>The Rochester parapodium differs from the Toronto design in the hip and knee hinge and locking mechanisms. The hip joints unlock together with a single lever release and lock automatically on extension. The hip joints unlock with a forward motion and have no lateral projections, which allows ease in releasing hip lock in a confined space such as a wheelchair. The knee joints also unlock independent of the hip joints with a second single lever release and lock automatically on extension with the aid of an extension assist bar.</p>
<p><b><a href="/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg">Figure 1</a>: The hip joints unlock independent of the knee joints.</b></p>
<p>Without lateral projections, rolling is easier for the child who applies the orthosis sitting or in the supine position on floor, then rolls to prone position in order to elevate to a standing posture. This separated locking and unlocking action has simplified many everyday activities for the paraplegic child.</p>
<p>With increased control, the child can become independent in sitting and standing from a chair with arms. He can also bend over to pick up objects from the floor with hips flexed and knees locked. These are important functions for a preschooler exploring his or her surroundings and participating in peer group activities.</p>
<p><b><a href="/files/original/f48d51f3218c758f4338e50f0b689234.jpg">Figure 2</a>: Both joints unlock with a pull of a lanyard.</b></p>
<p>Previously, children wearing the parapodium had to get up from a prone position on the floor by pulling to standing with fully extended knee and hip joints. Now a child can use jackknife-like movements to stand. These movements appear to require much less energy and open the activity to children with higher levels of paralysis.</p>
<p>The lateral supports have also been redesigned for the Rochester parapodium, using bar stock instead of tubular sections. These flat lateral supports facilitate rolling, a very important movement for a child who is independent in dressing and changing positions. The new side bar design, a more rigid construction, also improves the child's momentum during swivel walking. With polypropylene added to the bottom of the base, many children can learn to swivel-walk at functional speeds, with hands free.</p>
<p><b><a href="/files/original/812c173d343ffad067c6c208af011518.jpg">Figure 3</a>: A child can bend over to pick up objects with hips flexed and knees locked.</b></p>
<p>The activities now possible with the new design allow the paraplegic child to function at home and in school with relatively little need for adult supervision or assistance.</p>
<p><i>Partial support for this work has been provided by the J.M. McDonald Foundation, Cortland, New York.</i></p>
<em><b>James A. Brown, O.P.A. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em><br />
<div style="width: 400px;"><em><b><br />Gerald A. Tindali, C.P.O. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em></div>
<div style="width: 400px;"></div>
<div style="width: 400px;"><em><br /><b>P.W. Haake, M.D. </b> 220 Alexander Street, Rochester, New York 14610</em></div>
<div style="width: 400px;"><em><b><br />Franklin V. Peale, M.D., P.C. </b> 220 Alexander Street, Rochester, New York 14610.</em></div>
<div style="width: 400px;"><br /><em><b>Kenneth V. Jackman, Ph.D. </b> Associate Professor of Pediatric Orthopedics, University of Rochester, Rochester, New York 14642.</em><br /><br /></div>
<div style="width: 400px;"><em><b>Martha Gram, P.T. </b> Dept. of Pediatrics, University of Rochester, Rochester, New York 14627.</em></div>
<div style="width: 400px;"><br /><em><b>Edwin Kinnen, Ph.D. </b> Dept. of Electrical Engn, University of Rochester, Rochester, New York 14627.<br /><br /><br /></em></div>
Page Number(s)
24 - 25
Year
1984
Volume
8
Issue
4
Figure 1
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Figure 3
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Rochester Parapodium
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Edwin Kinnen, Ph.D. *
Martha Gram, P.T. *
Kenneth V. Jackman, Ph.D. *
Franklin V. Peale, M.D., P.C. *
P.W. Haake, M.D. *
Gerald A. Tindali, C.P.O. *
James A. Brown, O.P.A. *
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Title
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Clinical Prosthetics & Orthotics
Description
An account of the resource
The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2).
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The American Academy of Orthotists and Prosthetists
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English
DRFOP - Legacy
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<h2>Below-Knee Prosthesis with Total Flexible Socket (T.F.S.): A Preliminary Report</h2>
<h5>John Sabolich, B.S., C.P.O. <a style="text-decoration: none;">*</a><br />Thomas Guth, CP. <a style="text-decoration: none;">*</a></h5>
<p>Recent efforts in Oklahoma City, and San Diego have borne fruit to a promising new way to fit below-knee amputees. The basic design consists of a thin walled thermo-plastic socket secured in a frame by nylon strapping tape so that most of the socket is left exposed and unsupported (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg"><b>Fig. 1</b></a>). This design, named the Total Flexible Socket (T.F.S.), was conceived out of necessity with a few patients that were so difficult to fit that even aggressive techniques such as multiple transparent diagnostic sockets, alginate injections, total surface bearing modifications, and silicone gel inserts failed to provide a measure of comfort acceptable to them. It was felt that a more unconventional method would have to be implemented. Currently, this technique is being used with most of the geriatric population seen, and with time and experience it is being applied to an ever increasing proportion of the total below-knee amputee population served. Forty or more of these sockets have been fitted over the past five months to patients ranging in age from ten to 89 years with results that were beyond initial expectations. Patient reaction has been extremely positive. Plans are to submit an up-dated article when over 100 documented fittings with the described technique have been accomplished.</p>
<strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg">Figure 1. Medial and lateral views of T.F.S. in an exoskeletal version. Suspension sleeve and cosmetic hose rolled down for clear view of socket secured in place with band of fiberglass tape.</a></strong><br />
<p>The idea for the T.F.S. design was prompted during the course of fitting a patient with a flexible diagnostic test socket. The patient was comfortable in this socket even when bearing his full weight on a padded fitting stool. Subsequently, when a full socket receptacle for the test socket was laminated and it was rigidly contained, this comfort was lost. The patient still complained of pressure even when holes were cut out over bony prominences.</p>
<p>Finally, when the maximum amount of material was cut away and the former socket receptacle was reduced simply to a means of attaching the socket to the rest of the prosthesis, thus allowing the socket to return to its former measure of flexibility, comfort was regained.</p>
<p>Several interesting phenomenons were noted:</p>
<ol>
<li>
<p>Since the T.F.S. design is totally flexible, allowing ML as well as AP expansion and retraction, the socket finds and seeks its own level of pressure distribution. If the AP is too tight, it automatically expands, causing the ML to tighten up, wrapping around the tibial flare and the fibula. This, of course, is not true when a receptacle is only opened up over bony areas allowing no reciprocal ML-AP displacement and minimal flexibility, even over bony areas. With the T.F.S., if the ML is too tight, then the AP automatically tightens as the ML loosens, and vice-versa if the AP is too tight (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg"><b>Fig. 2</b></a>).</p>
<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg"><strong>Figure 2. Transverse view of a socket cross section showing, in an exaggerated fashion, the reciprocal AP-ML displacement.</strong></a></li>
<li>
<p>The AP-ML "Milking" action seems to have a positive effect on circulation since the residual limb seems palpably warmer when a T.F.S. is removed, as compared to when a rigid socket is used. In the case of flexible sockets thinner than 3/32 inches thick, the entire socket moves with the residual limb, seeming to expand and contract due to the open nature of the frame. This phenomenon can be felt better than seen by holding the socket as the patient alternately places weight on the prosthesis and removes it, especially after the socket warms up to body temperature. This dynamic socket movement and improved circulation could be very significant for the geriatric P. V.D. patient. This action also seems to enhance atmospheric suspension: when the patient removes weight, the socket collapses and grips the residual limb like the familiar childhood toy, a Chinese fingertrap.</p>
</li>
<li>
<p>Atmospheric Suspension (A.S.) assorted methods of achieving suction suspension for the below-knee amputee have been tried for years, with varying degrees of success. The main reason behind this effort is the desire to solve the number one problem of the below-knee amputee, that of skin shearing and pistoning between the residual limb and socket. Another major problem has been that of the patient wanting a lighter weight, more responsive prosthesis. With the T.F.S.A.S. combination, most patients have been responding favorably with such comments as "It feels like my own leg!" and "It feels like part of me!" With atmospheric suspension, the patient no longer needs to wear a suspension sleeve to maintain full suction. The Total Flexible Socket holds suction better than a rigid socket because the socket can move and conform to the changing contours of the residual limb, through all phases of gait and sitting. A loose elastic knee cage is recommended to enhance proximal brim seal during knee flexion past 90°. For sports prostheses, use of a rubberized sleeve of choice is recommended. Cosmesis is also enhanced since the patient no longer has the extra bulk of socks or inserts increasing calf circumference. It's a little too early to tell, but it is felt that atmospheric suspension may well become the standard below-knee fitting technique for all types of patients.</p>
</li>
<li>
<p>Use of a cuff suspension strap is improved since the cuff and socket brim can contour in about the patella (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg"><b>Fig. 3</b></a>). Use of a suspension sleeve with the T.F.S. is also possible, and if anything, enhances the function of a T.F.S. since the suspension sleeve supports the socket brim and soft tissues, holding the two in close conformity through the full range of knee motion.</p>
<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg"><strong>Figure 3.</strong></a></li>
<li>
<p>Flexibility allows greater containment posteriorally in the popliteal region. The posterior wall can be higher since it flexes away during sitting. Little posterior flare is needed. In fact, this area could be rolled in slightly, similar to how the cubital fold is contained in myoelectric below-elbow arms (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg"><b>Fig. 4</b></a>). If the practitioner desires, the socket can be made flexible all the way down to the distal tibia. This is accomplished by building a thick distal end pad (with or without an insert) inside the socket, or an extension on the exterior of the socket which extends the trimline of the frame distally, allowing total flexibility in the distal regions of socket.</p>
<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg"><strong>Figure 4. Lateral view of T.F.S. showing suggested modified contour.</strong></a></li>
<li>
<p>The ML measurement of the knee becomes wider as the knee flexes. This can be demonstrated by placing an ML gauge on the knee and watching the gauge as one puts the knee through its range of motion. The T.F.S. design allows for this dynamic variance.</p>
</li>
</ol>
<p>Last but not least, overall hygiene and circulation seem to be dramatically improved. Especially impressive is the absence of red marks on the skin following doffing of the T.F.S. There are none of the usual red marks left by conventional sockets. Patients who had to have many reliefs before in their rigid sockets now require none.</p>
<p>Since several prosthetists have been fitting these sockets successfully, using various modification techniques, it has been concluded that it is irrelevant which particular modification technique is used. Results from all modification techniques have been improved utilizing the Total Flexible Socket. The use of negative modifications only is recommended. One simply does not need to add positive build-ups to the model since the reciprocal AP-ML displacement dynamically accommodates the patient's anatomy. The bony areas are accommodated automatically (most of the time) as the patient ambulates. It is, of course, most exact to use multiple transparent diagnostic sockets, alignate, or oil injection procedures (as well as other means) to obtain the best fit possible.</p>
<p>The flexible socket seems to work so well that it is tempting to skip the check socket stage. Do not succumb to this temptation, or you will never know just how comfortable the socket can be once you get the patient fairly comfortable in the rigid transparent socket and clone it to the T.F.S.</p>
<p><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg"><b>Diagram</b></a></p>
<br />
<p>After the hard socket is fit, it is necessary to remove an additional 1/4" to 3/8" of plaster from the positive model around the superior brim, close to the patella, to allow a flexible clamping action about the proximal brim. Use of this extra modification can not be emphasized enough for final comfort and stability. An intimate fit must be maintained around the proximal brim with the T.F.S. design. No other additions or modifications are necessary.</p>
<p>If a liner or insert is used, it is fabricated over the positive model with a thick distal end pad to provide extra distance distally. This extra length is necessary if one desires to make the distal tibia area flexible since the frame can be trimmed more distal, even past the end of the distal tibia. Alternately, as mentioned, an extension can be added to the socket following vacuum forming.</p>
<p>One can use any of four materials for the flexible part of the socket: The first is Surlyn,® which is preferred in most cases. This material can be molded fairly thin, and yet it provides excellent structural strength and integrity. Surlyn® stock material of 1/8"-3/16" thick is used (depending on the degree of flexibility) for vacuum forming. A final thickness of about 1/16" or less is adequate. It is not necessary for this socket to be extremely flexible, as with a fenestrated socket, since the majority of the socket is open and flexible in all directions with two adjacent sides being able to move relative to the frame.</p>
<p>The second material is polyethylene, which is more flexible and sometimes more desirable for children or geriatrics who are somewhat inactive. The third is Streifylast, which is a material that is being utilized more and more lately since it has a high level of flexibility while maintaining its structural integrity, and is especially resistant to tearing and breakage. A fourth material called Polyethylene Plus® (available through Maramed) seems to be superior even to Streifylast and has an extremely good tear resistance.</p>
<p>Once the socket is vacuum formed, a fiberglass nylon polyester frame is fabricated. Carbon fiber and acrylic resin can be used, if one desires greater strength and less weight, but is not necessary in most cases. The thickness of this frame depends on the activity level of the patient, but usually ranges in thickness from 1/16" to 1/8".</p>
<p>As in<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg"> <b>Fig. 5</b></a><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg"><b></b></a>, there are two basic frame designs: one for geriatrics, and one for active or sports oriented patients. The geriatric type extends proximally to the medial tibial flare and is cut away everywhere else except around the distal end pad (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg"><b>Fig. 6</b></a>). The sports type frame for younger patients comes more proximal pos-teriorally, lending more strength. It maintains total AP-ML flexibility since it still has only two sides adjacent to each other. As long as one does not place a third wall on the frame, reciprocal AP-ML flexibility is preserved and provides for automatic pressure distribution. It must be emphasized that these are only guidelines and the actual trimlines of the frame are variable and modified as the patient's needs dictate.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg"><strong>Figure 5. Four views of the T.F.S. showing sports and geriatric trimlines and distal end pad or buildup. Distal buildup is especially useful when it is desired to cut the anterior trimline below the distal tibia.</strong></a></p>
<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg"><strong>Figure 6. T.F.S. showing geriatric trimline. Ultralite construction.</strong></a><br />
<p>The flexible socket can be attached to the rest of the prosthesis by using two or three bands of nylon fiber tape wrapped circumferen-tially about the frame and socket to provide strength, while not affecting flexibility. If one desires even more strength, pressure sensitive tape can be wrapped over the nylon tape or even over the whole frame and socket. The socket can be riveted or fastened with Chicago screws in addition to the tape, for additional security.</p>
<p>The final finishing of the prosthesis is relatively simple. If an endoskeletal approach is used, the soft foam cover hides the socket frame interface as well as the nylon strapping tape and results in a very cosmetic prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg"><b>Fig. 7</b></a>). The T.F.S. prosthesis finishes especially well as an endoskeletal since it feels more life-like all the way up the prosthesis. If one desires an exoskeletal finish, one can easily use polyurethane foam for shape, laminate the outer covering, remove the flexible socket, and grind the foam away from around the frame and cosmetic shell as desired. This leaves a void or hollow of about 1/8" (all that is necessary) between the flexible socket and cosmetic shell. Alternately, the prosthesis can be shaped and finished about the socket in the same fashion as an endoskeletal prosthesis. The proximal external contours can then be established with a soft fairing of PE-LITE® or Plastazote glued to the flexible socket and frame.</p>
<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg"><strong>Figure 7. T.F.S. with soft cosmetic covering.</strong></a><br />
<p>Fabrication of an Atmospheric Suspension Socket is the same as for any T.F.S., except for the placement of either an expulsion valve or a small suction valve on a 45° angle at the distal posterior of the total flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg"><b>Fig. 8</b></a>).</p>
<strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg">Figure 8. T.F.S.-A.S. showing placement of valve distally</a>.</strong><br />
<p>Modification on the other hand, is a little different than a non-atmospheric suspension T.F.S. The socket must be a little snugger to accommodate total self-suspension. After achieving the "perfect skin fit" with a clear diagnostic socket and the alginating procedures, the model is poured and modified the same as any T.F.S. by slightly tightening it about the patella area. The technician then takes the modified model and laminates a two layer cotton rigid socket over it, which is rolled or slushed twice with promoted liquid polyester resin to tighten all areas of the socket equally. This socket, with reduced internal dimensions, is then poured with plaster of Paris and the T.F.S. socket is subsequently vacuum formed over the resulting positive model. It is felt that this extra tightening is necessary to compensate for the fact that a rigid diagnostic socket cannot be donned as easily as a T.F.S. of equal or greater tightness.</p>
<p>In conclusion, a new concept for the fabrication of a below-knee prosthesis has been described, as well as the preliminary results of fitting some 40 patients for up to five months. It is sincerely hoped that other prosthetists will find it as beneficial to their patients as it has been found to be in both Oklahoma City and San Diego.</p>
<h3>Acknowledgments</h3>
<p>We would like to thank one of our own prosthetists, Bill Etheridge in Oklahoma City for forcing John out of conventional thinking so we could aggressively research this interesting phenomenon.</p>
<p>We would like to thank Mary Healy, San Diego, for her help in Atmospheric Suspension Technique.</p>
<p>We also wish to thank Alan Finnieston, CPO for materials research and for finding an appropriate tear resistant thermoplastic.</p>
<b><b>Thomas Guth, CP.<br /></b></b><em>Thomas Guth, CP is Secretary Treasurer at RGP Orthopedic Appliance Company, 6147 University Avenue, San Diego, California 92115.</em><b><b><br /><br /></b></b><b>John Sabolich, B.S., C.P.O.</b><br /><em>John Sabolich, B.S., CPO is with Sabolich, Inc. at 1017 N.W. 10th Street in Oklahoma City, Oklahoma 73106.</em>
Page Number(s)
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Year
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Volume
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Below-Knee Prosthesis with Total Flexible Socket (T.F.S.): A Preliminary Report
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<h2>The Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management</h2>
<h5>Barbara L. Sypniewski <a style="text-decoration:none;">*</a><br /></h5>
<h3>Introduction</h3>
<p>This independent-study honors project dealt with congenital skeletal limb deficiencies. This paper discusses and
reviews the literature concerning the prosthetic management of the individual
with unilateral terminal transverse partial hemimelia of the upper extremity.
Specific topics considered are: a general description of the entity, including
etiology and incidence; psychological factors affecting the limb-deficient child
and his parents; normal and abnormal biomechanics of the upper extremity;
components of the prosthesis (terminal devices, wrist units, elbow hinges,
cuffs, harnessing, and sockets); prosthetic prescription and fitting; the trend
toward early fitting; preprosthetic therapy; and prosthetic training. One
section discusses the information elicited from a survey conducted by letters
and questionnaires that were sent to the 28 clinics participating in the Child
Prosthetics Research Program, conducted under the auspices of the Subcommittee
on Child Prosthetics Problems of the Committee on Prosthetics Research and
Development to ascertain the age of the congenitally skeletally limb-deficient
child at the time of his initial fitting for a prosthesis. An analysis of the
data from the 12 clinics replying is presented, along with
the developmental criteria for fitting.</p>
<p>The scope of this paper is limited to the
unilateral upper-extremity, below-elbow congenital amputee. Bilateral amputees,
cineplasty, surgical conversion, or externally powered prostheses are not
considered. The literature review was limited by time to the books and journals
published in 1960 or later, with selected earlier articles. Articles published
before 1960, as well as those not available at the Albany Medical College
Library or through the inter-library loan system, are listed in the
"Bibliography." Both reference lists were compiled from <i>Index Medicus;
Amputees, Amputations, and Artificial Limbs </i>(published by the Committee on
Pros-thetic-Orthotic Education of the National Academy of Sciences-National
Research Council, Washington, D.C.); and the bibliographies of articles I
reviewed.</p>
<p>Terminal transverse hemimelia indicates
congenital absence of the entire distal part of the limb below the elbow. The
term is part of the modified Frantz-O'Rahilly<a></a> classification
nomenclature. Hemimelia is the absence of a large part of a limb, from the Greek
<i>melos </i>meaning limb and <i>hemi, </i>half. <i>Partial </i>hemimelia
indicates that less than half the limb is missing. The defect we are considering
is transverse rather than longitudinal, presenting a short or very short stump
similar to that of an acquired below-elbow
amputation.</p>
<p>The etiology of skeletal limb
deficiencies is largely unknown, except for the well-documented teratogenic
effects of thalidomide. The thalidomide tragedy has led to an increased interest
in, and awareness of, what can be done for the congenital amputee. <a></a></p>
<p>The list of proposed etiological factors
includes environmental conditions such as drugs, maternal health and nutrition,
genetic factors or predisposition, and chromosomal aberrations.<a></a> Most congenital defects have their origin during the first eight weeks of
embryonic life.<a></a></p>
<p>Glessner<a></a> indicates that there
are two distinct groups of congenital absence of limbs: (1) spontaneous
intrauterine amputation after limb formation, caused by focal deficiencies, and
(2) limb-bud arrests or agenesis of the terminal part of the limb. Amniotic
bands wrapped tightly around part of an extremity may lead to necrosis and
eventual intrauterine amputation.<a></a> Terminal deficiencies due to
limb-bud arrests are by far the most common type of congenital absence.<a></a> The terms <i>congenital amputation </i>and <i>congenital
skeletal limb deficiency </i>are used interchangeably in the
literature.</p>
<p>Terminal transverse partial hemimelia is
the most common type of congenital limb deficiency. There is unexplained
preponderance of left-sided absence (2 or 3 to 1), and females are involved more
frequently than males. Studies by Bergholtz,<a></a> Davies, Friz, and
Clippinger,<a></a> Munson and Dolan, <a></a> and Gehant<a></a>
failed to show the greater incidence in females exhibited in Kay and
Fishman's report.<a></a></p>
<p>The measures of prosthetic management in
habilitation of a congenital amputee are somewhat different than those employed
in the rehabilitation of an "acquired" amputee. The child must learn functional
skills that he never possessed, rather than relearning substitute functional
activities. The fact that the juvenile amputee is neither skeletally nor
emotionally mature is an important consideration in the prosthetic management.
The growth and development of the limb-deficient child is essentially the same
as that of the normal child; the environmental stimuli to motor development are
not decreased significantly by unilateral deficiency. Ideally, prosthetic
management should extend from birth through vocational training.</p>
<p>Function of the upper extremity is
extremely complex and relatively independent of the contralateral extremity.
With unilateral absence, there is an increased use of the remaining extremity,
since the ability of a prosthesis to compensate for the loss of an arm is
significantly less than is possible in the lower extremities. Below-elbow
amputees are least in need of externally powered prostheses.<a></a> They can effectively use body power to activate the prosthesis and receive
the benefits of sensory feedback through the socket and harness. The prosthesis
should be considered as an assistive device in bimanual activity. Because
absence of one extremity can be easily compensated for, getting the unilateral
amputee to use his prosthesis presents a great challenge. Fitting and training
should be started as early as possible, before these compensations can
develop.</p>
<p>It is generally believed that a team
approach is most successful in the management of the limb-deficient child. The
foremost members are the mother, who spends the most time with her child and
influences him the most,<a></a> and the child. Other possible members
of this interdisciplinary team are the physician, orthopedist, prosthetist,
occupational therapist, physical therapist, psychologist, social worker, and
biomedical engineer. Each child presents unique problems to be met. Epps and
Brennecke<a></a> outlined a sequence of treatment that includes referral,
history and medical examination, intake evaluation, preprosthetic physical and
occupational therapy, prescription, fabrication, thorough check-out by
the team, training, and regular recheck every
three or four months.</p>
<p>Factors influencing the cost of the
prosthesis are: age at initial fitting, regular maintenance, frequency of
harness adjustment, wearing pattern, operating skill, acceptance, and components
prescribed.<a></a>Average service for a prosthesis ranges from two to
three years, but a child fitted during infancy may require three to five
prostheses before school age.<a></a> The additional cost of early fitting
is compensated for over the years,<a></a> especially in regard to the
benefits of skill and acceptance.</p>
<h3>Psychological Aspects</h3>
<p>The importance of parental attitudes
towards the child, his disability, and the idea of a prosthesis, and their
effect on the eventual acceptance or rejection of a prosthesis, has been
emphasized throughout the literature. There is no direct correlation between the
degree of the child's deficiency and the mother's perception of the child's
abnormality, her feelings toward him and the way she handles him.<a></a> The way
in which parents deal with the birth of a limb-deficient child depends to a
great degree on how they have coped with previous crises. Replacement of a
missing extremity with a well-functioning artificial one is valuable only if the
parents can accept the idea of a prosthesis. Often, children have rejected
prostheses because the parents, consciously or unconsciously, could not accept
the fact that it was necessary.<a></a></p>
<p>The way in which the parents are informed
of the child's deficiency may influence their later reactions. If he desires to
do so, the father should be allowed to inform the mother, in the presence of a
physician.<a></a> Mothers can be profoundly influenced by the reactions of
the delivery-room staff.<a></a> The training of the limb-deficient child
can best begin by providing the parents with a detailed, factual, realistic, and
sympathetic appraisal of their baby and his prospects for future educational,
vocational, and social rehabilitation.<a></a> Unrealistic
claims that modern prosthetics and engineering can provide artificial devices as
natural-looking and as efficient as the human hand can seriously hinder the
habilitation program. The first few hours after the birth of the child are
crucial; it is during this period that parents form attitudes and defenses that
can have tremendously far-reaching effects.</p>
<p>With the birth of a deformed child, the
parents suffer a severe psychological shock, for which they are totally
unprepared. Certain emotions have been commonly expressed by parents of
congenital amputees: guilt, hopelessness, death wishes, fear, anger, rejection,
despair, shame, repulsion, grief, shock, hostility, and abandonment.<a></a> The need for prompt, professional assistance is crucial. </p>
<p>Parents are extremely sensitive to the reactions and attitudes of others, and
they need help to know that they and their child are accepted. In addition to
individual counseling by a psychologist, social worker, or other qualified
persons, group sessions have been established.<a></a> Parents
benefit from the opportunity to verbalize their feelings and receive support and
help in handling their emotions and in developing constructive attitudes.
Wallace<a></a> noted the impact of these group-therapy sessions on the
fathers, citing fewer absences, less hesitation about expressing their feelings,
and awareness that their attitudes affect the child's adjustment and help to
mold his self-image.</p>
<p>If, instead of realistic acceptance,
strong defense mechanisms are built up by the parents during this early period,
they will not be able to communicate with their child when he becomes aware of
and questions his deficiency. One indication of the mother's acceptance of the
child is the way she handles the baby. Some important factors to look for in
observing parental behavior are: avoidance of direct contact with the baby,
ritualistic organization and emphasis on cleanliness, barriers to communication,
aggression toward professionals, and subconscious refusal
to accept the existence of the child's abnormality.<a></a> The mother will eventually become the
child's best therapist, and the early months must provide a basis for her later
role. Parents must be aware of the importance of their love in the future
rehabilitation of their child. Hall<a></a> and Mongeau and others<a></a>
advocate that children become an integral part of the family immediately.
Mongeau found that children taken home directly from the hospital after birth
have shown greater capacity for adaptation than those who were
institutionalized. A strong family basis can be of great help to the child when
he may later face repeated hospitalizations for prosthetic training or other
reasons. According to Gesell and Amatruda,<a></a> a child's basic behavior
traits are fairly well established by the time he is a year old. Some of these
traits are hereditary and some are absorbed from the attitudes of the
family.</p>
<p>Crisis intervention, as described by
Brooks and others<a></a>, is the awareness of impending crises in the development
of the limb-deficient child and the intervention by qualified professional
personnel to aid in making those transitory periods as easy as possible. One
such crisis is that of homecoming. The curiosity and concern of relatives and
friends must be faced. The effect of the birth of a limb-deficient child
naturally has a great impact on his siblings.<a></a> They too must be
aided in adjusting to this stress situation. Other potential crisis periods are
prosthetic fitting, entering school, and adolescence.<a></a> During the child's period of growth and
development, he has the same needs for independence and self-sufficiency that
normal children have. Dependence and overprotection must be avoided. Discipline
must be consistent and realistic, neither extremely permissive nor extremely
restrictive. The profound effects of the parents on the child cannot be
overemphasized.</p>
<p>The manner and degree to which
the child is influenced by his deficiency is
determined before he reaches conscious awareness of his condition. If he has
been provided with a sense of security, acceptance, and love, he will have a
strong basis from which he can develop a positive self-image and achieve
independence. The limb-deficient child faces the same problems and sequence in
emotional and social development as normal children, but each crisis is likely
to be of greater intensity and magnitude.<a></a> The child who has
received encouragement and support from his family will expect the same type of
relationship from outsiders and will approach social contacts spontaneously,
rather than attempting to avoid them. The child will attain a balance between
the dominance of his parents' influence and the satisfaction he gains from his
independence.<a></a> He should be encouraged to enter into social
relationships with a minimum of special attention.</p>
<p>Taylor<a></a> has discussed at
length the psychological needs of handicapped children. In addition to the
fundamental needs of love and acceptance, she cites the needs for adventure and
exploration, rebellion to release pent-up frustration, limitation of freedom,
friends and social experience, privacy, achievement as a basis of self-esteem,
and the need for awareness of the child as a person. These needs are the same as
those operating in all nonhandi-capped individuals.</p>
<p>Gouin-Decarie<a></a> recognized that
a pertinent problem in studying the psychology of a limb-deficient child relates
to his conception of space, which is closely associated with the formation of
the body image. She found that these children made use of a visual, rather than
a tactile, image in recognizing familiar objects. Several authors have discussed
the concept of body image, or schema, in child amputees.<a></a>
All have indicated the absence of marked distortion of body image in most of
these individuals. Alteration of body image is, however, a significant problem
in noncongenital amputees. Centers and Centers<a></a> analyzed the results
of a draw-a-person test administered to
congenital amputees. The majority of amputees represented themselves
realistically, either leaving out the missing limb or including the prosthesis.
They concluded that, while body images differed in a matter-of-fact way, they
did not differ markedly in signs of greater conflict, anxiety, or defensiveness.
The study did not support the authors' hypothesis that amputee children will
have more conflict and defensiveness about their bodies than will nonamputee
children.</p>
<p>The body image is critical in relation to
the acceptance or rejection of a prosthesis. Congenital amputees experience the
same processes in the formation of body image as normal children. The earlier
the child is trained to wear a prosthesis, the easier it will become a part of
his body image.<a></a> One factor in the ready incorporation of the
prosthesis is that modern prostheses are functionally adequate for many of the
activities engaged in by young children.<a></a> A prosthetic device is
never really useful until it is integrated into the body schema. Acceptance and
rejection of the prosthesis is more extensively considered in the section on
early fitting.</p>
<p>The question of the possibility of the
phenomenon of phantom sensation in congenital amputees is an interesting one. A
discussion of the theories concerning the cause of this phenomenon is beyond the
scope of this paper. Hoover,<a></a> Lambert,<a></a> and Simmel<a></a> believe that neither phantom-limb sensation nor pain exists in this group of
individuals. Lambert bases his belief on the principle that nerve endings going
to the distal limb have never developed. Simmel attributes the impossibility of
phantom sensation to the fact that the absent part has never been represented in
the body schema. In their census of the juvenile-amputee population, Kay and
Fishman<a></a> reported three instances of phantoms in congenital amputees,
but these could not be substantiated by further interrogation. Weinstein and
Sersen<a></a> reported phantoms in 5 out of 30 children with congenital
deficiencies. If the presence of a phantom reflects the
"need" of the child to experience a missing part, it should have functional
properties. The phantoms reported in this study were usually shrunken,
telescoped parts with gaps and missing appendages.</p>
<p>Certain other psychological aspects can
best be discussed as they relate to the chronological age groups of the
congenital amputee. The significant divisions are: preschool, entry into school,
latency, and adolescence.</p>
<p>In the preschool category, a period of
negativism and resistance occurs around two years of age. This is a normal
reaction; the child is trying to establish his personality and achieve a little
independence.<a></a> This period of negativism often conflicts with
prosthetic-training procedures, especially terminal-device
activation.</p>
<p>Entry into school is an important
milestone for any child. He moves from the security of his home environment into
a competitive social society. The limb-deficient child needs a reliable basis
for dealing with this new group of people. This is provided by his parents and
family during the early childhood years. In his group experience, the child will
test and validate ways of dealing with people outside his family <a></a>.
Adjustment is facilitated if the teacher and class are prepared and informed
in advance. Healthy curiosity is the most frequent reaction of classmates, and a
factual explanation of the prosthesis and its use should lead to acceptance by
the classmates and increased self-confidence of the limb-deficient child. Wilson
<a></a> expresses the belief that it is preferable for the
limb-deficient child to attend regular school. Unnecessary special consideration
should be avoided. The handicapped child may experience feelings of social
devaluation, which any member of a minority group feels.<a></a> Centers
and Centers<a></a> discuss the results of a social-discrimination
questionnaire. The hypothesis that peer-group children express more covert
rejecting attitudes toward amputees than toward nonamputee children was
supported. They attribute this finding to the fact that one of the
most significant variables operating in social interaction is personal
appearance. Centers and Centers conducted their study almost ten years ago. It
would be interesting to retest this hypothesis in light of recent social trends
toward greater acceptance of minority groups and increased emphasis on
individual merit as opposed to sterotyped generalizations.</p>
<p>The preadolescent latency period is
relatively calm, with no major crisis periods. The normal child experiences many
conflicts during adolescence, many of which are associated with appearance.
These conflicts are all compounded in the limb-deficient child. During this
period, a cosmetic hand is often prescribed for the adolescent amputee to
replace the functional hook for social occasions. Vocational guidance becomes
increasingly important during this period of adolescence.</p>
<h3>Normal and Abnormal
Biomechanics</h3>
<p>The arm enables the hand to be placed in
position for skilled functional activities. The most commonly recognized forms
of prehension include tip, palmar, three-jawed-chuck, lateral, hook grasp,
cylindrical grasp, and spherical grasp. Palmar prehension employing opposition
of the thumb predominates in picking up objects and holding them for use. Long
tendons with muscles at a distance permit the great variety of motion
characteristic of the human hand. In addition to skill, the hand frequently
functions in support postures. Sensation is another major function of the hand.
The hand is richly supplied with sensory-nerve endings mediating touch,
temperature, pain, and position. Large areas of the cerebral cortex represent
the complex sensory and motor function of the hand. Boivin<a></a> advocates
investigation into the prehension patterns and sequences commonly used in
activities of daily living. Stabilization of the wrist in various positions aids
prehension. For example, the wrist assumes an angle of 145° when very strong
prehension is required.<a></a> Finley, Wirta, and Cody <a></a>
studied the synergic action of muscles of the
upper extremity resulting in a better understanding of the relationship between
central and peripheral control of movement. The three major components of the
response phenomenon that they noted were: cognitive, ballistic-type physical
displacement, and apparent sensing to compare, confirm, or adjust to assure
successful accomplishment of the desired act. The information regarding time
sequences is useful as reference material in studying
pathomechanics.</p>
<p>Finger and hand movement, wrist flexion
and extension, and varying degrees of pronation and supination are lacking in
the congenital below-elbow amputee. Prosthetic replacement of the wrist and hand
is poor, only crude prehension and positioning are possible, and there is no
substitution for the lack of sensory feedback. Maximum utilization of the
residual biomechanics is essential in prosthetic replacement.<a></a> The
biggest challenge is to design an upper-extremity prosthesis that (1) can be
powered by and controlled with little effort, (2) can perform through the almost
spherical range of a normal arm, (3) has a terminal device that can achieve
prehension, (4) will respond to sensation, and (5) is cosmetically acceptable.<a></a> Upper-extremity prosthetics are significantly deficient in all of
these areas. Because of the fixed prehension pattern of the terminal device and
the fixed wrist, nearly all fine orientation movements must be made at levels
higher than the forearm by compensatory motions of the elbow, hand, and shoulder
.<a></a> Prosthetic controls permit only the simplest motions decomposed
into their basic elements and executed slowly, in series, one at a
time.</p>
<p>Stoner<a></a> notes that no
prosthesis accomplishes any of the wrist-flexion movements. The reasons for this
neglect of wrist replacement are: (1) usually no controls from the harness are
available to furnish the power, (2) wrist motions are used in fine movement of
the hand and are not essential to bring the hand into the major spheres of
action about the body, and (3) loss of wrist flexion can be compensated
for grossly by other arm motions. Preposition flexion devices are available and
are useful for activity close to the body.</p>
<p>Pronation and supination are functions of
forearm length. Wrist joints allow passive positioning for the most advantageous
angle of terminal-device operation. With shorter forearm stumps, the mechanical
advantage of flexion is decreased, in addition to the loss of pronation and
supination.</p>
<p>Joint motions in congenital amputees are
often bizarre<a></a>. Kruger and Breyan<a></a> report that, in an X-ray
evaluation of 16 extremities with terminal transverse partial hemimelia, 13
showed dislocation of the head of the radius. Of these, 77% showed dislocation
before prescription of the initial prosthesis. It is therefore concluded that
the phenomenon is inherent in the disability itself. The dislocation is
asymptomatic. The authors offer two possible explanations for the phenomenon:
deficiency of the ligamentous structures, or unopposed action of the biceps
brach-ialis muscle. They consider the latter explanation the more likely. In
short stumps, the pronator teres muscle is absent, and the biceps in flexing and
supinating meets no opposition, thereby dislocating the radial head.</p>
<h3>Harnessing</h3>
<p>Harnessing techniques for upper-extremity
prostheses must be based on bio-mechanical analyses of the remaining movements.
Successful use of the prosthesis requires a harness that allows the most
efficient use of those movements that are available. The socket limits some of
the residual motion of the stump itself, and the harness limits the motion of
the sound extremity to some extent. The harness should distribute the weight of
the prosthesis evenly over a wide area and be functional in as many positions of
normal use as possible. It should transmit power with a minimum of interference
and be operable by relatively inconspicuous body motions. Power is provided by
the stump itself (elbow flexion) or by the relative motion between two body parts
(glenohumeral flexion and/or scapular abduction). Control-cable systems transmit
this power from the amputee's body to the prosthesis. The suspension system may
use a figure-of-eight, figure-of-nine, or shoulder-saddle chest-strap type of
harness. The most common suspension is a figure-of-eight harness with a
Northwestern ring-type cross.<a></a> The Northwestern ring allows
adjustment of individual harness straps. The figure-of-nine harness is often
used for power transmission with Munster-type sockets, which do not require a
great deal of additional suspension. The chest strap is useful in spreading the
load in heavy work<a></a> and maintaining the prosthesis in the proper
position in the presence of baby fat. The harness provides some degree of
feedback from the environment. O'Shea<a></a> has described a
shoulder-saddle chest-strap harness with the primary advantage of increased
comfort. Hile<a></a> described the adaptation and reinforcement of a
brassiere to replace the chest-strap harness when breast development
occurred.</p>
<p>Requirements for suspension and
harnessing vary from individual to individual, and skillful use of the available
power sources is essential to good prosthetic use. Rapid rate of growth and
limited power are critical factors in designing harnesses for congenital
amputees.<a></a> Frequent adjustment by the prosthetist assures optimum
harness and prosthetic function.</p>
<h3>Components of the Prosthesis</h3>
<h4>Terminal Devices</h4>
<p>Two major considerations in the design of
a prosthesis for a child are the continual neuromuscular and skeletal changes
due to growth and the child's limited sources for power and control. Linear
growth is more rapid than circumferential growth. The prosthesis can be
fabricated to allow for later adjustments for growth, thus extending the
functional life of the device. The components must be sturdy enough to withstand
vigorous use, yet must be light enough to be controlled by the
child. Some of the problems involved in the prosthetic replacement of human body
parts are control, feedback, reliability, size, and appearance.<a></a>
Upper-extremity prostheses for children are essentially scaled-down models
of adult types. However, Hall<a></a> and Wilson<a></a> note that
recent advances in children's prosthetics include improved design and function
of terminal devices, lightweight plastic sockets and shells, and more efficient
harnessing methods. There are a large number of mechanical components available
that can be combined to best meet the needs of the individual child. Split
mechanical hooks stress the restoration of function at the expense of abnormal
appearance, while artificial hands with cosmetic gloves attempt to combine
modest levels of function with near-normal static appearance. Both hooks and
artificial hands should be given the same care as the normal hand; since
sensation is absent, they are more prone to damage.</p>
<p>There are two mechanisms of
terminal-device operation: voluntary opening and voluntary closing. In the
voluntary-opening type, tension on the control cable opens against a variable
spring force, while in the voluntary-closing type, control-cable tension closes
against the spring force. Hooks and hands are available with either mechanism.
Voluntary opening is the simplest form of prehension mechanism: the prehension
force is provided by special heavy rubber bands. Among the disadvantages of this
type are the inability to handle delicate or heavy objects, and the fact that
this mechanism is opposite to the prehension of the normal hand. An advantage of
the voluntary-closing terminal device is that it more accurately simulates
normal prehension, and pressure can more easily be graded to the object to be
grasped. Formerly, manually controlled locks were employed, but now automatic
locking is available. The fact that, to release the lock, the cable pull must be
greater than the pull that closes the terminal device may be a
disadvantage. Neither mechanism has been proved
superior in a wide range of activities,<a></a> but research to
improve both types for juvenile amputees is continuing.</p>
<p>Ritter and Sammons<a></a> have
elaborated on the advantages of voluntary-closing devices for children's
prostheses. The fact that normal prehension is simulated is especially relevant
in bilateral grasping. Performing different hand patterns simultaneously, as is
necessary with voluntary-opening devices, is particularly difficult for the
preschool child to learn, since he is still developing refinement of prehension.
A description of the Army Prosthetics Research Laboratories (APRL)
voluntary-closing hand, which provides palmar prehension of the three-jaw-chuck
type, has been presented by Stoner.<a></a> Teska and Swinyard<a></a> have described a test to evaluate its functional capacity, versatility, and
durability. Research is also being conducted concerning the Robins-Aid
voluntary-opening hand.<a></a> The concept of cosmesis, or the
appearance of the prosthesis, is difficult to define, but is very important. It
is a very individualized concept, having varying importance for different
people. Function, cosmesis, and acceptance are almost inextricably allied.<a></a> The area of compromise between function and cosmesis is a delicate and crucial one. Those professionals vitally concerned with function must be
careful not to look down on the parents who may seem to be overly concerned with
cosmesis. Several new plastics have been reported<a></a> that, while not
identical to the color and texture of the human skin, do convey an idea of
softness and warmth. These new terminal-device designs represent an attempt to
combine improved function with an aesthetically satisfactory appearance, but
without trying to imitate representationally the characteristics of the missing
part.</p>
<p>It was formerly common practice to
provide the congenital amputee with a plastic mitt or wafer as the initial
terminal device. Dean,<a></a> Lineberger,<a></a> and Watkins and Ford
<a></a> have presented arguments supporting this practice. Among the major
reasons given are: cosmetic appeal, flexibility, support without slipping in
creeping, avoidance of injury to the child himself or others during play, and
other factors supporting early fitting in general.</p>
<p>The infant passive hook is now considered
the better choice as an initial terminal device. Some of the reasons for its
preferred function are listed by Blakeslee<a></a>: (1) it provides for gross palmar
prehension and body-support activities with skill equal to the mitt, (2) it
allows the infant to hook over objects for support in pulling to a standing
position, (3) it provides a holder for small objects that are placed in it, (4)
it helps the infant to develop bilateral prehensile awareness, being recognized
as a device to hold objects, and (5) parents who were willing to accept a
prosthesis for their child readily accepted the passive hook. Shaperman<a></a>
reported the results of an evaluation of the passive mitt and the passive
hook with similar results. She also noted improved skill and increased speed of
learning when the control cable was added to the passive hook. Initially, the
hook presented a slightly greater safety hazard, but the injuries that did occur
were minor. Shaperman noted that the hook was one ounce heavier than the mitt,
but it appeared to be well within the limits of the infant's ability to lift and
manipulate it easily.</p>
<p>Hooks are available in a variety of
sizes, shapes, and weights. The Dorrance 12P or 10P hook are commonly provided
for the unilateral juvenile amputee. They are canted and plastic-covered.
Proponents of prescribing hooks cite the advantages of greater prehensile
function, with greater visibility and facility available. Numerous authors
<a></a> have expressed a preference for the use of
the hook rather than the hand. Edelstein maintains that the cosmetic appeal of a
skillfully used hook is greater than that of a cadaverous-looking glove. The
idea that the hook can only be accepted as a tool, and that therefore it is hard
to see the need for a more cosmetic socket, has been expressed by Boivin
.<a></a> Research toward improved hook design and
function is being carried out. The literature reveals progress reports in the
development of the Sumida hook,<a></a> the Northwestern University
Center control hook,<a></a> the Steeper split hook no. 65,<a></a> and
other more recent advances in prosthetics.<a></a> Carroll<a></a> conducted a study to
analyze the prehension force needed by child amputees. The test items were
related to function and varied with the age of the child. Most items tested
static prehension only; the individual could either hold the object, or it
slipped out of the hook because of insufficient prehension force. Dynamic
prehension, or the child's ability to control the prehension force, was tested
by the ability to hold a paper cup with water in it. The results of this study
showed that more children were fitted adequately in regard to the size of the
terminal device than in relation to the prehension force. None of the children
were found to be wearing an excessive number of rubber bands. With the exception
of the toddler group, the prehension force was found to be inadequate for
performance of one or more of the test items. One result of this study was a set
of suggested pinch forces for below-elbow amputees:</p>
<table>
<tbody>
<tr>
<td>
<p><b><i>Age (years)</i></b> </p>
</td>
<td>
<p><b><i>Pounds of
force</i></b> </p>
</td>
</tr>
<tr>
<td>
2-4</td>
<td>2.25
</td>
</tr>
<tr>
<td>
3-9</td>
<td>3.5
</td>
</tr>
<tr>
<td>
5-9</td>
<td>4
</td>
</tr>
<tr>
<td>
8-17</td>
<td>5
</td>
</tr>
<tr>
<td>
15-20</td>
<td>6
</td>
</tr></tbody></table>
<p>Greater consideration needs to be given
to the adequacy of prehension forces for the functional activities of congenital
amputees.</p>
<p>Cosmetic hands are often prescribed when
the juvenile amputee reaches adolescence. Interlocking wrist-unit mechanisms are
available that permit the use of a hook for functional activities and a more
cosmetic hand for social occasions. These hands usually provide a modified
three-jaw-chuck prehension between movable index and middle fingers and a thumb
that can lock in position. Hands available for children include the
Dorrance no. 2 hand<a></a> and the APRL-Sierra child-size no. 1 hand.<a></a> One disadvantage that must be considered is the greater weight of the hand as compared to the hook. The APRL-Sierra no. 1 hand weighs
170 grams, while the Dorrance 10x hook weighs 60 grams.<a></a> This is
especially important, considering that this additional weight has the mechanical
advantage of a long forearm lever and the congenital amputee does not possess a
great deal of muscle power.</p>
<p>The APRL-Sierra no. 1 hand was developed
to meet the need for a functional and cosmetically acceptable hand for juvenile
amputees. It is a voluntary-opening mechanism with a hand shell of cast
aluminum, articulated index and middle fingers, a two-position thumb, and
nonarticulated but flexible ring and little fingers.<a></a> In this field
study, only 7 of 77 children rejected the hand completely. The remaining
participants fell into four groups: those that used the hand exclusively, those
that used the hand predominantly, those that used both equally, and those that
used the hook predominantly. The authors suggest that the age of the child is a
major factor regarding hook or hand preference. Younger children may experience
difficulty with hand weight and opening forces, may be more careless in their
use of the hand, and may be less subject to social pressures toward cosme-sis.
Sex appeared to be an even greater consideration than age. Girls of all ages
appear to be potentially the best candidates for the Sierra-APRL no. 1 hand,
while younger boys would seem least likely to accept the device. Fishman and Kay
<a></a> performed a study to delineate the relative usefulness of the hook
and the hand. The results were at variance with previous clinical impressions,
which indicate that a hand is a significantly less functional terminal device
than a hook. In an extensive evaluation of the Dorrance no. 2 hand in 72
bimanual activities, Gorton<a></a> found that no definite trends emerged to
indicate that the hook was measurably more functional than the hand or that the hand was significantly more
functional. The test employed by Fish-man and Kay analyzed general and specific
patterns of grasp by means of functional activities. The rating scale for
performance of activities was somewhat subjective, but the detailed analysis of
the results was excellent. From this study, the authors concluded that: (1) the
APRL-Sierra no. 1 hand was heavier and, in most cases, more difficult to operate
than the previously used hook, but these were not serious drawbacks for the
majority of subjects; and (2) the hand provided somewhat less pinch force than
most of the hooks and a less precise grasp. While the majority of children
reported that they could perform more activities better with the hook, they also
were able to specify a number of activities that were performed better with the
hand, such as picking up a pencil, grasping paper, and holding silverware for
eating.</p>
<p>Constant research and re-evaluation of
prostheses is essential.<a></a> Boivin<a></a> has written an
excellent article criticizing present artificial-hand design. He maintains that
an inherent belief exists that the refinement of the normal hand cannot
presently be reproduced, leading to the assumption that it can never be
reproduced. He cites the apparent lack of coordination and integration in
biomedical engineering research, and proposes that a reason for this is that the
goal is providing normal hand function, but that this is being attempted without
sufficient consideration for the actual anatomical and physiological functions
of the hand according to the kinesiological data presently available. One
example is the fact that artificial hands flex only at the metacarpophalangeal
joint, while the flexor digitorum profundus, the most active finger flexor,
flexes at the interphalangeal joints as well. Boivin presents two suggestions
for modification of artificial-hand design: first, that the normal transverse
arch be reproduced in artificial hands, adding to cosmesis and function; and
second, that artificial hands be made smaller and covered with a soft
subcutaneous tissue-like material under the glove. Besides
improved cosmesis, this would improve grasp by allowing better molding of the
fingers over the object to be grasped. This second approach is presently being
used by the Otto Bock Orthopedic Industry, Incorporated, in their new modular
arm. The catalogues illustrate an above-elbow arm, but it is quite possible to
employ this system for below-elbow amputees by fabricating the socket, attaching
the proper length tube and the terminal device. This "System Arm" can be used
for every level of upper-extremity amputation except wrist disarticulation and
extremely long below-elbow amputations. Child-size systems are available. (This
information was received from personal communication with Otto Bock Orthopedic
Industry, Incorporated.)</p>
<h4>Wrist Units, Elbow Hinges, and
Sockets</h4>
<p>Wrist units perform the dual function of
attaching the terminal device to the prosthetic forearm and providing
terminal-device rotation for manual preposi-tioning. There are manual-friction,
manual-lock, and active-rotation units. Manual-friction is the most commonly
used type. A rubber washer and a metal washer are compressed as the terminal
device is screwed into place. Behavior of the unit is unpredictable because of
the uneven compression and the easy accumulation of dirt, but it has the
advantages of simplicity and easy maintenance. Manual-lock units allow rotation
and locking of the terminal device by separate steps through the use of
cylindrical inserts that have index teeth around their circumference.<a></a> The inserts are threaded to fit the terminal-devicestud. Active-rotation devices use stump rotation to produce rotation of the terminal device and are
able to amplify residual stump rotation.<a></a> Wrist-flexion units that provide partial
replacement for lost palmar and dorsal flexion of the wrist are available. By
adding the extra degree of freedom, they can minimize the need for compensatory
motions at higher levels. These units are presently only suitable for light duty.<a></a> Clarke, Kral, and Shaperman
<a></a> evaluated wrist-flexion units for children. The advantages of the
addition of a wrist-flexion unit to an upper-extremity prosthesis include: (1) the ability to bring the arms close to the body for self-care activities,(2) the ability to bring the arms
together in the midline for bimanual activities, and(3) less need for body exertion and
bending to accomplish these activities. The authors found that one angle of
flexion or flexion and radial deviation is sufficient for all activities. Wrist
flexion of 25° or less is comfortable and useful, and there is no advantage
above 25°. They advocate that the conventional wrist unit be laminated into the
forearm unit in a flexed position, after careful evaluation to determine the
most advantageous angle. This overcomes the disadvantages of wrist-flexion units
for children, such as added weight of the terminal device, an additional
component to preposition, and mechanical unreliability. It would seem that the
need for dorsiflexion at the wrist for functional activities should be further
evaluated, since this study only considered variable degrees of palmar
flexion.</p>
<p>Flexion of below-elbow prostheses is
provided by hinges of various types; the main classes are "rigid," "semirigid,"
and "flexible." They can be made of metal, leather, or metal cable. Some elbow
hinges are polycentric and have a step-up ratio to provide a greater range of
motion for a short below-elbow amputation. This is useful if adequate power is
available, since flexion strength is lost through this mechanism. When both
power and range are insufficient, it is possible to utilize the stump power to
activate a locking hinge. Flexion of the forearm is then provided by humeral
flexion.</p>
<p>Most below-elbow prostheses require an
upper-arm cuff made of leather to help to stabilize the connection between the
amputee and the prosthesis necessary to adequate control.<a></a> The most
common types are the very light triceps pad and the open cuff. These would be the most
useful for congenital amputees; the heavy-duty closed cuff would not usually be
necessary.</p>
<p>The socket is the foundation of all
upper-extremity prostheses. The standard socket designs are used for juvenile
amputees, but they may fit poorly because of the large amount of soft tissues in
the child and the lack of well-developed bony prominences. It is through the
socket that power and control are transmitted from the stump to the prosthesis
and some degree of feedback is received. Double-wall construction allows a
stump-fitted inner wall with an outer wall designed for structural uniformity
and cosmesis. Retention of pronation and supination in short and very short
below-elbow amputees is usually not a consideration, since pronation and
supination are factors of forearm length. Another important matter is stability
in flexion. In short and very short stumps, a single-axis hinge helps to provide
this stability.</p>
<p>Among the types of sockets available are
single-socket, split-socket, preflexed socket, and Munster-socket designs.
Single sockets are often lacking in the necessary flexion stability for
congenital amputees. Because of limited range of motion, a short or very short
stump may require a split socket with a step-up hinge. One degree of stump
movement gives 2° or 3° of prosthesis movement, thereby increasing the range of
motion, but two or three times normal force is needed to accomplish this.
VanDer-werker and Rosenberger<a></a> described the mechanism and
installation of a flexor assist for use with the step-up split socket. Pellicore
<a></a> noted the unfavorable cosmesis of the split socket, which was later
largely replaced by the use of a preflexed forearm. This improved the cosmesis
somewhat and increased the functional forearm power, but the range of motion was
limited to 100°-110° instead of the normal 135°.</p>
<p>A great deal of the recent literature is
devoted to a description and discussion of the Munster-type socket. The
technique, involving intimate encapsulation of the stump, was developed by Dr.
O. Hepp and Dr. G. G. Kuhn of Munster, Germany, and introduced into the United
States in 1958. Short below-elbow stumps present a small attachment area, poor
leverage, and a decreased useful range of motion. Some of the characteristics of
the Munster technique that help to overcome these deficiencies are: (1) the
elbow is set in a preflexed position yielding the most useful range of motion,
usually about 35 deg., (2) a channel is provided at the antecubital space for
the biceps tendon to avoid interference between the socket and biceps tendon
during flexion, and (3) the posterior aspect of the socket is fitted high around
the olecranon and the epicondyles, taking advantage of these bony prominences to
provide attachment and stability to the socket.<a></a> These
characteristics eliminate the need for split sockets with step-up hinges, giving
improved prosthetic control and feedback, and often eliminate the need for a
harness for suspension purposes. Younger congenital amputees may require more
harnessing to maintain the prosthesis in place.</p>
<p>Epps and Hile<a></a> described the
fabrication techniques and evaluated the Munster prosthesis. Among the
favorable points they found were: simplified harnessing, light weight, no
perspiration problem, and excellent stability under axial-load testing. They
also noted the elbow hyperextension characteristic of the individual with
terminal transverse partial hemimelia. They concluded that the Munster-type
prosthesis is the fitting choice for the child with a unilateral short or very
short below-elbow amputation. In their investigation of the applicability of
Munster-type fittings, Fishman and Kay<a></a> found that all of the
subjects were definitely in favor of this type of prosthesis. The decrease in
flexion range had no appreciable effect on prosthetic function for unilateral
amputees. (Some modifications, such as lowering the anterior trim line and
provision of a wrist-flexion device, may be necessary for the bilateral amputee.) Among the advantages
cited are the facts that the stump does not slip out while performing overhead
activities, and that less energy is required in operation of the prosthesis.
They suggest that this type of fitting is functionally advantageous for amputees
with very short to medium below-elbow stumps. Two factors limit the
applicability of this technique for stumps of longer lengths: (1) the pronation
and supination in these stumps cannot be harnessed with a Mun-ster prosthesis,
and (2) the proximal socket opening at a sharp angle to the shaft presents
increasing difficulty in donning and doffing the prosthesis as stump length
increases.</p>
<p>Gazeley, Ey, and Sampson<a></a>
reviewed four cases of fitting children with Munster sockets and concluded
that the technique is not satisfactory for bilateral amputees, because of the
limited flexion. Except for that, they were very pleased with its use. Gorton,<a></a> Kay and Fishman, <a></a> and Pellicore<a></a> have all
cited the usefulness of the Munster-type prostheses in fitting short and very
short below-elbow stumps. Gorton found the positive factors to be: increased
stability and socket retention, socket comfort with minimal stump motion within
the socket, harness comfort with the elimination of the triceps pad and front
support strap, and improved cosme-sis due to the minimization of the harnessing
system. The negative features listed were: decreased range of motion (limited to
about 70°), limited elbow flexion, and harness discomfort due to the control
strap riding low across the back. The other authors discovered similar findings.
With the limited range of motion, it is necessary to make this the most
functional range. Partial flexion is necessary to keep the prosthesis on the
stump. Complete extension is not as essential to functional activity as an
adequate flexion range.</p>
<p>The use of sockets that do not completely
enclose the stump is more extensive in Germany than in the United States. With
this type of prosthetic fitting, the end of the stump remains free for
gripping and touching. According to Fletcher
<a></a> and an article in the <i>British Medical Journal, </i><a></a> in
congenital limb deficiency the end of the limb has a tactile sensation
equivalent to that of a normal fingertip, even when the distal two-thirds of the
forearm is missing. He attributes the prosthetic rejection by many children to
the fact that standard prostheses rob them of this important sense of touch. He
feels that fitting such an individual with an artificial limb is, in effect,
performing a physiological amputation. Kuhn<a></a> and Jentschura,
Marquardt, and Rudel<a></a> have described an open-end socket that enables
the patient to use the sensory surface of his stump as well as the terminal
device. The socket is provided with a friction joint on the dorsum of the
prosthesis so that the terminal device can be bent away from the end of the
stump. The economic advantage of an increased "life span" of the prosthesis, as
well as the functional advantages of the open socket, have been presented by
Jaramillo and Lehneis.<a></a> The preservation of tactile sensation is an
important consideration in upper-extremity prosthetic design. Increased research
on open sockets is indicated, since they seem to provide a critical advantage
over the standard prostheses, especially for the bilateral amputee.</p>
<h3>Prosthetic Prescription and
Fitting</h3>
<p>The prescription of a prosthesis for a
congenital amputee, as for any amputee, is best achieved by a team approach. The
child's functional needs and developmental status must be ascertained in order
to provide the optimum combination of components. Actual fabrication is followed
by a final check-out of the compatibility of the amputee and the
prosthesis.</p>
<p>The physician, prosthetist, and physical
and occupational therapists are the main members of the prosthetic-clinic team.<a></a> The physician, in writing the prescription, must combine his
knowledge of the individual with the results of evaluations performed by other
members of the team. The prosthetist advises about possible solutions to the case, measures the
patient, fabricates the prosthesis and harness, and evaluates the functional
results of fitting. The physical and occupational therapists evaluate motor
development, range of motion, and muscle strength, advise the physician and
pros-thetist of available body power for control, suggest possible solutions to
fitting problems, and perform the final checkout evaluation.</p>
<p>As a functional replacement for the
missing limb, the prosthesis must be a simple, lightweight device that will
enable the child to perform certain tasks, but not necessarily all tasks. Stamp,
Mahon, and Morgan<a></a> found that, with the unilateral below-elbow
amputee, the use of a prosthesis improves the function of the opposite, normal
extremity. The combination of a normal extremity and a prosthesis is much more
functionally efficient than is the combination of a normal extremity and a
stump.</p>
<p>The functional needs of the child must be
determined in order to provide a prosthesis that will fill these needs.
Self-care needs are an important part of the functional evaluation. Observing
the compensatory patterns that the child has naturally developed for holding or
reaching yield an indication of his specific functional needs. One approach to
functional evaluation<a></a> has been to observe which parts are missing and to
formulate a prescription on the theory that these are the parts that need to be
replaced prosthetically. This theory assumes that, once these are provided, the
child will meet all of his activity needs. It is important that the total effect
of the prosthesis is a significant gain in function. The advantages and
disadvantages for each individual must be carefully considered.</p>
<p>It is necessary in the early examination to determine the developmental status of the child.<a></a> This evaluation
bears a significant relationship to the timing and type of prosthetic fitting.
In much of the literature, the achievement of a secure sitting balance is designated as an
important criterion to upper-extremity prosthetic fitting. (The criteria for
fitting are discussed more completely in the section on the trend toward early
fitting.) An important part of the evaluation is the observation of the infant's
prehension patterns. The infant's ability to control and relate his various arm,
hand, and body movements predicts his pattern of prosthesis operation and use
<a></a>. The development of compensatory prehension patterns is one of the positive
indications for fitting the child with a cable-operated hook. The child's
interest, attention span, and coordination must also be determined. All of this
information aids in prescribing a prosthesis and planning a training
program.</p>
<p>In addition to this evaluation of
neuromuscular development, the therapist must also determine muscle strength and
range of motion. The prosthetist needs to know which structures are present and
which are absent, and what sources of power are available. Muscle defects may
accompany skeletal defects, as pectoral agenesis occasionally accompanies
below-elbow deficiency.<a></a> Some of the abnormalities of neuromuscular-system
function to notice are: involuntary motion, deviations in the speed of motion,
resistance to passive movement, atrophy, fatigue, and static or dynamic postural
deviations.<a></a> Functional muscle testing as described by Daniels,
Williams, and Worthingham<a></a> provides valuable information.
Range-of-motion tests are useful in noting any contractures or other factors
limiting the range and in determining the scapular movement available to operate
the devices prescribed. Sequential testing and accurate recording are necessary
in functional, motor-developmental, muscle-strength, and range-of-motion
evaluations.</p>
<p>Exact body measurements, both
longitudinal and circumferential, are often made by the prosthetist at the time
of fitting. In the unilateral amputee, the epicondyle-to-thumb length is
important as a sizing reference for the total
length of the finished prosthesis.</p>
<p>The choice of the components for the
prosthesis is based on a thorough knowledge of the functional needs and the
potentials of the individual. It was formerly accepted practice to prescribe a
passive mitt, but this practice has been replaced by the use of a passive,
plastic-covered hook. The hook gives the child the opportunity to incorporate
the concept of a prehensile device from the start. The manual-friction wrist
unit is often useful for congenital amputees. At first it can be positioned by
the parents, and later by the child himself. Sockets that permit rotation are
not usually indicated in short below-elbow stumps, since residual pronation and
supination is minimal. The Munster-type socket, or modifications of it, as well
as conventional below-elbow double-walled laminated sockets, seem to be
successful in fitting the individual with terminal transverse partial hemimelia.
Harnessing and suspension are highly individualized and can make the difference
between successful and unsuccessful prosthetic prescription. Some of the
greatest problems in prescribing and fitting the congenital amputee arise from
his rapid, uneven rate of growth, the presence of baby fat, the lack of
well-defined bony prominences, and the almost constant mobility of all young
children. It must be emphasized that good prescription of prosthetic components
must be based on a thorough knowledge of the individual. The prosthesis should
allow him to function at his highest level in his environment. For the
congenital amputee, this may mean providing him with the opportunity to assume a
normal pattern of development of bimanual activity. In unilateral amputees, the
prosthesis functions as a helper, not as the dominant hand.</p>
<p>Fabrication and interim fittings are
performed by the prosthetist. After careful initial measurements, a plaster cast
of the stump is made. This is used to make a mold of the stump. A full
description of the techniques for fabricating the prosthesis is beyond the scope of this paper;
however, a step-by-step account of fabrication is given in the <i>Manual of
Upper Extremity Prosthetics.</i><a></a> There is no universally acceptable
check-out procedure for the child amputee. The standardized adult forms are not
useful, because child prosthetics is a relatively new field in which
improvements in techniques are constantly being made<a></a>. Additional
contraindications to a standardized form are the varied ages and developmental
levels of the children, philosophies of case management and prescription which
may vary from clinic to clinic, and the fact that so many modifications of the
prostheses for congenital amputees are needed. The standard check-out forms must
be adapted if they are to be used for child amputees. The clinic team must
evaluate the fit and function. The pros-thetist's primary interest is the
mechanical aspects, the therapist's is the child's functional benefit. The
physician must coordinate the efforts of all of the paramedical personnel.
Blakeslee<a></a> has presented some of the important considerations regarding
check-out for the juvenile amputee.</p>
<p><i>Prosthesis fit</i></p>
<ol>
<li>Is the prosthesis cosmetically
acceptable? Is it well made, and does the workmanship follow all of the
specifications of the prescription?</li><li>Is the prosthesis of the proper
length, and is the socket fit satisfactory? Do bony prominences have sufficient
space? Do the component controls appear to be within reach of the
amputee?</li><li>In the upper-extremity
prosthesis, is the harness adjusted properly and is it comfortable?</li><li>When the prosthesis is
removed, are there any excessive pressure points in the socket area? </li></ol>
<p><i>Functional
considerations</i><br />All components must be checked to make
certain they are in good working order, and must be adjusted for efficient
operation by the child and/or adult. Some of the primary functional
considerations are:</p>
<ol>
<li>Is the prosthesis properly
aligned?</li><li>If it is an upper-extremity
device, is the control system appropriate for this child? Will he be able to
control the arm and operate the controls in the desired range of motion? Is the
terminal device in good condition and does it operate smoothly? Does the harness
appear to be correctly positioned and in balance?</li><li>Can the prosthesis be applied with
ease? Is the amputee comfortable in the standing, sitting, and walking positions
and while performing functional activities?</li></ol>
<p>These check-out procedures emphasize the
points to consider in preprosthetic evaluations, prescription of components, and
fabrication. The prosthesis must be made to fit the needs of the child; the
child should not be expected to adapt to the prosthesis.</p>
<h3>The Trend Toward Early Fitting</h3>
<p>A great deal has been written concerning
the advantages of early fitting, and a variety of developmental criteria for
fitting have been described. This section deals with the advantages of early
prosthetic fitting for the upper-extremity juvenile amputee, a brief discussion
of normal motor development, and a discussion of fitting at various ages. The
age levels can be roughly grouped as follows: before school age, nine to twelve
months, six to eight months, four to six months, and three months or younger.
This grouping is the distribution that occurred naturally in the literature. The
concept of prosthetic acceptance or rejection is also discussed in this
section.</p>
<p>The philosophy of early fitting is the
dominant theme of much of the literature. The difference exists in the
definition of the term <i>early. </i>Before this concept was accepted,
prescription of an artificial limb was not advised until the patient reached the
middle or late teens,<a></a> in order to avoid the expense of purchasing a
device that soon would be outgrown. More recently, the child was fitted just
prior to school age,<a></a> but still after the child had become
oriented to one-handed function. Frantz<a></a> has presented a brief
history of the management of the juvenile amputee during the past twenty
years.</p>
<p>Mongeau and others<a></a> recommend
that the habilitation of congenitally deformed children be initiated at an
early age. Many other authors have proposed
reasons for early fitting. Friedmann<a></a> lists the following advantages:
(1) to stimulate bilateral function, (2) to help the child and parents to accept
the prosthesis for function or cosmesis, (3) to incorporate the prosthesis into
the child's body image, (4) to improve balance, (5) to get the child accustomed
to the normal length of the limb, (6) to prevent scoliosis and other skeletal
abnormalities due to asymmetry, (7) to make the child aware of prehensile
function, and (8) to promote eye/hand control. In addition to the advantage of
greater acceptance, Blakeslee<a></a> cites the fact that early fitting leads
to a more normal development of the residual parts and diminishes atrophy caused
by disuse and hypogenesis. The prosthesis encourages physical activity, which
increases growth and strength. The avoidance of substitute patterns of grasp,
such as holding objects in the axilla or elbow-bend and working in an awkward or
energy-consuming position, was noted as an advantage by Blakeslee<a></a>, Brooks and others,<a></a> Gillis,<a></a> and Klopsteg, and Wilson
et al..<a></a> More of the movement patterns of the upper extremity are
acquired than in the lower extremity, thus increasing the importance of early
fitting. Gillis maintains that the movement patterns necessary to control the
prosthesis are most perfectly developed at the same time as those for the
natural limb. The possibilities of atrophy through disuse and the development of
contractures are greater with later prosthetic fitting.<a></a> As the
result of a study conducted at the Rehabilitation Institute of Montreal, Gingras
and others<a></a> found that in a majority of cases there was hypotrophy of
the deficient limb. They found an average difference of one centimeter between
the lengths of the humeri. The hypotrophy was attributed to disuse because it
had been observed that patients who had early prosthetic training were enabled
to put their muscles to greater use and therefore they showed less limb-length
inequality. An additional advantage of early fitting mentioned by Edelstein<a></a> is that it aids the
limb-deficient child in crawling. Children learn to use the upper-extremity
prosthesis as well as, if not better than, adults.<a></a> The advantages of
skill in prosthetic use resulting from early fitting have been cited by Brooks
and others,<a></a> Dean,<a></a> and Mayo.<a></a> Some of the
favorable results of early prosthetic fitting for the unilateral below-elbow
amputee presented by Brooks and Shaperman<a></a> include: (1) full-time wearing of
the prosthesis, (2) skillful operation of the prosthesis, (3) natural and
spontaneous patterns using the prosthesis and including it in normal activities,
(4) good habits of prosthesis maintenance, and (5) good acceptance of the
prosthesis by the child, family, and community.</p>
<p>In reviewing the literature, the author
noted that earlier fitting was advocated more often for children with bilateral
and multiple limb deficiencies than for those with unilateral deficiencies. One
possible explanation for this may be the comparatively greater need for sensory
input for development and function by the former group. The supposition of
earlier fitting was substantiated in a census study by Kay and Fishman.<a></a>
They suggested that this may be related to the greater need by multiple
limb-deficient individuals for prosthetic assistance.</p>
<p>The developmental norms of Gesell and
Amatruda<a></a> form the basis of much developmental evaluation. They are
especially relevant to the unilateral congenital amputee. For instance, he may
first be aware of his missing limb at about three months of age, when he
attempts two-handed grasp. Vitali<a></a> cautions that a limb-deficient
child should not be expected to achieve standards of developmental performance
before others in his age group.</p>
<p>In an analysis of data collected over a
two-year period ending on June 30, 1967, Davies, Friz, and Clippinger<a></a>
noted that a relatively high percentage (32%) of congenital amputees were
not fitted until after their eleventh birthday. Since the current philosophy is
to fit congenital amputees at a very early age, it would be
interesting to know the reason for this delay. The authors could not determine
whether the fault lay with the amputee clinics or with parents who were
reluctant to take their children to clinics or ignorant of the prosthetic
opportunities available to them.</p>
<p>In discussing the advantages of early
fitting, there is variability in the definition of <i>early. </i>Brooks and
Shaperman,<a></a> Kay and Fishman,<a></a> and Watkins and Ford <a></a> support the idea of fitting the unilateral below-elbow amputee before school
age, at the latest. Of those authors advocating fitting when sitting balance has
been achieved, some are referring to independent sitting without support (about
ten months of age) and others to sitting with support (about six months). In
either case, this leaves the upper extremities free in a functional position.
The group of proponents includes Aitken,<a></a> Brooks and others<a></a>,
Caine and Reeder,<a></a> Catto and MacNaughtan, <a></a> Jansen,<a></a> Shaperman,<a></a> and Wilson.<a></a> Several authors indicate a preference for
fitting at six to eight months of age. Among these are Blakeslee<a></a>, Gillis,<a></a> Hall,<a></a> Kempner,<a></a> Lineberger,<a></a> and
Vitali.<a></a> Lineberger and Gillis have cited the benefit of having a
prosthesis to aid in crawling and pulling to a standing position.</p>
<p>Encouraging bilateral movement patterns
and establishing familiarity with and tolerance for the limb are advantages of
prosthetic fitting between four and six months of age. This is considered the
best age for fitting by Edelstein,<a></a> MacNaughtan,<a></a> Martin,<a></a> and Mayo.<a></a> Lambert and others<a></a> maintain
that the congenital amputee should be fitted with a prosthesis as soon as he
needs it. For the unilateral upper-extremity amputee, this may be as early as
three months. According to Gingras and others,<a></a> fitting this early is
based not only on considerations of function, but also on the idea of helping the child incorporate the
presence of an artificial arm into his body image and to accept it better.
Tolerance and adaptation to the prosthesis as well as aid in developing sitting
balance has been stressed by Nichols and others.<a></a> Prosthetic acceptance or rejection is a
very complex concept. It is an accepted psychological principle that an
individual is better able to achieve adequate adjustment to a total loss of
function than to a partial one, yet prosthetic devices restore partial function.
The relationship of the amputee to his prosthesis is that of man to machine. It
is an intimate and long-term contact between a human being and a mechanical
device. The gadget tolerance of the individual is of great importance,
especially as the child grows older and develops greater skill in using the
prosthesis. Both the visual consideration of cosmesis and the auditory factors
of a mechanical device, such as the sound of a terminal device closing on an
object, play major roles in the formation of the individual's attitude toward
his prosthesis. If the prosthesis is regarded as a tool that makes him less
different and gives him a better opportunity for integration into his peer
group, then the child is more likely to wear and use his prosthesis. If he
believes that the prosthesis accentuates the difference between himself and
others, it is likely that he will reject it.<a></a> Throughout the literature, it has been
emphasized that children usually accept a prosthesis without too much difficulty
.<a></a> It helps if the individual can gain immediate
satisfaction from its use, rather than feeling that it is a deterrent to his
activity. A child can be helped to appreciate the usefulness of the prosthesis
by providing him with toys and chores that require two hands. Both a full-time
wearing pattern and the ability to talk freely and openly about the prosthesis
are good indicators of acceptance.</p>
<p>Several authors have emphasized the
positive relationship between early fitting and good prosthetic acceptance. A
patient most easily accepts a prosthesis if
he obtains it before becoming accustomed to one-handed activity.<a></a>
Kempner,<a></a> Mongeau and others,<a></a> and Wilson <a></a> believe that early fittings lead to complete patient and family acceptance.
In evaluations by Brooks and Shaperman<a></a>, children with short below-elbow
stumps fitted before two years of age received the best scores for "acceptance."
Gingras and others<a></a> found that rejection is a common occurrence if
prosthetic fitting takes place after adolescence, while Blakeslee<a></a> found
excellent acceptance and utilization if the child was fitted before four years
of age, and increased rejection after that age.</p>
<p>Congenital amputees experience the same
structuring process in regard to body image as do normal children. If a child is
presented with a prosthesis during the critical stage when his body image is
forming,, he will incorporate the limb into his pattern of activity and
self-image.<a></a> Centers and Centers<a></a> note that modern
prostheses are functionally adequate for many of the activities engaged in by
children. This may be a factor <i>in </i>the incorporation of the prostheses
into their body images. Personality factors are directly related to acceptance
of a prosthesis.</p>
<p>In the case of the congenital amputee,
his parents' attitudes affect his personality and his acceptance or rejection of
a prosthesis. Parental influence cannot be overemphasized. It is within the
family structure that all of the child's attitudes are developed. A clear view
of parental influence is presented by Brooks and Shaperman<a></a> in their
discussion of a group of children who had rejected their prostheses. The group
was characterized by a lack of parental support and guidance in the child's
general behavior. There was a great deal of emphasis on the child's
accomplishments without the prosthesis. These parents expected less of their
children than their potential, openly expressed dislike for the appearance of
the prosthesis, and had a limited ability to communicate feelings and problems. One
review<a></a> indicated that the better-educated middle-class families are
most likely to help their children accept prosthetic appliances.</p>
<p>All of these considerations regarding
acceptance and rejection are interrelated.</p>
<h3>Questionnaire Survey Concerning Age at
Initial Fitting</h3>
<p>The questionnaire survey sought to
document a trend toward earlier initial fitting of upper-extremity prostheses in
the congenital amputee. As the most frequently occurring limb deficiency,
unilateral terminal transverse partial hemimelia was selected as the focus of
consideration. An extensive review of the literature had seemed to indicate a
trend toward earlier fitting. While children were formerly fitted just prior to
school age or even during the middle or late teens, the achievement of
independent sitting balance is now a widely accepted criterion for prosthetic
prescription. According to Gesell and Amatruda's studies of motor development,<a></a> the norm for the achievement of this maturational level is nine
months (36 weeks).</p>
<p>It was the belief of the author that (1)
even earlier fittings are being performed in significant numbers, (2) a passive
hook is most frequently prescribed, and (3) the development of the Münster-type
socket has played a role in the trend toward earlier fitting.</p>
<p>Questionnaires were mailed to the 28
clinics participating in the Child Prosthetics Research Program, a cooperative
endeavor conducted under the auspices of the Subcommittee on Child Prosthetics
Problems of the Committee on Prosthetics Research and Development. The
information requested was of three types: age at time of initial fitting, type
of socket and terminal device most frequently prescribed, and basic
developmental levels considered essential for fitting the prosthesis.</p>
<p>The sample consisted of 40 new patients
with upper-extremity terminal transverse partial hemimelia who were initially
fitted between March 1, 1969, and approximately March 1, 1971. The frequency of
fittings is indicated in <b>Table 1.</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 1.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>One clinic whose data arrived too late to
be included in the chart reported fitting more than 200 cases. A relatively
small number (between 15 and 20) were fitted between the ages of 6 and 9 months,
and a much larger number (50 or 60) were fitted after the age of 12 months. Two
other clinics indicated that the information needed to complete the
questionnaire was not readily available. (One of these stated that all of their
children were fitted after the age of 12 months.) In requesting the data, no upper limit
was set on the last interval (later than 12 months). For this reason, no
statistical analysis of the central tendency (mean or median) was possible. The
return on this survey was 43%, the low response level being partly attributable
to the fact that no date was designated for the return of the
questionnaire.</p>
<p>The frequency distribution indicated that
65% of the children were fitted under one year of age. Using nine months as the
age for reaching the developmental level of independent sitting, the data
indicates that 37.5% were fitted before that age. It is also interesting to note
that 20% of the sample was fitted before six months and 7.5% before three
months. This information indicates a trend toward fitting earlier than the
widely accepted criterion of independent sitting balance. The very important
concept of parental attitudes and other intangible factors were not considered,
nor was the age when the child was first seen at the clinic taken into
account in this study. If it were, perhaps
an even stronger trend toward earlier fitting would be noticed.</p>
<p>Regarding the type of terminal device,
seven clinics prescribed a Dorrance 10P or 12P passive hook most frequently. One
fitted a nonfunctioning hand (mitten) initially and changed to a hook at about
two years of age. The other clinic listed both the passive hook and the passive
hand in their response. Five of the clinics prescribed a conventional
double-walled plastic-laminate socket most frequently, and four clinics most
often prescribed a Münster or modified Münster socket.</p>
<p>An interesting outcome of this survey was
the compilation of the developmental criteria for fitting employed by the
various clinics. In the following chart, the list of criteria is paired with the
developmental norms described by Gesell and Amatruda.<a></a> </p>
<table>
<tbody>
<tr>
<td>
<p><b><i>Developmental
Criteria</i> </b></p>
</td>
<td>
<p> <b><i>G and A Norms
(mo)</i> </b></p>
</td>
</tr>
<tr>
<td>
<p>Beginning to prop on
elbows</p>
</td>
<td> 3
</td>
</tr>
<tr>
<td>
<p>Readiness for bimanual
activity</p>
</td>
<td> 4
</td>
</tr>
<tr>
<td>
<p>Head control</p>
</td>
<td> 5
</td>
</tr>
<tr>
<td>
<p>Object transfer</p>
</td>
<td> 7
</td>
</tr>
<tr>
<td>
<p>Beginning sitting</p>
</td>
<td> 8
</td>
</tr>
<tr>
<td>
<p>Independent sitting
balance</p>
</td>
<td> 9
</td>
</tr>
<tr>
<td>
<p>Controlled voluntary grasp and
release</p>
</td>
<td> 9-12</td>
</tr></tbody></table>
<p>One clinic responded that they did not
adhere to any developmental criteria, but felt that as soon as the child was
three or four months old, a prosthesis could be fabricated with adequate socket
fit. It was their belief that the earlier the socket was fitted, the
better.</p>
<p>The data collected on this sample did not
establish a relationship between the development of the Münster-type socket and
the trend toward earlier fitting.</p>
<p>It is hoped that persons responsible for
prescribing prostheses might consider the criteria proposed by other clinics for
fitting of prostheses for congenital upper-limb amputees. The advantages that
prompted the change from pre-school-age fitting to fitting at the developmental
level of independent sitting continue to exert an influence toward still earlier
fitting. The greatest advantage claimed is that of acceptance of the prosthesis.
Logically, if the artificial limb is provided before a one-handed activity
pattern is developed, changes for acceptance are increased. It would further
seem logical that, when the capacity for two-handed grasp in the midline
develops (at approximately four months), a prosthetic limb should be there to
oppose the normal limb. The proximal stability necessary for control is
developed previously in the on-elbows position. Many factors interact to affect
the age of initial fitting. The age at which the limb-deficient child is
referred to the clinic is certainly a significant one. Parental attitudes are
closely associated with this consideration. The development of prosthetic parts
specifically designed for children is important, as is the increase in knowledge
in the entire field of prosthetic management of the juvenile amputee.
Dissemination of this knowledge to the related health fields, especially to
those individuals in contact with the mother of the newborn child with limb
deficiencies, may promote earlier referral to the appropriate prosthetic
team.</p>
<p>It is believed that the trend toward
earlier fitting is advantageous. A difference in the practice of various clinics
has been noted. A polarity exists with a tendency for some clinics to fit
predominantly at a very early age range and others only later. Three of the
clinics indicated fitting only after 12 months. It would be useful for all the
clinics that participate in the management of congenital amputees to carefully
evaluate their criteria for prosthetic fitting and training.</p>
<h3>Preprosthetic Therapy</h3>
<p>Preprosthetic care should begin as early
as possible. Hall<a></a> believes that physical and occupational therapy
should be started as soon as the child begins to take part in his environment. A
highly individualized treatment program to correct the deficiencies in range of
motion, posture, and muscle strength is an important goal of preprosthetic
therapy. The evaluations described earlier as prerequisites
to prescription are also a part of the preprosthetic therapy program. Jaramillo
and Lehneis<a></a> suggest that the child's poor attention span or
negativism may be due to the lack of preprosthetic training by means of a good
exercise program, rather than to poor family cooperation.</p>
<p>Several authors have emphasized the
important role the mother plays as the therapist.<a></a> She can
be the best therapist for her child, since she spends more time with him than
anyone else. She must understand the purposes of the therapy program and carry
out the program at home. A good home program will facilitate prosthetic
training. A well-informed mother can help to prevent contractures and postural
deviations and to correct existing problems. It is a significant psychological
asset for the mother to be an active member of the prosthetic team. An
additional consideration that is the mother's responsibility in the early stages
of habilitation is stump hygiene. The stump should be washed, rinsed, and dried
thoroughly and inspected daily for any minor irritation or abrasion. The
limb-deficient child perspires more than normal because of reduced body area.
<a></a> He should be dressed in light, unrestrictive clothing for cooling and to
allow freedom of movement.</p>
<p>Limitations of range of motion do not
occur as often in the upper extremity, and when they do occur, they do not as
markedly affect its use.<a></a>The best treatment is prevention. This
can be accomplished by instructing the parents in positioning and active
exercises to prevent contractures and build strength and endurance. Extreme
caution should be used in stretching any joints in the congenital limb-deficient
child. The elbow is especially vulnerable, and passive stretching is
contraindicated. (The tendency for radial-head dislocation has already been
discussed.) The best techniques for increasing range of motion are those that
achieve relaxation of the shortened group by heavy resistance to the
antagonist muscle group. The PNF techniques of
repeated contractions, slow reversal, slow reversal-hold, rhythmic
stabilization, hold-relax, or slow reversal-hold-relax, as described by Knott
and Voss would be appropriate. Since the young child is more flexible in his
muscular structure, it is easier to reverse the adaptive shortening of the
muscles than it would be in adults. Blakeslee<a></a> also notes the use of passive
stretching, casts, and braces for the correction of flexion
contractures.</p>
<p>The delay in the early neuromuscular
development of children with congenital skeletal limb deficiencies has been
noted by Blakeslee<a></a>, Hall <a></a>, Jaramillo and Lehneis <a></a>, and Steele.<a></a> The child may be delayed in the development of head and neck
control, rolling over, creeping, and sitting. He may need assistance in
achieving developmental tasks. For example, if the child lacks head and neck
stability, placing a small pillow under his chest allows development of the
trunk and neck extensors. During this early period, assistance may be needed to
help strengthen the neck and trunk flexors, extensors, and rotators. Later, it
may be necessary to stimulate bimanual activity, especially gross grasp, by
providing large objects for the child to hold. The upper-extremity amputee may
need help in pulling to a standing position so that he can adequately develop
his lower-extremity musculature.</p>
<p>Essential muscle groups are exercised to
maintain mobility and increase strength. Specific muscle groups must be
strengthened in order to provide sufficient power to operate the prosthesis.
Bates and Honet<a></a> and Montero <a></a>advocate the use of isometric
exercises for this purpose. Exercises for neck and back extensors, flexors, and
rotators are best accomplished through play activity. Catto and MacNaughtan
<a></a> suggest using mirrors to stimulate the desired movement. The sound
side should be included in the exercise program. Emphasis on strengthening the
shoulder-girdle musculature for elevation, depression, scapular abduction and adduction, and general
chest expansion (respiratory exercises) is important, since these muscles are
needed to operate the prosthesis.<a></a> For the below-elbow
amputee, strengthening elbow flexion and extension and any available pronation
and supination is of prime importance.<a></a> Blakeslee<a></a> has emphasized the
importance of general conditioning. Limb-deficient children tend to have a low
energy output. This was observed even in below-elbow amputees who were otherwise
normal in appearance and physiognomy. Greater than average endurance and output
are required to operate a prosthesis. He also mentions that individual and group
sports and other group activities have been successful in increasing energy
output and improving general physical condition. Swimming has been found
particularly advantageous.</p>
<p>A preprosthetic therapy program provides
a good foundation for later training of the child in the use of the
prosthesis.</p>
<h3>Prosthetic Training</h3>
<p>Prosthetic training begins when the
congenital amputee receives his prosthesis and continues periodically through
vocational training. The initial training and orientation with a passive
terminal device is essentially the same as that with an active terminal device,
so both are considered together in this section.</p>
<p>Training is one of the most difficult and
important phases in the management of the congenital amputee. It is essential
that the child is enabled to handle his environment rather than adapting the
environment to his needs. Training a congenital amputee is very different than
training a traumatic juvenile or an adult amputee who once had a functional
extremity. The functional level of a normal child of the same age should be the
basis of achievement goals.<a></a> The program progresses naturally from
gross bimanual grasp to skilled functional activity. Factors affecting training
are the child's neuromuscular development, attention span, functional requirements, and
parental cooperation.</p>
<p>The parents play an important role in the
training of the juvenile amputee. The care and function of the prosthesis must
be carefully explained to the parents, and they must be very aware of what it
can and cannot do. The importance of the parents in prosthetic training has been
emphasized by many authors.<a></a> Unless contraindicated by medical or
other reasons, full-time wearing of the prosthesis from the first application
should be the aim. According to Blakeslee,<a></a> one advantage to achieving
a full-time wearing pattern as early as possible is the avoidance of the habit
of removing the prosthesis for little or no reason. Later in childhood, the
wearing pattern will be interrupted for repairs and refitting, so a stable
pattern is desirable. Infants accept prosthesis-wearing easily, unless there is
discomfort or the parents do not allow the prosthesis to be worn all day.
Mac-Naughtan, <a></a> Shaperman, <a></a> Steele,<a></a> and
Watkins and Ford<a></a> advise a gradual increase in tolerance leading to
full-time wear except for sleeping, bathing, and rough contact sports. This
seems to be a more logical approach than to expect immediate full-time wearing
after the child has become accustomed to complete freedom of movement. During
the period when the child has a passive prosthesis, he should be encouraged to
use it as a "helper" in bimanual grasp, crawling, and pulling to a standing
position. Toys are an excellent medium for encouraging bimanual activity. The
infant amputee who receives his prosthesis during the first year of life shows
remarkably early proficiency in gross arm movements; he develops habits of
including the arm as a total unit rather than any specific part of the arm such
as the hook, tip, or elbow.<a></a> An awareness of the hook's holding
function should be developed as early as possible.</p>
<p>In response to the questionnaire survey
conducted by the author, the University of California at Los Angeles included
a discussion of the criteria for the
addition of a cable. Some of the factors proposed as prerequisites for
terminal-device activation are: the readiness for bimanual activity, a
reasonable attention span (approximately five minutes), the ability to follow
two-step directions, tolerance of handling by the therapist, the presence of
sufficient neuromuscular development to operate the cable, a full-time
prosthesis-wearing pattern, and an awareness of the hook's holding function. At
UCLA, the cable is usually added at a developmental age of two or two and
one-half years.</p>
<p>Like the variations observed in the age
of choice for initial fitting, similar variability occurs in the age at which
the terminal device is activated. The usual age seems to be about two years.
Mac-Naughtan<a></a> has expressed the opinion that training should be
conducted at the 14-to-20-month age. Depending on the ability of the child and
the nature of his deformity, active control can be accomplished at 16 to 24
months, according to Hall<a></a> and Kempner. <a></a> Edelstein<a></a> cites 18 months, and Lambert<a></a> cites 18 to 24 months for the
below-elbow amputee. By the age of 21 to 24 months, the child has developed a
two-handed functional pattern, and he shows signs of a need to develop a pinch
grasp as opposed to purely palmar prehension. <a></a> By two years of age,
according to Blakeslee<a></a>, the child is ready for effective terminal-device
activation, although this is typically a period of profound negativism. Dean
<a></a> and Mayo<a></a> suggest that a single control cable be
activated at 24 to 30 months, while Gingras and others<a></a> believe that,
if active prosthesis training is begun by age two or three years, control can be
achieved by four years of age.</p>
<p>A study by Trefler<a></a> reveals
the drawbacks of normally fitting around two years of age. Some of these
considerations are that the child is ready for bilateral grasp before that age;
he may be difficult to work with at the "terrible twos" stage of hyperactivity
and negativism, and he may have already developed compensatory
patterns, which are more easily prevented than broken. The advantages of
terminal device activation at 15 months of age with a goal of spontaneous
terminal-device use are: (1) the child is easy to work with for short periods of
time (he has an attention span of one to two minutes), (2) when the cable system
is applied to the child's prosthesis, it often helps to eliminate the problem of
excessive external rotation of the socket, and (3) the availability of active
grasp can enhance the activity pattern of an intelligent child. No disadvantages
of early terminal-device activation were discovered. The cable did not restrict
the child's movement during play at all.</p>
<p>Wendt and Shaperman<a></a> conducted an interesting study to determine whether an infant amputee with
unilateral below-elbow deficiency who was fitted initially with a prosthesis
that included a cable would achieve purposeful control of the terminal device as
part of his normal developmental progression without formal training. The
results indicated that only a minority of the patients (approximately 25%) did
achieve spontaneously the degree of skill usually acquired after formal
training. Some patients partially learned skills, and others remained unaware of
the function of the hook. It is possible that some children were negatively
conditioned by the experience of trying to operate the terminal device and
finding that they were unable to do so because of a lack of skill and guidance
and concluding that the hook was a poor and unreliable tool. An alternative
method of case management that has been suggested is to add the cable when
manual hook-opening appears and then to allow natural development of
terminal-device control. If the skill does not develop spontaneously, the
therapist should intervene with the training program. This emphasizes manual
hook-opening as a relevant step toward the eventual development of active
opening. It was found that children who do learn terminal-device operation
without training develop good skill and use
patterns. If they are going to do so independently, they give evidence of this
well before two years of age and achieve a well-established pattern by that
time. It seems that, if a child is ready to develop the skill for
terminal-device operation naturally, he should be allowed to do so.</p>
<p>Prosthetic training once the control
cable has been added is composed of two parts: training in the control of the
terminal device and later functional training in activities of daily living. The
child's ability to operate a hook relates primarily to his maturity.<a></a>
Because of the child's short attention span, brief, frequent training
sessions are desirable. Patients may sometimes be required to enter the hospital
for the initial training sessions and occasional retraining later. At home, the
mother can encourage these brief, frequent practice sessions. The child can best
learn the correct control operations and realize the potentials of this
prosthesis through play. There is a tendency for the child to continue to use
his prosthesis as a passive device even after active control has been added.<a></a> Early training before the control cable
is added should establish the concept of the prehensile function of the
prosthesis. Manual hook-opening, at first by the parent and later by the child,
and placing toys into the hook, should be encouraged. Flexion of the humerus
opens the terminal device. The child must be helped to achieve the awareness of
the relationship of these two incidents. The concept of stabilizing the sound
shoulder in order to operate the terminal device is a difficult one to grasp.
Having the child reach toward the terminal device with his sound arm may be
helpful, or the therapist may need to stabilize the harness. The technique of
immobilization seems to be mastered abruptly and inexplicably<a></a>, but it may
take a great deal of time. The important objective is to get the child to open
the hook, no matter how awkwardly it is accomplished. It may be necessary to cut
down on the number of rubber bands on the hook to enable the child to open it;
at this point in training, a large prehension force is not needed. The therapist
can help hy offering objects to the child and placing them so that the hook will
open when he reaches for them. One of the most difficult things for a child to
learn is to pick up objects from a horizontal surface.</p>
<p>The sequence of learning grasp and
release with the prosthesis has been described by Blakeslee<a></a>, Richardson and
Lund,<a></a> Shaperman,<a></a> and Wendt and Shaperman.<a></a>
Although there may be variations in the pattern among individuals, it is
agreed that a pattern does exist for learning terminal-device operation. A brief
summary of the patterns observed by the above authors is presented
here.</p>
<p>Children learn first to actively maintain
the hook in an open position and then to initiate hook-opening actively. Early
opening is often accomplished by abducting and internally rotating the arm
rather than by flexing the shoulder. This closely resembles grasp by the normal
infant. The child finds it easier to open the terminal device with the elbow
extended than in any other position. There is a tendency for the child to place
objects into the hook with the sound hand. The ability to actively close the
hook around an object develops before active release. At first, release of
objects is accomplished by pulling them out of the hook with the sound hand. The
child seems to be unaware that he can open and close the hook for release and
that this requires the same motions that were used for grasp. It takes a long
time and a great deal of practice for a child to become proficient in the use of
the prosthesis. He must learn how far to open the hook to accommodate objects of
different sizes and shapes, to position the hook accurately, and to properly
time the release of an object. The child must also learn to extend the
prosthetic arm and still maintain grasp on an object by releasing his sound
shoulder so it no longer acts as the reaction point for control. The younger
child cannot be expected to learn these more complex skills.</p>
<p>Training hints have been offered by many
therapists. The most frequent suggestion is the use of toys that require
bimanual activity.<a></a> A lengthy list of toys suitable to each
age group and each desired activity can be compiled. It was also mentioned that
feeding time has been found to be one of the most successful training periods.
Drill activities cannot be neglected, but relating them to functional play
activities as soon as possible is desirable. <i>The Limb-Deficient Child</i><a></a>
contains an excellent and extensive section on prosthetic
training.</p>
<p>Three prime functions that require
prosthetic training are feeding, toilet care, and dressing. Other functional
patterns that add to patient independence and satisfaction are: playground,
household, and schoolroom activities, sports, musical instruments, card playing,
and any other activities commensurate with the child's age. Special assistive
devices are available commercially or can be fabricated when necessary.<a></a>
Vocational training and preparation is a major consideration as the child
grows older. For the unilateral amputee, the prosthesis is a helping or
assisting device, and the sound arm is the dominant one in all activities. The
part of functional training described in this paper is donning and removing the
prosthesis. It is not practical to expect the very young amputee to be able to
put on his prosthesis independently from the beginning. This is in contrast to
the training procedure in adults, which would begin with this skill. Application
is accomplished in the same manner as putting on a coat.<a></a> The
socket is grasped with the sound arm and the stump is slipped under the
inverted-Y strap. If the prosthesis is raised above the head so that the harness
hangs down, the sound arm can reach back through the axilla loop, and the
harness then can be properly placed. To remove the prosthesis, the child raises
both arms over his head and grasps the socket with his sound arm. He can
withdraw the stump while pulling up on the socket and then remove the axilla loop. Although a stump sock is
usually worn to absorb perspiration, prevent suction, and allow greater comfort
in the socket, it is a matter of individual preference. Some children with
below-elbow deficiencies prefer not to wear a stump sock.<a></a> It is
recommended that a T-shirt be worn under the harness to decrease local pressure
and irritation, especially in the axilla, and to absorb perspiration.</p>
<p>Successful training will permit the child
to function freely and independently in his environment. Additional training may
be required when the needs of the individual change.</p>
<p>Follow-up studies of juvenile amputees
after long-range treatment from infancy to adulthood have been conducted by
Davies, Friz, and Clippinger,<a></a> Hamilton,<a></a> and Lambert,
Hamilton, and Pellicore.<a></a> All three indicate the excellent results of
long-term prosthetic management as indicated by good social adjustment,
excellent prosthetic utilization, high employment rates, and high levels of
educational achievement. Increases in these favorable results can be expected as
children with congenital limb deformities are referred to prosthetic centers for
treatment earlier and earlier.</p>
<h3>Conclusion</h3>
<p>This paper has discussed the prosthetic
management of the congenital amputee with upper-extremity terminal transverse
partial hemimelia. Psychological aspects, components of the prosthesis,
prescription and fitting, the trend toward early fitting, preprosthetic therapy,
and prosthetic training have been considered. A review of the literature and a
questionnaire survey were completed. Several questions are raised and areas for
further research are suggested as a result of this study.</p>
<p>Research concerning the etiology of
congenital limb deficiencies is indicated, including the unexplained phenomenon
that the highest incidence of these deficiencies involve terminal transverse
partial hemimelia of the left upper extremity in
females.</p>
<p>Information regarding phantom sensation
in the congenital amputee is lacking. Study in this area might help to explain
the phenomena of phantom pain and sensation in traumatic amputees.</p>
<p>Reports regarding peer attitudes toward
juvenile amputees show some disagreement. Some authors maintain that the
attitude exhibited is one of healthy curiosity easily satisfied by an
explanation, while a study by Centers and Centers showed more covert rejecting
attitudes toward this group of individuals. It would be interesting to retest
this hypothesis of social discrimination in the light of recent changes in
attitudes toward many minority groups, since this study was conducted nearly ten
years ago.</p>
<p>A great deal of research is indicated and
is being conducted in the area of prosthetic design. The results of
biomechanical and kinesiological studies must be incorporated in the design of
components. Analysis of the forces used in prehension and the most frequent
types of prehension employed would be beneficial in improving terminal-device
design. Further evaluation of the hooks and hands presently available and the
voluntary-opening and voluntary-closing mechanisms are needed to determine which
is most efficient and to delineate areas for further research. Some work has
been done regarding optimum wrist-flexion (palmar) angles for functional
activity close to the body. However, no consideration has been made as to the
need for dorsiflexion, which is used very frequently in functional activity of
the normal hand. The field of plastics offer a great source for improvements in
fabrication of prostheses. Durable hooks with improved cosmesis may be a
possibility with the new plastic materials available, as it has already aided in
light weight and durable socket design and fabrication. The open-ended sockets
that permit the use of the sensation at the tip of the stump seem to be an
excellent development, especially for the bilateral amputee. Investigation into the
advisability of increased use in the United States is indicated.</p>
<p>Some disagreement exists concerning the
development of prosthetic tolerance by the juvenile upper-extremity amputee. It
is not, however, a significant controversy, since the goal of full-time wear is
agreed upon, with differing opinions only concerning the rate at which this goal
is reached.</p>
<p>The results of the questionnaire survey
indicate a trend toward earlier prosthetic fitting of the congenital amputee.
Among the most interesting and valuable of all the information received was the
developmental criteria for fitting. This information should be made available to
the clinics participating in the Child Prosthetics Research Program, thereby
enabling each of them to re-evaluate their criteria in light of this newly
accumulated knowledge. Perhaps this can be accomplished through the
<i>Inter-Clinic Information Bulletin.</i>The survey conducted did not consider
the important factors of parental attitudes and age at time of referral to the
prosthetic center. Any future study should incorporate these factors. Another
study might better be able to establish or negate a relationship between the
development of the Münster-type socket and the trend toward early
fitting.</p>
<p>Additional information concerning
activation of the terminal device is needed. The proposal by Wendt and Shaperman
of allowing natural development of the terminal device control once manual
opening occurs, then intervening with formal training if control is not
established by two years of age, merits consideration.</p>
<p>Prosthetics for congenital amputees is a
relatively new area, largely developed since the thalidomide tragedy of a few
years ago. It has many areas requiring further research, such as the need for
lightweight prostheses that can be operated with the available muscle power and
the constant consideration of rapid growth. Research in this specific field of
prosthetics for congenital amputees will contribute to and continue to benefit from
the ongoing research in prosthetics in general. The goal of this research is
improved functional ability for individuals with congenital skeletal limb
deficiencies of varying degrees of severity and for all amputees.</p>
<h3>Addendum</h3>
<p>Three additional responses from the
questionnaire survey were received after the statistical analysis had been
completed and the article had been prepared. These brought the total return to
53.5%. A summary of the information received is presented here.</p>
<p>The results were generally similar to
those previously reported, with a number of individuals fitted at each interval
except the first (less than three months).</p>
<p>The developmental criteria presented
were: bilateral gross grasp, beginning to sit, independent sitting, and (not
previously mentioned) initiation of hand-eye coordination, as with holding a
bottle, blocks, and general grasp for objects.</p>
<p>Two of the clinics indicated that they
usually fit a first prosthesis at six months of age if the developmental level
allows it. Those fitted later in the statistics returned were not referred to
the clinics until after that age.</p>
<h3>Acknowledgments</h3>
<p>I would like to thank Miss Dorothy Page,
my advisor, for her help and guidance during this project. I would especially
like to thank Miss Mildred C. Ey, O.T.R., Director of Occupational Therapy at
Sunnyview Rehabilitation Center Hospital; and Mr. Klaus H. Lohman, C.P., of
LaTorre Orthopedics Laboratory. I also extend my appreciation to Dr. Sidney
Fishman, Mr. Hector W. Kay, the A. J. Hosmer Corporation, the Dorrance Company,
the Otto Bock Company, and the clinics answering the questionnaire.</p>
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<li>Kay, Hector W., and Sidney Fishman, <i>1018 Children with Skeletal Limb Deficiencies, </i>Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </li>
<li>Kay, Hector W., Kevin A. Cody, George Hart-mann, and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, <i>Artif. Limbs </i>9:2:4-25, Autumn 1965. </li>
<li>Kempner, Shirlee, Recent articles of interest, <i>Inter-Clinic Inform. Bull. </i>5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, <i>Manitoba Med. Rev. </i>44:552-557, 1964. </li>
<li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human Limbs and Their Substitutes, </i>McGraw-Hill, New York, 1954. </li>
<li>Knapp, Miland E., Upper-extremity amputations: surgical considerations, <i>Postgrad. Med. </i>45:2:237-240, Feb. 1969. </li>
<li>Kruger, Leon M., and Nicholas R. Breyan, A study of radial-head dislocation in children with transverse partial hemimelia of the upper limb, <i>Inter-Clinic Inform.Bull.</i>10:1:1-4, 1970. </li>
<li>Kuhn, Gotz Gerd, Treatment of the child with severe limb deficiencies, <i>Inter-Clinic Inform. Bull </i>10:3-S:l-26, 1970. </li>
<li>Kyllonen, Ronald R., Body image and reaction to amputations, <i>Conn. Med. </i>28:19-23, Jan. 1964. </li>
<li>Lambert, Claude N., The juvenile amputee, <i>Illinois Med. J. </i>123:514-517, May 1963. </li>
<li>Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, <i>J. Bone Joint Surg. </i>(Amer.) 51-A:6:1135-1138, Sept. 1969. </li>
<li>Lineberger, Mildred I., Habilitation of child amputees, <i>Journal of the American Physical Therapy Association </i>42:6:397-401, June 1962. </li>
<li>McCollough, Newton C., Interpersonal problems of the handicapped child, <i>Inter-Clinic Inform. Bull. </i>4:11:1-4, 16, 1965. </li>
<li>McGraw, Myrtle B., <i>Neuromuscular Maturation of the Human Infant, </i>Columbia University Press, New York, 1943. </li>
<li>McLaurin, Colin A., and Fred Sammons, Independent-control harnessing in upper-extremity prosthetics, <i>Artif. Limbs </i>7:1:11-16, Spring 1963. </li>
<li>MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, <i>Physiotherapy </i>52:201-203, June 1966. </li>
<li>McWilliam, R., and S. R. Montgomery, Artificial arms—are they practical?, <i>Med. Biol. Illus. </i>19:4:200-201, 1969. </li>
<li>Martin, J. K., Congenital malformations associated with thalidomide and their management, <i>Amer. Heart J. </i>67:284-285, Feb. 1964. </li>
<li>Mayo, Eileen J., Upper extremity prostheses for children, <i>Canad. Nurse </i>58:145-148, Feb. 1962. </li>
<li>Mitchell, C. Leslie, Amputation and prosthesis: past research and future needs, <i>Clin. Orthop. </i>no. 37:110-112, Nov.-Dec. 1964. </li>
<li>Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, <i>Canad. Med. Assoc. J. </i>95:390-395, Aug. 27, 1966. </li>
<li>Montero, Jose C, Rehabilitation of the amputee, <i>Mod. Treatm. </i>5:5:1047-1056, Sept. 1968. </li>
<li>Munson, Nancy K., and Clyde M. E. Dolan, <i>Patient Census at Child Amputee Clinics</i>— <i>1967, </i>Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968. </li>
<li>Murphy, Eugene F., The challenge of replacing human parts and functions, <i>Bull. Pros. Res. </i>10-3:4-19, Spring 1965. </li>
<li>Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, <i>Artif. Limbs </i>12:1:13, Spring 1968. </li>
<li>O'Shea, Barbara, A chest strap harness for the below-elbow child amputee, <i>Inter-Clinic Inform. Bull. </i>6:7:1-4, 18, 1967. </li>
<li>Peizer, Edward, Veterans Administration Prosthetics Center research, <i>Bull. Pros. Res. </i>10-6:257-260, Fall 1966. </li>
<li>---------, Veterans Administration Prosthetics Center research, <i>Bull. Pros. Res. </i>10-10:270, Fall 1968. </li>
<li>Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, <i>Inter-Clinic Inform. Bull. </i>3:11: 1-8, 1964. </li>
<li>Richardson, Geraldine, and Aida Lund, Upper extremity prosthetic training for the young amputee, <i>Amer. J. Occup. Ther. </i>13:2:57-63, Mar.-Apr. 1959. </li>
<li>Ritter, Diane, and Fred Sammons, An interesting terminal device modification, <i>Inter-Clinic Inform. Bull. </i>4:9:7-10,19, 1965. </li>
<li>Santschi, William R., (Ed.), <i>Manual of Upper Extremity Prosthetics, </i>2nd ed. rev., University of California, Los Angeles, 1958. </li>
<li>Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, <i>Amer. J. Occup. Ther. </i>14:1:17-23,26, 1960. </li>
<li>---------, Learning techniques applied to prehension, <i>Amer. J. Occup. Ther. </i>14:70-74, Mar.-Apr. 1960. </li>
<li>---------, A comparison of two infant terminal devices, <i>Inter-Clinic Inform. Bull. </i>3:7:1-6, 1964. </li>
<li>Simmel, Marianne L., The absence of phantoms for congenitally missing limbs, <i>Amer. J. Psychol. </i>74:467-470, Sept. 1961. </li>
<li>Sokolow, Jack, Management of the amputee in practice, <i>Med. Clin. N. Amer. </i>53:3:659-664, May 1969. </li>
<li>Spring, John M., and Charles H. Epps, Jr., The juvenile amputee: some observations and considerations, <i>Clin. Pediat. </i>7:76-79, Feb. 1968. </li>
<li>Stamp, Warren G., Sharon Mahon, and Harry C. Morgan, Problems of management of the child with multiple amputations, <i>Arch. Phys. Med. Rehabil. </i>46:354-368, May 1965. </li>
<li>Stanek, William F., Orthopedic service at children's hospital: the amputee center, <i>Rocky Mountain Med. J. </i>63:54, Oct. 1966. </li>
<li>Staros, Anthony, and Edward Peizer, Veterans Administration Prosthetics Center research report, <i>Bull. Pros. Res. </i>10-12:331-333, Fall 1969. </li>
<li>Steele, Shirley, Children with amputations, <i>Nurs. Forum </i>7:411-423, 1968. </li>
<li>Stoner, Emery K., Functional evaluation of the upper extremity, in <i>Handbook of Physical Medicine and Rehabilitation, </i>ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </li>
<li>Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, <i>Clin. Orthop. </i>no. 37:82-97, Nov.-Dec. 1964. </li>
<li>Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, <i>Amer. J. Surg. </i>109:294-299, Mar. 1965. </li>
<li>Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, <i>Inter-Clinic Inform. Bull. </i>3:6:1-4, 1964. </li>
<li>Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in <i>Selected Articles from Artificial Limbs, </i>Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </li>
<li>Taylor, Isabelle Wagner, Psychological needs of the handicapped child, <i>Inter-Clinic Inform. Bull. </i>9:8:9-17, 1970. </li>
<li>Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, <i>Amer. J. Occup. Ther. </i>15: 17-18, Jan.-Feb. 1961. </li>
<li>Trefler, Elaine, Terminal device activation for infant amputees, <i>Inter-Clinic Inform. Bull. </i>9:9: 11,14, 1970. </li>
<li>VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, <i>Inter-Clinic Inform. Bull. </i>3:1:1-3, 1963. </li>
<li>Veterans Administration Prosthetics Center, Semiannual report, <i>Bull. Pros. Res. </i>10-3:135-136, Spring 1965. </li>
<li>---------, Semiannual report, <i>Bull. Pros. Res.</i> 10-4:157-159, Fall 1965. </li>
<li>Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, <i>Inter-Clinic Inform. Bull. </i>2:7:7-12, 1963. </li>
<li>Wallace, Maxine T., Group therapy for parents of congenital amputees, <i>Inter-Clinic Inform. Bull. </i>5:2:10-14, 1965. </li>
<li>Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, <i>Arch. Phys. Med. Rehabil. </i>43:293-296, June 1962. </li>
<li>Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, <i>Neurology </i>11:905-911, Oct. 1961. </li>
<li>Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, <i>Amer. J. Occup. Ther. </i>24:393-402, Sept. 1970. </li>
<li>Wilson, A. Bennett, Jr., Limb prosthetics— 1967, <i>Artif. Limbs </i>11:1:1-46, Spring 1965. </li>
<li>---------, Limb prosthetics —1970, <i>Artif. Limbs</i> 14:1:1-52, Spring 1970. </li>
<li>---------, The prosthetics and orthotics program, <i>Artif. Limbs </i>14:2:1-18, Autumn 1970. </li>
<li>For an Additional Bibliography, please refer to the PDF at the top of this page.</li>
</ol>
<br />
<div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Hamilton, Robert C, A vocational evaluation of juvenile amputees who have attained the age of twenty-one years: a preliminary report, Inter-Clinic Inform. Bull. 3:7:8-9, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Spring, John M., and Charles H. Epps, Jr., The juvenile amputee: some observations and considerations, Clin. Pediat. 7:76-79, Feb. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">---------, Learning techniques applied to prehension, Amer. J. Occup. Ther. 14:70-74, Mar.-Apr. 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Richardson, Geraldine, and Aida Lund, Upper extremity prosthetic training for the young amputee, Amer. J. Occup. Ther. 13:2:57-63, Mar.-Apr. 1959. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr><tr><td class="clsTextSmall"><b> 93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bates, Marion D., and Joseph C. Honet, Isometric exercises for the upper-extremity stump, Journal of the American Physical Therapy Association 44:1093-1094, Dec. 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Kyllonen, Ronald R., Body image and reaction to amputations, Conn. Med. 28:19-23, Jan. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Knapp, Miland E., Upper-extremity amputations: surgical considerations, Postgrad. Med. 45:2:237-240, Feb. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Martin, J. K., Congenital malformations associated with thalidomide and their management, Amer. Heart J. 67:284-285, Feb. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Jansen, Knud, Amputation: principles and methods, Bull. Pros. Res. 10-4:5-41, Fall 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Caine, Donald, and A. J. Reeder, The problem of the congenital amputee, Med. J. Aust. 50: 1:301-305, Mar. 2, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Management of severe bilateral upper limb deficiencies, Clin. Orthop. no. 37:53-60, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116 .</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b> 79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Frantz, Charles H., An evolution in the care of the child amputee, Artif. Limbs 10:1:1-4, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b> 119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Daniels, Lucille, Marian Williams, and Catherine Worthingham, Muscle Testing: Techniques of Manual Examination, 2nd ed., W. B. Saunders, Philadelphia, 1956. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Epps, Charles H., Jr., Upper extremity limb deficiency with concomitant infantile structural scoliosis, Inter-Clinic Inform. Bull. 5:2:1-9, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">McGraw, Myrtle B., Neuromuscular Maturation of the Human Infant, Columbia University Press, New York, 1943. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Stamp, Warren G., Sharon Mahon, and Harry C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med. Rehabil. 46:354-368, May 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Jentschura, G., B. Marquardt, and E. M. Ru-del, Inter-Clinic Inform. Bull. 4:9:11-14, 1965. (Reprinted from Behandlung und Vorsorgung bei Fehlbildungen und Amputationen der oberen Extremitdt, Georg Thieme Verlag, Stuttgart, 1963.) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">Kuhn, Gotz Gerd, Treatment of the child with severe limb deficiencies, Inter-Clinic Inform. Bull 10:3-S:l-26, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Amputations and substitutes for limbs, Brit. Med. J. 2:195-196, Apr. 22, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">---------, Malformations of the upper limb, Proc. Roy. Soc. Med. 62:1:55-56, Jan. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">---------, Dorrance model 2 hand field study, Inter-Clinic Inform. Bull. 6:8:11-13, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gazeley, William E., Mildred C. Ey, and William Sampson, Follow-up experiences with Muenster prostheses, Inter-Clinic Inform. Bull. 7:10:7-11, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Epps, Charles H., Jr., and John H. Hile, Experience with the Muenster-type below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 7:10:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hart-mann, and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs 9:2:4-25, Autumn 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Sammons, Independent-control harnessing in upper-extremity prosthetics, Artif. Limbs 7:1:11-16, Spring 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Clarke, Susan, Carole Kral, and Julie Shaperman, Built-in wrist flexion for children's prostheses, Inter-Clinic Inform. Bull. 9:5:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">McWilliam, R., and S. R. Montgomery, Artificial arms—are they practical?, Med. Biol. Illus. 19:4:200-201, 1969. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Mitchell, C. Leslie, Amputation and prosthesis: past research and future needs, Clin. Orthop. no. 37:110-112, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Carroll, Leila, Sizing and prehension forces of Dorrance voluntary opening devices, Inter-Clinic Inform. Bull. 2:9:7-10, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Contini, Renato, Engineering in medicine, Bull. Pros. Res. 10-8:4-19, Fall 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Veterans Administration Prosthetics Center research report, Bull. Pros. Res. 10-12:331-333, Fall 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Semiannual report, Bull. Pros. Res. 10-3:135-136, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 113.</b> </td><td class="clsTextSmall">---------, Semiannual report, Bull. Pros. Res. 10-4:157-159, Fall 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">---------, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-10:270, Fall 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ritter, Diane, and Fred Sammons, An interesting terminal device modification, Inter-Clinic Inform. Bull. 4:9:7-10,19, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>121.</b> </td><td class="clsTextSmall">---------, The prosthetics and orthotics program, Artif. Limbs 14:2:1-18, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The challenge of replacing human parts and functions, Bull. Pros. Res. 10-3:4-19, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Hile, John, Below-elbow harness without axillary loop, Inter-Clinic Inform. Bull. 6:5:7-8, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">O'Shea, Barbara, A chest strap harness for the below-elbow child amputee, Inter-Clinic Inform. Bull. 6:7:1-4, 18, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Kruger, Leon M., and Nicholas R. Breyan, A study of radial-head dislocation in children with transverse partial hemimelia of the upper limb, Inter-Clinic Inform.Bull.10:1:1-4, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in Selected Articles from Artificial Limbs, Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Finley, F. Ray, Roy W. Wirta, and Kevin A. Cody, Muscle synergies in motor performance, Arch. Phys. Med. Rehabil. 49:655-660, Nov. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>117.</b> </td><td class="clsTextSmall">Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, Neurology 11:905-911, Oct. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Simmel, Marianne L., The absence of phantoms for congenitally missing limbs, Amer. J. Psychol. 74:467-470, Sept. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Hebert, Bernard, the psychological implications of traumatic amputation in children, Inter-Clinic Inform. Bull. 7:4:7-10, 21, 1968. </td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">Taylor, Isabelle Wagner, Psychological needs of the handicapped child, Inter-Clinic Inform. Bull. 9:8:9-17, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">McCollough, Newton C., Interpersonal problems of the handicapped child, Inter-Clinic Inform. Bull. 4:11:1-4, 16, 1965. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Observations and findings concerning upper-extremity prosthesis wearers, Inter-Clinic Inform. Bull. 3:8:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Janelle, Claire, The role of the social service worker in the rehabilitation of the juvenile amputee, Inter-Clinic Inform. Bull. 7:4:20-21, 1968. </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Cohen, Pauline C, Impact of the handicapped child on the family, Social Casework 43:137-142, Mar. 1962. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputation, in Psychological Practices with the Physically Disabled, ed. James F. Garrett and Edna S. Levine, Columbia University Press, New York, 1962. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Sokolow, Jack, Management of the amputee in practice, Med. Clin. N. Amer. 53:3:659-664, May 1969. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Gehant, Barbara A., Patient Census at Child Amputee Clinics—1968, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Oct. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Munson, Nancy K., and Clyde M. E. Dolan, Patient Census at Child Amputee Clinics— 1967, Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Davies, Elizabeth J., Barbara R. Friz, and Frank W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull. 9:3:6-19, 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bergholtz, Susan G., Patient Census at Child Amputee Clinics—1969, Prosthetics and Orthotics, New York University Post-Gradu-ate Medical School, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, Clin. Orthop. no. 37:82-97, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Gingras, G., and C. Corriveau, Modern amputations and prosthetics, Appl. Ther. 9:537, June 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Burtch, Robert L., A study of congenital skeletal limb deficiencies, Inter-Clinic Inform. Bull. 2:7:1-6, 1963. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">---------, The classification of congenital skeletal limb deficiencies: a preliminary report, Inter-Clinic Inform. Bull. 3:1:4-9, 1963. </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Frantz, Charles H., and Ronan O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.) 43-A:8:1202-1224, Dec. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Barbara L. Sypniewski </b></td></tr><tr><td class="clsTextSmall">This article was prepared as part of an honors project at Russell Sage College - Albany Medical College SChool of Physical Therapy, Troy, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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<h2>Body Segment Parameters, Part II</h2>
<h5>Renato Contini <a style="text-decoration:none;">*</a><br /></h5>
<p>The performance of human (animal) activity requires the expenditure of energy. During the contraction of the muscles involved in this activity, chemical energy is converted first into mechanical energy, then into work and heat. Some of this chemical energy is required for maintenance of body functions. In movement, however, much of the mechanical energy is required to overcome friction and tissue displacement at the joints, gravity, inertial forces, air and water resistance—all of which oppose the action desired.</p>
<p>Biomechanics is the science that is concerned with such effects. In order to understand better the biomechanics of movement, it is necessary to know certain characteristics of the segments involved. Among these characteristics are the mass of the segments, their centers of mass, and their mass moments of inertia. The characteristics (body parameters) themselves are not readily obtained on living subjects.</p>
<p>It was the purpose of two studies conducted at the New York University School of Engineering and Science to obtain some of these body parameters. The first of these studies, <a></a> completed in 1966, was conducted on normal, healthy American males in the age range of 20-40 years. The second study, <a></a> completed in 1970, was conducted on a random selection of adults, young males and females 20-30 years of age, some females in the 40-50 age bracket, and a number of amputees and hemiplegics, male and female, in all age ranges.</p>
<p>A history, survey of measurement techniques, and data developed over the years was given in "Body Segment Parameters: A Survey of Measurement Techniques," which appeared in <i>Artificial Limbs, </i>Spring 1964. <a></a> Also, a condensation of four of the most important monographs in this field ("Center of Gravity of the Human Body" by W. Braune and O. Fischer; "Theoretical Fundamentals for a Mechanics of Living Bodies" by O. Fischer; "The Human Motor" by J. Amar; and "Space Requirements of the Seated Operator" by W. T. Dempster) has been prepared by Krogman and Johnston <a></a> under the sponsorship of the United States Air Force.</p>
<h3>Methods</h3>
<p>Most studies undertaken previously used cadavers, but in a few studies, including those at New York University, living subjects were used. Although some available measuring techniques for compiling the data are similar for live subjects and for cadavers, other techniques must obviously differ. In general, the techniques covered here are for living subjects; thus, all techniques used on dissected cadavers are not included. When living subjects are used, particularly the elderly and those suffering with some affliction or disability, any technique utilized must be at the convenience of the subject. Some subjects cannot comfortably assume the necessary postures during the measurement processes, while for some others the procedures are physically impossible. As a result, not all measurements can be taken on all subjects, but, because of the various techniques available, most of the desired data can be obtained.</p>
<p>The techniques are only briefly presented here because more adequate descriptions are available in other references.</p>
<h4>Volume Determination</h4>
<p>The body and all of its segments are irregular solids. The volume of an irregular solid may be obtained or approximated in a number of ways: by mensuration, immersion, or photogrammetry. Only the first two were used in both studies.</p>
<p><i>Mensuration</i></p>
<p>A relatively good approximation of body-segment volume can be obtained by using circumferential measurements at certain selected stations on the segment and the linear dimensions between any two consecutive circumferential measurements. If all these measurements are known for the full length of the segment, then an approximate volume can be determined. Accuracy will increase with the increased number of such measurements. This technique assumes that any two successive cross sections of the member are parallel and essentially similar geometrically. In that event, the volume contained within the two cross sections may be expressed as: <b>Equation 1</b></p>
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<p>It is obviously impossible to obtain cross-sectional areas on the body segments of living subjects. If it is assumed, however, that the cross sections of the limbs are elliptical, it is possible to establish a relationship between the cross-sectional area and the perimeter at any chosen level. For any segmental portion between two levels, the volume may now be expressed as: <b>Equation 2</b></p>
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<p>For a total limb divided into n segments, each <i>h </i>distance apart: <b>Equation 3</b></p>
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Equation 3.
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<p>The derivation of this equation is given in reference. <a></a></p>
<p><i>Immersion</i></p>
<p>In this method, the segment whose volume is to be determined is immersed in water. Incremental volumes are taken of the segment whose total volume then is the sum of these increments. For these studies, four tanks were specially designed: an arm tank, a hand tank, a leg tank, and a foot tank. Each tank was constructed of Plexiglas, the first three cylindrical in cross section, and the last, rectangular.</p>
<p>The limb or body segment was completely immersed in the tank. Water was permitted to drain off in controlled increments, each representing a known change in cylinder height. Drained water was collected and measured. The difference in volume between that collected and that obtainable without the body segment in place (the actual volume of the tank for that increment) represents the volume of the body segment contained within the height increment. Whenever possible, these increments were 2.0 cm apart, but, if subjects with limited physical tolerance had minimal cross-sectional variation, the increments were increased to every 4.0 cm apart.</p>
<p><i>Photogrammetry</i></p>
<p>Two types of photogrammetric techniques are available-mono and stereo. In the former, lines or colored shadows are projected on the subject in such fashion as to produce a contour map on the particular segment of interest. The areas contained within these contours may be measured with a planimeter, and the same general equation for determining the volume as given previously may be used. Again, the sum of all the incremental volumes of the segment represents its total volume.</p>
<p>In stereophotogrammetry, two cameras are used side by side to create an illusion of depth when the two photographs are juxtaposed. The resulting picture is treated as an aerial photograph of terrain upon which contour levels are applied. These then are treated as in monophoto-grammetry.</p>
<h4>Density Determination</h4>
<p>To obtain the overall body density of living subjects is extremely difficult. To obtain the density of individual segments on living subjects is virtually impossible. There are ways, however, to obtain fairly accurate values. The problems involved will not be discussed here; some of them are described in the two referenced reports. <a></a></p>
<p><i>Empirical (Whole Body)</i></p>
<p>Whole-body volume may be approximated in several ways. The mass may be obtained by weighing accurately. The density is the ratio of mass to volume. For lean bodies, the density is higher than for fat bodies. One provisional formula for determining density, developed by Dupertuis in 1950, <a></a> makes use of Sheldon's somatotyping system <a></a> and introduces the first component (x) of the system into the equation:<br /><i>d(ensity) =</i> 1.094 - 0.0119x</p>
<p>A second equation developed by the Biomechanics Group at NYU, using data developed by Behnke, <a></a> is based on the height <i>(H) </i>in inches, and weight <i>(W) </i>in pounds of the individual (<b>Fig. 1</b> and <b>Fig. 2</b>): <b>Equation 4</b></p>
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Fig. 1.
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<p><i>Anthropometric (Whole Body)</i></p>
<p>Many studies have established the reasonably close relationship between body fat and certain skin-fold thicknesses. <a></a> The equations used for the NYU study were those developed by Pascale. <a></a></p>
<p>The first depends on the measurement of the skin-fold thickness at the triceps:</p>
<p><i>d(ensity) </i>= 1.0923 - 0.0202(S<sub>t</sub>) x 10<sup>-1</sup></p>
<p>The second depends on the measurement of the skin-fold thickness at the scapula:</p>
<p><i>d</i> = 1.0896 - 0.0179(S<sub>s</sub>) x 10<sup>-1</sup></p>
<p><i>Mensuration (Whole Body)</i></p>
<p>Skerlj in 1954 <i>(13) </i>developed a method for determining whole-body volume. He measured 10 circumferential dimensions and 6 linear dimensions (<b>Fig. 3</b>). From these he developed a formula that gives an approximate value for whole-body volume.</p>
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Fig. 3. Linear measurements: measurements for body-volume determination (after Skerlj).
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<p>The NYU group presented <a></a> a modified equation using the Skerlj notation and included some correction factors derived by applying the equation to five subjects for whom the volume of the various body segments was known. The modified formula is: <b>Equation 5</b></p>
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<p>With the volume so determined, the mass may be obtained by direct weighing and the overall (whole body) density may be obtained: <i>d(ensity) = M(ass) /V(olume)</i></p>
<p><i>Empirical (Body Segments)</i></p>
<p>Until recently, very little work has been done to establish segment densities. Harless <a></a> conducted some studies with cadavers, as did Dempster. <a></a> At NYU, in the first of the two studies, the mass of certain body segments was established by the reaction-board method, which is described below.</p>
<p>Based on these studies, two graphs were developed that relate whole-body density to body-segment density (<b>Fig. 4</b> and <b>Fig. 5</b>). These are approximations only, since no exact data are available.</p>
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Fig. 4.
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</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 5.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<h4>Mass Determination</h4>
<p>In studies conducted with cadavers, weight and eventually mass are obtained directly by accurate weighing techniques applied to the total segment or to its increments. In studies with live subjects, this cannot be done. The reaction-board method may be used.</p>
<p><i>Reaction-Board Method</i></p>
<p>This method is dependent on the validity of two assumptions. The first is that the center of mass can be established if the center of volume is known. This is true only if the density of the segment is constant along its entire length. The studies conducted by the Aerospace Medical Research Laboratory showed that the density is not constant along the segment and the variation in density is not the same for all segments.</p>
<p>The second assumption is that the rotation of a segment occurs about a single axis. If this were so, in the movement of a segment the centers of mass of all other body segments would remain fixed relative to the center of rotation. Since no body joint is uniaxial, and since the muscle masses shift in the course of any movement, this also is not quite correct.</p>
<p>Nonetheless, the method has been used (<b>Fig. 6</b>). For the purpose, a board or platform is supported on two knife edges- one on a fixed base, the other on the platform of a weighing scale. The subject is. placed on the board in a position that can be maintained or reproduced if necessary. A reading is taken on the scale. The subject is then asked to flex the segment of interest (forearm, arm, etc.) through a given angle-usually 45 deg., 90 deg., or 135 deg. A new reading is taken. The mass of the segment can then be determined substituting the appropriate readings in the formula: <b>Equation 6</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 6. Determination of the arm mass (reaction-board method).
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Equation 6.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i>Empirical</i></p>
<p>For body segments the mass may be determined if the volume and density have been established. The mass, of course, is the product of the volume of the segment and the density of the segment. <i>M<sub>s</sub> = V<sub>s</sub>d<sub>s</sub></i></p>
<h4>Center-of-mass Determination</h4>
<p>The center of mass of the whole body may be determined readily by several methods since the mass is readily obtainable. The center of mass of a body segment on a live individual is not easily obtained, but may be approximated by one of several techniques.</p>
<p><i>Volumetric Approximation</i></p>
<p>A number of researchers, the NYU group included, have assumed that the density along the segment is constant and thus have concluded that the center of mass is coincident with the center of volume. Under this assumption, the center of volume, hence the center of mass, is found in the following way:</p>
<p>A base line is established, usually the proximal joint of the segment. This segment is divided into a number of increments for which the volume is obtained by one of several methods (<i>V1, V2, V3</i>,..., <i>Vn). </i>The distance to the center of volume is measured from the base line (<i>d1, d2, d3, . . ., dn</i>).</p>
<p>The center of volume is determined by dividing the sum of the products of each volume times its distance from the base line, by the sum of the volumes. <b>Equation 7</b>, <b>Equation 8</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Equation 7.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Equation 8.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i>Reaction-Board Method</i></p>
<p>With cadavers, segments, or with plaster models of body segments, the center of mass may be obtained by use of the reaction board, previously described.</p>
<p>Of these techniques, the one using the cadaver segment and the reaction board is the most accurate; the true center will vary in this technique only by the change that has occurred in the body tissues after death. Use of the plaster-of-paris cast creates the same error as that obtained by use of the volumetric technique; i.e., the error is introduced because it is assumed that the density along the segment is constant, whereas the density in any segment usually increases from the proximal to the distal end. This occurs because the ratio of bone to muscle and fat increases distally.</p>
<h4>Segment Mass Moment Of Inertia</h4>
<p>The motions of body segments are essentially rotatory, and linear movement is the result of a number of coordinated rotatory motions. The motion is assumed to occur about a fixed axis that is perpendicular to the plane in which the motion occurs. It is assumed that frictional and inertial forces occur in the plane of rotation. Rotation can be caused by a force at some distance from the axis of rotation, or by a force couple. In rotation, an inertial force resists angular acceleration which acts at the center of mass resulting in an inertial moment. This mass moment of inertia depends on the size, shape, and mass distribution of the body.</p>
<p>The mass moment of inertia may be determined in several ways.</p>
<p><i>Empirical</i></p>
<p>The mass moment of inertia of a body with respect to a given axis of rotation is the sum of the products of the mass increments <i>mi </i>(into which the total mass may be divided) by the square of their respective distances from the particular axis of rotation: <b>Equation 9</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Equation 9.
</p>
</td>
</tr>
</tbody></table>
</td>
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</tbody></table><br />
<p><i>Quick Release</i></p>
<p>If a force <i>(F) </i>is applied to a segment at some distance <i>(d) </i>from the axis of rotation of the segment, it will be imparted at an angular acceleration (a) in accordance with the equation: <i>Fd = Ia</i></p>
<p>Because of this relationship, it is possible to determine the mass moment of inertia (<i>I</i>) experimentally by this quick-release method.</p>
<p>In this method, the body segment of interest is arranged so that it may be free to swing about the proximal joint, which in turn is restrained from motion. At some distance (<i>d</i>) from the axis of rotation, a cable is attached to the segment such that it will prevent rotation in one direction. The other end of the cable is attached to a spring restraint, which in turn is attached to a force-measuring device. The subject is instructed to pull against the spring with a force <i>(F), </i>which is recorded. The cable is cut suddenly and the segment accelerates with an acceleration <i>(a) </i>that is appropriately recorded. By substitution of the known values <i>F, d, a, </i>the mass moment of inertia <i>(I) </i>can be obtained. <i>I</i> = Fd/<i>a</i></p>
<p><i>Pendulum</i></p>
<p>The period of a pendulum is related to the mass moment of inertia of the pendulum. For a simple pendulum, i.e., one where the mass is concentrated at some distance from the center of oscillation, the relationship is expressed by the equation: <b>Equation 10</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Equation 10.
</p>
</td>
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</tbody></table>
</td>
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</tbody></table><br />
<p>This method utilizes plaster casts of body segments or the severed cadaver segments. The segment or its counterpart is suspended at one point near the end of the segment. It is permitted to swing through an arc of limited magnitude. The period of oscillation is obtained by some appropriate instrumentation. The values that are obtained are substituted in the above equation.</p>
<h3>Results</h3>
<p>Results are given for tests conducted both in the first and second series of experiments. In the first series of tests, data were collected on 12 male subjects in the age range of 20-40 years. In the second series of tests, data were collected on 9 male subjects in the age range of 20-30 years, 5 female subjects ages 17-20 years, and 3 female subjects ages 40-50 years, all without disabilities. Data were also recorded on 19 additional subjects with either hemiplegia or an amputation. In the second series of tests, not all data were recorded for every subject. The following tables contain the most valid data acquired.</p>
<h4>VOLUMES</h4>
<p><b>Table 1</b> contains the volume of body segments recorded during the first series of tests. There is only one major difference between the two series on males. In the first series, the value for volume of the upper arm—and hence the value for the whole arm—included the shoulder cap, i.e., the volume from the axilla to the acromion process. In the second series (<b>Table 2</b>), the values of volumes for the upper and whole arm are only up to the axilla. On the basis of the mean values for the upper arm in the two series, the volume of the shoulder cap is approximately 36% of the whole upper arm.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 1.
</p>
</td>
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</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
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<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Table 2.
</p>
</td>
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</tbody></table>
</td>
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</tbody></table><br />
<p>In the second series of tests, a limited number of shoulder caps were cut off from the plaster-of-paris arms at the level of the axilla. Their dimensions, circumference at the axilla (c), and height to the acromion process <i>(h) </i>were taken. The volumes were obtained by immersion.</p>
<p>An approximate equation for determining the volume of the shoulder cap was then established: <i>Volume </i>(shoulder cap) = 0.0526 <i>hc</i><sup>2</sup></p>
<p>This equation is approximate to + 20% of the true value.</p>
<p>In all other respects, the two series of tests give comparable results. The differences in mean values are of the order of 1%-10%. Considering the limited numbers of subjects, 12 and 8 in the respective samples, the differences are not serious, and the mean values are useful in general computations. Of interest in the second series of tests is the close relationship between mean values for right-hand and left-hand volumes. The variation between means in most instances is less than the variation between the volume of right and left segments in any subject.</p>
<p><b>Table 3</b> indicates similar values for female subjects. There was greater inter-subject variation in this population than in that for the males. In view of this, and because there was such a limited number of subjects both in the younger and older age groups, the values for the two groups were combined. Even so, these mean values may be less accurate than those for the male population. They are presented, however, because few other similar data are available.</p>
<table>
<tbody><tr>
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<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Table 3.
</p>
</td>
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</td>
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</tbody></table><br />
<p>The body-segment volume may be expressed as a ratio or percentage of the whole-body volume. If it is desired to estimate body-segment volume, it is better to do so on the basis of the segment volume as a percentage of whole-body volume. This probably will give a more accurate result than using an average value for the volume of body segment.</p>
<p><b>Table 4</b> gives such values for the first series of males. <b>Table 5</b> gives similar values for the second series of males, and <b>Table 6</b> gives these values for females.</p>
<table>
<tbody><tr>
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<table>
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<p class="clsTextCaption"><br />
Table 4.
</p>
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</tbody></table><br /><table>
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<table>
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<p class="clsTextCaption"><br />
Table 5.
</p>
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</tbody></table><br /><table>
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<table>
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<p class="clsTextCaption"><br />
Table 6.
</p>
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</tbody></table>
</td>
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</tbody></table><br />
<h4>Densities</h4>
<p>As mentioned previously, it is very difficult to determine densities accurately. In <b>Table 7</b>, the densities have been determined by the equations shown in the section III-B for males first series. The densities for both males and females, second series, have been determined by dividing the mass (weight) by the volumes derived by using the NYU and Skerlj formulas and by using Pascale's equations A and B and skin-fold thicknesses.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Table 7.
</p>
</td>
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</td>
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</tbody></table><br />
<h4>Center Of Volume</h4>
<p>In the absence of satisfactory techniques for determining the center of mass, it has been assumed to be coincident with the center of volume. <b>Table 8</b> shows the location of mass centers (volume centers) obtained by various researchers. Some studies conducted on cadavers are probably more truly mass centers. Others, conducted on live subjects, are probably the centers of volume.</p>
<table>
<tbody><tr>
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<table>
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<p class="clsTextCaption"><br />
Table 8.
</p>
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<p><b>Table 9</b> has been prepared to provide information as to the location of the center of volume of the various body segments, measured from the proximal joint. Again, it should be noted that the values for the upper arm are measured from the axilla. In both <b>Table 8</b> and <b>Table 9</b>, the value indicated is in percent of the segment length.</p>
<table>
<tbody><tr>
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<table>
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<p class="clsTextCaption"><br />
Table 9.
</p>
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<p>A study was conducted on seven above-knee amputees. There was considerable variation in the length and contour of the stumps, although all of them could be described as modified truncated cones. The average distance from the crotch, measured downward and expressed as a percentage of the total stump length, was 32.1%, with an upper limit of 44.0% and a lower limit of 23.0%. The standard deviation was + 6.4%.</p>
<h4>Radius Of Gyration</h4>
<p>The radius of gyration (p) is a distance measured from the true center of mass to a point within the mass at which, if all the mass were concentrated, its effect in rotatory movements would be similar to the effect of the mass as it is actually distributed. For geometrically similar shapes, the radius of gyration along a particular axis may be expressed as a percentage of the length of that shape along that axis.</p>
<p>It has been assumed that every body segment-arm, leg, upper arm, forearm- for one subject is geometrically similar to that of any other subject. If it were so, then the radius of gyration expressed in percentage of the length <i>(p/L) </i>should be relatively constant. It was found to be so, with minor variations. The values of <i>p/L </i>for the various body segments obtained by previous researchers and in the first NYU study are given in <b>Table 10</b>. Values for the second NYU study are given in <b>Table 11</b>.</p>
<table>
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<table>
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<p class="clsTextCaption"><br />
Table 10.
</p>
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<table>
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<p class="clsTextCaption"><br />
Table 11.
</p>
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<p><b>Table 12</b> has been included as a guide against which the computed values of <i>p </i>may be compared. This table indicates the average values of <i>p </i>(the radius of gyration) for the populations included in the second series of NYU studies; not all values were determined for each category, and the table reflects this. The results were computed on the basis of tests and measurements were made as previously described.</p>
<table>
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<table>
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<p class="clsTextCaption"><br />
Table 12.
</p>
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<h3>Discussion</h3>
<p>The data may be used in a number of ways. Consideration must be given to the nature of the problem for which a solution is sought and the accuracy desired. If a situation exists where a prosthesis or orthosis is desired for a specified individual, it would be best to obtain data directly on the individual. In such a case, judgment should be made as to which of the various techniques available would be adapted best to the set of conditions present, i.e., the condition of the subject, the skills of available personnel, and the facilities available.</p>
<p>When extreme accuracy is not required, or in cases when the problem is confined to a class of individuals, or the solution may have a general application, the data may be used in various ways, with differing degrees of accuracy. In successively decreasing order of accuracy, the following maybe done:</p>
<ol>
<li>Obtain the weight and height of the subject and length and circumferences of the segments under consideration; use tables and graphs judiciously and, where several sets of data are available, use the most appropriate.</li><li>Obtain weight and height of the subject only and use tables as suggested.</li><li>Obtain weight and height of subject and use average data only. Data may be used for determining the length of a segment, its volume, mass, center of volume, center of mass, radius of gyration, and moment of inertia.</li></ol>
<h4>Sample Computation</h4>
<p>To determine the mass moment of inertia of the upper arm, forearm, and hand for a male patient (possibly for application of an externally powered orthosis), only the height and weight of the subject need be known.</p>
<p><i>Procedure</i></p>
<p>If the subject weights 190 pounds and is 73 inches in height:</p>
<ol>
<li>On graph (<b>Fig. 1</b>), join the weight in pounds (190) to the height in inches (73) by a straight line. At the intercept of this line with line c a value for c, approximately 12.8, is obtained.</li><li>On graph (<b>Fig. 2</b>), locate c = 12.8, proceed vertically upward to intersect solid black line, then proceed horizontally from this point to determine the value of whole-body density <i>d: d = </i>66.8 pounds per cubic foot</li><li>On graph (<b>Fig. 4</b>), proceed as in, <a></a> from <i>d = </i>66.8 vertically downward to intersect lines of segment densities:<br /><i>d, </i>upper arm = 68.1 lb/ft^3<br /><i>d, </i>forearm = 70.7 lb/ft<sup>3</sup><br /><i>d, </i>hand = 72.2 lb/ft<sup>3</sup></li><li>Given the weight of 190 pounds and whole-body density of 66.8 pounds per cubic foot, we may compute whole-body volume: 190/66.8 = 2.85 cubic feet</li><li><b>Table 4</b> gives values of volume for body segments in percentage of whole-body volume:<br />volume, upper arm = 3.495 x 0.01 x 2.85 = 0.0995 ft^3<br />volume, forearm = 1.70 x 0.01 x 2.85 = 0.0485 ft<sup>3</sup> volume, hand = 0.566 x 0.01 x 2.85 = 0.0161 ft<sup>3</sup></li><li>Multiplying the volumes of the segments by their respective densities, the mass (or weights) of the segments are obtained:<br /><i>m (w), </i>upper arm = 0.0995 x 68.1 = 6.78 lb<br /><i>m (w), </i>forearm = 0.0485 x 70.7 = 3.43<br />lb <i>m (w), </i>hand = 0.0161 x 72.2 = 1.16 lb</li><li>To obtain the approximate lengths of the body segments when they have not been measured, <b>Fig. 7</b> and <b>Fig. 8</b> may be used. The mean lengths expressed in terms of body height are 0.189<i>H</i>, 0.145<i>H</i> and 0.128<i>H</i> for the upper arm, forearm, and hand respectively. The lengths then are:<br /><i>Lv </i>= 0.189 x 73 = 13.8 in.<br />L<i>f </i>= 0.145 x 73 = 10.6 in.<br />L<i>h</i> = 0.128 x 73 = 9.35 in.</li><li>Having obtained the lengths of the segments, the location of the center of volume (mass) can be determined using values given in <b>Table 8</b> and <b>Table 9</b>: <br />c, upper arm = 0.461 x 13.8 = 6.37 in.<br />c, forearm and hand = 0.420 (10.6 + 9.35) = 8.38 in.</li><li>The radius of gyration (p) for the segments may be obtained using the values in <b>Table 10</b> or <b>Table 11</b>:<br /><i>p, </i>upper arm = 0.268 x 13.8 = 3.70 in.<br /><i>p, </i>forearm and hand - 0.263 x (10.6 + 9.35) = 5.25 in.</li><li>The moment of inertia about its proximal axis of rotation is expressed by the equation: Ij = m(p^2 + c^2)</li></ol>
<p><b>Fig. 7</b> and <b>Fig. 8</b></p>
<table>
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<table>
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<p class="clsTextCaption"><br />
Fig. 7.
</p>
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</tbody></table><br /><table>
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<table>
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<p class="clsTextCaption"><br />
Fig. 8.
</p>
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</tbody></table>
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</tbody></table><br />
<p>The moment of inertia of the upper arm about the shoulder: <b>Equation 11</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Equation 11.
</p>
</td>
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</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>The moment of inertia of the forearm about the elbow: <b>Equation 12</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Equation 12.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>If the moment of inertia of the forearm and hand about the shoulder joint is desired, then the equation is: <b>Equation 13</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Equation 13.
</p>
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<p><b>Fig. 9</b>, <b>Fig. 10</b>, <b>Fig. 11</b>, <b>Fig. 12</b>, and <b>Fig. 13</b> have been included to facilitate any computations, to ease conversion from metric to British systems of measurement, and for graphically determining the moments of inertia.</p>
<table>
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<table>
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<p class="clsTextCaption"><br />
Fig. 9.
</p>
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<table>
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<p class="clsTextCaption"><br />
Fig. 10.
</p>
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<p class="clsTextCaption"><br />
Fig. 11.
</p>
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<table>
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<p class="clsTextCaption"><br />
Fig. 12.
</p>
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<tbody><tr>
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<table>
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<p class="clsTextCaption"><br />
Fig. 13.
</p>
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<h3>Acknowledgment</h3>
<p>Appreciation is expressed to Dr. Rudolfs Drillis and Messrs. Darrell Hill, Howard Gage, Maurice Bluestein, Albert Yatkauskas, and George Vadell for their contributions to this research project, and to Mrs. Mary Klaus for the preparation of the reports.</p>
<p><b>References:</b></p>
<ol>
<li>Behnke, A. R., Jr., B. G. Feen, and W. C. Welham, The specific gravity of healthy men; body weight devided by volume as index of obesity, J.A.M.A. 118:495-498, Feb. 14, 1942.</li>
<li>Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</li>
<li>Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</li>
<li>Dempster, W. T., Space Requirements of the Seated Operator, U.S. Air Force WADC Tech. Rept. 55-159, Wright-Patterson Air Force Base, Ohio, July 1955.</li>
<li>Dempster, W. T, The anthropometry of body action, Ann. N.Y. Acad. Sci. 63:559-585, 1956.</li>
<li>Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</li>
<li>Drillis, Rudolfs, Renato Contini, and Maurice Bluestein, Body segment parameters-a survey of measurement techniques, Artif. Limbs 8:1: 44-66, Spring 1964.</li>
<li>Dupertuis, C. W., and J. M. Tanner, The pose of the subject for photogrammetric anthropometry, with especial reference to somatotyping, Amer. J. Phys. Anthrop. 8:1:27-47, March 1950.</li>
<li>Harless, E., The static moments of human limbs, Treatises of the Math.-Phys. Class of the Royal Academy of Science of Bavaria 8:69-96, 257-294, 1860.</li>
<li>Krogman, Wilton Marion, and Francis E. Johnston, Human Mechanics: Four Monographs Abridged, U.S. Air Force Systems Command Tech. Rept. AMRL-TDR-63-123, Univ. Pennsylvania Graduate School of Medicine, Philadelphia, December 1963.</li>
<li>Pascale, L. R., M. I. Grossman, H. S. Sloane, and T. Frankel, Correlations between thickness of skinfolds and body density in 88 soldiers, Hum. Biol. 28:165-176, May 1956.</li>
<li>Sheldon, W. H., C. W. Dupertuis, and C. McDermott, Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages, Harper, New York, 1954.</li>
<li>Skerlj, B., Volume, density and mass distribution of the human body by means of simple an-thropometrical means, Bulletin Scient., Conseil Acad. RPFV, hub. 2:11, 1954.</li>
</ol>
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<div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 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>4.</b> </td><td class="clsTextSmall">Dempster, W. T., Space Requirements of the Seated Operator, U.S. Air Force WADC Tech. Rept. 55-159, Wright-Patterson Air Force Base, Ohio, July 1955.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Dempster, W. T, The anthropometry of body action, Ann. N.Y. Acad. Sci. 63:559-585, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Harless, E., The static moments of human limbs, Treatises of the Math.-Phys. Class of the Royal Academy of Science of Bavaria 8:69-96, 257-294, 1860.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Pascale, L. R., M. I. Grossman, H. S. Sloane, and T. Frankel, Correlations between thickness of skinfolds and body density in 88 soldiers, Hum. Biol. 28:165-176, May 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 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">Behnke, A. R., Jr., B. G. Feen, and W. C. Welham, The specific gravity of healthy men; body weight devided by volume as index of obesity, J.A.M.A. 118:495-498, Feb. 14, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Sheldon, W. H., C. W. Dupertuis, and C. McDermott, Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages, Harper, 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>8.</b> </td><td class="clsTextSmall">Dupertuis, C. W., and J. M. Tanner, The pose of the subject for photogrammetric anthropometry, with especial reference to somatotyping, Amer. J. Phys. Anthrop. 8:1:27-47, March 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 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">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Krogman, Wilton Marion, and Francis E. Johnston, Human Mechanics: Four Monographs Abridged, U.S. Air Force Systems Command Tech. Rept. AMRL-TDR-63-123, Univ. Pennsylvania Graduate School of Medicine, Philadelphia, 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>7.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, Renato Contini, and Maurice Bluestein, Body segment parameters-a survey of measurement techniques, Artif. Limbs 8:1: 44-66, 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>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 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>Renato Contini </b></td></tr><tr><td class="clsTextSmall">Prosthetic-Orthotic Education Program, UCLA, Los Angeles, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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Body Segment Parameters, Part II
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Year
1971
Volume
1
Issue
2
Page Number(s)
25 - 35
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<h2>Ulnar Hemimelia</h2>
<h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br />Ronan O'Rahilly, M.D. <a style="text-decoration:none;">*</a><br /></h5>
<p>Isolated deficits of the long bones form a well-recognized group of anomalies. They may be described as <i>terminal, </i>in which there are no unaffected parts distal to and in line with the deficient portion (<b>Fig. 1</b>); or <i>intercalary, </i>in which a middle part is deficient while those portions proximal and distal to it are present. (<b>Fig. 2</b>)<a></a></p>
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Fig. 1. Terminal longitudinal paraxial hemimelia, ulnar. There is absence of one or more digits (the absent parts have been ghosted in).
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Fig. 2. Intercalary longitudinal paraxial hemimelia, ulnar. Note that all five fingers are present.
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<p>Ulnar hemimelia is a postaxial longitudinal deficiency of the upper limb, wherein the ulna is completely or partially absent. Clinically, because of the multiplicity of forearm and hand deformities or contours, it may be very difficult to recognize precisely the deficiency without roentgen studies (<b>Fig. 3</b> and <b>Fig. 4</b>). The elbow joint may be in extension or in acute flexion. There may be fusion of the radiohumeral joint. The range of motion, if present, may be markedly limited. The proximal part of the radius may articulate with the underdeveloped capitulum, or it may be completely luxated. If the deficiency is incomplete, the ulnar remnant may vary in length and contour. The digits of the hand may vary greatly in number (<b>Fig. 5</b> and <b>Fig. 6</b>). At the shoulder girdle, one may observe considerable muscular atrophy, ligamentous relaxation, and a deep web in the axilla.</p>
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Fig. 3. <i>Left, </i>the short left upper limb is phocomelic. Note the severe atrophy of the left shoulder girdle. There are three digits in the hand. The right arm (ulnar hemimelia) demonstrates good shoulder musculature and motion. <i>Center, </i>abduction and forward flexion are limited by the axillary web. <i>Right, </i>X-rays reveal fused right radiohumeral joint (failure of cavitation).
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Fig. 4. <i>Left, </i>bilateral ulnar hemimelia, with monodigital hands. <i>Right, </i>note the deep web at the cubital fossa (pterygium). <i>Center, </i>X-rays reveal the radiohumeral relationship. There is no true elbow joint.
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Fig. 5. <i>Left, </i>bilateral ulnar hemimelia. The left is intercalary, since there are five digits; the right is terminal because there are only four digits. Patient has complete anonychia with distinctive pulp prints on the dorsum of the fingers. <i>Right, </i>X-rays reveal complete dislocation of the radiohumeral joints.
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Fig. 6. <i>Left, </i>monodigital ulnar hemimelia, incomplete. <i>Right, </i>X-rays reveal proximal remnant of the ulna with a bowed radius.
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<p>In 1932, Kanavel<a></a> reported 60 cases of ulnar deficiencies. Comparison of Kanavel's findings with those of the cases presented here reveals the digit deficits as shown in <b>Table 1</b>.</p>
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<p>O'Rahilly<a></a> presented a resume of 65 cases in the literature up to 1950. This deficit is seen much less frequently than is radial hemimelia, the literature indicating a ratio of 18:1. O'Rahilly's analysis revealed that 67% of the cases were unilateral, and 69% involved the right upper limb. The incidence in males was more common, with a ratio of 2:1. Radiohumeral fusion and/ or digital syndactyly were not mentioned.</p>
<p>The absence of a radiohumeral joint (fusion) indicates the failure of cavitation of this structure. It is suggested that the lack of cavitation is an integral part of the total deficit seen in some cases of ulnar hemi-melia (38.5% of Frantz's patients).</p>
<p>During the past 15 years, the staff at the Area Child Amputee Center has examined and managed 26 children with ulnar hemi-melia. An analysis of these cases reveals a follow-up of from 1 to 15 years. There were 16 males and 10 females.</p>
<p>This deficit appears to be a sporadic lesion, in that there were 59 normal siblings of the 26 patients studied. One patient had a fraternal twin who had no skeletal deficits.</p>
<p>Ten of the patients (38.5%) had unilateral ulnar hemimelia with no other skeletal deficiencies. Three children (11.5%) had bilateral ulnar hemimelia; seven also had lower-limb deficits. Six patients with unilateral ulnar hemimelia had varying deficiencies in the contralateral upper limb. These included terminal transverse hemimelia, phocomelia, absent thumb, and absent fifth finger. Ten patients (38.5%) had radiohumeral fusion accompanying the ulnar hemimelia.</p>
<p>The involvement of carpals and metacarpals is complex. The triquetrum and capitate often are absent. There is an increasing frequency of metacarpal failure as one passes from the radial to the ulnar side of the hand.</p>
<p>The frequency of digital absence is shown in <b>Table 2</b>. It is of interest to note that the three-fingered hand is preponderant, followed closely in occurrence by the mono-digital hand.</p>
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<h3>Management</h3>
<p>In our experience, most of these children can be managed without surgical intervention. The goal, of course, is to improve function, with or without the use of a prosthesis. Whether surgery is indicated depends upon whether both arms are involved, and on the range of motion, the number of digits present, and the presence or absence of syndactyly (<b>Table 3</b>).</p>
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<h4>Nonsurgical</h4>
<p><i>No Fitting</i></p>
<p>Some of these children had radiohumeral synostosis (<b>Fig. 3</b> and <b>Fig. 7</b>).</p>
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Fig. 7. <i>Left, </i>ulnar hemimelia with three-digit hand (left). The right upper limb is phocomelic. <i>Right, </i>X-rays show radiohumeral fusion (failure of cavitation).
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<p><i>Opponens Post</i></p>
<p>Children with one digit (monodigital hand) possessing good flexion power and lateral stability of the metacarpophalangeal joint were fitted to advantage (<b>Fig. 8</b>).</p>
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Fig. 8. This boy was born with bilateral ulnar hemimelia with monodigital hands (see fig. 4). At 4 years of age the right upper limb was fitted with an opponens post. The left limb was managed by elbow disarticulation and prosthetic replacement. The elbow unit has 11 positions, allowing from 45degrees flexion to 180degrees extension.
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<p><i>Below-elbow Prosthesis</i></p>
<p>Modified below-elbow sockets were sometimes prescribed (<b>Fig. 9</b>). However, range of elbow motion is significantly lacking.</p>
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Fig. 9. <i>Left, </i>monodigital ulnar hemimelia, with extension limited to 70degrees. Web release in the cubital fossa offered little additional motion. Initially the child was fitted with a below-elbow type of prosthesis <i>(center). </i>After a 2-year trial, the family expressed dissatisfaction with the limited motion and function of the arm. At 4 years of age an elbow disarticulation was performed and prosthetically fitted <i>(right).</i>
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<p><i>Above-elbow Prosthesis</i></p>
<p>This is a highly satisfactory method of fitting patients with unilateral, monodigital, ulnar hemimelia. The forearm segment is acutely flexed against and parallel to the humeral shaft and then encased within the humeral socket. The elbow-locking mechanism has a lever with which the single digit controls the elbow lock and unlock mechanism (<b>Fig. 10</b>).</p>
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<p class="clsTextCaption"><br />
Fig. 10. <i>Left, </i>ulnar hemimelia with a monodigital hand. Note the acute flexion and the deep cubital web. <i>Center, </i>the radiohumeral angle is 20degrees. <i>Right, </i>the monodigital segment is encased in a fenestrated humeral socket in an elbow-disarticulation type of prosthesis. The digit operates the elbow lock.
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<h4>Surgical</h4>
<p><i>Elbow Z-plasty</i></p>
<p>Z-plasty in the cubital fossa was performed in two instances in an endeavor to decrease the cubital web and in the hope of allowing a greater range of elbow flexion and extension. This procedure is somewhat advantageous in that it allows a better fit of the forearm socket, but it fails to offer any significant increased range of motion and therefore is not recommended (see <b>Fig. 9</b>).</p>
<p><i>Elbow Disarticulation</i></p>
<p>This surgical procedure is followed by fitting the limb with an elbow-disarticula-tion type of prosthesis. The surgeon should be meticulous in his technique so as not to disturb the distal humeral epiphysis during the disarticulation procedure.</p>
<p>The application of the elbow-disarticulation type of prosthesis with an outside locking elbow offers 11 different positions of the elbow joint.</p>
<p><i>Humeral Derotation Osteotomy</i></p>
<p>Two children received a humeral derotation osteotomy of at least 90 degrees (<b>Fig. 11</b>). One was lost to follow-up after early union.</p>
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<p class="clsTextCaption"><br />
Fig. 11. <i>Left, </i>ulnar hemimelia, left; there is radiohumeral fusion (failure of cavitation) with 90degrees rotation. <i>Center, </i>derotation osteotomy of the humerus at 4 years of age. <i>Right, </i>arm position following derotation osteotomy. Note the three-fingered hand; the parents refused to have a syndactyly-release performed.
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<h3>Discussion</h3>
<p>From this brief outline of management, it is obvious that the treatment of these children is highly individualized. The timing and procedure may be dictated by the age of the patient, the question of bilateral-ity, and the scope of the handicap. The decision as to whether or not to prescribe a prosthesis may be a difficult one. The approach to handling these children with ulnar hemimelia has been developed over the years by trial and error and by functional analysis.</p>
<p>In <b>Fig. 3</b>, severe as the deformities may appear to be, the right shoulder functions normally, and the boy is able to abduct and forward-flex the shoulder, which allows him to prehend with his right hand. The left upper limb is phocomelic; however, he has a functional "pinch force" with the digits for close-in functioning. In the occupational therapy department, he demonstrated a very acceptable level of accomplishment in the activities of daily living and therefore was not fitted with prostheses.</p>
<p>This logic is in accord with the problem faced by the boy shown in <b>Fig. 7</b>. The ef-ficency of this four-year-old's performance in dressing, undressing, and toilet care is such that he needs no prosthetic aids. Utilizing the ulnar hemimelic limb, this boy is able to feed himself and care for most of his daily living demands.</p>
<p>Bilateral ulnar hemimelia with monodi-gital hands is a severe handicap (see <b>Fig. 4</b>). One male in this group had the Cornelia de Lange syndrome. If a child is seen at an early age (i.e., before two years), one may be tempted to procrastinate. How long? The major question is whether one should fit one or both sides with a passive type of prosthesis (terminal devices with no cables, but with small rubber bands on the hooks) or whether to interfere surgically.</p>
<p>It has been stated that a Z-plasty at the cubital fossa offers little improvement of the radiohumeral arc of motion.</p>
<p>One approach may be to fit one side with an opponens post and the opposite side with a modified below-elbow prosthesis. Should the prosthetic side prove to be inadequate with a below-elbow type of prosthesis, one may then elect to perform an elbow disarticulation one year before kindergarten, allowing a year of prosthetic wearing before formal schooling. This was done in the patient shown in <b>Fig. 8</b>. At this writing, the boy is 14 years old. He is in junior high school and is the manager of the football team. Also, he is a fair bowler, for which he utilizes a special attachment to his prosthesis.</p>
<p>Unilateral, monodigital, ulnar hemimelia with a normal contralateral upper limb is not as serious a handicap. The patient shown in <b>Fig. 9</b> was fitted at two years of age with a modified standard below-elbow pros- thesis. At the age of four years, the patient and her mother were dissatisfied with the function afforded, because of limited elbow motion. (The Z-plasty at the cubital fossa offered little additional motion.) The child received an elbow disarticulation and was subsequently fitted with a standard elbow-disarticulation prosthesis with a medially placed outside-locking elbow. At the time of writing, she is 18 years of age, ready to enter college, and is considered a very good prosthesis-wearer.</p>
<p>The patient in <b>Fig. 10</b> was seen in 1964 at 15 years of age; she has a monodigital, left-sided, ulnar hemimelia. Her degree of radiohumeral flexion was more severe than that of the girl in <b>Fig. 9</b>. This patient was not particularly concerned with the cosmetic effect (and still is not). She was fitted with a prosthesis that encased the acutely flexed forearm within the humeral socket. The anterior, or ventral, wall of the socket was then fenestrated and a lever was attached to the elbow-locking cable, which permitted her to use the single digit to operate the elbow locking/unlocking mechanism. At this writing, she is in her second year in college and now wears a mechanical hand with a cosmetic glove. The upper arm is usually covered by a fluffy-sleeved blouse.</p>
<p>To summarize, there are four approaches to treatment of the monodigital hand: op-ponens post; below-elbow prosthetic fitting; elbow-disarticulation prosthetic fitting, encasing the forearm in the humeral socket; or no fitting, which is the least recommended procedure.</p>
<p>Rotational deformities occasionally are seen in which there may be up to 180 degrees of medial rotation of the forearm on the humerus. The hand rests at the side of the thorax, pointing dorsally. One patient was seen at eight months of age (see <b>Fig. 11</b>). There were three digits in the left hand with soft-tissue syndactyly. She received a derotation osteotomy of the humerus at the age of four years, and a fair result was ob- tained. Unfortunately, she was lost to clinic follow-up shortly after surgery.</p>
<p>Dislocation of the radiohumeral joint is rare. One such patient was first seen at four years of age. He has five digits on the left hand and four on the right. There were no fingernails. It is of interest to note that this boy has distinctive prints on both the palmar and dorsal surfaces of his fingers. His radiohumeral joint anatomically is nonexistent (see <b>Fig. 5</b>). The intrinsic muscles of the hands are weakened, and the wrists are unstable. The forearms and hands have been encased in a half-sleeve of plastic attached to crutches (he also has bilateral amelia of the legs). He is now 18 years old and attends a trade school.</p>
<p>Incomplete ulnar hemimelia occurred twice in this series. The proximal portion of the ulna is present, thus affording a normal-appearing elbow joint with an excellent range of motion (see <b>Fig. 6</b>). That child was seen at four years of age and fitted with a standard below-elbow prosthesis, which she is currently wearing.</p>
<p>Syndactyly was encountered four times in 26 cases. Two cases have been corrected surgically.-<i>Charles H. Frantz, M.D.</i></p>
<h3>Pathogenesis</h3>
<p>The term "hemimelia" was introduced in 1836-37 by Isidore Geoffroy Saint-Hilaire <i>, </i><a></a> who also introduced the term "teratology". In 1877, Verneuil proposed subdivision (of "ectromelia") into longitudinal and transverse varieties <i>. </i><a></a> In addition to absence of the distal half (two of the four segments) of a limb, it became clear that, in some cases, only one side of the distal half was affected, and such instances were named (after the defective portion) "radial," "ulnar," "tibial," and "fibular" hemimelia. By 1903, a further distinction, that between terminal and intercalary varieties of hemimelia, had been made<a></a>. Finally, in 1951, O'Rahilly suggested the term "paraxial hemimelia" for the longitudinal variety, because either the preaxial or postaxial side of the limb is involved in such cases.</p>
<p>It is not proposed to discuss here either the terminological basis<a></a> or the terato- genesis<a></a> of limb malformations in general, as these aspects have been considered recently elsewhere.</p>
<p>Ulnar hemimelia was first reported in 1683 by Goller<a></a> and hence is probably the first of the paraxial hemimelias to be identified as such, there being some doubt about the true identity of the case of hemimelia described by Pare in 1573 <i>.</i><a></a> Although chronological tables of all the early cases of radial, tibial, and fibular hemimelia are available in the literature, no such list other than the bibliography provided by Rabaud and Hovelacque<a></a> seems to have been prepared for ulnar hemimelia.</p>
<p>Among the hemimelias involving one of the four bones of the third limb segment, or "zygopodium" (forearm and leg), the ulnar type occurs the least. It differs from the others also in that a partial deficiency is more commonly found than complete absence. However, it resembles radial, tibial, and fibular hemimelia in that it is more frequently unilateral, more commonly seen on the right side, and more often observed in the male <i>. </i><a></a> Of particular interest are those cases in which thorough dissection has been possible <i>.</i><a></a> Several additional cases of ulnar hemimelia have been reported in the literature during the past two decades. The higher incidence of unilaterality and of right-sided involvement has been confirmed.<a></a> It is important to appreciate that the hemimelias may occur as isolated anomalies, or they may, as shown in this paper, be associated with other malformations. Ulnar hemimelia, for example, is sometimes a component of a sporadic syndrome that includes femoral and fibular defects.<a></a> The cause of the "FFU" (femur, fibula, ulna) syndrome is unknown; such factors as parental age and thalidomide have been ruled out, and familial occurrence has not been observed.</p>
<p>A striking example of familial occurrence in several generations was recounted to Roberts<a></a> by a patient with ulnar hemimelia. Partial ulnar hemimelia of the intercalary type, together with hypoplasia of the thumbs and fibular hemimelia, has more recently been described and illustrated in two brothers <i>. </i><a></a> A different condition, ulnofibular dysplasia, characterized by shortening of the ulna and fibula, was found to be inherited as an autosomal dominant <i>.</i><a></a> Ulnar hemimelia accompanied by Polydactyly is not unknown <i>, </i><a></a> and the coexistence of Polydactyly and a long-bone deficiency in the same limb has been noted previously (e.g., heptadactyly and tibial hemimelia) <i>. </i><a></a> In such cases, it has been suggested that this seeming paradox of excess associated with deficiency may perhaps result from an excessive outgrowth, which occurs relatively late in the early embryonic period, "involved only the digital area, and attracts some of the tissue immediately proximal to the area of excess outgrowth" <i>. </i><a></a> In the human, the hand appears in mesenchyme at about 41 postovulatory days (stage 17), so that it may be expected that Polydactyly would be observable by about six weeks after fertilization. Indeed, an example of this as an isolated anomaly has been described <i>.</i><a></a> What are generally termed "fusions" of skeletal elements-that is, the occurrence as a single structure of something that is usually composed of two or more elements-may be found either as an isolated anomaly or in association with other disturbances. Carpal and tarsal fusions, for example, are not infrequent in the paraxial hemimelias, and, as emphasized in this paper, ulnar hemimelia may include humeroradial fusion. Normally, of course, certain bony fusions, such as those between the epiphyses and their diaphyses and between the neural arches and their centra, are of constant occurrence. Even in areas where synovial cavities might be expected, however, fusions are not infrequent, such as symphalangia between the middle and distal phalanges of the little toe. The histological development of phalangeal fusion has been studied in detail<a></a>, and it is of interest to note that carpal and tarsal fusions have been observed in both the embryonic and the fetal period.<a></a> That such fusions arise early during embryonic development as an absence of joint cavitation<a></a> is also suggested by studies of experimentally paralyzed chick embryos, in which articular cavities do not form.<a></a> The cartilaginous skeletal elements, which are at first united by mesenchyme, become, under these conditions, joined together by fibrous tissue or by cartilage. In other words, fusion takes place across the presumptive joint regions.</p>
<p>That hemimelia occurs at a very early stage of embryonic life is indicated by the important, but neglected, observations of Hovelacque and Noel<a></a> on a strain of mice presenting tibial hemimelia. It was found that "the first manifestations of the anomaly are disclosed at a very early stage of development. They can be detected in embryos when the undifferentiated blastema begins to undergo change." In the tibial zone of the blastema, a "fibrous tract" appeared, and was connected to the fibula by the interosseous membrane. In some of these embryos, cartilaginous nodules developed in the area (especially proximally) where the tibia would normally form. Such nodules were in direct continuity with the fibrous tract; both constituted a unit that represented the tibia. The vascularization of the limbs was entirely normal. It was concluded<a></a> that "the tibia is never completely absent despite appearances; one can always find a trace of the element although it may be represented by only a nodule of pinhead size." There is no reason to believe that the above statements would not apply equally to the other types of paraxial hemimelia.</p>
<p>To return to the human-the mesenchymal femur, tibia, and fibula appear at about 41 postovulatory days (stage 17), and the humerus, radius, and ulna appear at about 37 postovulatory days (stage 16). In other words, it may be expected that, in the light of the French workers' observations, paraxial hemimelia could be detected in the human before six weeks after fertilization.</p>
<p>Prior to the first appearance of these specific skeletal elements, a sensitive period for teratogenic agents exists, as have been shown by correlations between the time of ingestion of thalidomide during pregnancy and the types of resultant anomalies.<a></a> Thus, tibial defects occurred mostly when ingestion began before the 46th menstrual day (perhaps about 32 post-ovulatory days). In one illustrated case, ingestion that commenced at 46 menstrual days resulted in bilateral radial hemimelia and malformations of the femur and tibia.</p>
<p>Finally, it may be mentioned that ulnar hemimelia has been found sporadically in various animals, such as the pig.<a></a> It also has been produced experimentally by the inclusion of large doses of acetazol-amide (a carbonic anhydrase inhibitor) in the diet of rats during pregnancy <i>. </i><a></a> Of particular interest in these experiments is the circumstance that the ulnar hemimelia was practically restricted to the right side of the body.-<i>Ronan O'Rahilly, M.D.</i></p>
<h3>Summary</h3>
<p>The management of 26 cases of ulnar hemimelia has been discussed. This deficit is seen 18:1 less frequently than radial hemimelia. Bilaterality was present in 23% of the cases. Prior to determining the plan of treatment, a complete functional analysis should be carried out. Most of these children do not need surgery and may be treated by prosthetic fitting only. The pathogenesis of paraxial hemimelia and the embryogenesis of associated conditions, such as Polydactyly and joint fusions, are discussed.</p>
<p><b>References:</b></p>
<ol>
<li>Drachman, D. B., and Sokoloff, The role of movement in embryonic joint development, <i>Develop. Biol. </i>14:401-420, 1966.</li>
<li>Duken, J., Uber der Beziehungen zwischen As-similationshypophalangie und Aplasie der Inter-phalangealgelenke, <i>Virchows Arch. Path. Anat. Physiol. </i>233:204-225, 1921.</li>
<li>Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, <i>J. Bone Joint Surg. </i>43-A: 1202-1224, 1961.</li>
<li>Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, <i>J. Bone Joint Surg. </i>41-A: 847-876, 1959.</li>
<li>Hovelacque, A., and R. Noel, Processus embryo-logique de l'absence congenitale du tibia, C. <i>R. Soc. Biol. Paris </i>88:577-578, 1923.</li>
<li>Kanavel, A. B., Congenital malformations of the hands, <i>Arch. Surg. </i>25:1-53, 282-320, 1932.</li>
<li>Klippel, M., and E. Rabaud, Sur une forme rare d'hemimelie radiale intercalaire, <i>Nouu. Ponograph. Salpetriere </i>16:238-251, 1903.</li>
<li>Ku'hne, D., W. Lenz, D. Petersen, and H. Schoneberg, Defekt von Femur und Fibula mit Amelie, Peromelie oder ulnaren Strahldefekten der Arme, Ein Syndrom, <i>Humangenetik </i>3: 244-263, 1967.</li>
<li>Laurin, C. A., and A. W. Farmer, Congenital absence of ulna, <i>Canad. J. Surg. </i>2:204-207, 1959.</li>
<li>Layton, W. M., and D. W. Hallesy, Deformity of forelimb in rats: association with high doses of acetazolamide, <i>Science </i>149:306-308, 1965.</li>
<li>Lenz, W., Zur Genese der angeborenen Hand-fehlbildungen, <i>Chir. Plast. Reconstr. </i>5:3-15, 1968.</li>
<li>Lenz, W., Der Zeitplan der menschlichen Organogenese als Massstab fur die Beurteilung teratogener Wirkungen, <i>Fortschr. Med. </i>87: 520-526, 1969.</li>
<li>Malgaigne, J. F., <i>Oeuvres Completes d'Ambroise Pare, </i>vol. 3, Paris, Bailliere, 1841.</li>
<li>Meckel, J. F., <i>Handbuch der pathologischen Ana-tomie, </i>Leipzig, Reclam, 1812.</li>
<li>Murray, P. D. F., and D. B. Drachman, The role of movement in the development of joints and related structures: the head and neck in the chick embryo, <i>J. Embryol. Exp. Morph. </i>22:349-371, 1969.</li>
<li>Nishimura, H., <i>Chemistry and Prevention of Congenital Anomalies, </i>Springfield, HI., Charles C Thomas, 1964.</li>
<li>O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, <i>Amer. J. Anat. </i>89: 135-193, 1951.</li>
<li>O'Rahilly, R., The development and the developmental disturbances of the limbs, <i>Irish J. Med. Sci. </i>pp. 30-33, January 1959.</li>
<li>O'Rahilly, R., The nomenclature and classification of limb anomalies, <i>Birth Defects: Original Article Series </i>5:14-17, 1969.</li>
<li>Pfeiffer, R. A., and K. Reinhardt, Ulno-fibulare Dysplasie, Eine autosomaldominant vererbte Mikromesomelie ahnlich dem Nievergeltsyndrom, <i>Fortschr. Roentgenstr. </i>107:379-391, 1967.</li>
<li>Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, <i>Bull. Biol. France Belg. </i>57:401-468, 1923.</li>
<li>Roberts, A. S., A case of deformity of the fore-arm and hands, with an unusual history of hereditary congenital deficiency, <i>Ann. Surg. </i>3:135-139, 1886.</li>
<li>Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, <i>Z. Orthop. Chir. </i>23:1-157, 1909.</li>
<li>Stroer, W. F. H., Die Extremitatenmissbildungen und ihre Beziehungen zum Bauplan der Extremitat, <i>Z. Anat. Entwicklungsgesch </i>108:136-160, 1938.</li>
<li>Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, <i>Nunt. Radiol. </i>26: 1040-1054, 1960.</li>
<li>Zwilling, E., and J. F. Ames, Polydactyly, related defects and axial shifts, a critique, <i>Amer. Naturalist </i>92:257-266, 1958.</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>10.</b> </td><td class="clsTextSmall">Layton, W. M., and D. W. Hallesy, Deformity of forelimb in rats: association with high doses of acetazolamide, Science 149:306-308, 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>23.</b> </td><td class="clsTextSmall">Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, Z. Orthop. Chir. 23:1-157, 1909.</td></tr><tr><td class="clsTextSmall"><b> 24.</b> </td><td class="clsTextSmall">Stroer, W. F. H., Die Extremitatenmissbildungen und ihre Beziehungen zum Bauplan der Extremitat, Z. Anat. Entwicklungsgesch 108:136-160, 1938.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Lenz, W., Der Zeitplan der menschlichen Organogenese als Massstab fur die Beurteilung teratogener Wirkungen, Fortschr. Med. 87: 520-526, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hovelacque, A., and R. Noel, Processus embryo-logique de l'absence congenitale du tibia, C. R. Soc. Biol. Paris 88:577-578, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Drachman, D. B., and Sokoloff, The role of movement in embryonic joint development, Develop. Biol. 14:401-420, 1966.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murray, P. D. F., and D. B. Drachman, The role of movement in the development of joints and related structures: the head and neck in the chick embryo, J. Embryol. Exp. Morph. 22:349-371, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 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>4.</b> </td><td class="clsTextSmall">Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, J. Bone Joint Surg. 41-A: 847-876, 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>2.</b> </td><td class="clsTextSmall">Duken, J., Uber der Beziehungen zwischen As-similationshypophalangie und Aplasie der Inter-phalangealgelenke, Virchows Arch. Path. Anat. Physiol. 233:204-225, 1921.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, J. Bone Joint Surg. 41-A: 847-876, 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>16.</b> </td><td class="clsTextSmall">Nishimura, H., Chemistry and Prevention of Congenital Anomalies, Springfield, HI., Charles C Thomas, 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>26.</b> </td><td class="clsTextSmall">Zwilling, E., and J. F. Ames, Polydactyly, related defects and axial shifts, a critique, Amer. Naturalist 92:257-266, 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">O'Rahilly, R., The development and the developmental disturbances of the limbs, Irish J. Med. Sci. pp. 30-33, January 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>25.</b> </td><td class="clsTextSmall">Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, Nunt. Radiol. 26: 1040-1054, 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>20.</b> </td><td class="clsTextSmall">Pfeiffer, R. A., and K. Reinhardt, Ulno-fibulare Dysplasie, Eine autosomaldominant vererbte Mikromesomelie ahnlich dem Nievergeltsyndrom, Fortschr. Roentgenstr. 107:379-391, 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">Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, Nunt. Radiol. 26: 1040-1054, 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>22.</b> </td><td class="clsTextSmall">Roberts, A. S., A case of deformity of the fore-arm and hands, with an unusual history of hereditary congenital deficiency, Ann. Surg. 3:135-139, 1886.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Ku'hne, D., W. Lenz, D. Petersen, and H. Schoneberg, Defekt von Femur und Fibula mit Amelie, Peromelie oder ulnaren Strahldefekten der Arme, Ein Syndrom, Humangenetik 3: 244-263, 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>9.</b> </td><td class="clsTextSmall">Laurin, C. A., and A. W. Farmer, Congenital absence of ulna, Canad. J. Surg. 2:204-207, 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>23.</b> </td><td class="clsTextSmall">Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, Z. Orthop. Chir. 23:1-157, 1909.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 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>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Malgaigne, J. F., Oeuvres Completes d'Ambroise Pare, vol. 3, Paris, Bailliere, 1841.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Meckel, J. F., Handbuch der pathologischen Ana-tomie, Leipzig, Reclam, 1812.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Lenz, W., Zur Genese der angeborenen Hand-fehlbildungen, Chir. Plast. Reconstr. 5:3-15, 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>19.</b> </td><td class="clsTextSmall">O'Rahilly, R., The nomenclature and classification of limb anomalies, Birth Defects: Original Article Series 5:14-17, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Klippel, M., and E. Rabaud, Sur une forme rare d'hemimelie radiale intercalaire, Nouu. Ponograph. Salpetriere 16:238-251, 1903.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">O'Rahilly, R., The nomenclature and classification of limb anomalies, Birth Defects: Original Article Series 5:14-17, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 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>6.</b> </td><td class="clsTextSmall">Kanavel, A. B., Congenital malformations of the hands, Arch. Surg. 25:1-53, 282-320, 1932.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. 43-A: 1202-1224, 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>Ronan O'Rahilly, M.D. </b></td></tr><tr><td class="clsTextSmall">Director of the Carnegie Collection, Dept. of Embryology, Carnegie Institution of Washington, Baltimore, Md. 21210; Professor of Anatomy, Wayne State Univ. School of Medicine, Detroit, Mich.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Codirector, Area Child Amputee Program (Mich. Dept. of Public Health), 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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Title
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Ulnar Hemimelia
Creator
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Charles H. Frantz, M.D. *
Ronan O'Rahilly, M.D. *
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DRFOP - Legacy
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Year
1971
Volume
1
Issue
2
Page Number(s)
16 - 24
Text
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<h2>Evaluation of the CAPP Cart</h2>
<h5>Barbara A. Gehant <br /></h5>
<p>Recent studies of juvenile amputees in the United States and Canada have revealed a sizable number of severely handicapped limb-deficient children. Fortunately, many of these amputees have been fitted with prostheses that enable them to perform skills necessary for daily activities. The quadrimembral amputee, however, presents particularly serious problems. While he may achieve considerable arm function with one or two upper-limb devices, the leg loss may not be adequately compensated for, especially in high-level amputees, and locomotion remains at best an exercise. In an effort to solve the problem of mobility for the most severely handicapped children, the Child Amputee Prosthetics Project at UCLA developed an electric cart. This article presents a study that was designed to determine the extent to which the CAPP cart assists children with quadrimembral deficiencies to achieve independent mobility.</p>
<p>The CAPP cart (<b>Fig. 1</b>) is 17 in. wide and 23 in. long, and consists of a seat mounted on a chassis. In the driving position, the seat is 18 in. from the floor. The seat can be raised to 27 in. to enable the child to sit at a table or to transfer to a standard chair or bed. The cart, powered by a 12-volt battery, travels at a constant speed of 1 1/2 mph. It is guided by a lever that is controlled by the chin, and which operates on a "joy-stick" principle. The control arm can be swung to the side to facilitate transfer or activities at a table or desk.</p>
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Fig. 1. The CAPP cart. Power is provided by a 12-v battery; direction is controlled by the chin-operated lever.
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<h3>Sample</h3>
<p>Since the cart was designed for the child with quadrimembral deficiencies, priority consideration was given to such candidates. The children were selected on the basis of the number of limb deficiencies and the degree of limitation. Eleven children from ten clinics participated in the study (<b>Table 1</b>). A twelfth child was provided with a cart (see Appendix) but not included in the sample, because this clinic already had two subjects represented in the study; additional data from the same reporters might have biased the study.</p>
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<p>The sample included four boys and seven girls, six to fourteen years of age. Their weights ranged from 20 to 74 lb; the average weight was 30 lb. Trunk measurements were taken of each child from the bottom of the buttocks to the crown of the head. Sitting height averaged 25 in. and ranged from 20 to 32 in.</p>
<p><b>Table 2</b> shows the skeletal deficiencies and prosthetic fittings for the eleven children. Of the five children with bilateral proximal femoral focal deficiencies (PFFD), two had not been fitted with lower-limb prostheses. One child ambulated with a lateral-sway walker, one wore below-knee orthoses bilaterally, and one wore a "brace-prosthesis" on the left and a socket, pylon, and SACH-foot prosthesis on the right.</p>
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<p>Four children had bilateral amelias. One wore hip-disarticulation prostheses with the knees locked, two used lateral-sway walkers, and the fourth child had not been fitted with any prostheses.</p>
<p>One child had a very short below-knee stump on the right, and a knee disarticulation on the left; the last child had a fusion of the right knee and a left knee contracture. Neither had been fitted with prostheses.</p>
<p>Again referring to <b>Table 2</b>, two children had bilateral upper-limb phocomelia, and neither had ever been fitted with arm prostheses.</p>
<p>Of the two children with bilateral amelia, one wore two conventional shoulder-disarticulation prostheses, and the other had been fitted unilaterally, alternating between an experimental Michigan feeder arm and a conventional shoulder-disarticulation prosthesis.</p>
<p>Of the four children with bilateral hemi-melia, three wore conventional above-elbow prostheses, and the fourth was fitted bilaterally with elbow-disarticulation prostheses.</p>
<p>Three children had a combination of right amelia and left hemimelia. One wore a Michigan feeder arm on the left only, another wore a conventional shoulder- disarticulation prosthesis on the amelic side and an above-elbow prosthesis contralaterally, and the third had not been fitted with any prostheses.</p>
<p>Three of the children were scoliotic, and three had skeletal problems involving the mouth. One child had bilateral hip dislocations; another had sacral agenesis, with associated loss of muscular mass in the lower extremities and bowel and bladder incontinence. Other abnormalities included hearing and visual deficiencies, and one child had an unspecified neuromuscular disorder manifested by generalized weakness.</p>
<p>Five children alternated between the use of wheelchairs pushed by others or walked with their prostheses. Two children either were pushed in a wheelchair or carried by adults. Two were able to push themselves in regular wheelchairs, and one child used an electric wheelchair. One child used an adapted cart that had been constructed by his father.</p>
<p>Six children lived in homes with steps at the outside entrance. The families of five of the children had ramps built to accommodate the CAPP cart. The sixth child lived in a two-story house, but used the cart only at school. Five children lived in homes with no stairs either outside or inside the building.</p>
<p>All the children were of school age. Six attended special schools for the handicapped, and four attended regular classes in public schools. One child received private tutoring at home.</p>
<h3>Procedure</h3>
<p>The study was conducted over a six-month period, with evaluations performed at the clinics on three occasions. The results were submitted to New York University. Each clinic was responsible for the routine maintenance of the cart, with major repairs or adjustment that required disassembly of the cart being referred to NYU.</p>
<p>The characteristics of each child, his physical and environmental conditions, and his prosthetic experience were recorded on the Selection Forms, which were returned to NYU.</p>
<p>A representative of the New York University research staff was present when each cart was delivered and described the study to the child, parents, and clinic team. The training instructions and evaluation forms were discussed with the clinic therapist, and the maintenance instructions with the parents and the prosthetist.</p>
<p>The child operated the cart under supervision until the clinic members felt that the child could drive it independently with safety. At the end of the training period, the therapist completed the Training Evaluation Form.</p>
<p>The child returned to the clinic after he had used the cart for three months. The therapist, in consultation with the child's parents, evaluated the cart in terms of design, safety factors, and function, and recorded the information on the appropriate form. A maintenance check was made, and any necessary repairs and adjustments were also recorded.</p>
<p>The child returned again to the clinic with the cart after six months. The clinic personnel recorded suggestions for improvements in the cart, the child was questioned as to his overall reactions to the cart, and all maintenance problems were recorded. The child's parents and teachers completed forms in which they described their reactions to the cart in terms of suggestions for cart modifications.</p>
<h3>Results</h3>
<p>Ten of the eleven children who participated in the study preferred the CAPP cart to other modes of transportation. Their parents were equally enthusiastic about the cart. The child who ultimately rejected the cart had a personality problem from the beginning; a strong mutual dependence between the child and her father was threatened by the increased independence offered her by the CAPP cart.</p>
<p>The features of the cart that were most appreciated by both the parents and the children were the increased independence and mobility it provided. The main objection voiced by the parents was the weight of the cart. <b>Table 3</b> lists the features the children and parents liked best and least about the cart.</p>
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<h4>Operational Skills</h4>
<p>As seen in <b>Table 4</b>, most of the children learned to control the cart with relative ease. The average training time was 5 1/2 hours. The oldest child (14 years) learned to operate the cart in 1/2 hour, while the youngest (6 years) required 14 hours of instruction.</p>
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<p>Training items were divided into ' 'starting and stopping," "driving," and "turning". The children were asked to start and stop smoothly while driving forward and backward. Most of the children learned this with little difficulty; four learned with no formal training.</p>
<p>The driving test consisted of moving forward and backward in a straight line and on a diagonal, crossing doorsills, and changing direction on command. The children learned to ascend and descend inclines of 10 degrees, to avoid obstacles, and to drive through a "slalom" course.</p>
<p>Finally, the children were taught to turn the cart on its base, using a rear wheel as a pivot, 90 degrees forward and backward. Three children required no training to perform these tasks, and all of the children learned to perform all activities independently.</p>
<p>Two of the younger children began training programs using cars with six-volt batteries because the speed of the cart with the larger battery frightened them at first. After training, they found the cart too slow, and the original twelve-volt batteries were reinstalled.</p>
<p>Seven children considered driving backward the most difficult operation to learn. Other areas of difficulty mentioned by the subjects were the delicate control required in confined areas, and turning.</p>
<p>Three children lost their balance while learning to operate the cart. One child lost his balance while turning and driving backwards and two, when they changed directions rapidly on a level surface. However, none of them lost sufficient balance to fall from the cart during the training period.</p>
<p>Six children damaged property while learning to drive the cart: scraping walls, door frames, or furniture. One child scratched the family car; another, through continued reckless driving, endangered other persons who were in his way.</p>
<h4>Safety</h4>
<p>Five children wore safety belts while driving the cart.</p>
<p>One child fell from the cart while at school. She was not wearing a safety belt, because it restricted her movements while in, and transferring in and out of, the cart. She had swung the control arm away while leaving the battery connected to the motor, and a classmate accidently touched the drive control, which sent the cart forward and caused the child to fall from the cart. Although the child was not injured, the episode dramatized the need for additional safety features.</p>
<h4>Extent of Use</h4>
<p><b>Table 5</b> shows the extent of cart usage. On the average school day, four children were in the cart at least 75% of their waking hours, three children utilized it between 40 and 70% of the day, and four children less than 10% of the time.</p>
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<p>On weekends, two children used the cart more than 75% of the time; two children, 25 to 30%; and seven children, less than 25% of the day.</p>
<p>In considering where the cart was used primarily, we found that four children used it both at home and at school; five, only in the home; and two, only at school. The principle reason for using the cart in only one location was its excessive weight, which made transportation difficult. Nine people commented on this problem. Those who used the cart only at home considered the danger of driving a cart with such sensitive controls too great to permit unsupervised use. Two clinics stated they were unable to rely on school personnel to pro- vide daily care for the cart, such as charging and filling the battery and reporting breakdowns.</p>
<p>As shown in <b>Table 6</b>, most children were independent in such activities as driving through a 24-inch doorway, entering and leaving an elevator, approaching objects, and adjusting the seat height. The children with upper-extremity amelia and phoco-melia continued to require assistance for activities involving reaching, such as pushing elevator buttons and opening and closing cupboards and drawers.</p>
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<p>The majority of the children were independent in transfer activities (<b>Table 7</b>), e.g., cart to bed, toilet, or chair. The most troublesome transfer activities involved the toilet; presumably, these difficulties arose because of the narrowness of many bathroom doors and the lack of removable armrests on the cart.</p>
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<p>After three months of use, most reporters noted a general improvement in driving and maneuvering skills.</p>
<h4>Advantages And Disadvantages</h4>
<p>Seven clinics reported that the greatest functional advantage of the cart was the adjustable seat (<b>Table 8</b>). Other assets reported were the increased maneuverability, easy control, the movable control arm that facilitated transfers, and the stability of the cart. The greatest disadvantages were the lack of an "on-off" switch, and insufficient ground clearance.</p>
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<p>Six children depended less on adult help while in the CAPP cart; four reported no change in the amount of adult help required; no information was available for the eleventh child. Nine parents reported that their children required less lifting; however, one child required more lifting. Before the arrival of the cart, this girl spent most of her time on the floor, where things had been built to accommodate her. Since she was unable to transfer in and out of the cart from the floor, she had to be lifted each time.</p>
<p>One child was unable to use his prosthesis while in the cart, because the control arm was on the same side and interfered with its use. Most of the children felt that the chin control was not the optimal control site, and they preferred to use their arm stumps. Two therapists suggested that, if the control arm were placed to the side, a child could control the cart more efficiently with his stump. One therapist objected to the chin control because she feared damage to the child's lower jaw while driving the cart over rough terrain, although there was no report that this occurred. It was suggested that, if the control arm were relocated, a child could maintain a more normal sitting posture and turn his head for driving, and the control arm would not hinder activities at a desk.</p>
<h4>Cart Maintenance</h4>
<p>The twelve-volt battery required recharging every 24 hours. The batteries normally were charged overnight, and none needed replacement during the test period. Filling the battery with water was a considerable problem for parents because of the small storage space in the cart, which made battery-removal difficult.</p>
<p>Most maintenance problems concerned the rear wheels and switches; five carts required wheel replacements. The rear wheels attach to the gear box and receive the power to drive the cart. Since they do not swivel as the front wheels do when the cart turns, a torque is applied. These wheels, which were commercially available as wheelchair casters, were not designed for this amount of force and broke as a consequence of the torque overload.</p>
<p>All the carts required replacement of the switches in the control mechanism. The original switches were not the model ordered, but, for reasons of expediency (low cost and commercial availability), they were installed in the carts. When it became apparent that these were unsatisfactory, they were replaced with the model originally ordered, and the problems were eliminated.</p>
<h3>Conclusions</h3>
<p>With one exception, all the children and their parents were very enthusiastic about the CAPP cart and preferred it to other modes of transportation. It provided increased independence to ten of eleven children with quadrimembral deficiencies.</p>
<p>Training did not present a problem, even for the youngest child; however, consideration should be given to introducing the very young or apprehensive child to the cart with a six-volt battery. Since the cart is very stable, most driving hazards arose because of recklessness or poor driving skills. Perhaps greater care should be directed toward predriving instructions, and the children should be given more opportunity to practice driving skills under supervision. It must be remembered, however, that children tend to be less responsible and less coordinated than adults, and more accidents are to be expected from them.</p>
<p>The CAPP cart afforded the children more independence in terms of mobility and endurance. Hemimelic children were able to perform many activities, such as opening and closing cupboards and drawers, as a result of the adjustable seat, which allowed them to approach objects more closely and normally.</p>
<h4>Design Considerations</h4>
<p>Although a number of clinics suggested the inclusion of a seat belt, this would tend to restrict a child's independence if he were able to transfer in and out of the cart without assistance, since most arm amputees would be unable to manipulate the belt independently. Seat belts are readily available or easily devised, and the application of a belt might best be left to the discretion of the clinic or the child's parents. Another suggestion was the incorporation of an "on-off" switch that could be controlled by the child, or a switch that would automatically cut the power when the control arm is swung to the side.</p>
<p>Although the present velocity of the cart is satisfactory for forward maneuvers, it is clearly too fast for driving backwards or for delicate control. Consequently, consideration should be given to including a variable speed-control mechanism.</p>
<p>Although wheelchair casters are commercially available and relatively inexpensive, they are not designed to absorb the high torque forces that are applied to the rear wheels of the CAPP cart. Stronger drive wheels would probably have prevented many of the mechanical breakdowns that occurred. Consideration should also be given to including pneumatic tires, which provide greater traction and more comfort.</p>
<p>Since most of the children preferred to control the cart with their arm stumps, consideration should be given to placing the control arm to one side, close to the shoulder or stump. This would also avoid interference with use of an upper-limb prosthesis. A second possibility, particularly for the upper-limb amelic child, is to lower the control arm to the level of the chair seat, which would allow the child to control the cart with his foot or leg stump while enabling him to sit straight and to turn his head freely.</p>
<p><i>Note: </i>As a result of the findings of the evaluation study, a new control box was developed that incorporates a variable-speed mechanism, and an "on-off" switch that can be controlled by the child. All carts have been recalled to UCLA, where a detailed analysis is also being conducted of the effect of use on the mechanical segments of the cart. The new control mechanism and a set of stronger wheels have been installed, and the carts were returned to the children for continued use. Each clinic will provide any further training required to operate the cart with the new control system. After six to eight weeks of additional use by the child, the clinic and the children will be asked to record their reactions to the modified cart.</p>
<h3>Recommendation</h3>
<p>On the basis of the results of the clinical evaluation of this item, and the design modifications implemented by the developer, it is recommended that the CAPP cart be made available to all limb-deficient children for whom conventional methods of transportation are unsatisfactory.</p>
<h3>Appendix</h3>
<p>J. T. was an eight-year-old girl with bilateral upper-limb amelia and lower-limb terminal-transverse hemimelia (A/K type). Initially, the control arm on the cart was lowered to the seat level to allow her to operate it with her leg stump. She did not wear lower-extremity prostheses while she was in the cart.</p>
<p>This child learned to operate the cart in approximately 2 1/2 hours; driving backwards and turning were the most difficult tasks for her to learn. As with the other amelic children, she was able to move about independently, but she continued to be totally dependent in activities involving the arms.</p>
<p>She used the cart for the entire school day, but she did not use it at home because her parents found that its weight made transporting the cart very difficult.</p>
<p>Both the child and her parents found that the cart was too slow for her to keep up with the other children. The child's other reactions were similar to those of the other children; that is, she liked the adjustable seat and the increased independence, but disliked the lack of an "on-off" switch and of sufficient ground clearance. Her teacher reported that the cart often became stuck in the school yard because of insufficient clearance.</p>
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Evaluation of the CAPP Cart
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Barbara A. Gehant
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DRFOP - Legacy
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Year
1971
Volume
15
Issue
1
Page Number(s)
46 - 67
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<h2>Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace</h2>
<h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5>
<p>In certain pathological conditions of the lower extremity, the stress of weight-bearing cannot be tolerated because of pain or the possibility of actual tissue damage. Pathologies encountered in such situations fall into three broad categories: <a></a> those affecting bone-delayed unions or nonunions of fractures; <a></a> those involving the ankle or foot joints, such as traumatic arthritis or similar conditions; and <a></a> those involving the soft tissue, such as ulcers and traumatic loss of the heel pad or other soft tissues.</p>
<p>In these circumstances, bracing is frequently used as an aid to management, the brace serving as a weight-bearing device to relieve the skin-muscle-bone complex of intolerable stresses.</p>
<p>Historically, the application of a brace to unweight the lower extremity has involved provision for support of the body weight at the level of the pelvis, typically some form of ischial weight-bearing. A variable proportion of body weight is then transmitted to the ground through side bars and a locked knee. This type of brace is inherently disadvantageous because of its bulk and because the locked knee imposes a stiff-legged gait which increases energy costs. In situations where the pathology is located above the knee, avoidance of these disadvantages may be impossible. However, in selected below-knee lesions, a brace which bears weight about the knee (like the patellar-tendon-bearing prosthesis) appears not only desirable but possible. A brace of this type would not only allow unrestricted knee motion, and hence a more natural gait, but it would have the advantages of reduced bulk and the absence of equipment above the knee.</p>
<p>In 1958, VAPC designed such a below-knee weight-bearing brace. <a></a> The VAPC design was based on the then current below-knee patellar-tendon-bearing (PTB) prosthetic techniques. The primary weight-bearing component is a partial socket of laminated plastic with a soft (Kemblo [TM]) liner similar to the proximal portion of a PTB prosthesis (<b>Fig. 1</b>). Stainless-steel uprights were used with a stainless-steel limited-motion stirrup (<b>Fig. 2</b>). The ankle joints were modified to permit 10 degrees of plantar flexion and to limit dorsiflexion at 90 degrees. The stirrup and uprights were fitted and aligned as in a conventional ankle brace. In wearing the brace, an open-end wool stump sock was used as with a below-knee prosthesis.</p>
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Fig. 1. Proximal weight-bearing portion of the PTB brace.
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Fig. 2. Completed brace of initial design.
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<p>As experience with the PTB-type brace accumulated at VAPC, a number of modifications were introduced (<b>Fig. 3</b>). A compressible heel, similar to that of the solid-ankle cushion-heel (SACH) prosthetic foot, and a rocker bar attached to the sole of the shoe became incorporated as standard components of the device. The SACH heel wedge and rocker bar were incorporated in the shoe to simulate plantar flexion and provide a more natural roll from heel to toe, thus minimizing gait deviations imposed by limited ankle motion. <a></a> The SACH heel wedge is also considered to function as a shock absorber, contributing to a smoother gait. Some patients with painful ankles were unable to tolerate motion in the ankle joint at the brace and were fitted with rigid joints.</p>
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Fig. 3. Views of the modified brace showing application of SACH heel and rocker bar.
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<p>The Veterans Administration Prosthetics Center submitted the PTB weight-bearing brace to the Committee on Prosthetics Research and Development for evaluation. Unfortunately, at that time procedures for the testing of orthotic devices were not available. However, in December 1963 an orthotic evaluation program was inaugurated by New York University, and the VAPC device was selected by CPRD as a suitable item for this program.</p>
<p>The initial phase of the NYU evaluation involved the review and examination of patients fitted by VAPC. Of the 22 patients who had been fitted by VAPC between 1958 and November 1963, 8 accepted the invitation to appear for interview and examination. The findings of this review study indicated that the VAPC pa-tellar-tendon-bearing brace was an effective device from the medical, orthotic, functional, and wearer-reaction points of view. <a></a></p>
<h3>Clinical Fittings</h3>
<p>On September 1, 1966, the National Academy of Sciences-National Research Council entered into Contract SAV-1053-67 with the Vocational Rehabilitation Administration (now the Social and Rehabilitation Service) to establish a pilot program for the clinical evaluation of prosthetic and orthotic devices under the jurisdiction of the Committee on Prosthetics Research and Development. Two orthotic items were selected to initiate this program: the Baylor (Engen) hand orthosis and the University of California dual-ankle control system. The Engen study was undertaken <a></a> but, for various reasons, the UC study could not be undertaken, and evaluation of the VAPC PTB brace was substituted for the UC item.</p>
<p>Since the earlier favorable NYU review, an instructional manual has been prepared by the developer. <a></a> Accordingly, five treatment centers were recruited as participants in a clinical application study of the VAPC PTB brace: the University of Alabama Medical Center, Birmingham, Ala.; Goldwater Memorial Hospital, New York, N.Y.; Jackson Memorial Hospital, Miami, Fla.; Rancho Los Amigos Hospital, Downey, Calif.; and the Rehabilitation Institute of Chicago, Chicago, Ill.</p>
<p>A course of instruction in the fabrication and application of the VAPC PTB brace was conducted at the Veterans Administration Prosthetics Center, New York, by the developers. Orthotists from the participating clinics undertook training for five days (May 8-12, 1967), while physicians had a one-day orientation (May 12, 1967).</p>
<p>A protocol for the study, together with appropriate data-recording forms, was prepared by the CPRD staff.</p>
<p>Following the instructional course, several fittings were accomplished at each of the participating centers. Subsequently, a number of factors arose to militate against the completion of the planned course of study. Two of the clinics suffered the loss of the physician member of the participating team, and two other centers became engaged in studies of cast braces for fractures of the lower extremity. These fracture-cast braces had some of the same characteristics and performed similar functions as the test item. The physician member of the fifth participating team suffered a prolonged illness, which disrupted the progress of the study at his center.</p>
<p>The clinical study of the VAPC PTB brace was reactivated early in 1970 when the physician who had been ailing recovered his health and it was discovered that the orthotics clinical group at the Duke University Hospital had been fitting the test item since 1962 and had accumulated a sizable series of patients. Arrangements were made, therefore, to review patients fitted in Birmingham and Durham. The data obtained in these reviews form the basis for this report. The experience of these two centers is presented in the following sections of this report.</p>
<h4>Birmingham, Alabama</h4>
<p>Following the return of the physician—orthotist team from the instructional course at VAPC, seven patients were fitted in the study. Two of these patients were civilians (one woman and one boy) and five were veterans. The injuries of three of the veterans were non-service-connected.</p>
<p>Review of the data available on these seven patients fitted in Birmingham indicates that in four instances the experimental brace was used satisfactorily and successfully. In two cases, the results were inconclusive in that the follow-up data are not available. The seventh patient must be considered a probable failure, although again follow-up data are not available. Condensed case histories on these patients follow.</p>
<h4>Successful Outcomes</h4>
<p><i>Case No. 1</i></p>
<p><i>P.S. </i>was born on February 28, 1953. He suffered from congenital pseudarthrosis of the right tibia and fibula, essentially constituting a defect similar to an ununited fracture. Prior to referral to the Crippled Children's Service Clinic in Birmingham, he had undergone surgery at an early age. This surgery, involving the use of metallic screws and sutures, was unsuccessful. Further surgical procedures were attempted subsequently, an onlay bone graft being done on July 20, 1965. This surgery was followed by infection and was unsuccessful. A sliding bone graft was attempted on June 6, 1967, but this also was unsuccessful.</p>
<p>The VAPC PTB brace was fitted in April 1968. The condition of the right tibial and fibular defects at that time is shown in <b>Fig. 4</b>. The brace prescription included a SACH heel and a rocker bar incorporated into the shoe build-up (the right leg being shorter than the left). Initially, no motion was provided at the ankle joint.</p>
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Fig. 4. X-ray of P.S.'s leg at time of fitting the VAPC PTB brace.
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<p>Following application of the brace, the leg shrank rapidly, and a new socket was required in approximately one month. Because of this loss of fit, the amount of weight borne on the defective limb was increased. This boy was a very active user; he played basketball and reported that he went hunting almost every day. As a result of this active use, numerous breakages occurred at the junction of the brace upright and shoe plate. The upright was eventually strutted for extra strength, and after about a year and a half of wear a few degrees of motion were introduced at the ankle joint. This limited motion resulted in reduction of the breakage problems.</p>
<p>Although the patient was well pleased with the brace and wore it satisfactorily, the tibial and fibular defects failed to unite (<b>Fig. 5</b>).</p>
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Fig. 5. P.S.'s leg after wearing the experimental brace approximately 14 months.
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<p>The physician, orthotist, and patient all considered this brace to be superior to any previously worn.</p>
<p><i>Case No. 2</i></p>
<p><i>C.S. </i>was born on April 17, 1915. He was injured on March 2, 1967, when he slipped on the ice and fell, sustaining fractures of the left tibia and fibula. He was treated with plaster casts, but union of the tibial fracture was delayed.</p>
<p>He was fitted with the VAPC PTB brace in September 1968. The prescription was standard, and included a SACH heel, a rocker bar, and a rigid ankle. A full leather cuff was applied over the fracture site.</p>
<p>This patient's treatment program proceeded uneventfully, and by June 1969 a good bone union was evident clinically and confirmed by X-ray (<b>Fig. 6</b>). This patient was discharged from the doctor's care.</p>
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Fig. 6. C.S.'s X-rays after wearing the experimental brace for 9 months Good bone union is evident at the fracture site.
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<p><i>Case No. 3</i></p>
<p><i>H.E. </i>was born on October 25, 1933. He was hit by a car on October 12, 1966, sustaining a fracture of the right tibia, which failed to unite. Draining osteomyelitis also was present.</p>
<p>He was fitted with the experimental brace on October 25, 1968. The prescription included a SACH heel, a rocker bar, a fixed ankle, a short leather cuff, and a high shoe. He initially walked with crutches or canes but later discontinued these aids.</p>
<p>This patient is a large, heavy man and very active. Many repairs were required at the shoe-plate junction, and eventually a strut had to be added for additional strength.</p>
<p>This patient's treatment program proceeded relatively uneventfully. In August 1969, the brace was reported as working well, and no drainage had been experienced since October 1968. Although the fracture had not healed, X-rays revealed some indications of healing (<b>Fig. 7</b>). In March 1970, apparent ankylosis of the ankle joint was noted, and progressive ossification within the fracture area was evident. The patient continues to wear the brace and tolerates it well. He still wears an elastic below-knee stocking, but this is apparently more for insurance than because of actual need.</p>
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Fig. 7. H.E.'s X-rays show indications of healing of fracture after the brace was worn for 10 months.
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<p><i>Case No. 4</i></p>
<p><i>J.C. </i>was born on October 27, 1948. He was injured by shrapnel on May 14, 1967, sustaining a fracture of the neck of the talus on the right leg and loss of soft tissue on the right heel. <b>Fig. 8</b> shows the condition of his right ankle approximately five months after the injury.</p>
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Fig. 8. X-ray of J.C.'s right ankle 5 months after injury.
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<p>The experimental brace was prescribed for this patient on November 21, 1967, and it was delivered on December 13. The prescription incorporated a SACH heel, a rocker bar, a reinforced foot plate, and no ankle motion. This patient experienced no particular problems other than the need for shoe changes. He found the brace useful and comfortable. X-rays taken on April 9, 1968, showed marked improvement (<b>Fig. 9</b>). His injuries proceeded to complete healing, and he is no longer wearing the VAPC brace.</p>
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Fig. 9. Marked improvement is evident in J.C.'s ankle after wearing the experimental brace approximately 5 months.
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<p><i>Case No. 5</i></p>
<p><i>S.D. </i>was born on May 18, 1927. She was injured on August 30, 1967, sustaining a comminuted fracture of the right tibia and fibula. The tibial fracture failed to unite.</p>
<p>She was treated with long and short leg casts and fitted with the PTB brace on May 29, 1968. The prescription was standard, and included a SACH heel, a rocker bar, and no ankle motion. The patient tolerated the brace well, and X-rays taken on July 1, 1968, indicated satisfactory progress (<b>Fig. 10</b>).</p>
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Fig. 10. S.D. shows satisfactory progress one month after fitting with a PTB brace.
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<p>Few maintenance requirements were found, except that the shoes had to be changed and one upright and one foot plate broke.</p>
<p>The patient was seen in August 1969, at which time she was using the brace with crutches. She has not been seen since, so the end result is unknown.</p>
<p><i>Case No. 6</i></p>
<p><i>D.E. </i>was run over by a truck in May 1966, and he sustained fractures of both legs and the left foot. The left tibia failed to unite, as indicated in X-ray films taken six months after the injury (<b>Fig. 11</b>). He was fitted for the VAPC PTB brace in December 1968, but left the hospital before the brace was delivered. The brace was delivered at home just before Christmas 1968, and he apparently has not been seen since except for a casual encounter with the or-thotist on the street, when it was reported that the fracture had healed and that the patient no longer needed the brace. Again, because of the loss of this patient to active follow-up, the full story is not known.</p>
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Fig. 11. Condition of D.E.'s leg prior to fitting with a PTB brace.
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<h4>Assumed Unsuccessful Outcome</h4>
<p><i>Case No. 7</i></p>
<p><i>R. McK. </i>was born on May 21, 1908. His injury occurred as a result of a land-mine explosion on February 27, 1942. He sustained the loss of the os calcis and the heel pad bilaterally.</p>
<p>He was fitted with the VAPC PTB brace on the right side only, the device having a fixed ankle, SACH heel, and rocker bar.</p>
<p>This patient was apparently dubious about the brace from the outset, and expressed lack of confidence in the doctors and the course of treatment. He wore the experimental brace for a very limited period (approximately five days) and claimed that it limited his freedom, particularly when driving. This patient subsequently became lost to follow-up, and all indications were that the application of the brace in this case was unsuccessful as well as perhaps ill-advised.</p>
<h4>Discussion And Conclusions</h4>
<p>The evidence in the Birmingham fittings of the VAPC PTB brace was strongly positive with respect to its value as a means of patient management. In some instances, this value was in providing partial un-weighting so that the damaged part could heal. In other instances, the unweighting provided by the brace permitted the patients to engage in vigorous programs of activity despite a lack of union in the tibia.</p>
<p>In addition to these general findings, some specific findings of interest emerged.</p>
<ol>
<li>Following application of the VAPC PTB brace, shrinkage of the limb enclosed by the plastic cuff was encountered. Close control of the fitting during this period is essential in order to avoid the development of loose fit and a reduction in the amount of weight borne by the brace.</li><li>As in all prosthetic-orthotic applications, judicious selection of patients is essential. In the Birmingham group, one fitting was apparently doomed to failure from the outset because of the patient's attitude, while another patient was a chronic alcoholic, so that the possibility of securing follow-up data was negated from the outset.</li></ol>
<p>It should be emphasized that the Birmingham fittings closely followed the technique practiced and taught by the Veterans Administration Prosthetics Center. Review by one of the co-developers of the device on a number of the cases fitted early in the study indicated good workmanship and generally excellent fit and alignment.</p>
<p>Some observations by the orthotist member of the fitting team were:</p>
<ol>
<li>Fabrication of the VAPC PTB brace requires experience in both prosthetics and orthotics, since elements of both specialties are involved.</li><li>A course of instruction in the technique during which the braces are actually fabricated under competent instructors is a most desirable means of transmitting fitting knowledge and skill.</li><li>The selection of patients for the device is most important and should include not only considerations of psychological factors such as those described above but also of physical factors which may increase the difficulty of fitting. (The presence of loose tissue around the knee which could become a flesh roll above the brace cuff was cited as an example of this type of difficulty.)</li><li>All patients fitted in the Birmingham group were initially provided with braces with no provision for motion at the ankle joint. In active and/or heavy patients, this resulted in numerous brace-upright and shoe-plate breakages. Later, some patients were provided with a small amount of ankle motion, and this had the effect of reducing incidence of breakage. Criteria for the prescription of fixed or limited motion in ankle joints should therefore be defined more carefully.</li></ol>
<h4>Durham, North Carolina</h4>
<p>Mr. Bert Titus, director of the Department of Prosthetics and Orthotics, Duke University, began fitting the VAPC-PTB-type brace in 1962. The initial braces were fabricated in accordance with the VAPC manual of January 3, 1961. <a></a> Over the years, however, the original VAPC procedures were modified at Duke in a number of ways. Although the original concept of patellar-tendon weight-bearing for reduction in the amount of weight borne by the affected part of the limb was maintained, the changes are significant enough to be worthy of note.</p>
<ol>
<li>The socket, which in the VAPC version was hinged on the medial side, was first changed to a bivalve construction involving anteroposterior sections joined by adhesive tape (<b>Fig. 12</b>). The type of socket now fitted in Durham involves a plastic laminate without liner which is flexible on the posterior aspect and the posteromedial corner (<b>Fig. 13</b>). The socket is split along the posterolateral corner and closure is effected by two or more Velcro (TM) straps (<b>Fig. 14</b> and <b>Fig. 15</b>). The fabrication of this socket is described in a report being prepared by Titus. An abbreviated description of the Duke procedures appears as a supplement to this article.</li><li>The sidebars in the Durham version of the weight-bearing brace are of either stainless steel or aluminum, and most recently have been attached to the outside of the socket with rivets. This procedure is in contradistinction to the VAPC method, which involves insertion of the proximal ends of the sidebars into prepared channels. Distally, the bars are detachable from the shoe.</li><li>All the VAPC-type braces fitted at Durham incorporated some degree of ankle motion. Typically, this was 20 degrees to 25 degrees of dorsiflexion with a 90 degrees stop. However, some of the ankle joints were completely free. This feature again contrasts with the VA practice in which the brace ankles are frequently of the rigid type. It was reported that none of the braces fitted at Durham had completely rigid ankles.</li><li>Typically, the Durham version of the weight-bearing brace does not include either a SACH heel or a rocker bar. Doubtless, the need for such aids to roll-over is reduced or eliminated by the provision of ankle motion.</li></ol>
<p>Between the initial fittings in 1962 and June 15, 1970, the Duke Limb and Brace Shop fitted approximately 27 PTB-type braces. Of these patients, 20 were civilians seen through the Orthopaedic Department of Duke University Hospital and 7 were veterans who were treated through the Veterans Administration Hospital at Durham. Three additional braces were being fabricated at the time of this review.</p>
<p>On June 22-23, 1970, the author, accompanied by William McIlmurray from the VAPC, reviewed 8 patients who had been fitted through the Duke University Department of Prosthetics and Orthotics. The group of patients reviewed included 5 civilians and 3 veterans. The case-history files of 12 additional patients were also reviewed. The data obtained in these reviews are presented below in three sections-one indicating the types of disabilities for which the brace was used, the second containing illustrative case histories of patients treated, and the third containing comments on fit and alignment. In general, the outcomes of the fittings appeared to be very positive.</p>
<h4>Types Of Disabilities</h4>
<ul>
<li>Chronic osteomyelitis with secondary deformity of distal tibia and fibula and partial ankle fusion.</li>
<li>Slow-healing spiral fracture of the tibia and fibula.</li>
<li>Compound fracture of the tibia and fibula and fracture of the left foot followed by infection and numerous operative procedures culminating in ankle fusion.</li>
<li>Fracture of the tibia and fibula.</li>
<li>Nonunion of the tibia and fibula with compression-plate fixation.</li>
<li>Nonunion of a tibial fracture with draining osteomyelitis.</li>
<li>Comminuted fractures of the distal right tibia and proximal right fibula and fracture dislocation of the right ankle. A painful ankle led to the performance of a triple arthrodesis.</li>
<li>Comminuted fractures of the ankle mortice bilaterally (right medial malleolus and tibia, left spiral fracture of tibia and fibula; both ankles stabilized with pins). Six pins were subsequently removed.</li>
<li>Traumatic arthrosis of the right ankle following fracture of the distal right tibia and fibula.</li>
<li>Compound trimalleolar fractures of the left ankle with dislocation.</li>
<li>Nonunion of a left tibial fracture with osteoporosis.</li>
<li>Calcaneal valgus deformity of the right foot treated with a triple arthrodesis of the right foot and ankle; delayed healing of subtalar, talonavicular, and calcaneocuboid joints with severe osteoporosis.</li>
<li>Pain on plantar aspect of heel following fracture of the os calcis.</li>
<li>Foot pain following football injury; triple arthrodesis performed.</li>
<li>Degenerative changes in left knee secondary to old fracture of the tibial plateau.</li>
<li>Nonunion of medial malleolus following trimalleolar fracture sequelae of traumatic arthrosis and arthrodesis.</li>
<li>Comminuted fracture of os calcis leading to a crushed heel pad, osteoporosis, and triple arthrodesis subsequently.</li>
<li>Right heel pain, characteristic of traumatic or degenerative arthritis.</li>
<li>Fracture of the right os calcis with painful right foot and ankle.</li>
</ul>
<h4>Case Histories</h4>
<p><i>Case No. 1</i></p>
<p><i>W.J. </i>was born on April 3, 1927. From early childhood, he had suffered from a defect in his left leg which had been attributed to an aftermath of diphtheria. His condition was reported as being chronic osteomyelitis with a secondary deformity of the distal tibia and fibula combined with partial ankle union.</p>
<p>The patient was fitted with a PTB brace in August 1962, and thus had worn the device for almost eight years. The brace worn had an ankle with a positive 90 deg. stop and approximately 30 deg. of dorsiflexion motion. He wore a low shoe with a 2 1/2-in. build-up. Otherwise, the brace was of the Durham type as described previously. He reported that he wore the brace for more than nine hours daily, and that it was generally quite comfortable and satisfactory. His condition was reported to have stabilized, although his ankle and shin sometimes ached after prolonged standing or walking. He stated that he felt that he was bearing more than 50% of his weight on the brace. From his remarks, it would appear that the brace was a definite aid to his mobility.</p>
<p><i>Case No. 2</i></p>
<p>J.G. is a 30-year-old male garbage collector who was jammed between the garbage truck and a brick wall, sustaining a fracture of his left tibia and fibula on March 22, 1967. A nonunion of the fractures with a draining osteomyelitis ensued (<b>Fig. 16</b>).</p>
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Fig. 16. J.G., with nonunion of fractures and draining osteomyelitis.
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<p>The patient was fitted with a PTB brace in September 1969. He reported that he was feeling fine, the osteomyelitis had stopped draining, and he had returned to work driving a garbage truck.</p>
<p>The brace worn was the Durham bivalve device with the ankle completely free (<b>Fig. 17</b>). He wore the brace all day every day and reported absolutely no problems with it.</p>
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Fig. 17. J.G,, with Durham bivalve-type brace.
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<p>From the patient's remarks, his return to work, and his comments concerning the brace, it would appear that this fitting was quite successful.</p>
<p><i>Case No. 3</i></p>
<p><i>T.L., </i>a physician, sustained a spiral fracture of the tibia and fibula on February 5, 1969. He wore a long leg cast for six months following the injury, and on August 8, 1969, he was fitted with the PTB brace. The condition of his fractures just prior to fitting is shown in <b>Fig. 18</b>. With the device, he was able to return to his medical practice. The fracture was pronounced healed in November 1969, and the PTB brace was discarded. His brace was of the standard Durham type with a completely free ankle joint.</p>
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Fig. 18. Views of T.L.'s fractures before fitting with PTB brace.
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<p>When interviewed, the patient's comments concerning the brace were very positive. So much so, in fact, that when the interviewer remarked that he seemed like a happy customer, he retorted that he was more than happy—he was delighted—and in fact had sent two patients with fractures to be fitted with the same type of brace.</p>
<p><i>Case No. 4</i></p>
<p><i>F.E., </i>a 43-year-old male, was buried under eight to ten tons of chemical in March 1966, sustaining compound fractures of the left tibia and fibula, a fracture of the left foot, and fractures of the pelvis and of the right upper femur. Following open reduction and internal fixation, the injury became infected and the fixation was removed. The patient had a number of operative procedures on his right hip, and on October 3, 1967, underwent multiple fusions of the ankle bones.</p>
<p>He was fitted with a PTB brace on March 27, 1968, and thus had worn it for slightly more than two years. The device is of a standard Durham type with a 90 degrees ankle stop and with approximately 5 degrees of dorsiflexion. The sidebars were of aluminum with an anterior aluminum calf band. A low shoe was worn with a build-up on the opposite side because of a shortening of the right leg related to the pelvic and femoral fractures. The brace was of the bivalve type. <b>Fig. 19</b> and <b>Fig. 20</b> show the condition of the foot and distal tibia and fibula over the period from January to October 1969. The patient reported that without the brace he experienced discomfort at the fracture sites, but that with the device he was reasonably comfortable and could wear the brace all day. He claimed that he took about 30<i>% </i>of his weight on the brace. Again, it appeared that this brace is a highly acceptable aid to the mobility of the patient.</p>
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Fig. 19. X-rays of F.E.'s distal leg, ankle, and foot.
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Fig. 20. Condition of F.E.'s limb 9 months later.
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<p><i>Case No. 5</i></p>
<p><i>H.H., </i>40 years of age, sustained multiple fractures of the lower extremities on August 4, 1969. His injuries included fractures of the left femur, tibia, and fibula, and right tibia and fibula. He was fitted with a PTB-type brace in February 1970. His condition two months after fitting (eight months after injury) is shown in <b>Fig. 21</b>. His device was of the single-lamination type and incorporated a free ankle and a high shoe. The fit of the socket was somewhat loose, and the patient expressed the opinion that no weight was being taken on the socket. He used Canadian-type crutches bilaterally. The clinical notes on his condition indicated good alignment of the bony fragments and no pain. He was wearing the brace all day and had no problems with it.</p>
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Fig. 21. Condition of H.H.'s fractures 8 months after injury (2 months' wear of PTB brace).
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<p><i>Case No. 6</i></p>
<p><i>J.H., </i>born in 1927, suffered his injury in December 1966. Nonunion of the left tibia and fibula ensued, with compression-plate fixation.</p>
<p>The patient had been fitted initially with the bivalve-type socket (separate anterior and posterior sections), but was currently wearing the one-piece laminated socket with a flexible posterior section. The brace incorporated a free ankle, and a low shoe was worn.</p>
<p>Recent clinical notes on this case indicated that on March 25, 1970, there was good alignment of the bony fragments, and early bridging of bone had begun in the tibia and fibula. On May 27, 1970, the patient was reported to be feeling well, but there was still nonunion of the fibula (<b>Fig. 22</b>). The patient reported no problems with the brace.</p>
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Fig. 22. Persisting nonunion of fibula approximately 4 1/2 years after injury.
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<p><i>Case No. 7</i></p>
<p><i>R.C.M., </i>39 years old, sustained a comminuted fracture of the left tibia and fibula when a tree fell on his leg in March 1967. Nonunion of the left tibial fracture ensued, with chronic osteomyelitis and drainage (<b>Fig. 23</b>). A bone graft to the tibia was attempted in March 1968.</p>
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Fig. 23. Nonunion of tibial fracture 10 months after accident.
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<p>The patient wore a long leg cast, followed by an initial weight-bearing brace. He was fitted with the PTB device in December 1969. His clinical record indicated that there was intermittent drainage in December and January but no drainage in February or March 1970 (<b>Fig. 24</b>). On April 1, 1970, it was reported that no active osteomyelitis was evident. However, at the time of the review (June 24, 1970), the patient reported that drainage had restarted.</p>
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Fig. 24. Nonunion persisting 3 years after accident. PTB brace worn 3 months.
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<p>His brace included a 90 degrees posterior stop with about 10 degrees of dorsiflexion motion evident. The patient wore a built-up low shoe to accommodate a 2 1/2-in. shortness of the affected limb. His socket was of the two-part (bivalve) type. He used a cane as an aid in ambulation.</p>
<p>The patient reported that the brace felt comfortable most of the time, although he had occasional swelling of the leg after long use and some discomfort at the site of the fracture after prolonged sitting.</p>
<p><i>Case No. 8</i></p>
<p><i>R.McC, </i>69 years old, was injured in an automobile accident on November 15, 1969. He sustained fractures of the head of the tibia, the head of the fibula, and the proximal third of the fibula (<b>Fig. 25</b>). He was fitted with the PTB brace on April 6, 1970 (<b>Fig. 26</b>). Thus, at the time of the review, he had been wearing the device for approximately two and one-half months. He reported that the brace was generally comfortable, but that he had had some problems with swelling and stiffness in the ankle. He estimated that the brace was taking approximately 25% of his body weight. His brace was a standard Durham type with a 90 degrees posterior stop and dorsiflexion motion of approximately 30 degrees. When first fitted with the PTB brace, he had used two crutches, but now was only using one.</p>
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Fig. 25. <i>Left, </i>R.McC.'s initial injury, Nov. 15, 1969. <i>Right, </i>after open reduction and internal fixation, Jan. 2. 1970.
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Fig. 26. <i>Left, </i>R.McC.'s fractures at time of fitting the PTB brace, 4 1/2<i> </i>months after injury, April 1970. <i>Right, </i>after 1 month's wear of PTB brace, May 1970.
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<p>Although in this instance the period of brace wear was too short for definite conclusions to be drawn, the brace was being tolerated well by the patient and was of assistance to him in ambulation.</p>
<p><i>Case No. 9</i></p>
<p><i>J.B., </i>67 years old, was admitted to Duke University Hospital on March 12, 1969, with a closed comminuted fracture of the left distal tibia, fibula, and ankle joint, and an open trimalleolar fracture of the right ankle. Operative procedures were carried out the same night, and the patient was discharged from the hospital on April 11, 1969, with the wounds healed and the feet in apparently satisfactory condition, with the right foot in a better state than the left.</p>
<p>X-rays taken on January 12, 1970, showed an old fracture of the right ankle with fixation by metallic pins and screws and good external bony bridging and normal alignment (<b>Fig. 27</b>). On the left side, internal-external bridging of the fibula with marked angulation, as well as poor healing of the tibial fragments, was evident.</p>
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Fig. 27. <i>Left, </i>J.B.'s left ankle 10 months after reduction, Jan. 1970. <i>Right, </i>views of ankle 12 months after reduction (1 month after fitting with PTB brace) March 1970.
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<p>He was fitted with the PTB brace in February 1970. Four weeks later, the clinic notes reported that the fibula had healed, and that the tibia was nontender.</p>
<p>No significant further changes were noted at examination on May 26, 1970. However, that patient reported that since wearing the PTB brace he had experienced practically no pain in the ankle or foot. He was to continue wearing the brace.</p>
<h3>Critique Of Fabrication And Alignment</h3>
<p>William McIlmurray of the Veterans Administration Prosthetics Center, one of the co-developers of the PTB brace, participated in the review of patients at the Durham facilities. Mr. Mcllmurray described the fitting and alignment of the braces seen as generally good. He noted some of the characteristics of the Durham devices previously mentioned: the one-piece socket lamination, the ankle motion provided in all prostheses in contrast to the need that VA found to fit some braces with rigid ankles, the external attachment of the sidebars, the use of detachable stirrups, and the absence of SACH heels and rocker bars on the shoes of the patients. The absence of a liner in the sockets fitted and the fact that some patients did not wear stump socks was also noted.</p>
<p>Mr. Mcllmurray subsequently discussed these features of the Duke fittings with Werner Greenbaum, the other co-developer of the VAPC technique. Their joint comments follow.</p>
<blockquote><p>No objection is raised to the use of hard, unlined sockets which have a flexible medioposterior corner. However, it should be emphasized that, if this portion of the socket is too flexible, it will not offer support and the weight-bearing effectiveness of the brace will be reduced.</p>
<p>In courses of instruction on the PTB brace, it would be desirable to teach fabrication methods for both lined and unlined sockets. Clinics would then have the choice of using either method, thus creating a situation similar to current practice in the prescription of PTB prostheses.</p>
<p>VAPC also employs a one-piece socket fabrication procedure, and the use of this method is endorsed by the Duke experimentation.</p>
<p>The channels which are prepared in the socket for insertion of the sidebars result in a product which is cosmetically more acceptable than one with bars externally attached. Moreover, these channels are very necessary for alignment adjustability during the fitting procedures. They permit us to make minute height adjustments and to tilt the socket either medially or laterally. This adjustability is a most important feature, and we would not agree to its elimination.</p>
<p>We think that, in general, detachable stirrups are contraindicated, although they might possibly be used on lightweight, inactive patients.</p>
<p>Usually we do allow some ankle motion if warranted by the pathology. However, the weight-bearing characteristics of the brace are better maintained if only plantar flexion is allowed. When mechanical ankle-joint motion is not provided, SACH-heel and rocker-bar principles are applied.</p>
</blockquote>
<h4>Discussion And Conclusions</h4>
<p>The clinical records of 27 patients fitted with the patellar-tendon-bearing brace through the Department of Prosthetics and Orthotics at Duke University were reviewed. A number of the patients in this series were interviewed and examined. From the data gathered, it appears incontrovertible that this type of brace has useful applications for a variety of below-knee problems.</p>
<p>Two broad areas of application were noted:</p>
<ol>
<li>In instances where fractures or operative procedures were slow to heal, the brace was used as a means of mobilizing the patients more rapidly than might otherwise have been the case.</li><li>In cases of chronic pain in the leg, ankle, or foot arising from fractures, traumatic arthritis, and the like, the weight-bearing relief provided by the brace permitted patients to be ambulatory with considerably less pain and discomfort than was the case without the brace.</li></ol>
<p>The review data indicated that the outcomes of the application of the brace were viewed very positively by the orthopedists, the orthotists, and the patients.</p>
<p>The variations in fabrication and fitting procedures used at Durham as compared with those originally promulgated by VAPC are noteworthy:</p>
<ol>
<li>One-piece fabrication of the PTB-type socket or cuff without a liner appears to be a possible improvement over the original VA procedure.</li><li>The external attachment of sidebars appears somewhat less cosmetic than the original technique, but is probably somewhat simpler and faster to do.</li><li>Detachable stirrup-type upright applications showed some loosening tendencies.</li></ol>
<p>In some cases, the provision of ankle motion in the brace undoubtedly eliminated the need for a SACH heel and a rocker bar, and resulted in less breakage of sidebars at the shoe attachment. However, the question as to whether some of these patients should have had rigid ankles with a SACH heel and/or rocker bar is unclear. The rule of thumb used at Duke appeared to be that, the closer the disability was to the ankle joint, the less motion had to be provided. However, as reported, all patients were given some degree of ankle motion.</p>
<p>In conclusion, it would appear that the Duke application of the PTB brace was in general highly successful. Some of the changes made in the original VAPC procedures appeared to have definite merit.</p>
<h3>Recommendations</h3>
<p>Since the results of this study indicate that the VAPC PTB brace can be successfully and beneficially applied by unaffiliated treatment centers, thus corroborating the developer, it is recommended that: (1) the results of the study be broadly disseminated by publication in <i>Artificial Limbs </i>and by other means, (2) the prosthetics-orthotics schools be encouraged to include instruction in the PTB brace as part of the lower-extremity orthotics curriculum, and (3) the fabrication modifications introduced by the Duke University Department of Prosthetics and Orthotics be tried at VAPC, and that following these trials the two institutions collaborate on the production of a fabrication manual for the PTB brace which will incorporate the best procedures currently known.</p>
<h3>Summary</h3>
<p>In the late 1950s, a brace to unweight the leg was designed at the Veterans Administration Prosthetics Center (VAPC), New York, N.Y. This brace incorporated a lined plastic cuff essentially similar to the proximal portion of the patellar-tendon-bearing (PTB) prosthesis. By varying the tightness of this cuff and the lengths of the uprights connecting it to the shoe, the amount of body weight borne on the proximal shank could also be varied. By these mechanisms, the distal portions of the limb could be unweighted to the desired degree.</p>
<p>The VAPC PTB brace was reported by the developer as having beneficial applications in cases of delayed or ununited fractures (tibia and fibula), painful ankles, and soft-tissue damage to the heel and the plantar aspect of the foot. It appeared potentially useful in any leg condition which produced pain on weight-bearing. Patients fitted by VAPC were reviewed by an independent agency (New York University) in 1963, and the developer's claims for the device were essentially substantiated.</p>
<p>The present report presents the results of VAPC PTB brace fittings performed by two groups other than the developer. The clinical records of 36 patients were reviewed, and approximately one-third of the patients were examined and interviewed.</p>
<p>The studies generally corroborated the positive findings previously reported by the developer. Wide dissemination of information concerning the VAPC item and its incorporation in orthotics instructional courses is recommended.</p>
<h3>Acknowledgments</h3>
<p>To all who participated in the various phases of the VAPC PTB brace evaluation study, we express our sincerest appreciation. To Chestley L. Yelton, M.D., Moody L. Smitherman, Jr., of Birmingham, Ala., and Bert R. Titus of Durham, N.C., we extend our special thanks for their extraordinary efforts in scheduling and reviewing patients and in providing the X-rays and pictures for this report.</p>
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Fig. 12. Front, rear, and side views of PTB brace with earlier Durham bivalve socket lined with horsehide,
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Fig. 13. Front, rear, and side views of current Durham socket.
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Fig. 15. Current version of Durham modification fitted to patient.
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<p><b>References:</b></p>
<ol>
<li>Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</li>
<li>Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</li>
<li>McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</li>
<li>McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 1959.</li>
<li>Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 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>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 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">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 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>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 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>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, 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>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace
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DRFOP - Legacy
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Year
1971
Volume
15
Issue
1
Page Number(s)
27 - 45
Text
Any textual data included in the document
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<h2>A Technique for Fitting Converted Proximal Femoral Focal Deficiencies</h2>
<h5>Carman Tablada. C.P. <a style="text-decoration:none;">*</a><br /></h5>
<p>Proximal femoral focal deficiency (PFFD) is a congenital limb deficiency affecting the proximal end of the femur and, usually, the iliofemoral joint. The condition is characterized by shortness of the affected limb; flexion, abduction, and external rotation of the extremity; inadequate proximal musculature; and unstable proximal joints. <a></a> The condition may be unilateral or bilateral, and other anomalies may be present (<b>Fig. 1</b>).</p>
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Fig. 1.
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<p>Aitken <a></a> has demonstrated four types of PFFD based on serial X-rays of patients before and after skeletal maturity:</p>
<ul>
<li><i>Class A: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are joined at maturity.</li>
<li><i>Class B: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are not joined at maturity.</li>
<li><i>Class C: </i>Severely dysplastic acetabulum. Femoral head never ossifies. Short femur.</li>
<li><i>Class D: </i>No acetabulum or femoral head. Short, deformed femoral segment.</li>
</ul>
<p>At the Child Amputee Prosthetics Project (CAPP) in Los Angeles, the preferred treatment for children who have unilateral PFFD and functional upper extremities is conversion of the limb deficiency to an above-knee amputation. The surgical procedure consists of a Syme's amputation of the foot in all cases, and fusion of the knee in selected cases to give a single skeletal lever (<b>Fig. 2</b>). The children are then fitted as above-knee amputees, using a specially designed socket.</p>
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Fig. 2.
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<p>Since 1967, the prosthetists at CAPP have used a socket with a flexible inner wall to fit PFFD patients who have had the surgical conversion described above. This paper describes the total fabrication and fitting procedure as it is done at CAPP. Only its application to the patient with PFFD will be considered here, although we have used the same principle with success in fitting other amputees who have a stump with a bulbous end.</p>
<h4>The Stump</h4>
<p>The converted PFFD stump is relatively fleshy in the proximal area. The shape of the proximal portion is related to the patient's classification: In those with class A or B involvement, the shape is normal enough for the usual anatomic landmarks to be seen, and in those with class C or D involvement, the proximal stump is cylindrical.</p>
<p>The shaft is usually narrow and bony, and the distal end is bulbous, with soft tissue padding its inferior surface. There are bony projections in the bulb which may not be seen but which can be located by palpation. These projections are sensitive to pressure.</p>
<p><i>Telescoping</i></p>
<p>When the structures in the hip region do not provide adequate articulation between the pelvis and the lower-extremity elements, upward pressure under the end of the stump causes upward displacement of the bony elements and apparent shortening of the limb. This motion is called "telescoping," and is frequently seen in patients with PFFD. As much as three inches of telescoping can be demonstrated in some patients.</p>
<p>Telescoping can be a passive or an active motion. In varied cases, some patients can voluntarily retract their limbs and others cannot; they can, however, voluntarily lengthen it beyond the resting position by thrusting down. Traction on the stump also causes lengthening. This apparent shortening and lengthening of the stump in response to pressure and traction has important implications for measuring the stump length, for making the cast, and for weight-bearing (<b>Fig. 3</b>).</p>
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Fig. 3.
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<h4>The Socket</h4>
<p>The socket consists of a rigid outer shell and a three-layered flexible inner wall, with an air space between the flexible layers and the hard socket. The flexible layers extend from the bottom of the socket to at least the level at which the bulbous end can pass through freely, comparable to the placement of the window in a standard Syme prosthesis. This arrangement provides room for expansion of the flexible wall as the bulb is inserted into the socket. Once the stump is fully inserted, the flexible wall closes around it, giving a total-contact fit without using a window and making it possible to use the bulb for suspension.</p>
<p>Since the patient has a Syme's amputation, it would seem logical to fit him with an end-bearing socket. However, if this were done, pressure under the end of the stump during the stance phase of gait would cause telescoping and relative shortening of the leg. The patient would then have excessive lateral trunk bending during stance. For this reason, the socket is designed to be ischial weight-bearing, with the patient taking light contact on the end of the stump. The ischial weight-bearing minimizes the amount of telescoping and therefore decreases the lateral trunk bending. The light contact at the distal end gives him better control over the prosthesis.</p>
<h4>Materials and Components</h4>
<p>The hard outer socket is formed with 4110 polyester resin.</p>
<p>Considerable thought was given to selecting the materials for the flexible layers. Our clinical experience has shown that, with continued use, RTV develops an odor and the material becomes fuzzy; nor will RTV bond to the rigid shell of the outside socket.</p>
<p>Therefore, flexible polyester resin was selected for the layer closest to the skin. It is durable, is easy to keep clean and free of odor, and has a surface that is relatively friction-free. 384 RTV was used for the center layer because it laminates readily and will stretch and return to the same shape repeatedly. Flexible polyester resin was also used for the layer next to the outer socket, for it bonds to the hard material if the polyester resin is "roughed up" sufficiently. The polyester resin also protects the RTV from impregnation by wax during socket fabrication. In all the cases in our experience, the materials have retained these properties until the child outgrew the prosthesis.</p>
<p>Primary suspension is provided by closure of the flexible layers over the bulbous end of the stump. A Silesian bandage, worn about an inch below the iliac crest, gives lateral support and secondary suspension.</p>
<p>We have used a constant-friction knee and SACH foot for all children fitted with this type of prosthesis. The constant-friction knee is light in weight and has provided good function. All of the children have had adequate strength to lock the knee joint during stance.</p>
<h4>Special Measurements</h4>
<p>Before describing the fabrication procedure, a brief discussion of the measurements is in order, for much of the success of this method of fitting depends upon having ischial weight-bearing and a total-contact fit.</p>
<p><i>Socket Brim Aand Ischial Seat</i></p>
<p>In patients with class A or B involvement, the shape of the proximal thigh is normal enough to enable the prosthetist to make the A-P and M-L measurements as he would for a patient with a standard above-knee amputation. The socket will have a modified quadrilateral shape at the ischial level.</p>
<p>In patients with class C or D involvement, the shape of the proximal stump is cylindrical, and there is no area comparable to the adductor-longus-tendon area of the standard above-knee amputee. In these cases, the M-L dimension is measured with outside calipers at the level of the adductor fold, and the ischial-seat measurement is made on a horizontal line from the ischium to the lateral edge of the stump at the ischial level.</p>
<p>The inside measurements of the socket must be the same as the circumferential measurements of the stump. The prosthe-tist must reproduce the size and shape of the stump in the cast, positive mold, and socket to insure total contact without looseness or constriction.</p>
<p>The stump length is measured from the ischium to the distal end of the stump with the stump at its greatest stretched length. The importance of measuring the length and taking the wrap with the stump fully elongated cannot be overemphasized, for two reasons: First, it helps ensure that the patient will take most of his weight on the ischium so that telescoping will be minimal; second, the length of the cast can be modified by only 3/8 in. in either direction.</p>
<h3>Measurements</h3>
<h4>Brim</h4>
<p><i>Mediolateral</i></p>
<p>In class A and B patients, take the M-L measurement as for a standard above-knee amputee.</p>
<p>In class C and D patients, caliper the horizontal distance from the adductor fold to the lateral aspect of the stump (<b>Fig. 4</b>).</p>
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Fig. 4.
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<p><i>Anteroposterior</i></p>
<p>Take standard above-knee A-P measurements for classes A and B.</p>
<p>For classes C and D, to measure the ischial seat, caliper the horizontal distance from the inferior edge of the ischium to the lateral aspect of the stump (<b>Fig. 5</b>).</p>
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Fig. 5.
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<h4>Socket Length</h4>
<p>With the stump at its greatest length and vertical to the floor, measure from the ischium to the end of the stump (<b>Fig. 6</b>).</p>
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Fig. 6.
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<h4>Circumference</h4>
<ol>
<li>Measure the circumference of the largest part of the bulb, and from this point to the distal end of the stump (<b>Fig. 7</b>).</li><li>Measure the circumference of the narrowest part of the shaft, and from this point to the distal end of the stump (<b>Fig. 8</b>)</li><li>Beginning at the narrowest part of the shaft, measure the circumference at one-inch intervals to the adductor fold (<b>Fig. 9</b>).</li></ol>
<h4>Bulb</h4>
<ol>
<li>Caliper the A-P and M-L dimensions at the largest part of the bulb (<b>Fig. 10</b>).</li><li>Palpate the bulb to locate the bony prominences and mark them with indelible pen.</li></ol>
<h4>Overall Length</h4>
<p>Measure the sound side as for a standard above-knee amputee.</p>
<h4>Stump Sock</h4>
<p>Make a tracing of the stump to accompany the measurements for ordering stump socks.</p>
<h3>Cast Fabrication</h3>
<h4>Materials</h4>
<ul>
<li>Fast-setting Johnson and Johnson plaster bandage</li>
<li>Elastic plaster bandage (Johnson and Johnson Orthoflex)</li>
<li>Cast sock</li>
<li>Stockinette</li>
<li>1-in. elastic webbing</li>
<li>A-P caliper</li>
<li>Yates clamp</li>
</ul>
<h4>Fitting The Cast Sock</h4>
<ol>
<li>Mark the shaft at the level where the A-P or M-L dimension is slightly larger than the A-P or M-L dimension of the bulb.</li><li>Measure the distance between the two points selected and cut one piece of stockinette that length (<b>Fig. 11</b>).</li><li>Cut five more pieces of stockinette, each 1/2 in. shorter than the last, and place them on the stump to fill in the narrow part. Place the shortest piece on the stump first, then the longer ones over it, <i>in reverse of what is shown in <b>Fig. 12</b>. </i>This facilitates removal of the cast.</li></ol>
<h4>Making The Cast</h4>
<p>The patient should stand with his stump vertical to the floor.</p>
<ol>
<li>Using the same technique as for a standard above-knee amputee, make the brim with the 4-in. elastic bandage, beginning at the lateral side of the stump at the level of the iliac crest (<b>Fig. 13</b>).</li><li>Complete the wrap with the 3-in. regular plaster bandage (<b>Fig. 14</b>).</li><li>Form the ischial seat while the bandage is still wet. With the A-P caliper set to the length measurement of the stump plus 3/16 in., place the short end under the ischium and line up the long end under the end of the stump. Then apply pressure under the ischium and have the patient thrust down until the stump end touches the caliper (<b>Fig. 15</b>).</li><li>At the same time, apply three-fingers' firm pressure to the proximal anterior medial aspect of the cast (<b>Fig. 16</b>). This prevents the socket from rotating internally on the stump.</li><li>The patient must remain in this position and the pressures must be maintained until the plaster sets.</li><li>Remove the cast.</li></ol>
<h4>Checking The Cast</h4>
<ol>
<li>Check the M-L and ischial-seat measurements of the cast against those of the patient. Be sure that the ischial seat has a large enough surface for the patient to sit firmly upon it. If necessary, build up the seat with plaster before filling the cast (<b>Fig. 17</b>).</li><li>Check the length of the cast against the patient's stump length. They should be the same. If the cast is longer than the stump, pressure was not applied directly under the ischium. If the cast is shorter than the stump, the patient was not thrusting down to maximal stretch. If the difference does not exceed 3/8 in., the mold can be modified. If there is a greater than 3/8-in. difference, a new cast should be made.</li></ol>
<h4>Modifying The Mold</h4>
<p>To correct the length measurement:</p>
<ol>
<li>Measure from the ischial seat to the end of the mold.</li><li>Remove or add enough plaster (but no more than 3/8 in.) to the ischial seat to correct the length.</li></ol>
<p>To correct the flexion or extension angle (<b>Fig. 18</b>):</p>
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Fig. 18.
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<ol>
<li>Draw a line down the medial aspect of the mold, bisecting it into medial and posterior halves.</li><li>Set the goniometer at 90 deg.; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the medial aspect of the mold.</li><li>Shape the surface of the seat along this line. The shaft should be at 0 deg. of flexion and extension.</li></ol>
<p>To correct the abduction or adduction angle (<b>Fig. 19</b>):</p>
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Fig. 19.
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<ol>
<li>Draw a line down the posterior aspect of the mold, bisecting it into medial and lateral halves.</li><li>Set the goniometer at 90 degrees ; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the posterior aspect of the mold.</li><li>If the shaft is in <i>adduction, </i>remove plaster from the outside edge of the ischial seat. If the shaft is in <i>abduction, </i>add plaster to the outside edge of the ischial seat. The shaft should be at 0 degrees of abduction or adduction.</li></ol>
<p>To modify the anterior brim (<b>Fig. 20</b>):</p>
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Fig. 20.
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<ol>
<li>Form the height of the anterior brim: Draw a line at the ischial level across the anterior aspect of the mold from point A to point B. Divide the line in half at point C. From point C, draw a line at right angles to AB, extending it two inches proximal to point D. Line CD forms the height of the anterior brim.</li><li>To establish the anterior brim line, extend a line from point B one inch medially to point E. Point E should be in line with the ischial seat when viewed from the front. Draw a line on a smooth curve from point D to point E (<b>Fig. 20</b>).</li><li>Form a reverse curve along line DE to facilitate sitting and bending. Using a rasp or gouge, remove up to 1/4 in. of plaster from the area medial to line CD. This will ensure good contact along the anterior brim wall with the stump. If necessary, build up with plaster along line DE to form the reverse flare (<b>Fig. 21</b>).</li></ol>
<p>To modify the lateral brim:</p>
<ol>
<li>Continue line DE from the anterior brim proximally to encompass two-thirds of the distance between the ischium and the iliac crest. Continue laterally, following the contour of the lip, then distally to the posterior-lateral corner of the ischial seat (<b>Fig. 22</b>).</li><li>Contour the lateral wall. Do not remove plaster below the ischial level (<b>Fig. 23</b>). Establish flare along the lateral brim line.</li></ol>
<p>To modify the shaft:</p>
<ol>
<li>Correct the circumference measurements. Mark off the levels at which the circumference measurements were obtained. Note each measurement on the mold. Where it is necessary, the circumference measurements of the mold should be modified to be the same as those of the stump (<b>Fig. 24</b>).</li><li>At the brim area, blend the medial and posterior walls smoothly with the medial brim and ischial seat (<b>Fig. 25</b>).</li></ol>
<p>To modify the bulb:</p>
<p>Build up over the bony projections no less than 1/4 in. (These projections should be marked during the measurement and casting procedure.) <i>Be extremely careful while accomplishing this, as attempting relief in this area is extremely difficult </i>(<b>Fig. 26</b>).</p>
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Fig. 26.
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<p>Recheck the mold measurements. Smooth the entire mold (<b>Fig. 27</b>).</p>
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Fig. 27.
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<h3>Flexible-Socket Fabrication</h3>
<h4>Materials</h4>
<ul>
<li>Ambroid varnish or the equivalent</li>
<li>Five PVA sleeves (regular size and shape)</li>
<li>Two 1-oz. fitted Dacron (TM) sleeves</li>
<li>Four or five regular-length fitted nylon stockinettes (for fabricating the flexible layers)</li>
<li>Three extra-long fitted nylon stockinettes (for fabricating the hard socket)</li>
<li>Cast sock(s) (to equalize the stump sock)</li>
<li>Flexible polyester resin #4134</li>
<li>RTV elastomer Dow Corning #384</li>
<li>Rigid polyester resin #4110</li>
<li>150-A yellow wax (available from E. S. Browning Co., Los Angeles, Calif.) or any wax suitable for shaping</li>
<li>Outside calipers</li>
<li>Wood rasp</li>
<li>Vacuum machine</li>
<li>Oven with at least 200 degrees F temperature range</li>
</ul>
<p>Make the Dacron sleeves to fit the entire brim area. The Dacron must not be incorporated in the flexible layers.</p>
<p>The number of stockinettes needed depends upon the size and activeness of the patient. Four are used on the less active patient, and five on the more active. These are separate pieces, sewn on one end and trimmed to 1/2 in. of the stitching. The width of the stockinette should be such that it stretches very minimally in what is to be the flexible wall.</p>
<p>The three extra-length stockinettes must be long enough to double over in the brim area.</p>
<p>One heavy and one lightweight cast sock are used for a 3-ply wool sock; two heavy and one lightweight cast sock are used for a 5-ply wool socket, etc.; or an old wool stump sock of the same weight can be used.</p>
<p>The 150-A yellow wax is heated until it is soft enough to work with a spatula. With this type of wax, it is never necessary to melt it completely and pour it into a cone.</p>
<h4>Procedure</h4>
<ol>
<li>With the outside calipers, measure for the area where the bulb can pass through freely. Mark this area heavily with a pencil (<b>Fig. 28</b>).</li><li>If the cast is wet, seal it with three coats of ambroid varnish.</li><li>Apply the appropriate number of cast socks (or an old stump sock) needed for stump-sock clearance. Tie them off securely on the mandrel.</li><li>Apply the first PVA sleeve, which will be the parting agent. Cap it on the end and tie it off on the mandrel.</li><li>Apply two Dacron sleeves, being sure not to overlap into the flexible walled area which starts at the mark made in step 1. It is advisable to leave at least 1 in. between the mark and the Dacron sleeves (<b>Fig. 29</b>).</li><li>Apply one layer of stockinette and tie it off on the mandrel. If necessary, separate and smooth the extra half-inch of material. With the outside calipers, measure again for the area where the bulb can pass through freely, and mark this area with a pencil.</li><li>With pressure-sensitive tape, make a full turn around the model at the mark made in the previous step (<b>Fig. 30</b>). This seals off the proximal end of the flexible wall.</li><li>Attach the vacuum line.</li><li>Apply the second PVA sleeve and seal it off on the mandrel, then repeat step 7.</li><li>Mix thoroughly enough 4134 flexible polyester resin to cover the area from the tape to the end of the model. Using vacuum, laminate this area <i>only. </i>(It is helpful if, at the end of each laminating step, the excess is tied off, thus saving the time of grinding it away.) Allow to set well (<b>Fig. 31</b>).</li><li>Remove the second PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette. Do not break through to the parting PVA (<b>Fig. 32</b>). Apply two more layers of stockinette, again separating and smoothing down the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the third PVA sleeve, seal it off at the mandrel, and repeat step 7.</li><li>Mix thoroughly enough 384 RTV to cover the laminated area. Using vacuum, laminate this area only. Allow to set well (<b>Fig. 33</b>).</li><li>Remove the third PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette beyond the stitching (as in <b>Fig. 32</b>).</li><li>Apply one or two more layers of stockinette, again separating and smoothing the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the fourth PVA sleeve, seal it off on the mandrel, and repeat step 7.</li><li>Repeat step 10.</li><li>Remove the fourth PVA sleeve. Remove the pressure-sensitive tape around the model.</li><li>For the wax build-up (<b>Fig. 34</b>), apply wax to the model from the proximal end of the flexible wall distally to the <i>largest </i>circumference of the bulb end. The thickness of the build-up should be sufficient to allow the bulb to expand the flexible wall through the narrow area. Use the outside calipers to measure the thickness of the build-up. Allow 3/16-in. thickness for the flexible-wall lamination. (Keeping in mind some goals for the finished prosthesis, such as cosmesis and lightness in weight, in most cases it is possible and advisable to "go overboard" on the wax build-up. Cosmetic build-up is kept to a minimum, and air space is weightless.) Allow the wax to cool and harden (<b>Fig. 35</b>).</li><li>Smooth the surface and taper the proximal and distal edges (<b>Fig. 36</b>).</li><li>Using the wood rasp, roughen the exposed tip of the bulb end enough to cut through to the RTV layer and to raise the half-inch of stockinette beyond the stitching on the final 4134 resin layers. <i>This step is extremely important, </i>as it will securely bond the flexible portion of the socket to the rigid outside shell (<b>Fig. 37</b>).</li><li>Apply the three extra-long nylon stockinettes, doubling the first two layers back at the brim (<b>Fig. 38</b>).</li><li>Apply the fifth PVA sleeve and seal it off on the mandrel. Mix enough 4110 polyester resin to cover the entire mold. Using vacuum, laminate the entire mold. Allow it to set (<b>Fig. 39</b>).</li><li>After the resin has set, cut a flap through it 3/4 in. in diameter at the distal edge of the wax build-up. Tape the flap back (<b>Fig. 40</b>).</li><li>Hang the entire laminated cast in the oven (heated to 175 degrees F) and allow <i>all </i>the wax to drain out.</li><li>Remove the laminated cast from the oven after the wax has drained. Allow the lamination to cool just enough for the rigid shell portion to harden. Mark the approximate trim line and cut along it with a Stryker saw. A strong tug, along with use of a hammer and piece of wood when needed, will separate the socket from the cast (<b>Fig. 41</b>).</li><li>To complete the socket, finish sanding the brim down to the trim lines.</li></ol>
<h3>Fitting</h3>
<h4>Materials</h4>
<ul>
<li>Fitting stool</li>
<li>Talcum powder</li>
<li>Stump sock</li>
<li>Mandrel padded at the end with stockinette in the shape of a bulb</li>
<li>Heat gun</li>
<li>Silicone amputation-stump spray</li>
</ul>
<h4>Procedure</h4>
<ol>
<li>Set the socket in a wood block with the seat level.</li><li>Place the block on a fitting stool to get the correct ischium-to-floor length.</li><li>Lightly powder the socket.</li><li>Have the patient apply the stump sock and hold it firmly at the top as he pushes his stump into the socket (<b>Fig. 42</b>). (If the patient cannot push all the way into the socket, the flexible layers will need to be stretched as described in the next section.)</li><li>Check to see that the patient's ischium is firmly on the seat, and that he has light contact at the end of the stump. Do this by having him bear weight on the socket and by requesting him to "reach down into the socket" with his stump. If as he does this, he loses firm contact with the seat, the socket is too short. If he cannot feel contact on the bottom, the socket is too long. A sponge pad in the bottom of the socket may give the necessary light contact.</li><li>Have the patient lift his hip to take weight off the socket. There should be no more than 1/4 in. of piston action (<b>Fig. 43</b>).</li><li>Check for pressure areas in the bulb. With the patient standing, have him flex his hip while you apply resistance to the distal anterior end of the socket. Then have the patient abduct, extend, and ad-duct the hip, each time applying resistance to the distal end of the socket. There should be no pain from these maneuvers. (Pain may be caused by a wrinkle in the sock, by the presence of wax in the air space, or from inadequate relief over the bony prominences in the bulb.)</li><li>Establish the anterior and posterior trim lines. In the posterior lateral area, trim the socket so that it does not encase the gluteal area. Then have the patient sit in a chair and lean forward. Check for discomfort in the anterior area, and trim the socket to fit. There should be no gapping of the lateral wall. The anterior brim of the socket should be in firm contact with the skin, for looseness here would allow the socket to rotate internally on the stump when the patient walks.</li><li>To remove the socket, the patient should pull up on the top of the stump sock while pulling down on the socket. In a few cases, this was the only way in which the socket could be removed (<b>Fig. 44</b>).</li></ol>
<p><i>Stretching the Flexible Layers</i></p>
<p>If the patient cannot push his stump all the way into the socket, it will be necessary to stretch the flexible layers to allow the bulb to pass through the narrow part of the socket. This can be accomplished as follows:</p>
<ol>
<li>Place the padded mandrel in a vise.</li><li>Heat the inside of the socket to soften the flexible layers.</li><li>Work the socket back and forth on the mandrel, stretching the flexible layers.</li><li>Let the socket cool on the mandrel, with the padded end of the mandrel at the narrowest part of the socket.</li><li>Refit as in the preceding section, using silicone spray in the socket if necessary.</li></ol>
<h3>Alignment</h3>
<h4>Bench</h4>
<p>The initial set-up is made with the ischial seat level. The posterior plumb line for the heel center passes between the center of the end of the socket and the point where the ischium rests on the ischial seat (<b>Fig. 45a</b>). The lateral plumb is taken from the center of the end of the socket and passes % in. anterior to the knee center (<b>Fig. 45b</b>). The socket is set in 15 degrees -30 degrees of internal rotation to the line of progression to compensate for the patient's tendency to internally rotate the pelvis to advance the prosthetic leg (<b>Fig. 45c</b>).</p>
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Fig. 45a.
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Fig. 45b.
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<p class="clsTextCaption"><br />
Fig. 45c.
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<h4>Functional</h4>
<p>The prosthesis is the correct length when the patient's spine is as straight as possible when he stands with his weight on both legs, i.e., in the finished prosthesis. The iliac crests of these patients are not always symmetrical, and it may not be a reliable reference point for judging the length of the prosthesis (<b>Fig. 46</b>).</p>
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<p class="clsTextCaption"><br />
Fig. 46.
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<p>Dynamic alignment is done with the socket set on a child-size above-knee jig. Optimal dynamic alignment is based on standards set for the standard above-knee amputee.</p>
<h3>Summary</h3>
<p>This fitting technique can also be used on other stumps with bulbous ends: Syme's and above-elbow amputations and wrist disarticulations, for example.</p>
<p>At CAPP, more than 20 patients have been fitted in this manner: 18 PFFD's, 2 bilateral Syme's amputations, 1 wrist disarticulation, and 1 above-elbow amputation. All of these patients' deficiencies were congenital in origin.</p>
<p>The procedure described does require more fabrication time and material. Once the technique is mastered, it requires about three hours of the prosthetist's time, whereas a solid socket can be fabricated in an hour. However, the CAPP patients have shown a marked preference for this type of socket. It provides a very precise fitting, and in every case the child has expressed a feeling of greater security when wearing this socket (<b>Fig. 47</b>).</p>
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<p class="clsTextCaption"><br />
Fig. 47.
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<p>Another advantage is the apparent absence of skin breakdown. When the patient comes to the clinic for post-fitting examination, the characteristic blanching of the stump skin is absent, as are signs of rubbing, blistering, or callousing so often seen with use of the solid socket.</p>
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<p class="clsTextCaption"><br />
Fig. 7.
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<p class="clsTextCaption"><br />
Fig. 8.
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<p class="clsTextCaption"><br />
Fig. 9.
</p>
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<p class="clsTextCaption"><br />
Fig. 10.
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</tbody></table>
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<p class="clsTextCaption"><br />
Fig. 11.
</p>
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<p class="clsTextCaption"><br />
Fig. 12.
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</tbody></table>
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<p class="clsTextCaption"><br />
Fig. 13.
</p>
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<p class="clsTextCaption"><br />
Fig. 14.
</p>
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<p class="clsTextCaption"><br />
Fig. 15.
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<p class="clsTextCaption"><br />
Fig. 16.
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<p class="clsTextCaption"><br />
Fig. 17.
</p>
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<table>
<tbody><tr>
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<tbody><tr>
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<p class="clsTextCaption"><br />
Fig. 21.
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<p class="clsTextCaption"><br />
Fig. 22.
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<p class="clsTextCaption"><br />
Fig. 23.
</p>
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Fig. 24.
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Fig. 28.
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Fig. 29.
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Fig. 30.
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Fig. 31.
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Fig. 32.
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Fig. 33.
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Fig. 34.
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Fig. 36.
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Fig. 37.
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Fig. 38.
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Fig. 40.
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Fig. 42.
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Fig. 43.
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Fig. 44.
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<p><b>References:</b></p>
<ol>
<li>Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</li>
<li>Marx, Herbert W., An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li>
<li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 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>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carman Tablada. C.P. </b></td></tr><tr><td class="clsTextSmall">Mr. Tablada is a clinical prosthetist at the Child Amputee Prosthetics Project, University of California, Los Angeles. This study was made under MCH Project No. 204, Division of Health Services and Mental Health Administration, Maternal and Child Health Service, Department of Health, Education, and Welfare. The photographs were taken by Mary Louise Histon.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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Title
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A Technique for Fitting Converted Proximal Femoral Focal Deficiencies
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Carman Tablada. C.P. *
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DRFOP - Legacy
Full Text PDF
PDF Including Full Text and Original Layout
http://www.oandplibrary.org/al/pdf/1971_02_011.pdf
Year
1971
Volume
1
Issue
2
Page Number(s)
11 - 15
Text
Any textual data included in the document
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<td><p class="clsTextSmall">with original layout</p></td>
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<h2>The CAPP Electric Cart: Recent Developments</h2>
<h5>Carl Sumida, C.P.O. <a style="text-decoration:none;">*</a><br />Yoshio Setoguchi, M.D. <a style="text-decoration:none;">*</a><br />Julie Shaperman, M.A., O.T.R. <a style="text-decoration:none;">*</a><br /></h5>
<p>Since the development of the first Child Amputee Prosthetics Project (CAPP) electric cart<a></a> the device has been completely redesigned. A limited number were produced in 1968-69, and a field test was conducted by New York University. This article describes the mechanical changes that have been made in the cart. The report of the field test is presented elsewhere in this issue.</p>
<p>The changes in no way altered the basic concept of the cart, and the design is still consistent with the original criteria: (1) the cart should be a powered vehicle which provides mobility to severely limited, limb-deficient children; (2) the controls should be simple to operate; (3) the cart should be compact, highly maneuverable, yet very stable and transportable; and (4) it should require minimal maintenance, and be attractive in appearance without resembling a wheelchair.</p>
<p>Earlier models of the cart are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. These prototypes were built between 1962 and 1966. The changes made since prototype III have made the production of the 14 carts needed for the field test less costly. <b>Fig. 4</b> and <b>Fig. 5</b> show the cart produced in 1968-69 for the field test. The differences between this model and the 1966 prototype are described below.</p>
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Fig. 1. Prototype I, CAPP electric cart.
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Fig. 2. Prototype II, CAPP electric cart.
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Fig. 3. Prototype III, CAPP electric cart.
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Fig. 4. Field-test cart.
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Fig. 5. Field-test cart folded.
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<h3>Structural Changes</h3>
<p>The chassis, redesigned to simplify construction, is built of 1-in.-square mechanical tubing. The seat frame is made of 1/4-in. square, chromed mechanical tubing. The front axle was redesigned to allow torsional or vertical movement by means of a central pivot stud that is located at the center of the axle, which allows the chassis to travel over an uneven surface and still maintain four-wheel contact and stability.</p>
<p>A new folding-seat arrangement makes the cart more compact for transport and adds lateral support from the side arms. The arms are set back far enough to allow the cart to be placed close to a table, desk, or washbasin. The frame for the backrest can be folded flat by lifting it slightly out of its locking notch and allowing it to fold forward onto the seat cushion.</p>
<p>A shell made of metallic-green fiber glass covers the chassis and power equipment. The upholstery for the seat cushion and backrest is black Leatherette (TM). The seat frame is slightly larger than the seat cushion, thus leaving a small space for storage behind the cushion. Eight-inch, spoked casters with one-inch, solid-rubber tires (wheelchair type) are used on all four wheels.</p>
<h3>Power-System Changes</h3>
<p>The two drive motors are positioned independently on each side of the chassis. Each motor drives a specially designed worm-gear reduction box. The rear wheels are mounted directly on the output shaft of the gearbox, which is bolted to the frame. Power is fed into the gearbox through a Browning gear belt.</p>
<p>A third motor powers seat raising and lowering. This motor is mounted adjacent to the right drive motor and is connected to the two rear screw jacks by a Browning gear belt and to a single front screw jack by a flexible shaft. These screw jacks raise the seat platform nine inches.</p>
<p>The battery is positioned between the rear wheels and is easily accessible from the rear of the cart. This arrangement is more convenient than the side opening in the previous model, but it necessitated repositioning the motors and gear boxes, which had been a single package at the rear of the cart in prototype III.</p>
<p>The control box is a specially designed unit developed at CAPP. It has toggle switches for directional control and a separate switch to raise and lower the seat. A circuit breaker was added to prevent an overload of the drive system. The switch controls are housed in a compact cylindrical unit that is mounted at the end of an reshaped control arm, which is attached to the left side of the seat frame and extends to the child's chin. The control arm can be adjusted for height and distance from the seat back. The chin receptacle is positioned next to the seat-elevation-control lever and is foam-padded (see <b>Fig. 4</b> and <b>Fig. 5</b>). The control arm is held in position in front of the child by a ramp lock. When lifted slightly, the control arm swings out for seat folding, the child's use of the table top, or transfer.</p>
<p>The specifications for the cart's power equipment, size, turning radius, etc., are shown in <b>Fig. 6</b>.</p>
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Fig. 6. Dimensions and specifications of CAPP electric cart.
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<h3>Changes Since Field Test</h3>
<p>In November 1970, two additional changes were made. (The modified cart, with the new wheels and control unit, is shown in <b>Fig. 7</b>.)</p>
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Fig. 7. Cart with solid rear wheels and new control unit.
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<ol>
<li>A new solid-state proportional control unit, now available commercially, was selected to replace the previous control unit. This new unit (manufactured by the Motorette Corporation of Reseda, California) provides proportional (variable-speed) control and an on-off master switch. The manufacturer provided a control for raising and lowering the seat so that the unit could be used with the electric cart. The control box can be positioned for control by the chin or an extremity. The circuitry unit fits on the storage rack behind the seat.</li><li>The rear drive wheels were changed from spoke casters to specially designed cast-aluminum wheels to eliminate the possibility of breakage due to high torques, but they have the same solid-rubber tires as the front casters. Although the use of pneumatic tires is being considered, solid-rubber tires have been retained for the present because they provide less rolling resistance and thus prolong the life of the battery. Also, solid-rubber tires are more reliable for a testing program because no problems arise from variations in air pressure.</li></ol>
<h3>Production</h3>
<p>The gear box, control box, chassis, body, and seat-lifting mechanisms for the carts used in the field test were specially de- signed by Mr. Carl Sumida at the Child Amputee Prosthetics Project at UCLA. These items were manufactured by subcontractors, and other components were purchased from commercial sources. The fourteen carts were assembled for the field test at the CAPP (<b>Fig. 8</b>).</p>
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Fig. 8. Assembly of field-test carts.
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<p>During the field test, all mechanical repairs were made at CAPP. At the end of the test, all the carts were rechecked, new control boxes were installed, and new wheels were applied. The carts have been returned to the children who participated in the field test, who will continue to use them as long as necessary.</p>
<p>Attempts are now being made to find a commercial manufacturer for the electric cart because it has proven to be an extremely valuable aid to the mobility of the severely limb-deficient child.</p>
<p><b>References:</b></p>
<ol>
<li><i>Artificial Limbs </i>8:2:42-44, Autumn 1964.</li>
<li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, <i>Eighth Annual Report 1962, </i>pp. 51-53.</li>
<li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, <i>Ninth Annual Report 1963, </i>p. 20.</li>
<li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, <i>Tenth Annual Report 1964, </i>pp. 1-10.</li>
<li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, <i>Eleventh Annual Report 1965, </i>pp. 9-11. (Reprinted in <i>Inter-Clinic Inform. Bull. </i>5:9:12-14, 1966.)</li>
</ol>
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<div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Artificial Limbs 8:2:42-44, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, Eighth Annual Report 1962, pp. 51-53.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, Ninth Annual Report 1963, p. 20.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, Tenth Annual Report 1964, pp. 1-10.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, Eleventh Annual Report 1965, pp. 9-11. (Reprinted in Inter-Clinic Inform. Bull. 5:9:12-14, 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>Julie Shaperman, M.A., O.T.R. </b></td></tr><tr><td class="clsTextSmall">Mrs. Shaperman is a research therapist with the project.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Yoshio Setoguchi, M.D. </b></td></tr><tr><td class="clsTextSmall">Mr. Sumida is a research prosthetist.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carl Sumida, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Dr. Setoguchi is the medical director of the Child Amputee Prosthetics Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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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
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The CAPP Electric Cart: Recent Developments
Creator
An entity primarily responsible for making the resource
Carl Sumida, C.P.O. *
Yoshio Setoguchi, M.D. *
Julie Shaperman, M.A., O.T.R. *
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DRFOP - Legacy
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Year
1971
Volume
15
Issue
1
Page Number(s)
22 - 26
Text
Any textual data included in the document
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<h2>Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations</h2>
<h5>Maurice A. LeBlanc <a style="text-decoration:none;">*</a><br /></h5>
<p>In the past few years, a number of pros-thetists have been fabricating elastic-liner types of Syme prostheses, and their procedures have been described in the literature. <a></a> This article presents the most commonly used procedure and some of the variations to it.</p>
<p>The elastic-liner type of Syme prosthesis has the advantage of eliminating the door on the conventional prosthesis (<b>Fig. 1</b>), thereby allowing greater strength (with no openings) and a smoother cosmetic finish (with no straps) while maintaining total contact and suspension (<b>Fig. 2</b>). However, it cannot be used if the bulbous end of the stump is too large for satisfactory cosmesis of the cylindrical portion or for making the liner (not possible when the distal end is larger than the proximal brim).</p>
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Fig. 1. Conventional Syme prosthesis.
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Fig. 2. Elastic-liner Syme prosthesis.
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<h3>Basic Procedure</h3>
<ol>
<li>Felt patches are placed on the stump for relief of bony prominences and/or sensitive areas.</li><li>A plaster cast is taken of the stump with partial weight-bearing and with blocks making up the length discrepancy.</li><li>The largest diameter of the bulbous end of the stump is measured, and the proximal level of the stump model is marked where its largest diameter equals that of the bulbous end.</li><li>Using nylon stockinette, the inner socket is vacuum-laminated with Silastic (TM) elastomer #384 from the level marked in step 3 to the end of the stump (<b>Fig. 3</b>).</li><li>The remainder of the inner socket (the proximal brim down to the level of the elastomer) is laminated with Laminac (TM) #4110 polyester resin.</li><li>A wax build-up is made over the center portion of the inner socket between the bulbous end and the level marked in step 3 (<b>Fig. 4</b>). The build-up is cylindrical in shape to allow entry of the stump into the socket.</li><li>The outer shell of the socket is laminated with Laminac #4110. <b>Fig. 5</b> shows a cutaway view of the inner socket and outer shell of the prosthesis. Note that the end of the liner must be attached to the outer shell so it will not pull out with the stump.</li><li>Using reference lines established on the plaster cast, the socket is statically aligned following the attachment of a SACH foot which has been cut and shaped to receive the bulbous end of the socket. (There is normally about a three-inch height discrepancy with the Syme's amputation.)</li><li>The socket is then dynamically aligned to the amputee's gait. Depending on the method of attachment of the SACH foot to the socket, adjustment is usually provided by means of an alignment disc or by repositioning the socket with quick-setting epoxy resin.</li><li>The prosthesis is completed by laminating the socket and keel of the SACH foot and reattaching the sole (<b>Fig. 6</b>). Fiberglass reinforcement is usually used in the lamination.</li></ol>
<h3>Variations</h3>
<ol>
<li>Alginate can also be used to make the negative impression of the stump. It gives better detail, and its elasticity allows easy stump removal. However, it is expensive, and one cannot see to position the heel pad while it is setting.</li><li>Modification can be accomplished on the plaster model instead of using the felt patches. Either way is satisfactory, but using the patches saves time and is equally effective if they are properly placed.</li><li> A combination of 80% of Silastic elastomer #384 and 20% of #386 (foam) for the liner can be used to increase its expandability. More than 20% of #386 foams too much and reduces durability. <a></a></li><li> One variation on the size of the liner is to laminate the liner down to the largest diameter of the bulbous end rather than including the entire end. It is then not necessary to attach the end of the liner to the outer shell (<b>Fig. 7</b>).</li><li> Another method of sizing the liner is to make an elastic window in the inner socket instead of making a whole inner bladder (<b>Fig. 8</b>). This allows entry by rotating the stump as it goes into the socket, and makes possible a very cosmetic prosthesis.</li><li> Instead of making a wax build-up, it is possible to use Silastic elastomer #386 foam for the space between the liner and outer shell and to leave it in the prosthesis. It is lightweight and can be compressed to allow entry of the stump. (This procedure is being used by William Sinclair, C.P.O., at Jackson Memorial Hospital in Miami, Florida.)</li><li>Another way to modify the SACH foot and attach it to the socket is shown in <b>Fig. 9</b> and <b>Fig. 10</b>.</li></ol>
<p>A wooden block is fitted and fastened to the distal end of the socket, and the bottom is sanded so it establishes the flexion and adduction angles of the socket. The wooden block forms a socket base for attachment of the SACH foot with the hardwood base and plug which reinforce the keel.</p>
<h3>Acknowledgments</h3>
<p>The author wishes to thank Herbert W. Marx, C.P.O., and Robert Mazet, Jr., M.D., for lending several of the illustrations used in this article.</p>
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Fig. 3.
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Fig. 4.
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Fig. 5.
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Fig. 6.
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Fig. 7.
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Fig. 8.
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Fig. 9.
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Fig. 10.
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<p><b>References:</b></p>
<ol>
<li>Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</li>
<li>Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li>
<li>Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</li>
<li>Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</li>
<li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</li>
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<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">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, 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>Maurice A. LeBlanc </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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DRFOP - Legacy
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Year
1971
Volume
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Issue
2
Page Number(s)
6 - 10
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<h2>The Children's Prosthetics and Orthotics Program</h2>
<h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5>
<p>During the early 1950s, pioneering clinicians in the management of the child amputee repeatedly insisted that children were not miniature adults, to whom modes of fitting developed for adults could be applied indiscriminately. The physicians argued that these children had characteristics and problems that required special study and treatment. Primarily because of the missionary efforts of these men, the Committeee on Prosthetics Research and Development in February 1956 moved from an indirect role in the area of children's prosthetics to an active and dynamic one by the establishment of a standing Subcommittee on Child Prosthetics Problems (SCPP). The first chairman, Charles H. Frantz, M.D., guided the activities of the subcommittee until 1965, when he was succeeded by George T. Aitken, M.D. The current membership of the subcommittee appears at the end of this article.</p>
<p>Concurrently with the establishment of the SCPP, the Child Prosthetics Studies program at New York University was created under the direction of Sidney Fish-man, Ph.D. From its inception, the New York University program has been closely related to the activities of the Subcommittee on Child Prosthetics Problems. In essence, New York University has acted as an executive arm of the subcommittee in implementing many of its recommendations. This relationship led to the initiation and completion of numerous significant studies, some of which were: (1) extensive laboratory and field evaluations of various models of the APRL-Sierra no. 1 hand; (2) tests of the Dorrance juvenile hand, size no. 2; (3) studies of the application of the quadrilateral suction socket to the juvenile above-knee amputee, and of the patellar-tendon-bearing prosthesis to the skeletally immature below-knee amputee; (4) a field evaluation, preceded by the development of a fabrication manual and an instructional course, on the Minister-type fitting for the below-elbow amputation stump; and (5) laboratory and field studies of the CAPP electric cart.</p>
<p>Significant nonevaluation activities included studies of the prosthetic fitting of children amputated for malignancy, numerous surveys and census-type studies of children under treatment, and follow-up studies related to the early work of Frantz and O'Rahilly in the classification of congenital limb deficiencies, with efforts to achieve an internationally acceptable system.</p>
<p>As a result of the activities of the subcommittee and of the studies conducted at its instigation by New York University, a number of important by-products have emerged:</p>
<ol>
<li>The treatment of the limb-deficient child has become a recognizable subspecialty in medicine that has attracted many competent physicians.</li><li>The principle of fitting the child with congenital limb deficits at a very early age has been well established.</li><li>The early fitting of the juvenile who loses a limb because of malignancy, other diseases, or trauma has also become generally accepted.</li><li>Developers and manufacturers have been encouraged to produce prosthetic components for all age levels of the child-amputee population.</li></ol>
<h3>Cooperative Clinic Program</h3>
<p>A significant early action of SCPP was to bring together in August 1958 a group of persons with a known interest in the treatment of the child amputee. Included were the chiefs of 11 existing child-amputee clinics who agreed to cooperate in studies seeking improved treatment for the limb-deficient child. The participants in this historic meeting were:</p>
<ul>
<li>Gen. F. S. Strong, Jr., Washington, D.C.</li>
<li>Tonnes Dennison, Beverly Hills, Calif. </li>
<li>George T. Aitken, M.D., Grand Rapids, Mich.</li>
<li>Carleton Fillauer, Chattanooga, Tenn.</li>
<li>Charles H. Frantz, M.D., Grand Rapids, Mich.</li>
<li>Colin A. McLaurin, Chicago, HI.</li>
<li>Charles Radcliffe, Ph.D., Berkeley, Calif.</li>
<li>Harry Campbell, Los Angeles, Calif.</li>
<li>Leon DeVel, M.D., Grand Rapids, Mich.</li>
<li>Edward Hitchcock, New York, N.Y.</li>
<li>Bertram Litt, New York, N.Y.</li>
<li>Edward Peizer, Ph.D., New York, N.Y.</li>
<li>Anna M. Bahlke, Albany, N.Y.</li>
<li>Milo Brooks, M.D., Los Angeles, Calif.</li>
<li>Capt. Thomas Canty, Oakland, Calif.</li>
<li>Carleton Dean, M.D., Lansing, Mich.</li>
<li>George G. Deaver, M.D., New York, N.Y.</li>
<li>Sidney Fishman, Ph.D., New York, N.Y.</li>
<li>Col. Maurice Fletcher, Washington, D.C.</li>
<li>James Glessner, M.D., Newington, Conn.</li>
<li>J. Leonard Goldner, M.D., Durham, N.C.</li>
<li>Richard E. King, M.D., Atlanta, Ga.</li>
<li>Claude N. Lambert, M.D., Chicago, HI.</li>
<li>Arthur J. Lesser, M.D., Washington, D.C.</li>
<li>Robert Mazet, Jr., M.D., Los Angeles, Calif.</li>
<li>John R. Moore, M.D., Philadelphia, Pa.</li>
<li>Frank Potts, M.D., Buffalo, N.Y.</li>
<li>Frederick Vultee, M.D., Richmond, Va.</li>
</ul>
<p>Subsequently, other child-amputee clinics sought affiliation with the cooperative program, and, upon meeting the criteria or standards established by the subcommittee, additional clinics have been accepted into the cooperative research endeavor. Thirty clinics, broadly distributed, have now been accepted.</p>
<p>A large proportion of the studies authorized by the subcommittee have been carried out by the participating clinics under the guidance of New York University.</p>
<p>In addition to the 30 clinics currently enrolled in the cooperative program, contact is being maintained with 36 other child-amputee clinics.</p>
<h3>Projects</h3>
<p>By the mid-1960s, it had become apparent that significant advances had been made in prosthetics generally. Many of the improved fitting techniques that had been developed were found to be applicable to children, and numerous components of advanced design had been made available for use by the child amputee. As a result, children with less severe or with uncomplicated limb deficits, of either congenital or acquired origins, could be treated, and reasonably satisfactory results could be expected. However, the management of the child with severe losses, particularly those affecting both upper limbs at high levels, left much to be desired. The solutions to these problems were considered to be in the successful application and control of externally powered devices. Although available components and systems of this type were (and are) relatively crude, they are regarded as the hope of the future, and a major evaluation and redevelopment effort is being mounted. Already in progress or about to be initiated as a result of prior action by the Subcommittee on Child Prosthetics Problems are a number of studies of great potential value in the evaluation of improved devices and treatment procedures.</p>
<p>Studies will be conducted by New York University, through the participating clinics, on the Ontario Crippled Children's Centre (OCCC) coordinated electric arm, an advanced model of the Michigan Crippled Children Commission feeder arm, the OCCC electric elbow, the Rancho Los Amigos Hospital electric elbows, the Otto Bock myoelectric hand, and the Viennatone myoelectric hand.</p>
<p>At the request of SCPP, New York University has conducted an annual census of the child amputees who are being treated at the cooperating clinics. For 1969, the data indicated that the total population under treatment was 4,625-an increase of 236 over the prior year. An expanded census relative to the calendar year 1970 has been completed. <b>Fig. 1</b></p>
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<h3>Specialized Fitting Centers</h3>
<p>At its meeting on October 21, 1967, the Committee on Prosthetics Research and Development approved a proposal by the Subcommittee on Child Prosthetics Problems that an ad hoc committee be established to develop a detailed plan for the creation of specialized prosthetics fitting centers for severely handicapped children. At its meeting on June 12, 1968, CPRD received the report of the committee, which presented criteria for operation of the centers. This plan, which had been previously approved by the child-amputee clinics, was also approved by CPRD.</p>
<h3>Children's Orthotics</h3>
<p>At its meeting on November 4-5, 1969, the Committee on Prosthetics Research and Development charged the Subcommittee on Child Prosthetics Problems with the responsibility for enlarging its sphere of activities to include children's orthotics. An ad hoc committee of SCPP was appointed to investigate the implications of this new responsibility and to make recommendations for its implementation. It should be noted that the Subcommittee on Design and Development of CPRD had already conducted a number of meetings and workshops on orthotics topics, particularly in the area of lower-extremity bracing, which was the first segment of the orthotics field to be investigated, and many items with possible applications to orthopedically disabled children were beginning to emerge from this work.</p>
<p>Upon the recommendation of the ad hoc committee, a number of selected lower-extremity orthotics items that had emerged from the design and development effort and several bracing and ambulation aids that had been developed at the Ontario Crippled Children's Center were demon- strated at a meeting of amputee-clinic chiefs on June 11, 1970, and the clinic chiefs were polled as to their interest in clinical applications of the items demonstrated. Their responses were tabulated by New York University and revealed considerable interest in virtually all items. The Subcommittee on Child Prosthetics Problems reviewed these findings at its October 16, 1970, meeting and recommended that NYU undertake the recruitment of a nucleus of clinics interested in a cooperative research program on treatment devices for cerebral palsy, Legg-Perthes disease, and myelomeningocele. It was further recommended that orthopedic surgeons currently participating in the program be surveyed to identify clinics they knew to be interested in these problems. Subsequently, NYU reported that three clinics in the New York City area had indicated an interest in participating, and that discussions were being held with these clinics to develop a format for the initiation of a mutually useful program.</p>
<h3>Education</h3>
<p>A major requirement for participation in the cooperative clinical program has been that clinic personnel attend the appropriate upper- and lower-extremity courses at one of the three universities offering such programs. Moreover, since December 1961 at Northwestern University, and since 1964 at the University of California at Los Angeles, 26 courses in the management of the child amputee have been offered to 864 students, including 450 physicians, 238 therapists, and 146 prosthetists. New York University has offered special lectures in the management of the child amputee in its regular prosthetics courses. In connection with the evaluation of specific items where special application skills are required, courses of instruction have been given to the participants.</p>
<p>All these educational activities have tended to provide an increasingly higher level of competence among physicians and others in the management of the child with limb deficiencies. Moreover, the Child Amputee Program has been a direct par- ticipant in, and contributor to, the general transition procedures governing the overall prosthetics research and education program. These procedures have served to bring new research-derived information directly and expeditiously to the consumer through courses of instruction and published materials.</p>
<h3>Publications</h3>
<p>In May 1961, at a meeting of the 12 clinic chiefs then participating in the cooperative program, the chairman of the Subcommittee on Child Prosthetics Problems proposed the creation of a bulletin or newsletter that would serve as a medium for the exchange of information between the clinics. The idea was received enthusiastically by the clinic chiefs, who undertook to provide articles on a scheduled basis. The first issue of the <i>Inter-Clinic Information Bulletin </i>was published in October 1961. It was six pages long, and 100 copies were distributed. Now, 10 years later, the <i>Bulletin </i>is a 16-page printed booklet with circulation in excess of 2,700 copies per issue.</p>
<p>Initially, <i>ICIB </i>dealt solely with amputees and prosthetics management. In the past year, however, in line with the general trend, the scope of the <i>Bulletin </i>has been enlarged to include orthotics topics. Since 1967, <i>ICIB </i>has been catalogued in the Library of Congress (Catalogue Number 67-304).</p>
<p>At the last four annual meetings of the chiefs of the cooperating clinics, a feature of the program has been a symposium on a selected area of child-amputee management. The proceedings of the symposia held in 1967 <i>(Normal and Abnormal Em-bryological Development), </i>1968 <i>(Proximal Femoral Focal Deficiency), </i>and 1969 <i>(Surgical and Prosthetic Management of Lower-Extremity Anomalies) </i>have been published and distributed to clinicians, medical schools, and other interested groups. The proceedings of the 1970 meeting <i>(The Child with an Acquired Amputation) </i>are being prepared for printing.</p>
<p>Effective communication with and between the clinics has been maintained by means of the <i>Inter-Clinic Information Bulletin, </i>the annual meeting of clinic chiefs, and personal contacts through CPRD and NYU staff. These factors have been critical elements in the extremely successful operation of the cooperative child-amputee research program. As the scope of the endeavor now expands to include conditions requiring orthotic assistance, the same elements may be used to develop an equally successful program for children with orthopedic disabilities other than amputation.</p>
<h3>Subcommittee on Child Prosthetics Problems, CPRD</h3>
<ul>
<li>George T. Aitken, M.D., Chairman, Grand Rapids, Mich.</li>
<li>Charles H. Epps, Jr., M.D., Washington, D.C.</li>
<li>Sidney Fishman, Ph.D., New York, N.Y.</li>
<li>Cameron B. Hall, M.D., Los Angeles, Calif.</li>
<li>Douglas A. Hobson, P.Eng., Winnipeg, Canada</li>
<li>Leon M. Kruger, M.D., Springfield, Mass.</li>
<li>Claude N. Lambert, M.D., Chicago, 111.</li>
<li>Robert E. Tooms, M.D., Memphis, Tenn.</li>
</ul>
<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>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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Issue
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<h2>A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity</h2>
<h5>Newton C. Mccollough III. M.D. <a style="text-decoration:none;">*</a><br />Charles M. Fryer. MA. <a style="text-decoration:none;">*</a><br />John Glancy, CO. <a style="text-decoration:none;">*</a><br /></h5>
<p>There is little question that the field
of orthotics has taken a back seat to prosthetics in modern times, and perhaps
for good reason. The needs of the amputee are more immediate and obvious, and
the wars of the past thirty years have yielded untold numbers of young men in
their prime whose productivity depended upon satisfactory functional restoration
of their missing limbs. Medicine, engineering, and the prosthetic profession
have responded to the needs of the amputee through extensive research and
development, widespread educational programs, improved fabrication and fitting
techniques, and better delivery of services. The field of orthotics remains in
comparative disarray with more limited, though no less sophisticated, research
activities, few educational endeavors, and little improvement upon local
fabrication and delivery services over the past fifty years.</p>
<p>Much of the blame for this rather
distressing state of affairs must be laid to the physician, whose approach to
orthotic prescription has been somewhat less than scientific. More often than
not, little thought is given to analyzing specific biomechanical defects present in an
extremity with the aim of translating them into an appropriate mechanical
substitute. Even when this is done, all too often the device that is prescribed
impairs to some degree the normal biomechanical functions which coexist in the
same extremity. For example, a long leg brace prescribed for genu recurvatum may
also limit normal functioning of the subtalar joint. Much of the physician's
casual approach to orthotic prescription stems from a relatively sparse
education in orthotic principles, but an even greater deficiency is the failure
to relate well-known biomechanical principles to the mechanical substitute, or
orthosis. Therein lies the trap, for without this awareness, prescriptions will
continue to reach the orthotist calling for simply a "short leg brace" or a
"long leg brace," and thus there is no stimulation for new or improved design
criteria for orthotic components and systems.</p>
<p>There is little doubt that the great
advances which have been made in prosthetics in recent years have resulted
primarily from a systematic appraisal of normal human posture and locomotion,
with resultant attempts to duplicate not only the missing anatomy but also the
biomechanical functions of the extremity. The problem in orthotics is somewhat
different: specific functional losses must be substituted for in the presence of
intact anatomy, and the variety of functional losses which may be present in a
given extremity necessitates correspondingly varied design criteria. It is apparent,
therefore, that an initial step in developing a rational approach to orthotic
design and prescription would be some means of systematically analyzing the
biomechani-cal losses in an impaired extremity. Once properly identified, these
losses could then be matched against specific components or component systems to
substitute for the functions lost. In addition, such an analysis might point up
certain areas or functions for which truly satisfactory components are not
available, and thus it might serve as a stimulus for future design and
development.</p>
<p>Recognizing the need for a more organized
and systematic approach to orthotic prescription as a part of current efforts to
revise volume 1 of the <i>Orthopaedic Appliances Atlas, </i>the Committee on
Orthotics and Prosthetics of the American Academy of Orthopaedic Surgeons
appointed an ad hoc committee for the development of a lower-extremity analysis
form. In essence, this article represents a report of that committee, whose work
commenced two years ago. During the development of the form, workshops were held
periodically with the parent committee, together with representatives of the
American Orthotic and Prosthetic Association, the Veterans Administration
Prosthetics Center, and the Committee on Prosthetics Research and Development of
the National Research Council. The form underwent periodic revision as it was
applied to patients with a variety of disabilities, utilizing several clinics.
The most recent and final application of the lower-extremity analysis form was
in conjunction with the Workshop Panel on Lower-Extremity Orthotics held at
Rancho Los Amigos Hospital in Downey, California, in March 1970. Its
applicability to the evaluation of lower-extremity disability is now felt to be
such as to warrant description for more widespread usage.</p>
<h4>Lower-Extremity Analysis Form</h4>
<p>The form consists of four pages of
appropriate size for insertion into the patient's hospital chart. The first page
<b>Fig. 1</b> contains spaces for patient data, including the diagnosis and a summary
of major impairments existing in one or both extremities. At the bottom of the
first page there is a legend for symbols to be used on the extremity diagrams.
The second and third pages <b>Fig. 2</b>,<b>Fig. 3</b> contain skeletal outlines of the right and left lower extremities, respectively, in the sagittal, coronal, and
transverse planes. Overlying the major joints are shaded areas, representing the
normal ranges of joint motion within a circle divided into thirty-degree
segments. Similar smaller circles overlie the mid-shafts of the long bones for
diagraming angular, rotational, or translational deformities of the femur and
tibia. The fourth page <b>Fig. 4</b> includes spaces for summarizing the functional
disability, and for orthotic recommendations based upon this summary.</p>
<table>
<tbody><tr>
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<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 1. Front sheet of patient analysis
form, including summary of major impairments and legend.
</p>
</td>
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</td>
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</tbody></table><br /><table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Fig. 2. Second page of patient analysis
form, with diagram of right lower extremity.
</p>
</td>
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</td>
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<p class="clsTextCaption"><br />
Fig. 3. Third page of patient analysis
form, with diagram of left lower extremity.
</p>
</td>
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</td>
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<td>
<p class="clsTextCaption"><br />
Fig. 4. Fourth page of patient analysis
form provides space for summary of patient's functional disability and for the
orthotic recommendation.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i>Instructions for Use</i></p>
<p>Most of the "Major Impairments" portion
of the form is self-explanatory. "Abnormal bone and joint" conditions may
include such entities as osteoporosis, Paget's disease, and coxa vara. "Muscle"
may be normal, flaccid, or spastic, but a space is provided for description of
rarer disorders such as muscular dystrophy and fibrosis of muscle. Under the
heading of "ligament," check boxes are provided to indicate abnormal laxity of
the major ligaments of the knee and ankle. The sections on "sensation," "skin,"
and "vascular" impairments cover considerations which may influence orthotic
design, and are self-explanatory.</p>
<p>"Balance" is either normal or impaired,
and if impaired, the following definitions are applicable: "mild" impairment is
compatible with independent ambulation; "moderate" impairment is compatible with
ambulation utilizing external support; and "severe" impairment indicates the
need for maximal support or personal assistance in ambulation.</p>
<p>"Extremity shortening" is recorded as
follows: ischial tuberosity to sole of heel, ischial tuberosity to medial tibial
plateau, and medial tibial plateau to sole of heel.</p>
<p>In leg-length discrepancies exceeding
one-half inch, X-ray studies of leg length may be indicated, and an appropriate
space is provided for this measurement.</p>
<p><i>Legend and Extremity
Diagrams</i></p>
<p>Two terms must first be
defined:</p>
<ol>
<li><i>"Translatory motion"</i> is
motion in which all points of the distal segment move in the same direction,
with the paths of all points being exactly alike in shape and distance traversed
<b>Fig. 5</b>.</li><li><i>"Rotary motion"</i> is motion
of a distal segment in which one point in the distal segment or in its
(imaginary) extension always remains fixed <b>Fig. 6</b>.</li></ol>
<p>The symbols described in the legend are
used in conjunction with the right-and left-extremity diagrams according to the
following rules:</p>
<ol>
<li><b>Recording motion:</b>
The degrees of rotary motion or
centimeters of translatory motion are to be obtained from passive manipulation,
and are to reflect passive (not active) motion at the site being examined. In
the lower extremity, joints are to be observed during weight-bearing, and if the
degree of joint excursion is greater under conditions of loading than under
passive manipulation, this figure is diagramed rather than the smaller figure
(e.g., recurvatum of the knee).
<ul><li><i>Translatory motion:</i>
Linear arrows horizontally placed below
the circle indicate the presence of (abnormal) translatory motion at
one or more of the six designated levels of the lower extremity listed on the
left side of the form. The head of the arrow always points in the direction of
displacement of the distal segment relative to the proximal segment. Linear
arrows vertically placed on the right side of the circle indicate(abnormal) translatory motion along the
vertical axis at the site indicated.</li>
<li><i>Rotary motion:</i>
Normal ranges of rotary motion about
joints are preshaded on the diagram. Abnormal rotary motion, either as limited
or excess motion, is indicated by double-headed arrows placed outside and
concentric to the circle, to indicate the extent of available motion present in
the affected joint. In certain instances, it may be more meaningful to use two
double-headed arrows in order to describe the range of motion to either side of
the neutral joint axis, rather than a single arrow which describes the total
range of motion present. If one head of an arrow fails to reach the preshaded
margin, limitation of joint motion is denoted. Conversely, if one head of an
arrow projects beyond the preshaded margin, excess motion is designated. Numbers
in degrees are placed adjacent to the arrows to indicate the arc described. In
addition, radial lines drawn from the center of the circle and passing through
its perimeter at the tips of the double-headed arrow are to be used for more
graphic representation of the arc of available motion. At sites where rotary
motion does not occur (e.g., fracture site, or knee joint in the coronal plane),
the presence of abnormal rotary motion is similarly designated by a
double-headed arrow with adjacent numerical value in degrees.</li>
<li><i>Fixed position:</i> Double radial arrows indicate a fixed
joint position, and describe in degrees the deviation from the neutral joint
position. Horizontal or vertical double arrows indicate a fixed joint position
in a translatory sense, and the extent of abnormal translation is indicated in
centimeters adjacent to the arrow (e.g.,subluxation of the tibia in a hemophiliac
knee).<br /></li></ul></li><li><b>Muscle dysfunction: </b>
<ul><li><i>Flaccid muscle:</i>
Flaccid muscle is designated as such
under the section on major impairments. Muscle-group strength, not individual
muscle strength, is determined by conventional means on the examining table, and
the letter grade corresponding to volitional force is recorded adjacent to the
skeletal outline at the proper location for each muscle group. The letter grades
correspond to the standard muscle-grading system used in poliomyelitis. No
symbol is used if muscle strength is normal.</li>
<li><i>Spastic muscle: </i>Spastic muscle is designated as such
under the section on major impairments. It is further identified in the legend
as "SP." The letter grade (e.g., SP<sub>MO</sub>) for muscle-group tone, not
individual muscles, is to be placed adjacent to the skeletal outline at the
proper location for each muscle group. Spastic-muscle estimates are to be made
with the patient in the functional position for the lower extremity, i.e.,
observation during standing and walking. The subletter grades for spastic muscle
are as follows:<br />
"M" indicates a mild degree of
spasticity;<br />
"MO" indicates a moderate degree of
spasticity sufficient for useful holding quality;<br />
"S" indicates severe spasticity,
obstructive in terms of function.<br />
In certain instances, muscle groups in a
patient with spastic paralysis may be more appropriately graded according to
volitional force, e.g., dorsiflexion of the foot in a hemiplegic.<br /></li></ul></li><li><b>Recording fracture or bone
deformity: </b> All translatory or rotary motions at the fracture on the shaft of a
long bone are diagramed on the circle located</li></ol>
<p>The technique of completing the analysis
forms for specific lower-extremity disabilities is shown in <b>Fig. 7</b>,<b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b>,<b>Fig. 12</b></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 7. Record for patient with left
hemiplegia. Information given on front sheet includes spastic muscle picture
with inversion deformity of foot, mild loss of proprioception, venous stasis in
left leg, and mild impairment of balance.
</p>
</td>
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</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 8. Diagram of patient E.L.'s left
lower extremity. Muscles which are not normal are designated by letter grade.
Muscles which are not spastic clinically and which possess volitional control
are designated by conventional letter grading. The diagram illustrates presence
of good hip flexors, extensors, and abductors, good knee extensors, fair knee
flexors and foot invertors, poor foot dorsi flexors, zero foot evertors, and
mild calf spasticity. There is 15° of hyperextension at the knee, and the heel
cord is tight, limiting dorsiflexion of the foot to neutral. The presence of
edema from the knee to the foot is also noted at the mid-shaft of each bone. The actual
fracture site is indicated by the fracture symbol. All bony deformities such as
valgus angulation of the shaft are likewise diagramed on the circle located at
the center of the shaft, regardless of the position of the angular deformity.
The location of the angular deformity is designated by circling the appropriate
level on the left side of the chart.
</p>
</td>
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</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 9. Summary of the patient's
functional limb disability, and the orthotic recommendation based upon that
summary.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 10. Record for patient with residual
poliomyelitis affecting his left lower extremity. Information given indicates
flaccid paralysis with severe atrophy, laxity of the medial collateral ligament
of the knee, and 1 3/4 in. shortening of the left lower extremity. In addition,
the patient had an old supracondylar fracture of the femur and a previous triple
arthrodesis.
</p>
</td>
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</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
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<p class="clsTextCaption"><br />
Fig. 11. Diagram of patient W.S.'s left
lower extremity. In addition to showing the letter grades for muscle-group
strength, the diagram also shows 20° of hyperextension at the knee, 15° of
valgus instability of the knee, 15° of external tibial torsion, limitation of
dorsiflexion at the ankle, abnormal inversion and eversion at the ankle, and a
fixed position of the subtalar joint.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 12. Summary of patient W.S.'s
functional limb disability, and the orthotic recommendation based upon that
summary.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<h4>Discussion</h4>
<p>The stated purpose of developing a
patient analysis form of this type is to organize a systematic approach to
orthotic prescription. In addition, through stimulation of a careful appraisal
of biomechani-ical faults in a given extremity, it may also serve as a basis for
identifying certain areas in need of new or further design and development. It
is also viewed as a valuable teaching tool for students of orthotics at both the
technician and physician levels. Most importantly, it may serve as a common
ground upon which both the orthotist and the physician can meet to work out
satisfactory solutions to bracing problems. (Sample copies of the form are
available from the CPRD office).</p>
<p>As a further step in making such an
analysis form more meaningful to orthotists and physicians, a list of available
lower-extremity orthotic components is currently being compiled in such a way as
to categorize these components by their biomechanical function. Ideally then,
one might diagra-matically plot the biomechanical losses present in a limb and
then select a mechanical device from the appropriate category to substitute for
the lost function. In this way, the orthotic prescription can evolve as a
carefully thought-out combination of specific components to create a suitable
orthotic system for the deficient limb.</p>
<p>A revitalized approach to orthotics is
urgently needed. According to a recent estimate, there are 3,370,000 orthotic
patients in the United States as opposed to 311,000 amputees, or ten times as
many patients who need orthoses as need prostheses <i>(1). </i>Little that is
new has been done for many of these patients until very recently. Several
research centers in the United States and Canada are engaged in sophisticated
and promising orthotic research. Unfortunately, by and large, the products of
this research have not yet reached the masses of handicapped people. Stimulation
of new approaches to mechanical design at the local level must be achieved
through close and meaningful collaboration between physician and
orthotist. It is hoped that the material
presented in this article will be an initial step toward that goal.</p>
<p>Work is currently being done on a similar
approach to the upper extremity and the spine. These areas will be the subjects
of future reports.</p>
<h4>Acknowledgements</h4>
<p>The authors wish to express special
appreciation to Dr. George T. Aitken, former chairman of the American Academy of
Orthopaedic Surgeons Committee on
Prosthetics and Orthotics; Dr. Robert Keagy; Mr. A. Bennett Wilson, Jr.; Mr.
Anthony Staros; and Dr. Edward Peizer for their specific contributions to this
work.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
FIg. 5. "Translatory motion": motion in
which all points of the distal segment move in the same direction, with the
paths of all points being exactly alike in shape and in distance traversed. In
all three examples, the pathways between original position "A" and final
position "B" of four arbitrarily selected points in each figure are each exactly
alike in direction, form, and distance traversed. Note that the long axes of the
figures also remain parallel throughout the "translation" from A to
B.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 6. "Rotary motion": motion of a
distal segment in which one point in the segment, or in its (imaginary)
extension, always remains fixed. The axis "O," in each of the three examples,
represents a point in the figure (or as in "III" in its imaginary extension)
that always remains fixed in position when the body "rotates" from position "A"
to position "B."
</p>
</td>
</tr>
</tbody></table>
</td>
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</tbody></table>
<p><b>References:</b></p>
<ol>
<li>Committee on Prosthetics Research and Development, <i>Report of the Seventh Workshop Panel on Lower-Extremity Orthotics of the </i><a><i>Subcom.it-</i></a><i>tee on. Design and Development, </i>National Research Council-National Academy of Sciences, March 1970.</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>John Glancy, CO. </b></td></tr><tr><td class="clsTextSmall">Orthotic Division, Indiana University Medical Center, Indianapolis, Ind. 46207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 M. Fryer. MA. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic-Orthotic Center, Northwestern University Medical Center, Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Assistant Professor of Orthopaedics, Associate Director of Rehabilitation, University of Miami School of Medicine, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity
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Newton C. Mccollough III. M.D. *
Charles M. Fryer. MA. *
John Glancy, CO. *
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Year
1970
Volume
14
Issue
2
Page Number(s)
58 - 67
Text
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<h2>Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps</h2>
<h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5>
<p>At the present time, most sockets for
artificial limbs are made of a plastic laminate (usually polyester resin and
Dacron) which has been molded over a modified replica of the stump. A replica of
the stump is required because human tissues cannot withstand the temperatures
generated by the exothermic reaction of the plastic as it cures. The replica is
modified, using general rules established by research groups, in order to
achieve a relationship between the stump and socket that is physiologically
satisfactory, yet permits weight-bearing and provides stability. In addition,
reliefs must be provided to accommodate bony prominences and any tender spots. A
simple plaster-of-paris wrap will usually be too loose for normal use.
Therefore, fabrication of plastic-laminate sockets with presently available
materials involves at least the following steps <b>Fig. 1</b>: (a) development of a
female mold of the stump by wrapping the stump with plaster-of-paris bandages,
(b) casting a male model of the stump by filling the female mold with plaster
of paris, (c) modification of the male model by trimming away plaster in
selected areas and building it up in other areas when necessary, and (d)
lay-up and cure of the plastic laminate. The average time required to make a
hard socket below-knee plastic prosthesis is eight man-hours.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 1. Steps in the fabrication of a
plastic prosthesis for a below-knee amputation. <i>A, </i>taking the plaster
cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the
stump; <i>C, </i>introducing plastic resin into fabric pulled over the model to
form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted
on an adjustable shank for walking trials; <i>E, </i>a wooden shank block
inserted in place of the adjustable shank after proper alignment has been
obtained; <i>F, </i>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 />
<p>It has been the goal of a number of
research workers to find a simpler and less time-consuming method for
fabricating satisfactory sockets for all levels of amputation. After many
experiments involving a number of casting methods and a variety of materials,
the Veterans Administration Prosthetics Center<a style="text-decoration:none;">*</a> by 1961 had developed
a technique for molding a socket of synthetic balata directly over a below-knee
stump. The first successful results were achieved by using an air-pressure
sleeve over a tube of synthetic balata,<a style="text-decoration:none;">*</a> which had been softened by
immersion in hot water (160 deg F) and then pulled over the stump<a></a> <b>Fig. 2</b>.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 2. The air-pressure method of
forming synthetic balata sockets for PTB prostheses: application of the tube to
the lubricated sleeve of the stump; application of pressure to the sock-covered
pressure sleeve; and the socket and bonded tubing attached with screws to the
pylon.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>Upon the recommendations of the CPRD
Subcommittee on Design and Development, the Subcommittee on Evaluation undertook
responsibility for the evaluation of the new technique.</p>
<p>The claims of the development laboratory
were: (a) a substantial decrease in elapsed time between measurement of the
stump and production of a wearable limb, thereby speeding the rehabilitation
process, (b) a substantial reduction in man-hours involved, (c) a capability
for easy adjustment of the prosthesis at any time, and <i>(d) </i>a decrease in
the amount of skill and training required to produce an adequate
socket.</p>
<h4>Procedure</h4>
<p>A protocol (given at the end of this
article) was developed and five clinics<a style="text-decoration:none;">*</a> were asked to participate in
the evaluation. The prosthetists from the clinics were trained as a group at the
Veterans Administration Prosthetics Center on November 6-8, 1968. Each clinic
was requested to fit five new amputees and five amputees who had worn PTB
prostheses before, and provided with
sufficient material and equipment to carry out the fittings.</p>
<h4>Results</h4>
<p>Follow-up in the spring of 1969 revealed
that all the prosthetists were encountering difficulty in obtaining adequate
fits in nearly all cases except those with long tapered stumps, most of the
sockets being too loose proximally. To overcome this problem, the VAPC devised a
method whereby the air bag was eliminated, and molding pressure was brought about by wrapping the softened
balata tube with one-inch-wide elastic webbing and controlling the shape of the
socket with the hands and fingers as it cooled.</p>
<p>All of the participating prosthetists
were instructed in the revised method, and other prosthetists were instructed in
the new procedure at the same time. Shortly afterwards, plastic
pressure-sensitive tape was substituted for the
elastic webbing <b>Fig. 3</b>.<a></a></p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 3. The tape-wrap method of forming
synthetic balata sockets: application of pressure with elastic,
pressure-sensitive tape; molding by hand to define the medial tibial flare and
tibial crest; and the heated socket bottom joined to the pylon by an elastic
tape wrap. (Courtesy Veterans Administration Prosthetics Center. New York, NY)
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>The results with the revised procedure
were considerably better. The average synthetic balata prosthesis, with pylon
but without cosmetic treatment, weighed 3 1/2<i> </i>lb, and could be made in 2
1/2 hr. All of the claims of the developer were substantiated with the exception
of the relative amount of skill required, a factor that would be very difficult
to measure at this stage of development. At any rate, it is safe to say that no
more skill is required for the new technique than for older methods.</p>
<p>All prosthetists who used the technique,
with one exception, felt that synthetic balata is quite useful for temporary
prostheses. Some have adopted the method as standard procedures where
procurement practices permit use of temporary prostheses of this
type.</p>
<h4>Conclusions</h4>
<p>When this technique is used, a
considerable saving in time can be effected, and the patient can be provided with a
prosthesis within a few hours. Furthermore, the use of synthetic balata permits
easier adjustment of the socket later, and the adjustable pylon permits
adjustment in alignment at any time.</p>
<p>It is therefore recommended that use by
federal and state agencies of the VAPC technique for fabricating below-knee
temporary prostheses be encouraged, and that the technique be included in the
curricula of all below-knee prosthetics courses.</p>
<p><b>References:</b></p>
<ol>
<li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs, </i>6:2:25-73, June 1962.</li>
<li>The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, <i>Orth. and Pros., </i>23:1:36-61, March 1969.</li>
<li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, <i>Bull. Pros. Res., </i>10-12:34-47, Fall 1969.</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">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Bull. Pros. Res., 10-12:34-47, Fall 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Rancho Los Amigos Hospital, Duke University, the University of Miami, the Veterans Administration Hospital/Los Angeles, and the Veterans Administration Hospital/Buffalo</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artif. Limbs, 6:2:25-73, June 1962.</td></tr><tr><td class="clsTextSmall"><b>2 .</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">From Polysar X-414 resin produced by thePolymer Corporation Limited, Sarnia, Ontario,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>Footnote</b></td></tr><tr><td class="clsTextSmall">252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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Figure 2
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Figure 3
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Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps
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A. Bennett Wilson, Jr. *
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DRFOP - Legacy
Full Text PDF
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Year
1971
Volume
1
Issue
2
Page Number(s)
1 - 5
Text
Any textual data included in the document
<table><tbody><tr><td>
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<h2>A Method of Early Prosthetics Training for Upper-Extremity Amputees</h2>
<h5>Timothy V. Reyburn, MAJ., AMSC <a style="text-decoration:none;">*</a><br /></h5>
<p>Over the past ten years, there have been gradual changes in the treatment and training of patients who have had upper-limb amputations.<a></a> This paper discusses early training techniques used over a two-year period at Valley Forge General Hospital on 67 (32 above-elbow and 35 below-elbow) amputees. Thirty-four of the amputees were treated from July 1968 to February 1969, and 33 from February 1969 to July 1970.</p>
<p>Prior to February 1969, there was no separate ward for amputees, and each patient was placed on a ward appropriate to his overall disability, rather than according to his amputation. The upper-extremity amputees were pretrained in the leather-laced practice prosthesis with plaster-shell insert. However, this type of practice prosthesis was not fitted to the patient's stump until all wounds had healed and drainage had ceased. Consequently, preprosthetic training was delayed, and unilateral patterns could develop in the interim. When the patient did receive his practice prosthesis, training was initiated, with limited practice periods in occupational therapy for one hour a day. At first, the amputee wore the practice prosthesis only in the clinic. After he had mastered its operation and could tolerate the socket for longer periods, he was allowed to wear it the entire day. The patient was instructed to remove the prosthesis at night and to use the standard stump-wrapping procedure to control edema. A major problem during the training period was the constant separation of the plaster socket from the leather-laced cuff. Also, the functional alignment and the appearance were anything but desirable (<b>Fig. 1</b>). The therapist noted that the patients did not voluntarily wear their practice prostheses outside the supervised clinic environment. It was apparent that a more functional and streamlined type of practice prosthesis was urgently needed. In February 1969, the chief of orthopedics organized a separate amputee service, and a new training plan was initiated. The successful treatment of lower-extremity amputees by a technique in which a rigid dressing and plaster pylons were applied immediately after surgery lead to the hypothesis that a similar procedure might be beneficial for upper-extremity amputees. A practice prosthesis that consisted of a plaster socket with the terminal device and cable attachments embedded within the outer shell was fabricated (<b>Fig. 2</b>). From February 1969 to July 1970, 30 patients were fitted with the device (three amputees could not be fitted, because of transfer, infection, etc.). Their ages were between 19 and 39; the average age was 22 years.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 1. A leather-laced practice prosthesis with plaster-shell insert.
</p>
</td>
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</td>
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</tbody></table><br /><table>
<tbody><tr>
<td>
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<tbody><tr>
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<p class="clsTextCaption"><br />
Fig. 2. Adapted above- and below-elbow practice prostheses.
</p>
</td>
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</tbody></table>
</td>
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</tbody></table><br />
<p>The key to a successful practice prosthesis is a firm, nonconstrictive, well-made socket. Both the above- and below-elbow sockets must be formed firmly and evenly to control swelling and to forestall blisters from developing by movement of the stump within a poorly fitting socket. Fabrication of the plaster-of-paris socket and prosthesis is relatively easy, and the procedure is basically the same for both above- and below-elbow prostheses.</p>
<p>For the below-elbow socket, a layer of stockinet is pulled over the stump (<b>Fig. 3</b>) and extended two or three inches above the elbow, which allows for a fold and a trim on the proximal end. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump. An area is left open ventrally to allow room for maximum flexion of the forearm. Circular, non-constricting, single-thickness wraps are then applied (<b>Fig. 4</b>).</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 3. The first layer of stockinet applied to a below-elbow stump.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Fig. 4. Application of plaster to the below-elbow stump.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>For an above-elbow socket, the stump is completely covered with stockinet. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump (<b>Fig. 5</b>). Each strip is ended three or four inches distal to the axilla to facilitate removal of the piaster socket. Circular, nonconstricting, single-thickness wraps are then applied. The lateral proximal apex is reinforced in order to provide a firm base for attachment of the lateral harness buckle.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 5. Plaster being applied over the stockinet.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>Aluminum struts are attached to the prosthetic appliance and plastered into the socket (<b>Fig. 6</b>). When the socket is finished, a figure-eight harness with a Northwestern ring is fitted to the patient, and a terminal device is attached to the practice prosthesis. All of the cable, base-plate, and harness connections are adjusted for each patient. Once the connections are attached and in proper alignment, the patient is trained to operate the practice prosthesis (<b>Fig. 7</b>). Additional sockets are fabricated if stump shrinkage exceeds the thickness of two single-ply stump socks. This basic prosthesis is used by the patient until he receives his final prosthesis.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 6. Affixing aluminum struts and a terminal device to the plaster socket.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Fig. 7. A below-elbow amputee learns to operate the terminal device on a practice prosthesis.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>Because these prostheses have proved so acceptable to the amputees, a plaster socket is fitted immediately upon the patient's admission. A below-elbow amputee can be fitted and can start to use his prosthesis all in the same day. An above-elbow amputee, if not ready for a practice prosthesis, is fitted with a plaster-shell socket and figure-eight harness (<b>Fig. 8</b>). Anterior and posterior elastic straps are attached to the plaster shell to provide an even upward pressure.</p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 8. An above-elbow amputee fitted with a plaster shell with figure-eight harness and Northwestern ring.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p>The plaster shell replaces the standard elastic wrap and provides an exercise modality for the patient. The protection provided by the hard plaster shell and the non-constricting but firm pressure against the patient's stump are superior to that provided by an elastic-bandage wrap. An elastic bandage, when wrapped properly, is firm distally and becomes less and less firm proximally. The wrap is thus very unstable, and it readily falls off. The plaster shell provides a more constant pressure, and the elastic straps can be adjusted easily.</p>
<p>Once the patient masters his practice prosthesis, he is assigned to a work-therapy job, which usually is related to his future vocational interest. The ability to use his prosthesis on the job convinces the patient that he can function normally, which is another step in preparing the man for his permanent prosthesis and eventual discharge. If the patient cannot perform a certain function with his prosthesis, a therapist shows him how to solve the problem. The ability to hold grain sacks, handle meat knives, and lift pails are just a few of the everyday tasks that can be taught in work-therapy assignments.</p>
<p>At this point in his rehabilitation, the patient receives a thirty-day leave. It is during this period that the amputee can really give his prosthesis a workout, by wearing it around the house and using it while doing repair work or mechanical tasks. Completely relying on his prosthesis is the best way for him to work out any problems in its operation. He learns what works best for him, and this knowledge is of great value when he is sent to the prosthetist for the fitting of the permanent prosthesis. After the patient receives his permanent prosthesis, he needs no further training; he can operate it with maximum efficiency, and all that is needed is a final check-out. After minor pressure points and alignment problems are adjusted, the patient is ready for discharge.</p>
<p>If necessary, amputees can be fitted while their stumps were still open and in traction. The importance of skin traction cannot be overemphasized; 75 percent of the amputees received for treatment needed some type of skin traction before being fitted.</p>
<p>The skin-traction weight is removed, and the traction ties are folded back over the stump end. Another stockinet is then pulled over the skin traction, and a plaster socket is fabricated over both.</p>
<p>Although at first only the less open stumps were fitted in this manner, the method was so successful that we used it on grossly open stumps, and the fittings were accomplished without difficulty (<b>Fig. 9</b>).</p>
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Fig. 9. Stump ready for fitting with practice prosthesis and traction still maintained.
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<p>Training sessions in occupational therapy with the practice prosthesis are a tremendous boost to the patient's well-being. After the training session, he removes the prosthesis, reties the traction, and attaches the traction weights. As skin coverage and healing improve, skin-traction time becomes less, and practice-prosthesis-wearing time increases.</p>
<h3>Discussion</h3>
<p>Acceptance of the permanent prosthesis by the 30 patients fitted after February 1969, and their functional use of it, was evaluated. The degree of acceptance and functional use decreased as the level of amputation increased, with positive acceptance of the long below-elbow prosthesis and a gradual rejection of the shoulder-dis-articulation prosthesis. Every patient was given and trained with an APRL (Army Prosthetic Research Laboratory) hand. Two of the 30 patients preferred the APRL hand to the hook; both of these had shoulder disarticulations.</p>
<p>The post-February 1969 patients were fitted three to four weeks earlier than the pre-February 1969 patients. Duration of hospitalization remained about the same, but the post-February 1969 patients were on work therapy and were productive three to four weeks earlier.</p>
<p>Ease of fabrication and patients' acceptance of the streamlined practice prosthesis were noted. The patients' stumps tolerated the hard-shell sockets without difficulty.</p>
<p>Early fitting over open stumps and over skin traction is possible. Edema is reduced and the stump is desensitized while the patient uses his prosthesis.</p>
<p>Rehabilitating the upper-extremity amputee to normal activities as soon as possible requires a total team approach. Close coordination among the physicians, nurses, physical therapists, occupational therapists, and prosthetists is necessary. If everyone on the team understands the problems of the upper-extremity amputee, then all can work together in directing and guiding his treatment.</p>
<p><b>References:</b></p>
<ol>
<li>Bailey, Ronald B., <i>An upper extremity prosthetic training arm</i>, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</li>
<li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The Management of Lower-Extremity Amputations</i>, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</li>
<li>Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, <i>Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees</i>, Artif. Limbs 12:1:14-19, Spring 1968.</li>
</ol>
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<div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Bailey, Ronald B., An upper extremity prosthetic training arm, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The Management of Lower-Extremity Amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees, Artif. Limbs 12:1:14-19, Spring 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Timothy V. Reyburn, MAJ., AMSC </b></td></tr><tr><td class="clsTextSmall">Now Chief of Occupational Therapy, Fort Riley, Kans. 66442.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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A Method of Early Prosthetics Training for Upper-Extremity Amputees
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DRFOP - Legacy
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Year
1971
Volume
15
Issue
1
Page Number(s)
15 - 21
Text
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<h2>Technique for Forming Sockets Directly on Above-Elbow Stumps</h2>
<h5>F. L. Hampton, C.P. <a style="text-decoration:none;">*</a><br />J. N. Billock, C.P. <a style="text-decoration:none;">*</a><br /></h5>
<p>The ability to make a socket by applying a thermoplastic material such as Poly-sar X-414 (Polymer Corp. Ltd. TM) directly to an amputee's stump offers many advantages to the prosthetist, as pointed out by Wilson. <a></a> Direct forming obviously eliminates the casting procedures necessary to produce a good modified replica of the stump and eliminates the laminating procedures necessary to produce the socket. The thermoplastic properties of Polysar X-414 allows quick postforming of the socket in areas which may require relief, and the material lends itself well to the attachment of components during assembly. These time-saving advantages enable the prosthetist to fit amputees with a temporary prosthesis much earlier than the time normally required for a definitive fitting. This hastens the amputee's rehabilitation and helps to condition him <i>and </i>his stump for the definitive prosthesis. The prosthetist also has the advantage of noting any corrections which are applicable to the definitive prosthesis. These advantages are also helpful to the research prosthetist, for he can save valuable time in evaluating new control techniques and testing new components.</p>
<p>A direct-forming technique related to those developed by Staros and Gardner <a></a> for below-knee PTB sockets and by Labate and Pirrello <a></a> for below-elbow sockets using Polysar X-414 has been developed for above-elbow sockets. If done properly, this technique will provide a well-fitting socket which has the above-mentioned advantages. A complete above-elbow prosthesis can be fabricated in approximately three hours.</p>
<p>The technique was used at this center to construct Polysar sockets for four above-elbow amputees who participated in an evaluation study of externally powered upper-extremity prosthetic components. Each amputee (described briefly below) wore his prosthesis successfully for two hours a day, three days a week, during a two-month period without problems.</p>
<p><i>D. H., </i>a 38-year-old male, with a right above-elbow amputation 11 in. distal to acromion, acquired in June 1964. He was fitted with a standard above-elbow prosthesis, which he has used actively as a laborer since.</p>
<p><i>R. W., </i>a 35-year-old male congenital amputee, with a right 11-in. above-elbow stump from the acromion. He was fitted with his first standard above-elbow prosthesis in June 1954, and has been an active prosthesis wearer since that time. He is presently employed as a hotel clerk.</p>
<p><i>J. H., </i>a 44-year-old male with a left above-elbow amputation 8% in. distal to the acromion, acquired in March 1964. He was fitted with a standard above-elbow prosthesis and has been an active prosthesis wearer since that time. He is presently employed as a quality-control inspector for a leather factory.</p>
<p><i>R. R., </i>a 22-year-old male with a left above-elbow amputation 9 1/2 in. distal to the acromion, acquired in November 1968. He was fitted with a standard above-elbow prosthesis and has used it actively since. He is a student in college at the present time.</p>
<h3>Materials and Equipment</h3>
<p>A tube of the synthetic rubber 3 in. ID x 1/4 in. x 12 in. is adequate for the average above-elbow stump. The diameter can be reduced for smaller stumps by elongating the tube after it has been heated. Larger sizes of tubing should be used for larger stumps.</p>
<p>The only special equipment needed is a deep, water-filled container, approximately 20 in. in height and 8 in. in diameter. The water should be preheated to a temperature of 160 degrees F to 180 degrees F.</p>
<p>The following materials and equipment should be available within the prosthetic facility:</p>
<ul>
<li>Two 1 in. x 40 in. elastic webbings</li>
<li>Four Yates clamps</li>
<li>Tubegauz (TM), size #56 (tubular gauze)</li>
<li>Heavy cast sock</li>
<li>Braided Dacron (TM) line, approximately 130-lb-test</li>
<li>Standard Hosmer elbow turntable</li>
<li>Hose clamp, expandable to 11-in. circumference</li>
<li>Hot plate</li>
<li>Parallel bar</li>
<li>Pressure-sensitive tape</li>
</ul>
<h3>Preparations for Casting</h3>
<p>Cut a length of tubular gauze approximately 18 in. longer than the stump and slit it 6 in. from the proximal end. Apply the tubular gauze with the slit in the axilla, allowing the tubular gauze to encompass the shoulder proximal to the acromion process. Pass a piece of 1-in. elastic webbing under the axilla on the sound side and attach it to the anterior and posterior wings of the tubular gauze (<b>Fig. 1</b>). Cut the toe from a heavy cast sock and slit the proximal end in the same manner as the tubular gauze. Pull the cast sock on the distal third of the stump, with the slit under the axilla (<b>Fig. 2</b>).</p>
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Fig. 1. Tubular gauze suspended with elastic webbing.
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Fig. 2. Heavy east sock applied to distal one-third of stump.
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<p>Mark the proximal section of the synthetic rubber tube to be cut out for the axilla. The width of the section will depend on the stump size, and the depth must be sufficient to allow the synthetic rubber to pass over the acromion. The synthetic rubber stretches well; therefore, caution should be taken not to cut out too large a section. For average stumps, a section 3 in. x 3 in. is adequate.</p>
<p>Completely immerse the synthetic rubber tube in the preheated water. The tube will rise to the surface when it has reached the appropriate temperature. Remove it from the water and cut out the axilla section (<b>Fig. 3</b>). Allow the tube to cool until the hand may be placed inside the tube without discomfort.</p>
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Fig. 3. Cutting out axilla section after tube is heated.
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<h3>Application of Synthetic Rubber</h3>
<p>Stretch the proximal end of the tube at the axilla level to aid in starting the tube on the stump (<b>Fig. 4</b>). Roll the axilla edge to provide a good flare for the axilla (<b>Fig. 5</b>). Insert the tubular gauze and cast sock through the tube and apply the tube to the distal third of the stump.</p>
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Fig. 4. Synthetic rubber tube stretched at axilla level.
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Fig. 5. Medial edge rolled to provide a good flare for axilla.
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<p>The tubular gauze is anchored to a parallel bar so that the amputee can apply tension on the tubular gauze. The tension will compress the stump tissues and prevent tissue-bunching while the synthetic rubber tube is being applied. An adjustable webbing belt with an O ring is used as the anchoring point on the parallel bar (<b>Fig. 6</b>).</p>
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Fig. 6. Synthetic rubber tube applied to the distal end of the stump and tension applied to the tubular gauze.
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<p>Stand the amputee away from the parallel bar with the stump in abduction and the shoulder in depression. This will assist in placing the tube well into the axilla. Pull the synthetic rubber tube onto the stump, using the cast sock to work it up the stump (<b>Fig. 7</b>). Make sure it is well into the axilla and over the acromion. Support the tube with a piece of elastic webbing in the same manner as the tubular gauze (<b>Fig. 8</b>). This will also aid in forming the proximal end of the socket. Eliminate any wrinkles in the cast sock by pulling on it at the distal end of the tube.</p>
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Fig. 7. Synthetic rubber tube is pulled up the stump.
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Fig. 8. The tube suspended with elastic webbing.
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<h3>Contouring the Socket</h3>
<p>When contouring the socket for a left amputee, place the left hand firmly into the axilla, keeping the hand parallel to the sagittal plane. Have the amputee move back to the parallel bar, adduct his stump, and elevate his shoulder to the neutral position (<b>Fig. 9</b>).</p>
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Fig. 9. Left hand in the axilla and right hand contouring distal end of socket to accept elbow turntable
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<p>Firm tension should be maintained on the tubular gauze without causing the amputee to strain. Only the shoulder muscles should be used to maintain the tension. The finished socket will be loose if the stump muscles are contracted during contouring of the socket.</p>
<p>Reduce the diameter of the synthetic rubber distally to conform to the stump and to approximate the circumference of the turntable if necessary (<b>Fig. 9</b>). Mold the proximal section by placing the right hand so that the thumb and forefinger outline the anterior and posterior borders of the deltoid muscle group. The thumb is used to mold the anterior wing, and the remaining fingers to mold the posterior wing (<b>Fig. 10</b>). Hold the socket in this manner until the synthetic rubber cools enought to retain the contours.</p>
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Fig. 10. Right hand contouring the proximal socket.
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<p>Mark the proximal trim line before removing the socket. Either the conventional trim line can be used or the open-shoulder described by McLaurin et al. <a></a> After the trim line is cut out, the edges can be finished with a felt cone, fine-sand cone, or toluene.</p>
<h3>Attachment and Alignment of Turntable</h3>
<p>Determine the proper distance for the elbow center from the acromion process and mark where the turntable will be located on the tube. Reheat the distal end of the tube approximately one-half inch above the mark by immersing it in water. Insert the turntable into the tube and work the synthetic rubber into the knurling and tie-off groove. Secure the synthetic rubber by wrapping 130-lb-test, braided Dacron (TM) line around the tube and pulling it into the tie-off groove (<b>Fig. 11</b>). Two passes of line are sufficient. Cut away the excess tubing and apply pressure-sensitive tape around the tube, making sure the synthetic rubber conforms to the turntable (<b>Fig. 12</b>). A hose clamp can be used for more strength if necessary (<b>Fig. 13</b>).</p>
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Fig. 11. Turntable tied in place and excess synthetic rubber trimmed.
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Fig. 12. Socket compressed against turntable with pressure-sensitive tape.
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Fig. 13. Turntable attached with hose clamp.
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<p>Attach the elbow unit and forearm section and check the alignment of the turntable. If it is not properly aligned, reheat the distal end in water and realign.</p>
<p>The harness and cable system are attached in the conventional manner (<b>Fig. 14</b> and <b>Fig. 15</b>).</p>
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Fig. 14. The completed prosthesis.
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Fig. 15. The completed prosthesis.
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<h3>Acknowledgments</h3>
<p>The authors wish to thank Miss Carole Herhold and Dr. Dudley S. Childress for their help in the preparation of this report.</p>
<p><b>References:</b></p>
<ol>
<li>Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</li>
<li>McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</li>
<li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</li>
<li>Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</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, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>J. N. Billock, C.P. </b></td></tr><tr><td class="clsTextSmall">Research Prosthetist, Northwestern University Prosthetic Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. L. Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Coordinator, Prosthetic Research and Education, Northwestern University Prosthetic-Orthotic Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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Technique for Forming Sockets Directly on Above-Elbow Stumps
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Year
1970
Volume
14
Issue
2
Page Number(s)
49 - 57
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<h2>The Use of External Support in the Treatment of Low Back Pain</h2>
<h5>Jacquelin Perry. M.D. <a style="text-decoration:none;">*</a><br /></h5>
<p> The origin of therapeutic procedures can
generally be traced to local efforts directed toward resolving continuing
disability of the patient. In the treatment of low back pain, this approach
often included designing special supports by individual physicians and
orthotists. Such independent activity in numerous locales resulted in a long
list of brace designs, many of which carry impressive eponyms that tend to
stress differences rather than elements of commonality. </p>
<p> To compile the available information
concerning bracing, the American Academy of Orthopaedic Surgeons published the
<i>Orthopaedic Appliances Atlas</i><a></a> in 1953. Of the 30 types of spinal
support described in that volume, 17 were specifically designed for the
sacroiliac or lumbosacral areas. Ten years later, in 1962, a survey of
orthopedic services in the United States by Nattress and Litt<a></a> identified 30
braces, of which 22 corresponded to the design customarily considered effective
at the lumbosacral region. These two reports, along with the present study,
described a total of 40 different devices designed for low back
problems. </p>
<p> Details of designs are readily available,
but objective criteria to weigh the relative merits of the different devices are
almost nonexistent. As a consequence, physicians generally make their selection
either by adopting the customs observed during their training, or by accepting
the preference of the local orthotist. Undoubtedly, some braces have
withstood the test of time, while others have
become items only of historical interest. Superimposed on this background, the
more recent introduction of prefabricated parts for brace construction has
probably influenced the frequency with which certain types of braces are
prescribed.</p>
<p> The extent to which these influences have
altered the availability and prescription of brace designs today has not been
reported. Also unknown is the nature of the relationship between the etiology of
the low back pain and the type of support that clinicians have found to be
effective. Identification of this type of information is pertinent because the
subject of orthotics is now being presented in formally organized courses on a
nationwide basis. </p>
<p> This paper records the results of a
three-phase study conducted in 1968-69 by the Subcommittee on Orthotics,
Committee on Prosthetic-Orthotic Education (CPOE) of the National Research
Council. Approval of the Executive Committee of the American Academy of
Orthopaedic Surgeons was obtained. The purpose of the survey was to identify the
current practices of orthopedic surgeons with respect to external supports for
the management of low back pain. </p>
<h4> Method</h4>
<p><i> Pilot Study </i></p>
<p> An unstructured pilot questionnaire was
sent to 150 orthopedic surgeons selected because of their considerable
experience in the management of low back pain. They were asked to list the types
of support they prescribed, and to indicate the clinical conditions for which
each support was chosen. The results of this pilot
study formed the basis for the next phase of the investigation. </p>
<p> The 90 physicians (60%) who responded
were explicit in their choice of a device and the clinical indication for its
use. Eighty-three reported frequent prescription of external support as part of
their therapeutic program. (Two said they never used external supports, and five
indicated they rarely prescribed such aids.) </p>
<p> Within each class of support (brace,
corset, cast), a similar pattern of practice was evident. Numerous designs were
listed, but most were mentioned only occasionally. The majority of the
respondents preferred one or two types of support. Within a total of 12
different braces reported, three-fourths of the physicians listed the Chairback
(Knight) and Williams braces (<b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>). Six other designs were
mentioned only once. Identification of corset preference was a bit clouded by
the indiscriminate use of both generic and trade names. The generic term
"lumbosacral" was specified by half of those responding. An additional
one-fourth of the pilot-study participants used trade names such as Camp,
Spencer, and Winchester. The next most frequently mentioned device was the sacroiliac belt
(8%). Of the six casts identified, the flexion jacket was preferred by more than
half of the pilot-study orthopedists; the second choice was the body jacket
(19%). In designating the clinical conditions warranting external support, two
response patterns developed in the pilot survey. Seven types of disability were
mentioned frequently and in explicit terms, viz., postoperative fusion,
spondylolisthesis, chronic backache, acute strain, disc syndrome, degenerative
joint disease, and the postoperative disc. Several other conditions, identified
by a wide variety of terminology, were mentioned with moderate to rare
frequency. </p>
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<p class="clsTextCaption"><br />
Fig. 1. The Knight dorsolumbar brace.
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<p class="clsTextCaption"><br />
Fig. 2. A typical modification of the Knight brace.
</p>
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<p class="clsTextCaption"><br />
Fig. 3. The Williams lumbosacral brace.
(Illustrations from Orthotics for Physicians and Therapists, Prosthetic-Orthotic Education, Northwestern University Medical School, Chicago, HI.)
</p>
</td>
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</td>
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<p><i>National Survey of AAOS</i></p>
<p> The findings of the pilot survey were
used to construct a questionnaire applicable for a comprehensive national study.
This questionnaire was sent to the membership of the American Academy of
Orthopaedic Surgeons (AAOS). The form (presented at the end of this article) was
a check sheet on which physicians were asked to match the types of support they
prescribed with the clinical conditions they treated in this
manner. </p>
<p> The following supports, all of which were
more than rarely mentioned in the pilot study, were included. (The restriction
on corset choice was the result of a decision to use generic rather than trade
names in order to avoid repeating the confusion produced in the pilot
study.) </p>
<p><b><i>Braces</i></b></p>
<ol>
<li> Chairback
(Knight) </li><li>Williams </li><li>Norton-Brown </li><li>Goldthwaite </li><li>Bennett </li></ol>
<p> <i>Corsets</i> </p>
<ol>
<li>Lumbosacral </li><li>Sacroiliac </li></ol>
<p> <i>Casts</i> </p>
<ol>
<li>Flexion </li><li>Body jacket </li><li>Cast with one
leg </li></ol>
<p> Eleven clinical conditions were selected
for the national inquiry, based upon the </p>
<p> returns of the pilot study and upon the
clinical experience of the NRC committee. Provision was made throughout for
physicians to indicate devices or clinical problems other than those listed on
the form. The questionnaire was also designed to indicate the relative frequency
("usually" or "rarely") of the prescriptions. </p>
<p><i> Survey of the Functions of Support</i></p>
<p> Late in 1968, a second national survey
was conducted among the AAOS membership to determine prevailing opinions about
the functions of the various types of support. The purpose of this phase of the
study was to attempt to relate the anticipated function of the external support
to the different preferences in prescription. </p>
<p> Profiting from the findings of part one
of the national survey, the list of supports was again shortened. This time, the
orthopedists were queried about two braces (Williams and Chairback [Knight]);
"corset" was listed as a single category, as were the flexion casts. A
miscellaneous category was added for other comments. (The questionnaire appears
on page 57.) </p>
<p> Six probable functions were selected for
study. These included: immobilization of the spine, restriction of lumbosacral
motion, unloading of the intervertebral disc, support of the abdomen, correction
of posture, and psychological effect. As always, there was a provision for other
choices. </p>
<h4> Results </h4>
<p> On the first national survey, 5,215
questionnaires were mailed. With the aid of one follow-up, 3,140 (60%) were
returned completed. An additional 1% of the returns were incomplete because the
physicians had retired or their practices did not include patients with low-back
problems. </p>
<p> In the second phase of the study, the
same number of forms were sent out, with 2,192 (42%) being filled in and
returned. No follow-up mailing was conducted, </p>
<p> Annotated responses or explanatory
letters accompanied 1,034 (33%) of the questionnaires. These consisted of:
(<i>a</i>) identification of the type of device they preferred if it was not
specifically mentioned on the form; <i>(b) </i>comments regarding precise
fitting or construction characteristics considered to be important; (<i>c</i>)
reasons for not prescribing external support; and (<i>d</i>) other modes of
treatment which should accompany use of a support. </p>
<p><i> Use of Supports for Low-Back
Problems</i></p>
<p> Most of the orthopedic surgeons indicated
use of a judicious selection of braces, casts, and corsets; the average
physician reported that he used three different devices in his practice. A small
group stated that they used only one type of device: a brace (4%), a corset
(4%), or a cast (1%). Only 14 respondents stated that they "never used support"
for the patient with a low-back problem. </p>
<p> Among the clinical indications, the
inclusion of the term "fracture" caused considerable confusion in the
information collected. Either all types of braces are used for fractures in the
"low back," or the orthopedist's attention was directed to fractures of the
spine in general. The latter seemed highly probable, as most indicated that a
brace other than those listed was used. Typically, these were the Jewett,
Taylor, and Baker types, commonly used for lesions in the thoracic and
thoracolumbar areas. As the extent of this confusion could not be identified,
all data referring to "fracture" were omitted from the analysis. </p>
<p> Certain characteristics in the
prescription of external support became evident. A majority of the profession
used the same groups of devices. The nature of the disability dictated the
frequency of prescription as well as the type of support preferred. </p>
<p><i> Support Preference </i></p>
<p> The lumbosacral corset is the most
popularly used low-back support, followed by the Chairback (Knight) spinal
brace. Utilization of the other types of support fell far behind these two leaders
<b>Table 1</b>. </p>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Table 1.
</p>
</td>
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</td>
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</tbody></table><br />
<p> The degree of dominance by the
lumbosacral corset varied with the method of comparison; 28.5% of the physicians
indicated use of the lumbosacral corset for at least one condition. When all
clinical indications were considered, preference for the lumbosacral corset was
44.2%. The Chairback brace was used by 21% of the physicians for 22% of the
clinical conditions listed. All other types of support were used less than 9% of
the time. The Williams brace was third in popularity. A variety of casts
preceded any other choice of brace or corset <b>Table 1</b>. </p>
<p> As "lumbosacral corset" is a generic term
that overlooks design differences between the Camp, Winchester, Spencer, and
other specific corset styles, a comparison was made with the designated
preferences for the total group of "low-back braces." The relative preference
between the corset and the low-back brace again depended on the method of
comparison. The use of a brace at some time was indicated by 40.2% of the
physicians, in comparison to 32.4% for corsets. However, when all the clinical
indications were totaled, the preference reversed, with the corsets dominating
(46.7% in contrast to 39.0% for braces). </p>
<p> Some geographic patterns for brace
preference were found, especially for those used less frequently <b>Table 2</b>. The
middle and southeastern sections of the United States were the only areas where
the Williams brace was used widely; it was fourth in preference on the West
coast. With the exception of New York, no mention of it was made in the eastern
or New England states. The Bennett brace was second in popularity in Maryland
and third in Ohio. Predominance of the Norton-Brown<a></a> brace was
restricted to Massachusetts and Maine, a note consistent with the fact that the
originators are from Boston. </p>
<table>
<tbody><tr>
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<p class="clsTextCaption"><br />
Table 2.
</p>
</td>
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</tbody></table>
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<p> <i>Clinical Indications</i> </p>
<p> The survey form asked the physician to
check whether he rarely or usually used some type of support for each of ten
clinical conditions listed <b>Table 3</b>). Three patterns of use were apparent. The
responding physicians seldom used external support in the treatment of an acute
strain (17%), for an obese person with pain (19%), or during the postoperative
period following disc surgery (28%). When support was used for these conditions,
it was generally a corset. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 3.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> At the other extreme, most physicians
used support following spine fusion (84%), for treatment of spondylolisthesis
(70%), and for pseudoarthrosis (66%). In these instances, the most common type of support
was a brace. </p>
<p> The orthopedists were evenly divided as
to the advisability of prescribing any type of support in treating the
degenerative back, the disc syndrome of chronic backache, or as a preoperative
trial. A similar lack of agreement was indicated concerning the type of support
preferred. As a preoperative trial, there was equal preference for a brace or
cast. For the other disabilities, the preferred support was the lumbosacral
corset. </p>
<p> Comparison between the specific brace
design and the clinical condition <b>Table 4</b> showed that the Chairback was
the most frequently used brace in each
situation, and the Williams brace ranked second in preference. Spondylolisthesis
and the disc syndrome were the most common indications for the Williams brace.
Spondylolisthesis was also the primary reason for using the Bennett brace.
Otherwise, preference for the Norton-Brown, Goldthwaite, and Bennett braces
paralleled the use of back support in general. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 4.
</p>
</td>
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</tbody></table>
</td>
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<p> <i>Function of External
Supports</i> </p>
<p> Three approaches to the data collected on
functions of supports seemed pertinent: the general expectation for external
supports, the types of support chosen for each of these functions, and the
functions expected of each of the support designs. </p>
<p> The function most commonly ascribed for
external support was restriction of lumbosacral motion (30%); abdominal support
was second (19%), followed by postural correction (15%) and immobilization of
the spine (12%). </p>
<p> To restrict lumbosacral motion, the
Chairback (Knight) brace or a corset were equally preferred. The Williams brace
was the third specific device indicated for this purpose, although a larger
number of physicians indicated that they used some type of cast to restrict
motion. </p>
<p> Abdominal support was most often assigned
to the corset. This dominated its next competitor, the Chairback (Knight) brace,
by a ratio of two to one. Again, the Williams brace ranked third for the
function of supporting abdominal muscles. </p>
<p> Postural correction was almost equally
divided between the corset and a Williams brace, although the use of casts was
not uncommon. </p>
<p> An interesting situation developed in the
category of spinal immobilization. It was the only function identified for the
flexion cast, yet this device was fourth in preference. The support most often
indicated for spinal immobilization was the Chairback (Knight) brace, a finding
which probably reflects its national popularity. </p>
<p> While external supports are seldom used
for psychological reasons, when the practice is followed the corset is the most
popular device, followed by the Chairback brace. </p>
<p> The concept of unloading the disc has
obviously not been accepted by the majority of orthopedic surgeons, since only
8% indicated this as a function of external support. However, those who did
think in these terms showed a strong preference for the Williams brace, with a
cast as an alternate. </p>
<p> Focus on the individual types of support
showed that the prime functions of the corset were considered to be abdominal
support and restriction of lumbosacral motion. The Chairback (Knight)
brace was assigned the same functions, but with
greater emphasis on restriction of motion. This function was also considered the
main purpose of the Williams brace, with correction of posture as its second
indication. Casts were generally used to restrict lumbosacral motion, although a
surprisingly larger number were also assigned the function of correcting
posture. Consistent with the belief that immobilization, as opposed to
restriction of lumbosacral motion, is seldom accomplished with external support,
even casts were assigned this as a third function. </p>
<p> In addition to completing the survey
form, a third of the respondents (1,034) added notes to further explain their
preferences. These varied from a single listing of a specific brace to lengthy
letters explaining their philosophies of low-back management. A majority of
these replies were focused on either the fitting or construction characteristics
of their support preferences. </p>
<p> Sixty respondents emphasized the
advantages of using exercise early in the treatment of low back pain. Two
purposes were expressed: to avoid external support and to overcome the muscle
weakening and contracture development that accompanies prolonged immobilization.
One respondent summarized this philosophy very succinctly by stating he "never
prescribed support without a plan to eliminate it." A smaller group (30) felt
that the disadvantages were sufficient to preclude any prescription of external
support. All who said they "never" or "rarely" used support emphasized instead
their reliance on an organized program of exercise. Specific application of this
philosophy was frequently mentioned in relationship to postoperative management
of spine fusions. Many respondents also brought out the fact that the treatment
of low back pain must be individualized to fit the particular patient's need.
This fact must never be forgotten, of course, and the purpose of the survey was
not to contradict the concept of individualized patient care, but merely to
identify the spectrum of external support which
physicians have found adequate to meet their multiple goals. </p>
<h4> Discussion </h4>
<p> The potential list of 40 external-support
designs for low back pain has been severely pruned by the influences of
prolonged clinical experience, greater intermingling of orthopedists through
professional meetings, and the use of prefabricated parts. Notes by some of the
respondents indicated that cost, emphasis on exercise, and early surgery are
other important influences. </p>
<p> The clinical indications for use or
non-use of external support were rather sharply defined, but there is no
comparable distinction between the accepted styles of support. The latter was
indicated by the overlap between clinical entity and support design, as well as
by the identification of the functions of the different devices. The mechanical
characteristics and the limitations of these various designs which lead to such
ambiguity have yet to be objectively identified. </p>
<p> Investigators<a></a> have found that, unless
the support is carefully designed, motion at the lumbosacral joint could be
increased with the support rather than </p>
<p> restricted. Personal experience indicates
that this might also lead to increasing the patient's pain. </p>
<p> A problem still not studied is
identification of the characteristics of the patients which govern the choice of
support. </p>
<h4> Summary </h4>
<p> The lumbosacral corset is the most
commonly prescribed external support for low back pain. The Chairback (Knight)
and Williams braces are next in preference, with a cast being used least
frequently. There is a definite relationship between the etiology of the low
back pain and the type of support chosen. The major indication for support
prescription is to restrict lumbosacral motion. </p>
<p><b>References:</b></p>
<ol>
<li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, </i>J. W. Edwards, Ann Arbor, Mich., 1952. </li>
<li>Nattress, LeRoy Wm., Jr., and Bertram D. Litt, <i>Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, </i>American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </li>
<li>Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, <i>J. Bone Joint Surg., </i>39A:111-139, January 1957. </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">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 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>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 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>2.</b> </td><td class="clsTextSmall">Nattress, LeRoy Wm., Jr., and Bertram D. Litt, Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">American Academy of Orthopaedic Surgeons, Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, J. W. Edwards, Ann Arbor, Mich., 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jacquelin Perry. M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Kinesiology Service, Rancho Los Amigos Hospital, Downey, Calif.; Associate Clinical Professor of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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The Use of External Support in the Treatment of Low Back Pain
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DRFOP - Legacy
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Year
1971
Volume
15
Issue
1
Page Number(s)
1 - 14
Text
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<h2>Premodified Casting for the Patellar-Tendon-Bearing Prosthesis</h2>
<h5>Joseph H. Zettl. C.P <a style="text-decoration:none;">*</a><br />Joseph E. Traub. C.P. <a style="text-decoration:none;">*</a><br /></h5>
<p>Methods for producing a functional, comfortable, and well-fitting patellar-tendon-bearing prosthesis have been the subject of considerable discussion, and in fact some controversy, since the prosthesis was first introduced several years ago. Prosthetists use a variety of techniques to cast below-knee stumps, and there is an extensive literature on the subject, not excluding the technicians' differing viewpoints. There is agreement, however, that the effectiveness of the prosthesis depends to a great extent upon how well the wrap-cast (negative) was taken and, subsequently, how precisely the male plaster mold (positive) was modified.</p>
<p>The positive mold is modified in order to relieve pressure-sensitive areas by the addition of build-ups, and to increase the pressure to the pressure-tolerant (or natural weight-bearing) areas of the stump by the judicious removal of small amounts of plaster. These alterations prevent vertical displacement during stance and provide for comfortable accommodation of the stump during full weight-bearing. The precise amount of plaster removed varies with the individual patient, depending upon the muscle tone and the amount and resilience of the subcutaneous tissue. The procedure is by no means a difficult one, but timing is a complicating factor.</p>
<p>Authorities on the subject encourage immediate rather than later modification of the positive cast in order to prevent improper interpretation of the individual stump characteristics. Consequently, the well-qualified prosthetist who finds himself with a large number of plaster positives to be modified, or the less experienced prosthetist who is just developing a keen sense of technical judgment, is at a disadvantage because, even with the best memory and with detailed prosthetic information, he is limited by techniques which involve nothing more than intelligent guesswork and which are conducive to at least an occasional error, regardless of the individual's experience and skill.</p>
<p>This difficulty can be overcome by modifying the cast on the patient's stump when the negative-cast impression for the permanent prosthesis is taken. This paper describes such a procedure, essentially initial socket fitting during casting, which provides a plaster negative-positive that requires only a final smoothing to be ready for socket lamination. The method includes the application of felt pads to strategic areas of the stump. Elastic plaster bandage is used for the negative plaster wrap because it effectively conforms to the irregular stump surfaces, controls tissue compression and displacement, and yields a precise stump impression. The resulting positive plaster mold resembles the stump contours accurately, thus providing the basis for a comfortable, well-fitting, and functionally acceptable PTB prothesis.</p>
<p>Provision of a total-contact, hard PTB socket, without a soft end or the customary insert, is the standard procedure at the Prosthetics Research Study, and the pre-modified-casting procedure results in a precise reproduction of the stump socket, so essential in hard-socket prostheses. This method has been used routinely at this facility since 1964, during which time several hundred PTB prostheses have been effectively fitted.</p>
<p>The premodified-casting procedure can be used, with but relatively minor modifications, for the patellar-tendon supracondylar or the patellar-tendon supracondylar-suprapatellar (PTS) prosthesis, with wedge suspension. We have also used this technique, with promising results, for the production of interim prosthetic sockets using both synthetic rubber, Polysar X-414 (TM), and Lightcast (TM). Both these materials will produce an effective interim prosthetic socket for immediate and early fitting.</p>
<h3>Procedure</h3>
<h4>Negative Plaster Wrap</h4>
<p><i>Prosthetic Information</i></p>
<p>Examine the stump to obtain all pertinent prosthetic information. Measurements of the normal leg can also be recorded at this time on page B of the prosthetic information form, but measurement of the stump is postponed until all felt relief pads have been applied to the stump.</p>
<p><i>Materials and Equipment</i></p>
<p>Materials required for the premodified plaster cast for a PTB prosthesis are:</p>
<ul>
<li>One lightweight cast sock</li>
<li>One heavyweight cast sock</li>
<li>Dow Corning Medical Adhesive Spray Type B</li>
<li>Two rolls of 4- or 5-in. elastic plaster bandage</li>
<li>One roll of 4-in. conventional plaster bandage</li>
<li>Four plaster splints, 4 in. x 15 in., extra-fast-setting</li>
<li>Soft felt, approximately 5 in. x 10 in. x 1/8 in. thick</li>
<li>Medium felt, approximately 5 in. x 10 in. x 3/8 in. thick (or a right or left set of prefabricated felt relief pads, as used in immediate postsurgical prosthetic fitting)</li>
</ul>
<p>Equipment required for this procedure is:</p>
<ul>
<li>Two 48-in. lengths of 1-in. elastic webbing</li>
<li>Four Yates clamps</li>
<li>One pair medium-size scissors</li>
<li>Skiving knife</li>
<li>Inside calipers</li>
<li>Measuring tape</li>
<li>Combination square</li>
<li>VAPC knee-measuring caliper</li>
<li>Preshaped piano-felt, hamstring-tendon relief pads</li>
<li>Below-knee casting fixture</li>
<li>Bucket or basin of clear water, approximately 70 degrees F</li>
</ul>
<p><i>Preparation of Patient</i></p>
<p>Have the amputee sit on a table approximately 30 inches high, with the knee of the amputated leg extending six to eight inches beyond the table edge (<b>Fig. 1</b>).</p>
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Fig. 1.
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<p>Roll the heavy cast sock onto the stump and attach the proximal portion of the cast sock with two Yates clamps to the 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately four inches proximal to the patella (<b>Fig. 2</b>). The strap should exert considerable tension on the cast sock in order to support all soft tissues of the stump, particularly those located distally. <i>This is most important </i>because improper tissue support would result in too large a cast, necessitating modifications of the positive model or prosthetic socket to achieve proper fit.</p>
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Fig. 2.
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<p>Direct the amputee to flex his knee approximately 35 degrees and to maintain this flexion in a relaxed attitude throughout the entire casting procedure.</p>
<p><i>Preparation of Pressure-Relief Pads</i></p>
<p>By palpation, locate the surface areas of the stump which require pressure relief.</p>
<p>For the <i>tibial crest:</i></p>
<ol>
<li>Measure the entire length of the crest of the tibia from the proximal border of the anterior tibial tubercle to 1/2<i> </i>in. beyond the posterior edge of the transected tibia.</li><li>Measure the width of the anterior tibial tubercle and the cut end of the tibia.</li><li>Cut a piece of <i>soft </i>felt, 1/8-in. thick, to the length dimension taken in step 1 and width dimension taken in step 2. This results in a felt relief pad (<b>Fig. 3</b>) which has a long rectangular form and widens in its distal aspect into a well-rounded teardrop shape, approximating the contours of the cut end of the tibia.</li><li>Neatly skive the periphery of the tibial relief pad to assure a smooth transition between the stump sock and pad.</li><li>Usually, additional relief of the distal anterior tibial area is indicated. The additional relief pad should represent the contours of the cut end of the tibia, resulting in the general shape of a large metatarsal pad. The periphery of the pad is smoothly skived to blend in with the tibial relief pad (<b>Fig. 4</b>).</li></ol>
<p>For the <i>head of the fibula:</i></p>
<ol>
<li>Measure the proximal-distal and anterior-posterior dimensions of the head of the fibula.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to those dimensions, rounding off all corners and neatly skiving the periphery. The fibular relief pad should have a shape similar to a large metatarsal pad.</li></ol>
<p>VARIATION: If the cut end of the fibula is prominent, sensitive, or close to the surface, provide another felt relief pad according to its dimensions and skive all edges.</p>
<p>For the <i>anterolateral condylar ridge of the tibial plateau:</i></p>
<ol>
<li>Measure the length and width of this area.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to the dimensions obtained in step 1 (<b>Fig. 5</b>).</li><li>Round off all corners and neatly skive the entire periphery. This results in an oval-shaped condylar-ridge relief pad.</li></ol>
<p><i>Application of Pressure-Relief Pads</i></p>
<ol>
<li>Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li>Spray the appropriate areas on the cast sock where the relief pads will be located and allow the adhesive to dry for five seconds.</li><li>Apply the felt relief pads in their pre-established locations and recheck to be sure they adequately cover the bony prominences on the stump (<b>Fig. 6</b> and <b>Fig. 7</b>).</li></ol>
<p><i>Stump Measurements</i></p>
<ol>
<li>Remind the patient to maintain his stump in an attitude of 35 degrees of flexion, with the stump musculature relaxed.</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the femoral condyles. Measure the mediolateral stump diameter and record on the prosthetic-information form (<b>Fig. 8</b>).</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the patellar tendon and the popliteal tissues. With the stump relaxed, measure the anteroposterior diameter and record on the prosthetic-information form (<b>Fig. 9</b>).</li><li>Mark the apex of the patellar tendon with an indelible pencil (<b>Fig. 10</b>). Place one end of the combination square rule on the patellar tendon and rest the blade of the rule against the long axis of the tibial-crest felt relief pad. Square the distal stump end and record the resulting stump-length measurement in the appropriate box on the prosthetic-information form.</li></ol>
<p><i>Second Cast Sock and Hamstring-Tendon Relief</i></p>
<ol>
<li>The second cast sock, lightweight, is applied very wet. Carefully roll the sock onto the stump without displacing the previously applied felt relief pads.</li><li>The posterior socket brim line should have a well-rounded flare for comfort during prolonged sitting. Appropriate relief for the hamstring tendons provides additional comfort when the knee is maintained in an attitude of 90 degrees of flexion. For this purpose, two standard sets of relief pads in sizes large and average are fashioned from one-inch-thick piano felt. Each set consists of a right and left relief pad. They must resemble the finished rounded contours of the posterior socket brim and include skived distal projections for medial and lateral hamstring-tendon relief. Pad selection is based on matching the distal projections against the hamstring tendons.<br />Select a right or left piano-felt hamstring-tendon relief pad of the proper size (<b>Fig. 11</b>) and place it at the approximate level of the posterior socket brim behind the knee, between the first and second cast socks (<b>Fig. 12</b>). The projections on either side of the relief pad should be located directly over the hamstring tendons behind the knee. Maintain the knee in 35 degrees of flexion.</li><li>With the hamstrings relief pad in place, the second, or lightweight, cast sock is pulled up tight and attached with Yates clamps to a second 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately 4 in. above the patella (<b>Fig. 13</b>). This elastic-webbing strap must also exert considerable tension on the second cast sock, without creating wrinkles.</li><li>Recheck all felt relief pads for retention of their proper locations and adjust if indicated.</li></ol>
<p><i>Preparation of Compression Pads</i></p>
<p>By palpation, locate the surfaces of the stump which are pressure tolerant.</p>
<p>For the <i>pretibial area lateral to the tibial crest:</i></p>
<ol>
<li> Measure the length of the crest of the tibia from the inferior border of the anterior tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li> Measure the distance between the lateral edge of the previously applied tib-ial-relief pad to the anterior border of the fibular head.</li><li> Cut a piece of 3/8-in. <i>medium </i>felt to the dimensions recorded in steps 1 and 2.</li><li> Round off all corners of the pad. The entire periphery is now provided with a 1/2-in. skived border, with a uniform gradual taper, finishing in a feathered edge (<b>Fig. 14</b>).</li></ol>
<p>For the <i>pretibial area medial to the tibial crest, </i>including the medial tibial condylar flare:</p>
<ol>
<li>Measure the length of the crest of the tibia from the inferior border of the tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li>Measure the distance between the medial border of the previously applied tibial relief pad at the level of the tibial tubercle and the medial head of the gastrocnemius muscle.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2.</li><li>Measure down from one end of the felt compression pad 2 in. and mark that point with chalk.</li><li>Palpate the width of the tibia medial to the crest and measure this distance.</li><li>Mark the felt compression pad at the same distance from the long edge one inch below the mark made in step 4 (<b>Fig. 15</b>). Mark on the felt compression pad a smooth S curve from the posterior edge of the felt to the marks in steps 4 and 5.</li><li>Continue the mark made in step 5 with a straight line to the distal end of the felt compression pad (<b>Fig. 16</b>).</li><li>Cut the felt along the marked lines made in steps 4, 6, and 7 (<b>Fig. 17</b>).</li><li>Round off all corners. The entire periphery of the felt compression pad is now provided with a 1/2-in. skived border, with a uniform, gradual taper, finishing in a feathered edge.</li></ol>
<p>For the <i>long shaft of the fibula:</i></p>
<ol>
<li>Measure the length of the fibula from the inferior border of the head to within 1/2 in. of the distal cut end of the bone.</li><li>Measure the anteroposterior dimension of the head of the fibula.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2 (<b>Fig. 18</b>).</li><li>Round off all corners. The entire periphery of the fibular compression pad is now provided with a 1/4-in. skived border with a uniform, gradual taper, and finished in a feathered edge.</li></ol>
<p><i>Application of Compression Pads</i></p>
<p>Apply the felt compression pads to the second (lightweight) sock.</p>
<ol>
<li> Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li> Spray the corresponding areas of the cast sock where the felt compression pads will be located and allow the adhesive to dry for five seconds.</li><li>Carefully locate the felt compression pads in their pre-established positions on the thin cast sock (<b>Fig. 19</b>, <b>Fig. 20</b>, and <b>Fig. 21</b>). These pads <i>must not overlap </i>the areas of the previously applied pressure-relief pads. The felt compression pads should be in firm smooth contact with the thin cast sock to avoid reproduction of wrinkles, rough edges, or other irregularities in the plaster wrap.</li></ol>
<p><i>Application of Elastic Plaster Bandage</i></p>
<p><i>Wraps One and Two. </i>The wrap is always started on the distal lateral aspect of the stump, approximately 1 in. from the distal stump end, to avoid medial displacement of the gastrocnemius muscle (<b>Fig. 22</b>). Minimal tension is applied to the bandage with this circumferential wrap, which is applied clockwise for a right stump and counterclockwise for a left stump (viewed anteriorly). One and three-quarter circumferential wraps will secure the felt compression pads and anchor the elastic plaster bandage to itself (<b>Fig. 23</b>).</p>
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Fig. 22.
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Fig. 23.
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<p><i>Wrap Three. </i>The wrap is now at a posterior-lateral point on the stump. Bring it anteriorly in a diagonal direction over the distal <i>lateral </i>portion of the stump, pulling the plaster bandage almost to its limit of elasticity. At the anterior stump margin, release the tension slightly and carry the wrap medially and then posteriorly, with only a slight pull to the plaster bandage (<b>Fig. 24</b>).</p>
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Fig. 24.
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<p><i>Wrap Four. </i>This wrap is almost identical to wrap three, except that now the bandage covers the distal <i>center </i>of the stump, bandaging in an anteroposterior plane. The direction of the wrap is altered anteriorly and carried toward the lateral side of the stump, as if to resume circumferential wrapping.</p>
<p><i>Wrap Five. </i>The wrap is brought anteriorly up over the distal <i>medial </i>stump aspect with the same controlled tension to the plaster bandage (<b>Fig. 25</b>).</p>
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Fig. 25.
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<p><i>Wrap Six. </i>To achieve sufficient cast strength, a second layer of elastic plaster bandage is applied by repeating wrap five.</p>
<p><i>Wrap Seven. </i>Repeat wrap four, again altering the direction of the wrap to the medial side, which will cover the distal <i>center </i>of the stump with a second layer of plaster bandage.</p>
<p><i>Wrap Eight. </i>Repeating wrap three will now cover the distal <i>lateral </i>stump aspect with a second layer of plaster bandage. The remainder of the elastic bandage is wrapped in a circular manner to a level 1/2 in. superior to the adductor tubercle of the femur.</p>
<p>A second roll of elastic plaster bandage is applied when indicated. Pull the plaster bandage firmly so that it conforms smoothly to the stump without leaving wrinkles or ridges. Maximum tension should be applied to the bandage distally, with gradually decreasing tension as the wrap is extended proximal to the knee joint. Smooth the plaster gently to assure complete adherence of all layers, but avoid molding of the plaster as it hardens (<b>Fig. 26</b>).</p>
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Fig. 26.
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<p><i>Application of Below-Knee PRS-Model Casting Fixture</i></p>
<p>With the plaster still wet, apply the BK casting fixture (<b>Fig. 27</b> and <b>Fig. 28</b>).</p>
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Fig. 27.
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Fig. 28.
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<ol>
<li>Open the casting fixture and place the patellar bar on the patellar tendon.</li><li>Push the patellar bar into the joint space until firm resistance is felt, then release slightly. Push in a direct line with the femur (<b>Fig. 29</b>).</li><li>Attach the posterior popliteal section to the anterior portion of the casting fixture. Contouring of the plaster cast in the area of the popliteal space is achieved by joining the two sections of the casting fixture in proper relationship to the casted stump (<b>Fig. 30</b>).</li><li>Be sure that the patient is completely relaxing his stump musculature and that the knee-flexion angle is maintained at 35 degrees.</li><li>Adjust the casting fixture to the patellar size by rotating both halves of the patellar inverted-horseshoe section.</li><li>Recheck and maintain the outline of the patella. Makes necessary adjustments by means of the thumbscrews as indicated.</li><li>Hold the casting fixture in place until the plaster has hardened completely. Check the distal end of the cast to determine final firmness of the plaster wrap.</li><li>Open the casting fixture and remove carefully (<b>Fig. 31</b>).</li></ol>
<p><i>Reinforcement of Negative Plaster Wrap</i></p>
<p>Apply conventional plaster bandage to reinforce the cast.</p>
<ol>
<li>Two double layers of 4 in. x 15 in. plaster splints are applied over the distal portion of the cast, one anteroposteriorly and one mediolaterally (<b>Fig. 32</b>).</li><li>Reinforcement of the plaster wrap is completed with a roll of 4-in. conventional plaster bandage, starting at the distal stump aspect (<b>Fig. 33</b>) and wrapping prox-imally with even, overlapping, circular wraps.</li></ol>
<p><i>Removal of Negative Plaster Wrap</i></p>
<p>Remove the cast negative only after the plaster wrap has completely hardened.</p>
<ol>
<li>Release both elastic-webbing straps which hold the cast socks suspended.</li><li>Roll the proximal portion of the second (or thin) cast sock down over the brim of the cast negative.</li><li>Remove the posterior piano-felt hamstring-relief pad from between cast socks 1 and 2. If necessary, use a pair of long-nose pliers or the equivalent (<b>Fig. 34</b>).</li><li>Roll the top of the first (or heavy) cast sock down over the brim of the plaster wrap.</li><li>Place your fingers in the popliteal space and your thumbs in the patellar-tendon depressions. Direct the amputee to completely relax his stump.</li><li>With the amputee's knee flexed and relaxed, pull the proximal portion of the plaster wrap towards you to release the area of the patellar tendon by compression of the posterior soft tissue (<b>Fig. 35</b>).</li><li>Carefully remove the first (or heavy) inner cast sock from the negative (<b>Fig. 36</b>). Be extremely careful not to disturb the thin cast sock that adheres to the inside of the plaster-cast negative.</li><li>Inspect the cast critically to be sure that it is smooth and well contoured throughout (<b>Fig. 37</b>).</li></ol>
<p><i>Negative Plaster-Cast Measurements</i></p>
<p>To check the inside dimensions of the cast negative:</p>
<ol>
<li>Place the inside calipers in the cast to measure the anterior-posterior dimensions between the patellar-tendon shelf and the posterior popliteal bulge. Record this measurement on the prosthetic information form, side B. The measurement should be the same as the AP dimension plus 1/8<i> </i>inch.</li><li>Place the inside calipers in the cast at the level of the medial and lateral condyles of the femur. Record this measurement on the prosthetic information form, side B. The dimension should not be more than 3/8 inch larger than the ML stump dimension.</li></ol>
<p>To check the length of the cast:</p>
<ol>
<li>Place a ruler in the socket and measure the dimension from the deepest point of the cast to the center of the patellar-tendon bar. Keep the edge of the ruler parallel to the line of the crest of the tibia.</li><li>Compare this measurement to the length of the stump dimension on the prosthetic information form. It must be within ! <i>s </i>inch of the recorded length.</li></ol>
<p>NOTE: If any of the measurements recorded in steps 1 and 2 are not within the tolerances stated and cannot be reconciled by remeasurement of the stump, it will be necessary to make a new negative plaster wrap. Also, a new plaster negative must be taken if the plaster wrap has collapsed or if the wrap shows deep ridges or other severe irregularities.</p>
<p>The Negative-Positive Plaster Mold</p>
<p><i>The Positive Cast Model</i></p>
<ol>
<li>Fill the negative wrap cast with liquid plaster of paris in the usual manner.</li><li>As the plaster begins to harden, insert a length of vacuum pipe to a sufficient depth, but avoid contacting the negative plaster wrap.</li><li>After the plaster has set for 20 to 30 minutes, cut and strip off all wraps, exposing the positive model. Be careful not to disturb the contours of the model (<b>Fig. 38</b>).</li><li>If necessary, fill all holes in the model left by air bubbles in the plaster. Usually, this will not be necessary if proper care has been taken when filling the negative-cast wrap.</li><li>With a Surform (TM) rasp, smooth off all minor bumps and the irregularities on the model caused by the seam in the cast sock.</li><li>Provide a final smooth finish over the entire model with screen wire and finish with wet-or-dry Fabricut (TM) silicon carbide, 180 grit (<b>Fig. 39</b>). (Screen-baked Durite [TM] would be equally satisfactory.)</li><li>Seal the completed plaster model positive with Hosmer-Lac or the equivalent to prevent the dampness in the plaster from affecting the inner PVA bag during lamination.</li></ol>
<h4>Socket Fabrication</h4>
<p>Proceed with the standard PTB lay-up used for fabricating a polyester hard-socket laminate. The resulting prosthetic socket accommodates the stump very snugly, in most instances with a three-ply wool stump sock. If preferred, the conventional Kemblo (TM) insert can be prepared in the usual manner prior to the polyester lamination procedure.</p>
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Fig. 3.
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Fig. 4.
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Fig. 5.
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Fig. 6.
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Fig. 7.
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Fig. 8.
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Fig. 9.
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Fig. 10.
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Fig. 11.
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Fig. 12.
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Fig. 13.
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Fig. 14.
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Fig. 15.
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Fig. 16.
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Fig. 17.
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Fig. 18.
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Fig. 19.
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Fig. 20.
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Fig. 21.
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Fig. 29.
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Fig. 30.
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Fig. 31.
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Fig. 32.
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Fig. 33.
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Fig. 34.
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Fig. 35.
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Fig. 36.
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Fig. 37.
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Fig. 38.
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Fig. 39.
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<p><b>References:</b></p>
<ol>
<li>Fajal, Guy, Stump casting for the PTS below-knee prosthesis: prothese tibiale supra condylienne, <i>Prosthetics International</i>, 3:4-5:22-24, 1968.</li>
<li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs</i>, 6:2:25-73, June 1962.</li>
<li>Gardner, Henry, A pneumatic system for below-knee stump casting, <i>Prosthetics International</i>, 3:4-5:12-14, 1968.</li>
<li>Hampton, Frederick L., The suspension method for casting of below-knee stumps,<i> Prosthetics International</i>, 3:4-5:9-11, 1968.</li>
<li>Murdoch, George, The "Dundee" socket for the below-knee amuptation, <i>Prosthetics International</i>, 3:4-5:15-21, 1968.</li>
<li>Radcliffe, C. W , and J. Foort, <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley andSan Francisco, 1961 (rev. ed.).</li>
<li>Wilson, Leigh A , and Erik Lyquist, Plaster bandage wrap cast: procedure for the below-knee stump, <i>Prosthetics International</i>, 3:4-5:3-7, 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>Joseph E. Traub. C.P. </b></td></tr><tr><td class="clsTextSmall">Consultant, Rehabilitation Engineering, Social and Rehabilitation Service, Department of Health, Education, and Welfare, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Joseph H. Zettl. C.P </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
Figure 1
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Figure 19
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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
Premodified Casting for the Patellar-Tendon-Bearing Prosthesis
Creator
An entity primarily responsible for making the resource
Joseph H. Zettl. C.P *
Joseph E. Traub. C.P. *
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DRFOP - Legacy
Full Text PDF
PDF Including Full Text and Original Layout
http://www.oandplibrary.org/al/pdf/1970_02_019.pdf
Year
1970
Volume
14
Issue
2
Page Number(s)
19 - 48
Text
Any textual data included in the document
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<td><a href="al/pdf/1970_02_019.pdf"></a></td>
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<td><p><b><a href="al/pdf/1970_02_019.pdf">View as PDF</a></b></p></td>
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<h2>Amputees and Their Prostheses</h2>
<h5>Elizabeth J Davies. M.A. <a style="text-decoration:none;">*</a><br />Barbara R. Friz, M.S. <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, M.D. <a style="text-decoration:none;">*</a><br /></h5>
<p> Information on 8,698 amputations was
collected during a period of approximately two years, ending June 30, 1967. This
information was extracted from case-record forms provided by 44 prosthetics
facilities in 30 states. The case-record form used was initially developed and
standardized by the Conference of Prosthetists of the American Orthotic and
Prosthetic Association. Its purpose was to encourage prosthetists in the
accurate recording of pertinent information relating to the amputee and his
prosthesis. Duplicate copies of the case-record forms were submitted to the
Committee on Prosthetic-Orthotic Education (CPOE)<a></a>, National Research
Council, in order that significant data could be identified and
reported. </p>
<p> "The Facility Case Record Study: A
Preliminary Report"<a></a> and "Children with Amputations"<a></a>, both reporting
findings emerging from this study, have been published previously. </p>
<p> Data analyzed in the study included those
related to age, sex, level and cause of amputations, reamputations,
stump length and contractures, work status of
amputees, referrals, months to delivery of prosthesis, age of replaced
prosthesis and reason for replacement, components most frequently prescribed for
upper- and lower-extremity prostheses, and source of payment for
prostheses. </p>
<h4> Methods</h4>
<p> Each of the 44 facilities submitted case
record forms on amputees as they were seen. Three forms were utilized, one for
the amputee's medical history, one for the lower-extremity prosthesis, and one
for the upper-extremity prosthesis. In cases where the meaning of the data was
uncertain, follow-up forms were sent to the prosthetics facilities to clarify or
add to the information provided. </p>
<p> A coding system was devised, and
information was transferred from the case-record forms to coding sheets and then
to IBM cards and magnetic tape. Selection of pertinent data for retrieval was
determined by an ad hoc group and the staff of CPOE. </p>
<p> In order to make comparisons between
different areas of the country, the states represented in the study were
arbitrarily grouped into five geographical regions <b>Fig. 1</b>. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 1.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<h4> Subjects</h4>
<p> The study included 8,323 amputees with a
total of 8,698 amputations. Statistics in this study refer only to patients
fitted with a prosthesis; amputees not fitted are not included. <b>Table 1</b>
indicates the types of cases included in the study. </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> Amputees or amputations being fitted for
the first time were considered "new" cases. Amputees or amputations
being fitted with replacement prostheses were
considered to be "old" cases. There was a total of 4,034 "new" amputations and
4,664 "old" amputations <b>Table 2</b>. Amputations in males accounted for 6,848
amputations, and amputations in females, 1,850-a ratio of 3.7:1. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 2.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<h4> Findings </h4>
<p><i> Aage of Amputees</i></p>
<p> <b>Table 3</b> shows the age of amputees fitted
in prosthetics facilities during the two years covered by this study. The
incidence of amputations for males peaked in the fifth decade; for females, the
peak was reached in the seventh decade. Forty-eight per cent of the amputees
were 51 years of age or older, 30 per cent were over 61 years, and 12 per cent
were over 71 years. The fact that 23 per cent of the amputees were fitted with
either a new or a replacement prosthesis after 65 years of age has Medicare
implications. (It should be noted that Medicare was in effect during only the
second year of data collection.) </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 3.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i> Level of Amputations </i></p>
<p> Amputations of the lower extremity
accounted for 86 per cent of the total number of amputations <b>Table 4</b>. Of
these, 53 per cent were at the below-knee level. In
the upper extremity, 57 per cent of the amputations were at the below-elbow
level. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 4.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> There was no significant difference in
the incidence of left- and right- side amputation in either the upper or lower
extremities. A total of 4,386 left-limb and 4,312 right-limb amputations was
reported. The right upper extremity was involved slightly more than the left,
605 to 573, and the left lower extremity fractionally more than the right, 3,813
to 3,707. </p>
<p><i> Cause of Amputation</i> </p>
<p> Causes of amputation were considered in
four categories: congenital, tumor, trauma, and disease. Cases of
infection, gangrene, or osteomyelitis resulting from
trauma were classified under "trauma." Cases of trauma associated with vascular
disease were classified under "disease." </p>
<p> Causes of amputation were analyzed by age
group and level. Of the 8,698 amputations reported in this study, the cause was
known for 8,487 cases; both cause and age were known for 8,394 cases. Fifty per
cent of all amputations were caused by trauma, 37.3 per cent by disease, 8.4 per
cent were of congenital origin, and 4.3 per cent were due to tumor. <b>Table 5</b>
shows the relative incidence of amputation by cause and level. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 5.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> In <b>Fig. 2</b> the total number of
amputations by cause of amputation and age is indicated. Amputees most
frequently fitted or returning for replacement in the first
ten years of life were those with congenital limb deficiencies. Amputations for
trauma led all other categories fitted or returning for replacement between the
ages of 11 through 50. In the third, fourth, and fifth decades, this group
accounted for 76 per cent, 82 per cent, and 72 per cent, respectively, of all
cases fitted or returning. Of those fitted in the sixth decade of life, the
incidence was almost equally distributed between traumatic amputations and
amputations due to disease. After age 60, the latter group led all other
categories by a ratio of more than 2:1. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 2.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> <i>"New" Cases by Cause</i> </p>
<p> Analysis of all amputations entered in
the study gives an overview of the type of amputee being seen and fitted in
prosthetics facilities, as reported above. Analysis of those being fitted for
the first time, however, provides a picture of persons
amputated during the two-year period of data collection and gives a better
current indication of cause related to age, sex, and level of
amputation. </p>
<p> It is probable that the statistics on age
are slightly distorted, since age was reported as of the time of fitting. Age at
the time of amputation, therefore, would be less, and to a variable
degree. </p>
<p> In the group of "new" amputees, cause was
reported for 3,963 cases, and both cause and age for 3,920. <b>Fig. 3</b> indicates
the incidence of amputation by age. Of the "new" cases, 60.2 per cent of
amputations were caused by disease, 29.1 per cent by trauma, 5.9 per cent by
tumor, and 4.8 per cent were of congenital origin. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 3.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The predominance of trauma as the cause
of amputation in the overall amputee population of the study <b>Fig. 2</b> is in
striking contrast to the predominance of disease as a cause of amputation when
only new patients are considered <b>Fig. 3</b>. In the overall picture, the ratio of
trauma to disease is 1.3:1, whereas in new patients the ratio is reversed, and
disease as a cause of amputation outnumbers trauma 2:1. </p>
<p> Thus, the total sample data obviously
includes a considerable number of traumatic amputees who lost their limbs at an
earlier age and survived to require replacement prostheses. However, the
noteworthy finding is that, in the period surveyed, disease-caused amputations
were occurring at double the rate of those attributable to trauma. </p>
<p> <i>Congenital. </i>In the 191 reported n males, 86 in females <b>Table 6</b>. Of this number, 137 did not require amputation
surgery, while 54 did. This surgery presumably involved the conversion of
anomalous limbs to stumps that were more suitable for the fitting of a
prosthesis. Eighty-three amputations occurred in the lower extremity, of which
44 were at the below-knee level. Of 108 upper-extremity amputations, 78 were at
the below-elbow level. Thirty-two per cent of congenital amputations were not
fitted until after 11 years of age. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 6.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> <i>Tumor. </i>Of 235 "new" amputations
caused by tumor, 206 (88 per cent) were of the lower extremity <b>Table 7</b>. There
were 120 amputations at the above-knee level, accounting for 58 per cent of the
lower-extremity amputations. An additional 27 per cent were at a level
higher than above-knee, i.e.,
hip-disarticulation or hemipelvectomy. Males outnumbered females 130 to
105. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 7.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The highest incidence of tumor (66 cases
or 29 per cent) occurred in the second decade of life. Within this decade, no
particular pattern of incidence is discernible <b>Table 8</b>. These data are
somewhat at variance with those reported by Taft and Fishman<a></a> from a study
conducted by the staff of New York University Child Prosthetic Studies. This
study, which involved a larger sampling (278 children whose amputations were
caused by tumor), showed a gradual increase in incidence beginning about the 6-8
year period and peaking in the 14-16 year group. Unfortunately, the age
groupings are slightly different from those of our study, so an
exact comparison cannot be made. However, both studies agree that tumor occurs
most frequently in the second decade by a wide margin. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 8.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> <i>Trauma. </i>Of the 1,156 new cases of
amputations resulting from trauma, amputations in males accounted for a total of
1,050, and those in females for 106, a ratio of approximately 10:1 <b>Table 9</b>.
The highest incidence of trauma-related amputations occurred in the third decade
(250 cases), followed closely by that in the fourth decade (216 cases). The
number of amputees in these two decades accounted for 41 per cent of all new
cases where age was known. The incidence of amputations in females varied only
slightly in each decade between the ages of 11 and 60. The incidence of
amputations in males exhibited a sharp rise through the second and third
decades, and then receded gradually. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 9.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> In every decade the involvement of the
lower extremity exceeded that of the upper. Actually, the lower extremity was
involved 1.9 times as often as the upper, 753 times as opposed to
403. </p>
<p> <i>Disease. </i>Sixty per cent (2,381
cases) of all new amputations were caused by disease <b>Fig. 13</b>. Although males
outnumbered females by more than 2:1 in this category, the relative percentages
of males and females in each age group were closely parallel, e.g., 980 or 61
per cent of males were over the age of 61 years, while 464
or 62 per cent of females were also over the age of 61. After 40 years of age, a
sharp rise in the incidence of amputations caused by disease was noticeable.
Approximately one-third of the amputations occurred in the seventh decade.
Eighty-five per cent of all new amputees in the disease category were over the
age of 51 years, and 49 per cent were in the Medicare age group. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 13
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> In disease-caused "new" amputations,
involvement of the lower extremity greatly exceeded that of the upper, the ratio
being 73:1. </p>
<p> <i>Comparison with Amputee
Census</i> </p>
<p> The Glattly study<a></a>, reported in
1964 and commonly referred to as the "Amputee Census," included only "new"
amputees. It is of interest to compare the findings of that study with the
present one. Findings of our study relating to the sex and age of new amputees
and the cause, side, and level of amputations closely parallel the findings of
the Glattly study. Comparative data of the two studies are depicted in <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>, and <b>Fig. 7</b>, and <b>Table 11</b>. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 4
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 5
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 6.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 7.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 11.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> In our study, newly fitted amputees 51
years of age and older accounted for 60.2 per cent of the total, as compared
with 58.8 per cent in the Amputee Census <b>Fig. 4</b>. In both studies, the highest
incidence of amputation was in the seventh decade. Because many geriatric
amputees are not fitted with prostheses, the incidence of amputation in the older age groups would
presumably be even higher if statistics on nonfitted amputees were
included. </p>
<p> In both studies, male amputees exceeded
female amputees by approximately three to one <b>Fig. 5</b>. </p>
<p> The distribution of right- and left-side
amputations was almost equal in both studies, and lower-extremity amputations
still accounted for about 85 per cent of all new fittings <b>Table 11</b>. In <b>Fig. 6</b> a higher incidence of below-knee amputations and a lower incidence of
above-knee amputations were evident in the more recent study. Among new patients
in this study, there was a total of 3,254 above-and below-knee amputations. Of
these, 50.9 per cent were above-knee. </p>
<p> The relative incidence of trauma as a
cause of amputation decreased by four per cent from the Glattly to the present
study, and the incidence by cause in other categories increased, but by
relatively small amounts <b>Fig. 7</b>. </p>
<p> <i>Original Level of Amputation for
Disease Correlated with Geographical Area and Age</i> </p>
<p> The original level of amputation for
disease was examined for 2,242 new cases whose amputations were at either the
above- or below-knee level. Comparisons were made between below- and above-knee
as the choice of amputation level in each of the five geographical areas <b>Table 12</b>. Below-knee appeared to be the site of choice in less than half the total
number of cases. The South led the other geographical areas in percentage of
amputations at the below-knee level (54 per cent), followed in order by the
Midwest (51 per cent), New England (48 per cent), East Central (46 per cent),
and the West (45 per cent). </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 12.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> A look at the site of the original
disease-related amputation for new patients 41 years of age and above revealed
some interesting statistics <b>Table 13</b>. In the fifth decade, below-knee was
selected in preference to above-knee in 58 per cent of the cases. This
percentage gradually decreased over the next two decades to a low of 43 per cent
in the seventh decade. After the seventh decade, there was an increase to 47 per
cent in the eighth decade and to 50 per cent after the eighth decade. For all
new amputations for disease in patients 41 years of age and above, above-knee
was selected in 52 per cent of the cases, below-knee in 48 per cent. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 13.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The lack of a consistent pattern in these
data is intriguing. A progressive decrease in the proportion of below-knee
amputations with increase in age might logically be anticipated. Surgeons, for example,
might wish to be more sure of obtaining healing in older patients and elect to
amputate at the above-knee level. However, other factors than age of patient
obviously enter into the selection of amputation level. </p>
<p><i> Specific Causes of Traumatic
Amputations</i></p>
<p> Trauma was listed as the primary or
precipitating cause of 4,306 amputations ("old" and "new" cases). As noted
earlier, some of this number were classified in categories other than trauma,
since trauma was not considered the primary cause of amputation; hence, the
number 4,306 exceeds the number of cases actually coded in the trauma category.
Of these 4,306 instances where trauma was mentioned, there were 392 cases where
the type of trauma was unknown, so, for purposes of this analysis, reference
will be to the 3,914 cases where type was known. </p>
<p> <b>Fig. 8</b> summarizes the causes of
traumatic amputations. In this category, men were affected ten times as
frequently as women: 3,561 to 353. In males, cars, industrial accidents, and war
each accounted for approximately 20 per cent of the cases. On the other hand,
automobiles were by far the outstanding cause of traumatic amputations in women
(49 per cent), with no other cause approaching this in frequency. It is
noteworthy that the ratio of male to female automobile-caused amputations was
in the order of 4:1, in contrast to the 10:1 overall ratio. Since it is not
known whether these female victims were predominantly drivers or riders, the
full significance of these data is not clear. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 8.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> <b>Table 14</b> relates cause of trauma to sex,
side, and level of amputation. Involvement of the right upper extremity in males
was greater than the left. This preponderance was especially evident in farm and
industrial accidents and is doubtless related to handedness. In car accidents,
the left upper extremity was involved significantly more than the right for both
males and females, 62 per cent as compared with 38 per cent. One can speculate
that this incidence might be attributable to the fact that many motorists ride
with the left elbow extending beyond an open window. In the small sample of
train accidents, the involvement of the left upper extremity in males was also
considerably greater than the right but, because of the small number, this
probably was without significance. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 14.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The left lower limb was involved slightly
more than the right in males, and the right and left limbs almost equally in
females. </p>
<p> <b>Table 15</b> compares causes cited for "new"
traumatic amputations in males with those given for "old" traumatic amputations.
Twenty-six per cent of the amputations of "old" cases were due to war injuries,
whereas only 2 per cent of the new cases were due to this cause. At the time of
this study, the Vietnam War had not yet exerted its full impact. The greatest
increase in trauma-caused amputations was seen in the industrial-accident
category. Industrial accidents caused 29 per cent of the "new" traumatic
amputations, but only 15 per cent of the "old" amputations. Elimination of war
cases from the total number avoids distortion of the data due to the
preponderance of old war injuries, and thus presents a somewhat
truer comparative picture of other traumatic causes. With war injuries
eliminated, industrial accidents accounted for 29 per cent of the "new"
amputations and 20 per cent of the "old" amputations, which still reflects an
increased incidence of amputations caused by industrial accidents. Industrial
accidents exceeded all other categories as the cause of amputation in new
patients. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 15.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i> Reamputations of the Lower
Extremity</i></p>
<p> Reamputations were studied in relation to
cause, original level of amputation, and present level. Level was reported for
396 reamputations of the lower extremity. Some members of this group had second
reamputations, but for the purposes of this study, only the original and present
level of amputation were considered. An attempt was made to exclude simple
revisions that involved no shortening of bone. </p>
<p> In reviewing the figures presented here,
it should be remembered, again, that only those patients fitted with prostheses
at the time of the study are considered. Despite this limitation, analysis of
the available data is thought-provoking. Of 396 reamputations reported, 189 were
in the disease-related category involving a total of 3,122 cases <b>Table 16</b>, and
182 were in the trauma-caused group with 3,387 total cases <b>Table 17</b>. Thus,
reamputations in the first group ran a shade
over 6 per cent, those in the second group a shade under 6 per cent. Stated in
reverse, approximately 94 per cent of the cases in both groups did not require
re-amputation. The statistics for specific levels are also quite fascinating. In
disease-related below-knee amputations, approximately 6 per cent required
reampu-tation versus approximately 5 per cent in the like trauma group. In the
above-knee group, the comparative proportions are 1 per cent versus 0.6 per
cent. At the Syme's level, comparative figures are 25 per cent versus 28 per
cent, and for partial feet 96 per cent versus 25 per cent. The reasons for the
sharp increase in reampu-tations at the last two levels are worthy of further
study. It would also be of interest to know whether partial foot amputations,
for example, were or were not successfully performed on many patients who were
never fitted with prostheses. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 16.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 17.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> For the 189 (48 per cent) reamputations
due to disease, <b>Table 16</b> gives the final as compared to the original level. Of
93 below-knee amputations requiring ream-putation, 22 (24 per cent) remained in
the same segment, 67 (72 per cent) were converted to an above-knee level, 3 to a
knee-disarticulation, and 1 to a hip-disarticula-tion level. Of the 15 original
above-knee amputations, 9 were reamputated in the same segment and 6 became hip
disarticulations. </p>
<p> Of the 11 Syme's reamputations reported,
2 were reamputated to an above-knee level and 9 to a below-knee level. Of the 67
reamputations at the partial foot level, 22 were converted to an above-knee, 41
to below-knee, and 4 to a Syme's level. </p>
<p> Causes of reamputation for patients in
the disease category were indicated for 181 of the 189 reamputations. In some
instances, two causes of reamputation were cited. In each instance where a cause
was mentioned, it was counted as contributing to the reamputation. The total
number of contributing causes to reamputation in the disease category therefore
was 192 <b>Table 18</b>. "Recurrence of the original cause of amputation" accounted
for almost half (48 per cent) of the reasons cited for reamputations. This
generalized response is interpreted as meaning a continuance of the original
vascular problem responsible for the initial amputation. Specific causes cited
were a nonhealing wound (18 per cent), gangrene (12 per cent), infection (5 per
cent) stump breakdown (3 per cent), and "other" (14 per cent). </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 18.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> Most reamputations in the disease
category occurred very shortly after the original surgery, 49 per cent occurring
in less than 1 1/2 months, and 60 per cent occurring in less than 2 1/2 months.
Eighty-two per cent occurred in the first year following the
amputation. </p>
<p> In the category of traumatic amputations,
levels for 182 reamputations of the lower extremity were reported. Of the 114
amputations at the below-knee level requiring reamputation, 57 per cent (65
amputations) remained at the below-knee level, a percentage considerably higher
than was the case for reamputations due to disease. Forty-five amputations were
converted to above-knee levels and 4 were converted to knee disarticulations.
There were 29 Syme's reamputations, of which 23 were converted to below-knee, 3
to above-knee, and 3 remained at the Syme's level. Of the 22 partial foot
reamputations, 14 were converted to below-knee levels, 7 to Syme's and 1 to
above-knee. </p>
<p> Causes of reamputation were known for 157
of the trauma cases. As with reamputations in the disease category, every
instance where a cause was mentioned was counted. There were 165 contributing
causes to reamputations <b>Table 19</b>. In 71 instances (43 per cent), "other" was
coded as the cause of reamputation. Included in the "other" category were causes
that could not be readily classified, such as "stump not satisfactory for
prosthesis," "shorten bone and remove neuroma," "painful stump." The median
number of months between amputation and
reamputation was six. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 19.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> There were 16 reamputations for
congenital amputees and 6 for patients whose amputations were caused by tumor.
Three of the latter were reamputated because of recurrence of the tumor.
Reported reasons for reamputations in congenital amputees were too diverse for
classification, except that 4 reamputations were because of bony
overgrowth. </p>
<p> <b>Table 20</b> summarizes the total number of
reamputations for each level and includes the percentage of reamputations
converted to a higher segment or remaining in the same segment. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 20.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> Bony overgrowth was cited eight times as
a reason for reamputation: four tibial overgrowths, two fibular overgrowths,
and two not specified. All of these
reamputa-tions were performed on children, with the exception of one on a
27-year-old amputee. While not implicit in the data, it is conceivable that this
27-year-old had had bony overgrowth for a long time prior to reamputation (his
first amputation occurred at age 10). </p>
<p><i> Stump Length and Contractures</i></p>
<p> There were 2,602 above-knee amputations
for which the presence or absence of contractures of the hip was reported. Of
this group, 1,345 had either no flexion contracture or a contracture of less
than 5 deg, and are not included in this analysis, other than the notation that
they comprised over half of the group reported. Stumps with 5+ deg of
contracture ranged in length from 2 - 2 1/2<i> </i>inches to 14 - 15 1/2 inches. Three stumps had flexion contractures of more than 60 deg.
Hip-flexion contractures were greatest in the very
short stump. The average contracture at the above-knee level fell in the 5-9 deg
range. </p>
<p> There were 3,781 below-knee amputations
for which the presence or absence of knee contractures was reported. Of this
number, only 12 per cent were reported as having contractures of 5 deg or more.
In general, the shorter the stump, the more severe the contracture. Considering
only those cases reporting contractures of 5 deg or more, stumps averaging more
than 7 1/2<i> </i>in. in length had average contractures of between 5 and 9 deg;
for stumps between 4 and 7 1/2<i> </i>in. long, contractures averaged between 10
and 14 deg; and for stumps 3 1/2 in. and less in length, contractures averaged
15 to 19 deg. The average contracture, excluding those of less than 5 deg, was
10-14 deg. Three stumps had contractures of 60 deg or more. </p>
<p><i> Work Status</i></p>
<p> The work status of "old" male amputees
between the ages of 21 and 64, with 2,694 amputations, was reported. "New"
amputees were not studied, since the majority of the group had not yet had time
to return to employment. Eighty-four per cent of the "old" amputees in the cited
age group were employed, the highest employment rate (89 per cent) occurring in
the 41- to 50-year-old age group <b>Fig. 9</b>. In each of the age groups studied, a
higher rate of employment was reported for upper-extremity than for
lower-extremity amputees. It should be noted here that only 6.4 per cent of
amputees between the ages of 21 and 64 were reported as not being gainfully
employed. The remainder of the group (9.3 per cent) were students, retired, or
fell into some other category. This percentage of unemployment is a little
higher than that reported for the national average for the
years 1965, 1966, and 1967 (4.5, 3.8, and 3.8 per cent respectively). </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 9.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The rate of employment in relation to
each upper- and lower-extremity amputation level appears in <b>Fig. 10</b> and <b>Fig. 11</b>. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 10.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 11.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> Work status was reported for 383 female
amputees between the ages of 21 and 64. Of this number, 200 were housewives, 148
were gainfully employed, and only 18 were not gainfully employed. Seventeen had
either retired or reported their work status in some other category. </p>
<p><i>Referrals</i></p>
<p> The majority (58 per cent) of cases
fitted at prosthetics facilities were referred by amputee clinics; 26 per cent
were referred by physicians; 16 per cent were not referred. Of the "new" cases,
5 per cent were not referred to prosthetics facilities by either a clinic or
physician, as contrasted to the 26 per cent of the
"old" cases not so referred. </p>
<p><i> Months to Delivery of
Prostheses</i></p>
<p> For "new" amputations, the time from
amputation (or from birth for congenital amputees not requiring surgery) to date
of delivery of the prosthesis was analyzed by level and cause for the five
geographical regions <b>Table 21</b>. The median period to delivery for all
prostheses was 6 months. Comparing geographical areas, the median was 5 months
for New England, the Midwest and West, 6 months for the South, and 7 months for
the East Central region. Of the 3,588 prostheses with times to delivery
reported, 71 were delivered in 1 month or less, 67 were not delivered for 99
months or longer. Thirty-seven of the latter were for congenital amputations not
requiring surgery, i.e., 37 children were not fitted with their first </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 21.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> prosthesis until after the age of eight
years, three months. A comparison of time to delivery by levels indicated that
the median time lapse was 5 months for the below-knee prosthesis and 6 months
for all other levels. Time to delivery of prostheses ranged from a median of 4
months for below-knee prostheses in the New England area and the West to a
median of 10 months for below-elbow prostheses in the East Central region. These
data will provide a basis for later comparisons in areas where programs of
immediate and early prosthetic fitting have been instituted. </p>
<p> Data on months to delivery were analyzed
by cause of amputation and related to geographical regions <b>Table 22</b>. The
shortest median length of time for delivery was 3 months for congenital amputees
who had had surgery. The longest time was for congenital amputations without
surgery, where the median was 31 to 36 months; however, it should be
recognized here that this median also represents the median age of congenital
amputees not requiring surgery who were being fitted for the first time. Median
time to delivery for amputations caused by tumor was 4 months; by trauma, 5
months; and by disease, 6 months. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 22.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i> Age of Replaced Prostheses and Reasons
for Replacement</i></p>
<p> The average age of replaced prostheses
for all patients was 6.1 years. For children up to 21 years of age, it was 2.5
years, and for adults, 6.7 years. </p>
<p> Comparisons of the ages of replaced
prostheses for above- and below-elbow and above- and below-knee amputees in
relation to the age of the patient (by decade) are shown in <b>Table 23</b>. In almost
every instance, the "life" of the prosthesis increased with the age of the
patient. The average life of above-elbow prostheses for 124 amputations was 9.2
years. The range was from 2.5 years for the child through the age of 10 years to
16.7 years for amputees over the age of 61. The average age of below-elbow prostheses for
349 amputations was 6.5 years, ranging from 2.5 years for the child through age
10, to 10.3 years for amputees over age 51. The average age of above-knee
prostheses for 1,269 amputations was 6.2 years, with a range from 2.2 years for
the child in the first decade, to 8.1 years for amputees over age 71. The
below-knee prosthesis had the shortest life, averaging 5.8
years for 2,201 amputations, and ranging from an average of 1.7 years for the
child through age 10, to 8.6 years for amputees over 71 years of age. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 23.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> In comparing ages of replaced prostheses
by cause of amputation and the sex of the amputee, it is found that prostheses
for congenital amputees had the shortest life, averaging 3.5 years, and
prostheses for traumatic amputees had the longest life, averaging 6.8 years
<b>Table 24</b>. The growth rate of children in the congenital group undoubtedly
accounts for the more frequent replacements of prostheses evident here.
Replacement of prostheses for patients in the disease category occurred, on
average, every 5 years, and there was very little difference between
replacements for males and females. The life of prostheses for tumor patients
also averaged 5 years; however, prostheses for males in this category needed
more frequent replacement, lasting 4.5 years as compared with an average 5.6
years for females. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 24.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> It is interesting to note that the age of
replaced prostheses for males averaged 6.2 years, and that of females 5.4 years.
The large number of males in the trauma category may account for this
difference, inasmuch as the average life of prostheses in this category is
longer than in others. </p>
<p> <b>Table 25</b> indicates the reason for
replacement of prostheses. The majority of prostheses were replaced because they
were worn out. "Worn out" was listed as the sole or contributing cause of
replacing a prosthesis in 58 per cent of the cases.
It was the leading reason for replacing prostheses of persons whose amputations
were caused by tumor (50 per cent), trauma (67 per cent), and disease (44 per
cent). As would be expected, the primary reason for replacing prostheses of
congenital amputees was that the prosthesis was "outgrown." In 52 per cent of
replacements for congenital amputees, the prosthesis was outgrown; in 33 per
cent of the cases it was worn out. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 25.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> "Unsatisfactory" was cited as the reason
for replacement in four per cent of the cases. However, it should be noted that
although the "unsatisfactory" category was meant to include only those cases in
which problems arose relating to fabrication or patient tolerance, it was often
cited for other reasons which rendered the prosthesis unsatisfactory. Had this
item been interpreted correctly, the
percentage undoubtedly would have been lower. </p>
<p> The average age of all "worn out"
prostheses that were replaced was 7.6 years <b>Table 26</b>. This exceeds the average
age of prostheses replaced for any reason (6.1 years) by a year and a half. This
higher age undoubtedly reflects the longer life of the prostheses of traumatic
amputees reported above, since "worn out" was the sole or contributing factor
for 67 per cent of the replacements in the trauma category. Additionally, the
lower average age of all the replaced prostheses was affected by the inclusion
of children's prostheses, which had shorter lives. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 26.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p><i>Ccomponents for Upper-Extremity
Prostheses</i></p>
<p> The components most frequently used for
upper-extremity prostheses at the above- and below-elbow levels are depicted in
<b>Fig. 12a</b>,<b>Fig. 12b</b>. The voluntary-opening hook was used with 87 per cent (201 instances)
of the above-elbow prostheses and 90 per cent (517 instances) of below-elbow
prostheses. The preference for this type of hook was reflected in all areas
except the West, which showed a preference for the voluntary-closing hook with
below-elbow prostheses. New England was the only area that did not prescribe the
voluntary-closing hook at all. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 12a. Most frequently used components
for above-elbow prostheses.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 12b. Most frequently used components
for below-elbow prostheses.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The hand-type terminal device was
utilized to a limited extent, being prescribed 309 times as opposed to the
hook-type device which was prescribed 806 times. Many amputees for whom hooks
were prescribed were also equipped with hands. Where hand-type devices were
reported, the voluntary opening hand was prescribed for above-elbow prostheses
40 per cent of the time (36 cases) and for below-elbow prostheses 36 per cent of
the time (79 cases). Both the East Central and Midwest areas preferred
voluntary-closing hands for use with above-elbow prostheses. The East Central
and Western areas preferred voluntary-closing hands for below-elbow prostheses.
New England showed a preference for the passive hand with the below-elbow
prosthesis. </p>
<p> The simple friction wrist unit was
overwhelmingly preferred to quick-change types in all geographical areas, being
used with 83 per cent of above-elbow and 85 per cent of below-elbow
prostheses. </p>
<p> Although the triceps pad was used with 56
per cent of the below-elbow prostheses, its use ranged from 35 per cent in the
South to 94 per cent in the New England area. The South preferred the half cuff.
Plastic laminate was the cuff material of choice in 61 per cent of the total
cases, although the East Central and Western areas preferred leather to the
extent of 54 per cent and 55 per cent respectively. </p>
<p> The double-wall socket was used in 89 per
cent of the above-elbow and 77 per cent of the below-elbow prostheses.
Pre-flexed sockets, some of which also had double walls, were used in 11 per
cent of the below-elbow prostheses. Sixty-one per cent of the preflexed sockets
were utilized by children. </p>
<p> In 98 per cent of the upper-extremity
prostheses, the sockets were made of plastic. </p>
<p> The elbow unit with internal lock was the
item of choice for above-elbow prostheses in all geographical areas, being used
in 78 per cent of all fittings. Seventeen per cent of all elbow units had
spring-flexion assists. Sixty-four per cent of the elbow hinges used in
below-elbow prostheses were flexible, the range being from 44 per cent in the
West to 92 per cent in New England. The Midwest showed almost equal preference
for the single-pivot (47 per cent) and the flexible hinge (50 per
cent). </p>
<p> Dual-control systems were used in 80 per
cent of above-elbow and single control in 96 per cent of the below-elbow
prostheses. </p>
<p> Eighty-three per cent of the harnesses
for above-elbow prostheses were of the figure-eight type, the majority of this
group (55 per cent) being equipped with the Northwestern University harness
ring. The East Central area and the West showed a preference for the
figure-eight harness without the ring. Of the 14 cases with reported type of
harness in the West, none used the ring with the figure-eight. The South used
the ring to the greatest extent for above-elbow prostheses. </p>
<p> Ninety-two per cent of the below-elbow
harness were of the figure-eight type, 59 per cent of these being equipped with
rings. The East Central, South, and Midwest areas showed greatest preference for
the ring figure-eight harness; the New England and Western areas used the
figure-eight harness without the ring almost as often as with it. </p>
<p> <i>Components for Lower-Extremity
Prostheses</i> </p>
<p> Components most frequently used for
above- and below-knee prostheses appear in <b>Fig. 13a</b>,<b>Fig. 13b</b>. The various geographical
areas showed more consistency in prescription of lower-extremity than
upper-extremity components. In most instances, only the percentage varied, not
the type of component. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 13a. Most frequently used components
for above-knee prostheses.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Fig. 13b. Most frequently used components
for below-knee prostheses.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> The SACH foot was prescribed for 55 per
cent of the above-knee and 73 per cent of the below-knee prostheses. In area
comparisons, the South showed the greatest usage of the SACH foot, and the
Midwest the lowest. For the above-knee prosthesis, prescription of the SACH foot
rose from 76 per cent in the first to 83 per cent in the second decade, and then
gradually declined with advancing amputee age. In the below-knee group, the SACH
foot was prescribed 96 per cent of the time for children under 10 years of age;
the percentage declined steadily to a low of 56 per cent in the eighth decade,
then rose to 63 per cent for the group of amputees 81 years of age and
over. </p>
<p> Wood was used as the shank material in 95
per cent of the above-knee and in 90 per cent of the below-knee
prostheses. </p>
<p> The most frequently used knee component
for above-knee prostheses was the single axis, with friction being used in 74
per cent of the fittings. Twelve per cent of the knees were single axis with
manual locks. Eight per cent of the knees were hydraulic, with the West showing
the greatest preference (17 per cent) and the Midwest the least (4 per cent). In
instances where metal joints were reported for below-knee prostheses, the lap
joint was specified in 48 per cent of the cases and the clevis joint in 22 per
cent. The type of joint was not specified in 30 per cent of the
cases. </p>
<p> For above-knee amputees, the
quadrilateral socket was used in 85 per cent of the prostheses. It was the
overwhelming choice in each of the geographical areas.
The socket of choice for below-knee amputations was the patellar-tendon-bearing.
Preference for this socket averaged 58 per cent, the South and West showing
greatest utilization, 79 per cent and 82 per cent respectively, and the New
England and Midwest areas the least utilization, 44 per cent and 47 per cent
respectively. </p>
<p> Wood was used most often for above-knee
sockets, averaging 57 per cent, although the South showed a preference for
plastic, using it for 55 per cent of all sockets. Below-knee sockets were most
often (55 per cent) fabricated in plastic. New England showed a preference for
leather sockets, and the Midwest preferred wood (41 per cent) to either plastic
or leather. </p>
<p> The pelvic belt was the preferred method
of suspension (56 per cent) for above-knee prostheses. Only in the West
did the use of suction, either alone or in combination with other suspension,
exceed the use of the pelvic belt. In correlating methods of suspension with
age, it was noteworthy that during the second, third, and fourth decades,
suction alone was preferred to all other types of suspension. In all other
decades, the pelvic belt was preferred. </p>
<p> In considering types of suspension
reported for all below-knee prostheses, the knee cuff alone was the choice of
suspension in 36 per cent of the cases. It was least used in the Midwest (22 per
cent). The South and West utilized the knee cuff alone most frequently (55 per
cent). When type of suspension for the patellar-tendon-bearing prosthesis is
analyzed by age group, it is found that, while the knee cuff alone was used for
62 per cent of all </p>
<p> the prostheses, greatest usage occurred
in the second decade (73 per cent) and next greatest in the third decade (71 per
cent). Least use of the knee cuff alone occurred in the very young child (48 per
cent), but the inclusion of cases where a waist belt was used in conjunction
with the knee cuff raised this percentage to 68. </p>
<p><i> Sources of Payment </i></p>
<p> <b>Table 27</b>, <b>Table 28</b>, and <b>Table 29</b> indicate the
sources of payment for prostheses. More than one source was sometimes listed, in
which case they are reported under "combinations of the above "or" "other".
Medicare had been in operation only one year prior to the conclusion of this
study and presumably would rank considerably higher as a source of payment at
the present time. As mentioned earlier, over 23 per cent of the amputees in this
study were in the Medicare age bracket. </p>
<table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 27.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 28.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br /><table>
<tbody><tr>
<td>
<table>
<tbody><tr>
<td>
<p class="clsTextCaption"><br />
Table 29.
</p>
</td>
</tr>
</tbody></table>
</td>
</tr>
</tbody></table><br />
<p> Source of payment was given for 8,631
prostheses <b>Table 27</b>. The greatest contributors to defraying the costs of
prostheses were State Bureaus of Vocational Rehabilitation (22.5 per cent) and
the patient himself (22.8 per cent). Next in order were the Veterans
Administration (14.3 per cent), welfare (10.8 per cent) and insurance (9.9 per
cent). </p>
<p> The Children's Bureau paid for 46.5 per
cent of the prostheses for children up to the age of 21. Through the
wage-earning years, 21 to 64, State Bureaus of Vocational Rehabilitation paid
for 31.9 per cent of the prostheses, the amputee for 24.3 per cent, and the
Veterans Administration for 19.3 per cent. During the retirement years, 65 and
over, the amputee alone paid for 29.9 per cent of the prostheses, Social
Security and Medicare for 19.5 per cent, and welfare for 15.3 per
cent. </p>
<p> A further analysis of sources of payment
relating to the wage-earning years yields some interesting facts <b>Table 28</b>. The
Veterans Administration paid for 30 per cent of replacement prostheses, but
only 10 per cent of new prostheses. This
statistic doubtless reflects the continuing supply of prostheses to veterans of
World War II and the Korean War and a decreased
number of fresh cases. More "new" male amputees were supported by insurance or
compensation than "old" male amputees, 24 per cent as opposed to 8 per cent.
This may reflect the policy of some insurance companies to pay for the first
prosthesis only. On the other hand, it may indicate an increase in opportunity
for insuring oneself against disability and a greater awareness of the values of
health insurance. In comparing source of payment for males and females in this
age group, one notices the higher level of support by the amputees themselves
and the Bureaus of Vocational Rehabilitation for the female group, and also the
very low percentage of females supported by insurance or
compensation. </p>
<p> In correlating source of support with
occupation, only "old" amputees were considered, since in most instances "new"
amputees had not yet returned to work at the time the data forms were submitted.
Amputees were studied in three categories: those gainfully employed, those not
gainfully employed, and those who were students, housewives, or retired <b>Table 29</b>. </p>
<p> Of the 3,055 "old" cases included above,
only 187, or 6 per cent, were reported as not being gainfully employed. The
Bureaus of Vocational Rehabilitation paid for 35 per cent of the prostheses for
the gainfully employed group, the Veterans Administration for 28 per cent, and
the amputee for 25 per cent. For the group of amputees not gainfully employed,
the Bureaus of Vocational Rehabilitation were the source of payment for 28 per
cent of the prostheses, the Veterans Administration for 27 per cent, and welfare
for 24 per cent. In the 468 amputations of students, housewives, or retired
amputees, 31 per cent of the prostheses were paid for by the amputee, 28 per
cent by the Bureaus of Vocational Rehabilitation,
and 17 per cent by the Veterans Administration. </p>
<h4> Discussion </h4>
<p> In recent years, there has been
increasing interest in defining the characteristics of the amputee population,
and also in providing amputees with functional stumps and prostheses. Much
progress has been made in understanding the amputee and his problems, and in the
fabrication of improved prosthetic components. This study has sought to document
some of the characteristics of the amputee and his prosthesis during a
particular period in time-the approximately two years ending June 30,
1967. </p>
<p> Certain characteristics of amputees,
namely sex and age, and the cause, side, and site of amputation, were well
established in Glattly's study of 12,000 new amputees for whom data were
collected over a two-year period, ending in 1963. In the present study of over
8,000 amputees, 4,034 of whom were new, data were likewise collected over a
two-year period which ended in 1967, four years later. Unless some catastrophic
event had occurred immediately before or during either of the two periods, it
would be expected that in large samples such as these, the sex and age of the
amputee and side and cause of the amputation would be relatively constant. Such
was indeed the case, indicating that the sample in the latest study was a valid
cross-section of the amputee population. As noted before, neither the Medicare
Act nor the conflict in Vietnam had exerted a significant impact on this study.
Although medical advances over a number of years have been largely responsible
for the increasing age of the amputee, with a resulting shift from trauma to
disease as a predominant cause of amputation, such changes would not be expected
to exert a significant difference in as short a period as four years. </p>
<p> In amputations caused by disease, the
site of amputation can be influenced by medical judgment at a particular time. In
the vast majority of cases where amputation is categorized as disease, the
amputees had vascular insufficiency. For this condition, amputation at a level
above the knee had been widely advocated for many years because it was felt that
this procedure facilitated healing. It has been found, however, that amputation
may be performed at a below-knee level, with primary healing occurring in the
majority of cases.<a></a> By preserving the knee joint, amputation at this level
greatly enhances the rehabilitation potential of the patient. </p>
<p> Burgess has reported that most below-knee
amputations for ischemia heal primarily, and with proper prosthetic care do not
break down.<a></a> Lim reports that 92 per cent of below-knee amputations were
successful when a popliteal pulse was present, and 75 per cent were successful
when pulse was absent.<a></a> He also reports a lower mortality rate for below-knee
amputees, 16 per cent as opposed to 35 per cent for above-knee amputations.
Tracy cites a 90 per cent successful healing rate for below-knee amputations for
ischemic gangrene.<a></a></p>
<p> Although the increase in the percentage
of below-knee amputations in our study, as compared with the Glattly study, is
relatively small in view of the <i>potential </i>increase, it is nevertheless an
encouraging trend, and it is to be hoped that a dramatic increase will be
reflected in future surveys as the results of ongoing educational programs take
effect. </p>
<p> Although the incidence of amputations due
to trauma appears to have declined, as far as percentage of the total amputee
population is concerned, this does not necessarily imply a decrease in the
overall incidence of traumatic amputations. Actually, the increasing age of
amputees, with its corollary of increasing incidence of amputations due to
disease, is certainly partly responsible for the decline in percentage of trauma
cases. In the younger age groups, trauma continues as the major cause of
amputations. The Public Health Service report<a></a> published in 1964
shows that "absence of major extremity,"
classified as an accident "while at work," occurred almost three times as often
as amputation caused by "moving motor vehicles." In the present study, the ratio
was closer to 1:1 than 3:1, i.e., moving vehicles as a cause of traumatic
amputations was almost equal to that of industrial accident. A higher percentage
of auto accidents than industrial accidents occurred in the female group, a
pattern which is typical of other reported findings. These results may indicate
improved safety controls in industry, or may underscore the soaring rate of
automobile accidents, or both. The large number of amputations resulting from
trauma continues to have strong implication for improved accident-prevention
programs and more effective human-factors engineering. The need for greater
safety of design, particularly in cars and industry, continues to be
great. </p>
<p> It is of interest to note that prosthetic
prescription varied among the geographical areas, some areas having a greater
tendency than others to incorporate newer prosthetic techniques. It might be
expected that the latest prosthetic developments would be incorporated into
prosthetic practice in those areas which were near the prosthetic-orthotic
educational centers (New York, Chicago, and Los Angeles) or in areas of greatest
concentration of prosthetic facilities (California, Pennsylvania, New York, and
Illinois), or amputee clinics (New York, Pennsylvania, California, and Texas).
With the exception of the West, where newer developments were used in a high
percentage of cases, there appeared to be no relationship between the nature of
prosthetic services provided and the factors cited above. Both the South and the
West showed a more consistent use of newer techniques than did the other
areas. </p>
<p> The provision of prosthetic services
reported in the study indicates that much improvement is to be desired as far as
length of time for delivery of the prosthesis is concerned. The time
between the date of amputation (or reamputation)
and delivery of the prosthesis was inordinately long, ranging from a median of
four months for patients whose amputations were caused by tumor to six months
for patients with vascular disease. The provision of temporary prostheses and
immediate postsurgical fitting of prostheses would help shorten this time
lag. </p>
<p> The finding that a relatively high
percentage of congenital amputees (32 per cent) were not fitted until after
their eleventh birthday is distressing. Since current philosophy is to fit
congenital amputees at a very early age, it would be interesting to know the
reason for this reported delay. Whether the fault lies with amputee clinics, or
with parents who are either reluctant to take their children to clinics or are
ignorant of the prosthetic opportunities available to them, is not evident from
the present analysis. The implication is that more needs to be done at the
educational level. The growth and implementation of dynamic treatment programs
would surely result in a much more optimistic picture. </p>
<p> A composite picture of amputees reported
in this study would present the following profile: </p>
<ol>
<li>The congenital amputee seen in
prosthetic facilities was a male under 10 years of age with involvement at the
below-knee level. </li><li>The amputee whose amputation was
caused by tumor was a male between 11 and 20 years of age whose amputation was
at the above-knee level. </li><li>The traumatic amputee was a male
now between the ages of 41 and 50 years who had received his amputation between
the ages of 21 and 30 years. His amputation was at the below-knee level and was
most likely received as a result of a car accident, industrial accident, or war
injury. </li><li>The amputee whose amputation was
caused by disease was also a male, between the ages of 61 and 70 years, who was
amputated during these same years. His amputation was as likely to be at
the above-knee level as at the below-knee
level. </li></ol>
<h4> Summary </h4>
<ol>
<li>This study, which extended over
a two-year period ending in June 1967, presents data on 8,323 amputees with
8,698 amputations, all of whom were fitted with prostheses. </li><li>Of the "new" amputations
seen in prosthetic facilities, 60 per cent were caused by disease, 29 per cent
by trauma, 6 per cent by tumor, and 5 per cent were of congenital
origin. </li><li>Of all amputations, "new" and
"old," being fitted in prosthetic facilities, 50 per cent were caused by trauma,
37.3 per cent were caused by disease, 8.4 per cent were of congenital origin,
and 4.3 per cent were caused by tumor. </li><li> The greatest incidence of
disease-caused amputations occurred in the seventh decade, those of trauma in
the third decade, and those of tumor in the second decade. </li><li>Males outnumbered females
in every category, the ratio for "new" amputations of males to females being
approximately 2:1 for disease, 10:1 for trauma, and 1.2:1 for both congenital
causes and tumor. </li><li>Eighty-six per cent of the total
number of amputations were of the lower extremity, with 53 per cent of this
group being at the below-knee level. </li><li>Although automobile accidents
were cited as the single greatest cause of all traumatic amputations, war
injuries, industrial accidents, and automobile accidents were cited almost
equally for male amputees. </li><li>Forty-eight per cent of all
reampu-tations were in the disease category, 60 per cent of these occurring
within two and one-half months of the original amputation. The reamputation rate
for below-knee amputations caused by disease was not significantly higher than
that for trauma-caused amputations-approximately 6 per cent in both
instances. </li><li>Degree of contracture reported
at both hip and knee varied inversely with the length of the stump. Excluding
contractures of less than 5 deg, the average hip flexion contracture for
above-knee amputations was in the 5-9 deg range; the average knee flexion
contracture for be-low-knee amputations fell in the 10-14 deg range. Fifty-two
per cent of those cases reporting presence or absence of contractures had either
no contracture or one of less than 5 deg. </li><li> Unemployment rate for "old"
male amputees between the ages of 21 and 64 was 6.4 per cent, slightly higher
than the national average for the years covered by the report. </li><li>Fifty-eight per cent of
patients were referred to prosthetic facilities by amputee clinics, 26 per cent
by physicians, and 16 per cent were not referred. </li><li>The median time from amputation
to delivery of a prosthesis was six months, the below-knee prosthesis being
delivered in the shortest length of time. Congenital amputees who required
surgery received prostheses in a median time of three months postsurgery.
Patients in the disease category waited the longest time- six months. </li><li> Prostheses had an average life
of 6.1 years, with the life of the prosthesis increasing with the age of the
patient. Below-knee prostheses generally and prostheses for congenital amputees
had the shortest life. Prostheses for males lasted longer than those for
females. "Worn out" was the primary reason given for replacing a
prosthesis. </li><li>Prosthetic prescription varied
in the geographical areas, some regions demonstrating a greater tendency than
others to incorporate newer prosthetic techniques. Generally, as the age of the
amputee advanced, there was a tendency to use the older types of components,
e.g., pelvic hands, articulated ankles. </li><li>The Children's Bureau was the largest
single source of financial support for the purchase of prostheses for children,
and the State Bureaus of Vocational Rehabilitation provided the greatest
financial support for amputees during the wage-earning years. The Veterans
Administration paid for a high percentage of prostheses for males who were in
the "old" category. In all, the federal government paid entirely for 48 per cent
of all prostheses and provided partial support for another 3 per
cent. </li></ol>
<h4> Acknowledgments </h4>
<p> Grateful appreciation is extended to the
44 facility owners and their staffs who provided the data on which this study is
based. </p>
<p><b>References:</b></p>
<ol>
<li>Burgess, Ernest M., The below-knee amputation, <i>Bull. Pros. Res., </i>10-9:19-25, Spring 1968. </li>
<li>Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, <i>Inter-Clinic Inform. Bull., </i>9:3:6-19, December 1969. </li>
<li>Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, <i>Orth. and Pros., </i>23:1:8-17, March 1969. </li>
<li>Glattly, H. W., A statistical study of 12,000 new amputees, <i>Southern Med. J., </i>57:1373-1378, November 1964, </li>
<li>Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, <i>Surg. Gynec. Obstet., </i><b>125: </b>493-501, September 1967. </li>
<li>Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, <i>Surg. Gynec. Obstet., </i>129:799-802, October 1969. </li>
<li>Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, <i>Inter-Clinic Inform. Bull., </i>5:5:9-28, February 1966. </li>
<li>Tracy, G. D., Below-knee amputation for ischemic gangrene, <i>Pacif. Med. Surg., </i>74:251-253, September-October 1966. </li>
<li>U. S. Department of Health, Education, and Welfare, Public Health Service, <i>Impairments due to injury by class and type of accident, United States, July 1959-June 1961, </i>Washington, D.C., 1964. </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">U. S. Department of Health, Education, and Welfare, Public Health Service, Impairments due to injury by class and type of accident, United States, July 1959-June 1961, Washington, D.C., 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>8.</b> </td><td class="clsTextSmall">Tracy, G. D., Below-knee amputation for ischemic gangrene, Pacif. Med. Surg., 74:251-253, 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>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, 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>6.</b> </td><td class="clsTextSmall">Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, Surg. Gynec. Obstet., 129:799-802, October 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Glattly, H. W., A statistical study of 12,000 new amputees, Southern Med. J., 57:1373-1378, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, 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>2.</b> </td><td class="clsTextSmall">Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull., 9:3:6-19, December 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, Orth. and Pros., 23:1:8-17, March 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 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>Frank W. Clippinger, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopaedic Surgery, Duke University; Chairman, Subcommittee on Prosthetics Clinical Studies, CPOE.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Barbara R. Friz, M.S. </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, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Elizabeth J Davies. M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Professional Assistant, Committee on Prosthetic-Orthotic Education.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div>
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Dublin Core
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Title
A name given to the resource
Amputees and Their Prostheses
Creator
An entity primarily responsible for making the resource
Elizabeth J Davies. M.A. *
Barbara R. Friz, M.S. *
Frank W. Clippinger, M.D. *