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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_137.pdf Text Any textual data included in the document <h2>Seating for Children and Young Adults with Cerebral Palsy</h2> <h5>J. Martin Carlson, M.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />John Lonstein, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Karen O. Beck, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />David C. Wilkie, B.F.A.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>This paper will reflect the experience, perspective, and design rationale of one institution rather than attempt to give a comprehensive survey of the full spectrum of experience and designs.</p> <p>Several examples are given and references made to Duchenne muscular dystrophy (D.M.D). The D.M.D. examples are used when they are particularly good illustrations of a general principle which helps complete our understanding of seating for children with cerebral palsy. For more information on our experience and rationale relative to seating boys with Duchenne Muscular Dystrophy, refer to the reference section.<a></a></p> <p>The study of seating has many facets (cosmetic, functional, economic, etc.) and many professional perspectives (engineer, therapist, orthotist, physician, manufacturer, etc.). Engineers tend to relate to biomechanics and the economics of standard design. Therapists are concerned with function, development, inhibition of spasticity, etc. Each medical specialist has a different predominant focus. In different settings, it is inevitable that availability of professionals, availability of funds, age and severity of client population culture, etc., vary, and these factors will direct the seating program. Another important factor is that ortho-tists have not traditionally been trained in the provision of special seating, most are not active in special seating, and in most communities, there is a shortage of orthotists. These realities are a major reason why pre-manufactured, easy to assemble, and adjustable designs have predominated in many regions. The potential for commercial success and profit for the manufacturer, the ability to provide a system without the involvement of orthotic professionals (who are scarce and often inexperienced in seating), and the need to minimize costs, all seem to be best served by the wide distribution of pre-manufactured designs. In many communities, that is the best option available at this time. However, there are communities and settings wherein the circumstances make it possible to have a higher average of custom fabricated designs.</p> <p>To help you put this paper into perspective, we need to provide some information on the history of our seating program. The Orthotic/ Prosthetic Laboratory at Gillette Children's Hospital became involved with seating in 1974. Our seating program developed out of almost ideal circumstances. Orthotic services were strong and there was a close working relationship between our orthotists, therapists, and medical specialists. Weekly clinics brought a steady stream of clients through our outpatient clinic where the team members worked together to solve both general and individual problems. Also extremely important was our strong tradition and mechanisms for follow-up, which provided us with excellent feedback. Our early entry into seating, and the growth of the program, quickly gave us a significant volume so that specialists could be assigned and efficient procedures developed.</p> <p>Another factor bearing positively on our program is Gillette's extensive experience in spinal orthopedics. The volume of patients and specialization of our staff enabled us to offer quality care at economical costs.</p> <p>Although we have some experience with people of middle and advanced age, our experience at Gillette Children's Hospital is primarily with people from birth into young adulthood. This younger age group will be the focus of this paper. Our client population with cerebral palsy includes the full spectrum of severity, but the severe cases far out number the less severe.</p> <p>It is important that we all endeavor to recognize and respect the various aspects, perspectives, and variable circumstances mentioned earlier. Two very different seating programs may offer equally excellent care, but both can be even better if they "compare notes." This paper is a compilation of our "notes."</p> <h3>Fundamental Goals</h3> <p>The seating systems we provide must benefit the impaired person, those who care for that person, and society. Balanced against that, every piece of equipment inherently carries costs and disadvantages. Our systems cannot be all things to all people, but we will most nearly approach the ideal by keeping our sights aimed directly at the fundamental benefits and goals, while we endeaver to minimize the negatives.</p> <p>What are the fundamental goals? The main categories are outlined below.</p> <ol> <li> <p>Function</p> </li> <li> <p>Orthopedic/Neurologic</p> </li> <li> <p>Cosmesis</p> </li> <li> <p>Safety</p> </li> <li> <p>Economy</p> </li> </ol> <p>Function is primary. It affects a range of activities and benefits which can be best explained by examples: recreation for the child and family, making it easier for a care worker to feed a youngster, improving the child's field of vision, increasing his comfort, increasing the level of independence, etc. A functional seating system improves the childs development, decreases the amount of work required to take care of the child, and promotes a more enjoyable existence for the entire family.</p> <p>Federal laws passed in the U.S. in the early and mid 1970's mandated that children be transported from their living environments to educational settings. Safe transportation necessitates secure seating. Ultimately, society benefits, both tangibly and intangibly.</p> <p>From an orthopedic/neurologic standpoint, the ideal would be to prevent the progression of hip and spine deformities, and maintain body positions which reduce spastic reflex patterns. The benefits are better voluntary control, less severe deformity, less surgery, and a corresponding decrease in the work and cost of daily care. The advantages are perhaps most apparent to those of us who have visited state hospitals and have seen severely involved adult patients who were maintained only in recumbent positions during their earlier years. Positioning options for these adults are so severely limited that constant and expensive care is required to prevent ulcers and maceration. Also, hospitalization for those problems and pneumonia tend to be more frequent.</p> <p>Cosmetically the ideal is a well camouflaged, hidden, or attractive seating system which helps the youngster sit upright with the head in a position to see and be seen. The aesthetic and emotional benefits of a cosmetically appealing seating system accrue to the child and everyone in his environment.</p> <p>Comparing the costs of various seating approaches is difficult, because of the many costs which should be taken into account and the complexity of the various alternatives. We must take into account the cost of the seat, the cost of wheeled bases, repairs, frequency of replacement, and the cost of therapist involvement. The most important economic factor is the impact of a particular seating decision or system on the long range cost of daily care and health care. Long range costs must be considered, but they are very hard to estimate.</p> <h3>Biomechanics Of Seating</h3> <p>A normal head-trunk complex gets its stability from the spinal column, which acts as a controlled stack of compression elements, and partly from a multitude of muscles, which support it in different ways. The paraspinal muscles have a direct action on the configuration of the spine extention through lateral flexion and rotation. The abdominal (and to some extent, costal) muscles, in addition to being direct skeletal motors, affect the spine's stability and configuration indirectly, but importantly, through their action on the viscera. Muscle action to constrict and control the circumference of the abdomen and thorax allow compressive body weight loads to be taken partly down through the fluid filled abdominothoracic cylinder rather than all acting down through the spinal column. This adds significantly to the stability of the torso. We must note that recent research by Nachemson, et al.<a></a> (indicating that the Valsalva maneuver fails to lower pressure in the intervertebral disks) challenges this classical explanation of Morris,<a></a> but does not propose a new analysis of abdominal muscle function in trunk stabilization. Swedish data suggests that we don't fully understand what the Valsalva maneuver consists of and how it functions biomechanically. (The Valsalva maneuver is a general tensing of abdominal muscles.)</p> <p>The normal activity of sitting consists of a series of frequently changed postures. Each of those postures would be non-functional, uncomfortable, and even injurious if it were the only posture available to us and maintained for hours. It is the frequent voluntary change which makes those postures collectively safe, acceptable and tolerably comfortable for more than ten minutes. It is quite an undertaking to design a seating system in which our client can safely and comfortably sit, with little or no change, for a matter of hours. In the case of a person with cerebral palsy, the abnormally high muscle tone about the pelvis and thighs is the major reason this can be accomplished.</p> <p>It is important to note that when a child has some limited postural alignment capability, that capability is greatest at the head and neck. There is less ability to control the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg"><b>Fig. 1</b></a>). (This capability reflects the early developmental stages of an infant, but when we see it in the older child, it represents delayed or arrested development.) Arm-propping is typically used to stabilize the upper thorax for effective neck and head control. This illustrates two seating principles. The first is that the postural control and use of the superior body elements is dependent on the stability of body elements inferior to them. Second, the seat should bring the stability from the pelvis upward to meet the descending/decreasing voluntary stability of the client. Terminating stability too low will fail to maximize the child's function. Carrying stability too high will deprive the client of his full voluntary movement capability.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg"><strong>Figure 1. Alignment capability is greatest at the head and neck, less at the pelvis.</strong></a><br /> <p>Since "normal" sitting postures are so variable and changeable, we cannot relate supported sitting postures to a specific normal posture. We must reason and choose a sitting posture which has the most advantages, and propose it as a "standard."</p> <p>We choose the "sitting at attention" sagittal configuration (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg"><b>Fig. 2</b></a>), because it represents a mid-range spine configuration, it allows significant weight bearing on the proximal thighs as well as the bottom of the pelvis, it is a cosmetic posture (chest and head upright, facing outward), and it is a functional posture (head in a position to observe and thorax and shoulders forming a secure base for the neck and arms to move). In the sagittal plane, the sacrum is tilted anteriorly a moderate amount. There is moderate lumbar lordosis, thoracic kyphosis, and cervical lordosis. We would further propose that the "standard" posture consists of a pelvis level and the spine straight in the frontal plane. When the left side of the pelvis is elevated, the pelvis is said to be "tilted rightward," and when the right side is elevated, it is "tilted leftward" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg"><b>Fig. 3</b></a>). Likewise, in the sagittal view, the pelvis is "tilted posteriorly" or "tilted anteriorly" depending on which direction the upper parts of the pelvis are oriented relative to "standard" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg"><b>Fig. 4</b></a>). In the transverse plane, if the right side of the pelvis is rotated forward relative to the shoulders, we would say the pelvis is "torqued leftward." We do not present this nomenclature as the most correct, but offer it for use in the absence of standard nomenclature.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg"><strong>Figure 2. Sitting at attention represents a mid-range spine configuration.</strong></a><br /> <p>Cerebral palsy is a disease that expresses itself in a wide variety of static and dynamic patterns, and we cannot go into the mechanics of all those variations. We will limit ourselves to a discussion of what, in our experience, is the most common combination.</p> <p>Fortunately, even some of the children with severe cerebral palsy do not have a significant deformity or collapse in the frontal plane. This is not to say, however, that scoliosis is rare in this group. Scoliosis is quite common, and we see very severe cases. When we examine a child with scoliosis, we should evaluate whether or not the scoliotic collapse is aggravated by asymetric trunk muscle spasticity. We can expect to be much more effective at controlling a scoliosis deformity when asymetric trunk muscle spasticity appears not to be a significant factor.</p> <p>One of the usual characteristics of scoliosis in neuro-muscularly impaired sitters is lateral tilting of the pelvis in the direction of the convexity of the major scoliosis curve (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg"><b>Fig. 5</b></a>). This is not surprising when we consider that pelvic orientation is usually not under voluntary control. This characteristic will become more interesting later as we discuss the various methods for generating spine stability.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg"><strong>Figure 5. Lateral tilting of the pelvis in the direction of the convexity of the major scoliotic curve.</strong></a><br /> <p>There are several distinct biomechanical schemes for providing spine stability to resist scoliosis. These schemes do not, of course, operate exclusively in the frontal plane. Also, the employment of one scheme does not preclude the simultaneous employment of one or more other schemes. The first and most familiar of these is "three-point-force". We need not explain the principles of this scheme since they are so well known. However, it is appropriate to note that three-point-force schemes are much less effective at stabilizing a multi-joint, multi-axis system such as the spinal column, than stabilizing a single-joint system such as the elbow or knee. The application of the three-point scheme in a spinal support system, which includes a seat, has some advantage over a traditional spinal orthosis in that the most inferior force can be located at greater distance from the more superior forces to give a longer moment arm. However, the more the client functionally moves in his seated position, the less the seat is able to apply three-point support, because it doesn't move with the client. Furthermore, a spinal orthosis can be worn 23 hours per day, if necessary. These latter considerations make the spinal orthosis a stronger orthotic treatment of progressive spine deformity.</p> <p>The second scheme we will discuss has to do with the Valsalva maneuver, given earlier, in which the abdominal and costal muscles function to relieve the spinal column of compression and bending loads. No matter what exactly happens during the Valsalva maneuver, the Morris explanation is a valid biomechanical analysis of how a snug corset contributes to trunk/spine stability in the presence of flaccid paralysis of abdominal and costal muscles. Engineering analysis and empirical evidence indicate that when we passively apply circumferential abdominal constraint (ie. a snug corset), a hydraulic load bearing column is created and we reduce the magnitude of flexible collapse (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg"><b>Fig. 6</b></a>). In our experience, the corset is seldom used for children with cerebral palsy, but is virtually always useful for children with muscular dystrophy.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg"><strong>Figure 6. Reducing the magnitude of flexible collapse.</strong></a><br /> <p>The third scheme for enhancing spine stability derives from the fact that the sacro-pelvic complex forms the foundation on which the flexible spinal column rests. Voluntary pelvic control is an important component of spine stability in the unimpaired trunk. If, by a conforming design about the pelvis and a proper donning procedure, we can increase the foundation (bottom end) constraint conditions, much is added to spinal stability. The pair of diagrams on the left side of <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg"><b>Fig. 7</b></a> illustrates the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin jointed (free to tilt) at its lower end. The two diagrams on the right in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg"><b>Fig. 7</b></a> illustrate the similarity between the controlled pelvic case and the built-in base end condition. Elastic column buckling equations for the two beams indicate that the built-in beam will withstand almost twice as much load as the other before buckling.<a></a> To achieve this end condition stability, we need a well made seat, as well as a procedure to level the pelvis each time the child is seated.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg"><strong>Figure 7. The diagrams on the left illustrate the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin-jointed (free to tilt) at its lower end. The two diagrams on the right illustrate the similarity between the controlled pelvic case and the built-in base end condition.</strong></a><br /> <p>To fully appreciate the strength of this scheme in practice, compare the two x-rays in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg"><b>Fig. 8a</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg"><b>Fig. 8b</b>.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg"><b>Fig. 8a</b></a> is the x-ray taken just before the pelvic leveling procedure was performed and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg"><b>Fig. 8b</b></a> is the x-ray taken a few minutes later, after the pelvic leveling procedure was performed. The Cobb angle is reduced from 36 degrees to 20 degrees by this quick procedure, which is normally performed as a routine part of positioning the child in the sitting support orthosis. These x-rays are of a boy with Duchenne Muscular Dystrophy; he was not wearing a corset.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg"><strong>Figure 8a. An x-ray taken just before the pelvic leveling procedure was performed.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg"><strong>Figure 8b. The x-ray taken a few minutes later after the procedure.</strong></a><br /> <p>A second example is given in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg"><b>Fig. 9</b>.</a> The left and center x-rays show the progression which occurred in the eight months following fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, with the only difference being the pelvic leveling procedure was performed before the last film. Note: once a spine deformity has become partially structural, the pelvis can be leveled only to the degree that the deformity is still flexible.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg"><strong>Figure 9. The left and center x-rays show the progression which occured in eight months following a fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, and after the pelvic leveling procedure was performed.</strong></a><br /> <p>In summary, maintaining a level pelvis makes it easier to control the spine. Pelvic control and orientation in the frontal plane also relates strongly to the uniformity of pressures in weight bearing areas and minimizing the progressive deterioration of sitting comfort.</p> <p>Let us now look at two examples were these stabilizing schemes have been simultaneously applied. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg"><b>Fig. 10a</b> </a>is a photo of a 12 year old boy with muscular dystrophy, sitting as he was presented to us. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg"><b>Fig. 10b</b></a> shows the sitting support system properly applied. The corset is entirely independent; it is not attached to the seat. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg"><b>Fig. 10c</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg"><b>Fig. 10d</b> </a>compare his A-P spine x-rays without and with the orthotic system. The lateral tilt of his pelvis is reduced from 30 degrees to 14 degrees. The Cobb angle of his scoliosis was reduced from 65 degrees to 35 degrees. Curve control of this magnitude is not unusual as long as the deformity is still flexible. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg"><b>Fig. 11a</b></a> is the x-ray of J.S., a 14 year old girl with cerebral palsy. She presented a right thoraco-lumbar scoliosis of 38 degrees and a rightward pelvic tilt of 8 degrees. Her shoulders were tilted 13 degrees to the left partly because she used her right arm for propping to avoid falling to the right. We provided her with a soft corset and the Gillette Sitting Support Orthosis. The Sitting Support Orthosis was to provide pelvic control and bilateral "propping" support. It had no head rest or anterior support. The x-ray taken just after fitting shows pelvic tilt reduced to 2 degrees (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg"><b>Fig. 11b</b></a>), the Cobb angle of the scoliosis reduced to 22 degrees, and shoulders leveled. Both hands were free to function, and she said she could breathe deeper.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg"><strong>Figure 10a. A 12 year old boy with muscular dystrophy as presented.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg"><strong>Figure 10b. The Sitting Support System properly applied. Corset is independent.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg"><strong>Figure 10c. A-P spine x-rays without the orthotic system.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg"><strong>Figure 10d. A-P spine x-rays with the orthotic system.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg"><strong>Figure 11a. X-ray of J.S., a 14 year old girl with cerebral palsy.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg">Figure 11b. J.S. provided with a soft corset and the Gillette Sitting Support Orthosis</a>.</strong><br /> <p>In cerebral palsy, we occasionally see a case of lateral pelvic tilt and scoliotic posture secondary to a unilateral hip extension contracture. A right hip extension contracture, if not accommodated, will cause the right side of the pelvis to be elevated. The pelvis will be tilted leftward and a compensatory convex left scoliosis will be produced. When we see this problem, it is usually an older child or adult. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg"><b>Fig. 12</b></a> is an example of a rather extreme case of how the deformity was accommodated to minimize pelvic and spinal malalignment and stress.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg"><strong>Figure 12. An extreme case of how pelvic and spinal malalignment and stress is minimized in a cerebral palsy patient.</strong></a><br /> <p>In the sagittal view, we commonly see a posture dominated by the powerful, very active hamstring muscle group. The gluteals are often helping to resist adequate hip flexion for an ideal sitting alignment. To a greater or lesser degree, the pelvis is maintained in a posterior tilt position with weight bearing shifted posteriorly toward the sacrum. This pelvic alignment tends to reduce lumbar lordosis and convert it to a kyphosis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg"><b>Fig. 13</b></a>). The loss of lumbar lordosis makes it more difficult for the thoracic extensors to maintain a vertical upper thorax. This explains why a flexible spine, maintained with a pelvic belt and lumbar bolster to restore lumbar lordosis, often produces better active alignment of the upper thorax and head. (We would caution you that different solutions are necessary for people with rigid hyperkyphosis.)</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg"><strong>Figure 13. A sagital view illustrating the pelvis in a posterior tilt position with weight bearing shifted posteriorly towards the sacrum, converting lumbar lordosis to a kyphosis.</strong></a><br /> <p>The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg"><b>Fig. 14</b></a>). Attention must be given to properly provide all three. The seat bottoms must be configured specifically to provide optimum thigh support. A flat horizontal seat bottom will never maintain hip flexion against active extension (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg"><b>Fig. 15</b></a>). The anatomy itself calls for a depression under the pelvis to bring the femurs to a horizontal position (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg"><b>Fig. 16</b></a>). More importantly, the hip flexion required to "break through" the extensor spasticity varies from child to child, but we usually find that some degree of seat bottom incline (pelvis to knees) is needed for the more severely involved children (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg"><b>Fig. 17</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg"><strong>Figure 14. The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg"><strong>Figure 15. A flat horizontal seat bottom will never maintain hip flexion against active extension.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg"><strong>Figure 16. The anatomy calls for a depression under the pelvis to bring the femurs to a horizontal position.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg"><strong>Figures 17a and 17b. We usually find that some degree of seat bottom incline (pelvis to knees) is needed for more severely involved children.</strong></a><br /> <p>The pelvic belt force is perhaps the most critical. The pelvic belt must be perfectly anchored: close to the body posterolaterally for good "wrap around" and at the correct level to achieve a good downward force component (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg"><b>Fig. 18</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg"><b>Fig. 19</b></a>). The most common mistake is to anchor the lap belt too high. We have never seen one anchored too low. (We must remember that none of the hip/lumbar support forces function properly in service unless the caretakers know why and how to put the pelvis in position and snug up the pelvic belt. Without education and training of the users, our designs are worthless. We must train and retrain on every return visit.)</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg"><strong>Figure 18. The pelvic belt force is perhaps the most critical.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg"><strong>Figure 19. The pelvic belt must be perfectly anchored: close to the body posterolaterals for "good wrap around" and at the correct level to achieve a good downward force component.</strong></a><br /> <p>A fourth support force is sometimes needed in the area of the upper thorax or shoulders to maintain adequate thoracic extension. This is accomplished with a vest or shoulder straps which must be adjustable for grading the amount of support to fit the need, which may vary through the daily routine of activities.</p> <p>Seating misalignment and deformity problems in the transverse plane are not uncommon among the severely involved cerebral palsy population. The problem consists of the pelvis being torqued right or left by deformities of one or both hips. A severe adduction confracture of the right hip will, for instance, cause a seated misalignment which includes leftward direction of the thighs (with respect to the pelvis), a rightwardly torqued pelvis, and an apparently (not actually) short right femur. This misalignment has been well diagrammed in an article by Mercer Rang, et al.<a></a> A severe abduction contracture of the left hip will cause a similar misalignment. These deformities are often referred to as "wind blown hips." We can see that when such a condition exists, forcing the thighs to be aligned straight forward will obligate the client to sit facing to one side, or the spine will be continuously twisted. In most cases, the direction of the thighs may be altered enough to avoid much of the spinal twist. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg"><b>Fig. 20a</b> </a>is a photo of a top view of a Sitting Support Orthosis we provided for such a client. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg"><b>Fig. 20b</b></a> is the same view of the client in the orthosis.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg"><strong>Figure 20a. Top view of a Sitting Support Orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg"><strong>Figure 20b. A client seated in the S.S.O. The direction of the thighs is altered to avoid much of the spinal twist.</strong></a><br /> <p>It is of utmost importance, as we treat these clients, that we keep function and quality of life issues uppermost in our mind. Biomechanics and deformity prevention ideals often must be compromised to avoid undue impingement on any aspect of the child's development or function.</p> <h3>Client Evaluation</h3> <p>Seating evaluations at Gillette always include an orthotist, a therapist, and a physician in addition to the client, parents or caretakers, and, if available, a community therapist. The physical evaluation includes an assessment of orthopedic deformities, spastic reflex patterns, voluntary sitting capability, and other functional abilities. To assess sitting ability, two people manually control the child's thighs, pelvis and lower trunk. If, with this amount of stabilizing assistance, the child still cannot manage an upright sitting posture, we would grade voluntary sitting capability at non-existent to poor. If the child can, with that assistance, struggle to an upright sitting posture and maintain it for fifteen seconds, we would grade voluntary sitting capability at poor to fair. Better performance would be graded accordingly as better than fair.</p> <p>A thorough interview of parents and others with the child is immensely valuable. We want to find out about the child's daily routine, mode of family transportation, what they feel are positive and negative features about their present equipment and routine, and the child's usual status compared to what we are observing. We also seek all concerns and ideas they may have for optimum seating. The interview should gradually become more of an educational session and finally a discussion of options. The child and parents or caretakers should, as much as possible, feel they were heard, were educated, and have participated in the decisions made on the seat, mobility base, accessories, etc.</p> <h3>Seating Design</h3> <p>We currently solve the majority of the seating problems we encounter with variations on two basic designs. Both are custom made.</p> <p>Although there have been many very significant design changes along the way, the Gillette style Sitting Support Orthosis (S.S.O.) has continued, from 1974 to the present, as a portable system utilizing a custom molded unpadded plastic shell mounted in a plastic foam base (<b>Fig. 18</b> and <b>Fig. 24</b>). We have provided approximately 1100 of these Sitting Support Orthoses. Our present rate of S.S.O. production is about 140 per year.</p> <strong>Figure 24. Anterior upper thoracic support provided by shoulder straps.</strong><br /> <p>In the early years, we also constructed upholstery and plywood seats. In 1983, we converted that rectangular design to one that used upholstered removeable components attached to the inside surfaces of a plastic seat frame as shown in <b>Fig. 21</b>. (We first saw a design similar to <b>Fig. 21</b> at the Royal Ottawa Rehabilitation Center. In addition to our own changes, the present design incorporates features also learned from the Rehabilitation Engineering Center at Children's Hospital at Stanford.) To distinquish this design from the contoured plastic shell type S.S.O., we call it an Upholstered Sitting Support Orthosis (U.S.S.O.). We currently construct and fit about 200 of these units annually.</p> <strong>Figure 21. A plastic seat frame with upholstered removable components.</strong><br /> <p>A more specific discussion of the design of the S.S.O. must start with noting that the main structure is an unpadded, thin plastic shell. Because of the thinness of the supporting shell, the seat is less bulky, less visible, and lighter than other seats. It allows us to provide close thoracic support up to the axillary level and wrap around the thorax, between the arms and chest, and well past mid-line, without impinging on the arms (<b>Fig. 18</b> and <b>Fig. 19</b>). When properly contoured, the shell can be left almost totally unpadded. The unpadded shell is easier to clean and requires less maintenance. The pelvic portion is contoured and sized to fit the hip/pelvic area quite close, but not snug. At fitting time, we leave adequate space to push our fingers between the Glueteus Medius and the seat bilaterally. About 18 months ago, we began providing room in the shell to install bilateral pelvic growth pads (visable in <b>Fig. 22</b>), which are removed later as the pelvis grows wider.</p> <strong>Figure 22. An unpadded shell with room to install bilateral pelvic growth pads, which are removable as the pelvis grows wider.</strong><br /> <p>Anterior upper thoracic support is provided by either a special vest (<b>Fig. 23</b>) or shoulder straps (<b>Fig. 24</b>). The shoulder straps are more efficient at keeping the thorax in an extended, upright posture. However, when the child has some arm function, we prefer to use the vest because it can be configured to impinge less on the anterior deltoid muscles. Note that the lower attachment points for the vest or shoulder straps should be in the sub-axillary area to provide good wrap-around and a posteriorly directed holding vector. Some commercially available seats anchor the shoulder straps to the lap belt. That design is seriously flawed because the shoulder straps then pull the lap belt up out of proper position and pull down on the shoulders.</p> <strong>Figure 23. Anterior upper thoracic support is provided by a special vest or shoulder straps (see Figure 24).</strong><br /> <p>When the S.S.O. is used for people with severe scoliosis or hyperkyphosis, the polypropylene shell accomodates to the contours of the deformity. However, sometimes our best efforts fail to create sufficiently precise contouring to spread pressure evenly over the entire rib prominence. <b>Fig. 25</b> diagrams how we sometimes solve that problem: an adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour.</p> <strong>Figure 25. An adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour.</strong><br /> <p>Head support varies from nothing to a simple occipital prop to a variety of designs, depending on the particular challenge presented. A few of the many designs we have contrived over the years are shown in <b>Fig. 26</b>, <b>Fig. 27</b>, and <b>Fig. 28</b>. We do not have a good solution for the child who persists in actively bringing the head forward and down. In seating children with hydrocephalus, the sheer weight of the head presents special safety and weight bearing problems (<b>Fig. 29</b> and <b>Fig. 30</b>).</p> <p>We haven't the space to show and explain the wide variety of accoutrements which are variously added for shoulder protraction, arm positioning, etc. We work closely with the therapists so that they can help design the final configuration for best functional positioning.</p> <p>As emphasized earlier, a seating program must consider the sitting functional environment. The seating orthoses we produce are re-moveably mounted in wheelchairs, strollers, buggies, and other bases as the circumstances indicate. Being portable, they are also utilized as car seats, or to place the child very near the floor to facilitate peer interaction (<b>Fig. 31</b>). We have found that a seating program, to be effective, must address the full spectrum of life activities. It must also address related equipment in the sitting environment. Footrests, wheelchair upholstery, laptrays, and control boxes are some of the most common things which must be modified, moved, or completely replaced with special designs. It seems to us that the "standard" wheelchair was designed to be "slouched" into (<b>Fig. 32</b>) rather than to be sat erect in. Those chairs are not adequate, as manufactured, for extended use by anyone. In spite of the newer, more enlightened designs coming along, those "standard" wheelchairs are still part of the scene and must be dealt with. When we sit a client erect on a firm seat, and then place that seat in a wheelchair, the client's shoulders are far from the center of the drive wheels (<b>Fig. 33</b>). For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars. The standard upholstry must be removed and replaced with straps so that the seat can be recessed down and back between the bars (<b>Fig. 34</b> and <b>Fig. 35</b>).</p> <strong>Figure 31. The seating orthoses we produce are removable and made to mount in a variety of bases as the circumstances indicate.</strong><br /><strong><br />Figure 32. Lateral view of typical posture produced by hypotonic spine extensors and tight hamstrings.</strong><br /><strong><br />Figure 33. Lateral view of a patient positioned too high and forward.</strong><br /><strong><br />Figure 34. For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars.</strong><br /><br /><strong>Figure 35. Standard upholstery is removed and replaced with straps so the seat can be recessed down and back between the bars.</strong><br /> <p>At semi-annual follow-up visits, we accommodate the child's growth by adjusting the size</p> <p>of the S.S.O. Thigh length is added as necessary. The bilateral pelvic growth pads are thinned or removed when appropriate. The back and sides of the shell can be heated to widen the shell width across the chest. Axillary extensions are welded on as necessary to accommodate increase in thoracic height. Head rests and the anchor points for vests and shoulder straps are also elevated as necessary. Presently, the basic S.S.O. shell is serving for an average of 37 months for children between 3 years and 14 years of age. We expect the use of the pelvic growth pads to push that service life even higher. For adults, the average useful life of S.S.O.'s is much greater.</p> <p>We recommend the S.S.O. for children who have non-existent to poor voluntary sitting capability. Other factors which would indicate a need for the S.S.O., in our program, would be significant orthopedic deformities (of the hips and spine) and moderate to severe spastic reflex patterns. Completed physical growth may also be an indication for the S.S.O., because the polypropylene shell is very durable. It requires less repair maintenance than the upholstered systems. There is complete freedom within the design to reduce the level and amount of support or match the client's need: it may not include a head support, vest, or shoulder straps, and bilateral thoracic support may be terminated at a lower level and leave more room for movement as appropriate.</p> <p>Provision of a good quality S.S.O. requires a relatively high level of specific orthotic skill and practice. This may be considered a disadvantage, but we feel the adaptability and quality which results more than justifies the necessary investment.</p> <p>The structural components of the Upholstered Sitting Support Orthosis are made of ABS plastic. The upholstered firm inserts are removable to facilitate cleaning and adjustments for growth. Thoracic supports are thin (of metal) and can be easily adjusted to change height and spacing. The pelvic belt is used on every U.S.S.O. Lumbar bolsters, vests or shoulder straps, and head rests are used when appropriate. <b>Fig. 31</b> shows some of these design features. During therapy sessions, and for certain daily time periods, therapists or parents may wish to work specifically on improving upper trunk or head control. For this reason, shoulder straps and vests are designed for partial or complete loosening. Head rests can be easily removed from the unit (true of the S.S.O. as well as the U.S.S.O.).</p> <p>The U.S.S.O. is most appropriate for children with poor-to-fair voluntary sitting capability, minimal orthopedic deformities, and less severe spastic reflex patterns. The easy size-adjustability of this design gives it some advantage over the S.S.O. for younger, rapidly growing children. For children under two years, we often utilize one of the commercial infant seat or car seat frames to which we can add support bolsters, lap belt, etc. (<b>Fig. 36</b>).</p> <strong>Figure 36. A commercial infant car seat can be supplemented with bolsters, lap belt, etc.<br /></strong><br /> <h3>Fabrication</h3> <p>Much about the fabrication of these orthoses can be inferred from the photos and design information given earlier. Some information on fabrication of the "Gillette" S.S.O. has been discussed in earlier articles on that orthosis.<a></a> However, there are some serious errors in the S.S.O. fabrication process we made in the very beginning. Other orthotic labs might repeat those errors unless we reiterate a couple of the procedural steps and more clearly explain the rationale for those steps.</p> <p>The polypropylene shell is obtained by covering a pattern developed from an impression of the child. To obtain the impression, we position the child, on a supporting fixture (<b>Fig. 37</b>) in a face-down, hips-flexed, knees-flexed configuration (<b>Fig. 38</b>). We use the weight relieving (horizontal) trunk alignment, support under the knees, and a waist belt for the precise purpose of achieving an impression which does not possess the poor alignment characteristics we are trying to avoid. The support under the knees allows us to locate the pelvis as directly as possible in alignment with the spine. For the child with tight hamstring muscles, a waist belt on the fixture helps reduce lumbar kyphosis and perhaps achieve a little lumbar lordosis, if possible. The contrasting diagrams in <b>Fig. 39a</b> and <b>Fig. 39b</b> illustrate the critical role of knee support. The hip flexion angle of the fixture can be varied and is adjusted according to the amount of hip flexion we want in the seat shell. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences (<b>Fig. 40</b>). Plaster is added across the back of the upper thorax to give room for extension. <b>Fig. 41a</b> and <b>Fig. 41b</b> are posterior and lateral views of a positive model fully modified and ready for covering. The resulting polypropylene seat shell is mounted in a polyethylene foam base (<b>Fig. 42</b>). Final trim lines, lap belt and vest attachment points, head-rest placement, etc. wait until the child comes for fitting.</p> <strong>Figure 37. A supporting fixture.</strong><br /><br /><strong>Figure 38. To obtain an impression for a polypropylene shell, the child is positioned facedown, hips-flexed, and knees flexed on a supporting fixture.</strong><br /><br /><strong>Figure 39a. Hip flexion angle of the fixture can be varied.</strong><br /><br /><strong>Figure 40. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences.</strong><br /><br /><strong>Figure 41a. Posterior view of a positive model fully modified and ready for covering.</strong><br /><br /><strong>Figure 41b. Lateral view of a positive model fully modified and ready for covering.</strong><br /><br /><strong>Figure 42. The polypropylene seat shell.</strong><br /> <p>The molded "Chailey Heritage" supportive seat,<a></a> which also utilizes vacuum dilatancy to obtain an impression, creates a positive model, and vacuum forms the seat materials over that model. With the exception of those general similarities, the procedures, materials, and design of the Chailey Heritage seat is very different from the Sitting Support Othosis developed at Gillette Children's Hospital.</p> <p>Fabrication of the U.S.S.O. does not require a pattern and is therefore free of the potential problems inherent in obtaining and modifying a model.</p> <h3>Conclusions</h3> <p>This paper has dealt most heavily with biomechanics and design, but many other programmatic components have been mentioned. Devices do not solve seating problems. A program is required. A truly successful seating program, one that approaches the fundamental goals discussed at the beginning of this paper, must contain at least the following components:</p> <ol> <li> <p>Involvement of all appropiate and available professional disciplines.</p> </li> <li> <p>Comprehensive discussion with, and education of, the client (when possible), the parents and/or other caretakers, and other available community-based professionals.</p> </li> <li> <p>Attention to finding and solving the family-specific functional (including play, recreation, and transportation) problems and opportunities.</p> </li> <li> <p>Provision of effective equipment with thorough instructions on its use.</p> </li> <li> <p>Tenacious follow-up to uncover and solve the inevitable problems and opportunities brought on by growth and functional changes; to obtain feedback necessary to the efficient evolution of the program; and to reinforce, as necessary, the education of the users.</p> </li> </ol> <h3>Acknowledgments</h3> <p>The important roles of some individuals and institutions have been cited earlier and will not be repeated here. Our experience with Duchenne Muscular Dystrophy has come primarily through Dr. Lowell (Hap) Lutter, chief of the Growth and Development Clinic at Gillette, and orthopedic surgeon for the Muscular Dystrophy Clinic at Fairview Hospital. The seating systems were provided at Gillette by Team Leaders, Mark Payette and David Wilkie, and the people they supervise. Those people include (currently, and in the recent past) Tracy Lillehaug, Joe Bieganek, Dannel Friel, John Spielman, Katie Voss, Lee Hegfors, Bruce Tew, Wendy Schifsky, Rick Weber, Paul Swanlund, Paul Lemke, and Marcia Munson. Gene Berglund is orthotic group manager at Gillette. Former Therapy Superivsors, Diane Twedt and Jan Headley were very involved and important during the early years of the program. Gillette therapists significantly involved with the program currently (or in the recent past) include Rebecca Lucas, Lynn Bowman-Bathke, Cindy Theisen, Patricia Mathie, Gail Graff, Marilyn Kochsiek, and Ellen Kratz.</p> <p>Over the years, we have been privileged to work with many outstanding individuals and institutions in various communities in our referral area. Three institutions which have been especially cooperative and capable are the Cambridge Regional Human Services Center (formerly Cambridge State Hospital), People's Child Care Residence, Homeward Bound, Brainerd State Hospital, and Moose Lake State Hospital.</p> <p>We have significantly learned from (in addition to centers cited earlier) the professionals associated with seating programs at the Rehabilitation Engineering Center of the University of Tennessee, the Hugh MacMillan Center in Toronto, and the Winnipeg Rehabilitation Center for Children.</p> <p>Address inquires to: J. Martin Carlson, Director of Orthotics and Prostetics, Gillette Children's Hospital, 200 E. University Avenue, St. Paul, MN 55101.</p> <p><b>References:</b></p> <ol> <li><a href="http://www.acpoc.org/library/1973_10_007.asp">Bowker, John H. and Reed, "A Vacuum Formed Plastic Insert for Neurologically Handicapped Wheelchair Patients," <i>Inter-Clinic Information Bulletin</i>, 12:10, July, 1973, pp. 7-12.</a></li> <li>Carlson, J. Martin and Payette, Mark, "Seating and Spine Support for Boys with Duchenne Muscular Dystrophy," Program and Proceedings of the Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985.</li> <li>Carlson, J. Martin and Winter, Robert, "The Gillette Sitting Support Orthosis," <i>Orthotics and Prosthetics</i>, 32:4, December, 1978, pp. 35-45.</li> <li>Crandall, Stephen H. and Dahl, Norman C, "Stability of Equilibrium," <i>An Introduction to the Mechanics of Solids</i>, McGraw-Hill, 1959, Chapter 9, p. 420.</li> <li>Morris, J.M., Lucas, D.B., and Bresler, B., "Role of the Trunk in Stability of the Spine," <i>The Journal of Bone and Joint Surgery</i>, 43-A:3, April, 1961, pp. 327-351.</li> <li>Nachemson, Alf L., Andersson, Gunnar, B.J., and Schultz, Albert B., "Valsalva Maneuver Biomechanics: Effects on Lumbar Trunk Loads of Elevated Intra-abdominal Pressures," <i>Spine</i>, 11:5, June, 1986, pp. 476-479.</li> <li>Rang, M, Douglas, G., Bennet, G.C., and Koreska, J., "Seating for Children with Cerebral Palsy," <i>Journal of Pediatric Orthopedics</i>, 1:3, 1981.</li> <li><a href="poi/1978_01_030.asp">Ring, N.D., Nelham, R.L., and Pearson, F.A., "Moulded Supportive Seating for the Disabled," <i>Prosthetics and Orthotics International</i>, 2:1, April, 1978, pp. 30-34.</a></li> <li>Winter, Robert B., and Carlson, J. Martin, "Modern Orthotics for Spinal Deformities," <i>Clinical Orthopedics</i>, 126:5, July-August, 1977, pp. 74-86.</li> </ol> <em><b>*David C. Wilkie, B.F.A. </b> David C. Wilkie, B.F.A., is an Adaptive Equipment Team Leader at Gillette Children's Hospital.<br /></em><br /><em><b>*Karen O. Beck, R.P.T. </b> Karen O. Beck, R.P.T., is a Senior Physical Therapist at Gillette Children's Hospital.<br /></em><br /><em><b>*John Lonstein, M.D. </b> John Lonstein, M.D., is Chief of the Cerebral Palsy Spine Clinic at Gillette Children's Hospital and a Clinical Associate Professor with the Department of Orthopedic Surgery, School of Medicine at the University of Minnesota.<br /></em><br /><em><b>*J. Martin Carlson, M.S., C.P.O. </b> J. Martin Carlson, M.S., C.P.O., is Director of Orthotics and Prosthetics at Gillette Children's Hospital, 200 East University Avenue, St. Paul, MN 55101-2598, and Clinical Instructor for The Department of Orthopedic Surgery, School of Medicine at the University of Minnesota.<br /><br /><br /></em> Page Number(s) 137 - 158 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Seating for Children and Young Adults with Cerebral Palsy Creator An entity primarily responsible for making the resource J. Martin Carlson, M.S., C.P.O. * John Lonstein, M.D. * Karen O. Beck, R.P.T. * David C. Wilkie, B.F.A. * https://staging.drfop.org/files/original/ddb9544cef711c43e2cfbb495b556693.jpg 41460c268cc54217f8a01d00cf45d031 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL https://www.shifa.com.pk/rehabilitation-services/ Contact Name/Title Jawad Hussain - Director Address Ground Floor Modern Medical Center,Near Shifa Medical Center Mingor City Saidu Sharif Swat State/Province Khyber Pakhtunkhawah Countries Served Pakistan Regions: Middle EastCountries: Pakistan and KashmirSpecific cities, regions, or groups of people: Hyderabad, Multan, Karachi, Swat, Muzaffarabad AJKAge Group: Adults, ChildrenFees Charged: Sometimes Postal Code 19200 Phone 3009008257 Fax 92946721849 Email khan.jawad@live.com Organization Type Including ID and tax status Non-profit Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Education, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Accomodations for volunteers near or at the specified location. Need I Financial Assistance Need II Volunteers: Prosthetists, Orthotists, Technicians Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used, Medical Supplies, Other: Wheel Cahirs, Toilet Seats, Walking Frames, Crutches,CP Chairs, Physiotherapy Equipments 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 Shifa Rehabilitation Center for Disabled https://staging.drfop.org/files/original/45936845c560d4d5eebd237d926562f2.pdf 0ea2670a224e26f8a1b36cd756e5f496 https://staging.drfop.org/files/original/1e3bdc3b8dc622982e576909d90687d7.jpg 4c4de5849811d644713ec7230d7d0f02 https://staging.drfop.org/files/original/abf3a4d5ce92c8133b359340480b34ab.jpg 0ceb64af346708b11b688bc9aec46035 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_04_004.pdf Text Any textual data included in the document <h2>Should Functional Ambulation be A Goal for Paraplegic Persons?</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The goal of functional ambulation for paraplegic persons is a subject of long debate in virtually all rehabilitation settings. Such factors as lesion level, motivation, attitude of the clinic team, age, body build and occupation are important determinants when orthoses are prescribed for ambulatory purposes. Despite the various orthotic designs available, and the philosophies that accompany each design, the majority of paraplegic persons will either reject their orthoses or not have them prescribed.</p> <p>Personal experiences and published reports indicate that when a thoracic level lesion is present, only about two percent of patients fitted will reach the level of household ambulation. There are many reasons for this, the main one being the excessive energy expenditure needed to ambulate in an orthosis. The donning procedure for most orthoses is difficult and time consuming, and once the orthoses are on the patient they often interfere with transfer activities. In addition, crutches are needed for stability while standing and ambulating, which limits the use of the hands and arms. Other problems with standing and ambulation for paraplegic patients are the lack of bladder control while standing and obviously abnormal walking pattern.</p> <p>In this brief article, I will review some of the more pertinent articles on this subject, and then present my opinion concerning the provision of lower-limb orthoses for paraplegic persons.</p> <p>The history of the orthotic treatment of paraplegia does not go back much further than World War II, since previous to that time about 90 percent of the spinal-cord-injured persons died from genitourinary infections. The development of antibiotics to combat these infections reversed the fatality rate shortly after World War II.</p> <p>The physiological benefits of standing persons with paraplegia were first mentioned by Abramson <a></a> in 1948, who stated that an hour of standing each day will prevent osteoporosis in the lower limbs and helps to prevent urinary calculi and genitourinary infections. In 1964, Rusk, stated that "circulation and nutrition, as well as morale, are also aided by keeping the patient in the upright position for several hours each day".</p> <p>Rusk also recommended that the tenth thoracic vertebra be used as a landmark when prescribing orthoses; lesions at or superior to this level are usually given double-bar long leg-braces with a pelvic band and Knight spinal attachment (current terminology is LSHKAFO, or lumbo-sacral-hip-knee-ankle foot orthosis); lesions inferior to T₁₀ level are prescribed the same orthoses without the spinal attachment, and lesions inferior to L₁ are fitted without a pelvic band.</p> <p>Hahn <a></a> and Scott <a></a> from Craig Rehabilitation Hospital in Denver, Edberg <a></a> from Rancho Los Amigos Hospital in Downey, and Warren et al., <a></a> from the University of Washington, do not advocate the use of the pelvic band on paraplegic patients. Edberg feels that the pelvic band must apply excessive pressure against the skin to be effective, that it causes difficulty in donning the orthosis, limits flexibility and adds excessive weight. Hahn and Scott state that the two most important considerations for orthotic design for paraplegics are ease of donning and control of ankle dorsiflexion, hence the so-called Craig-Scott design KAFO (<b>Fig. 2</b>) has no pelvic band, only one thigh band, and a fixed but adjustable ankle joint.</p> <p>Hussey and Stauffer <a></a> studied the ambulatory function of 164 spinal-cord-injured patients at Rancho Los Amigos Hospital and stated that "no patient achieved any form of functional ambulation without pelvic control<a style="text-decoration: none;">*</a> and there appeared to be no effective method of bracing patients to overcome this deficit". The nerve supply for the pelvic control muscles is affected by a thoracic lesion.</p> <p>Rosman and Spira <a></a> reported similar problems in ambulating patients with thoracic lesions. In a study of 35 patients with lesions from the T₁ to T₁₁ level who were fitted with orthoses for ambulation, only one patient was ambulating out of the hospital, and five used the orthosis for standing only. The report concluded "that there is an essential difference between the 'occupation' of walking in the 'non-pressured' rehabilitation environment and walking when faced with the problems of everyday life". It further concludes that "some disabled persons with unusual strength, willpower, and motivation for walking will successfully overcome the difficulty, effort, and social strain involved in the continuous use of braces", but that "most will eventually relinquish these goals because the effort proves too great".</p> <p>Pneumatic orthoses (<b>Fig. 1</b>) were developed and first used in the United States, amid great fanfare, in 1973. Three major evaluations by Silber <a></a>, at New York's Bird S. Coler Hospital, Ragnarsson et. al., <a></a> at the Institute of Rehabilitation Medicine, New York University, and by the Committee on Prosthetics Research and Development, National Academy of Sciences <a></a> on a total of 62 paraplegic persons indicate that the orthoses were lighter than metal designs and required less energy for ambulation but severe mechanical limitations, such as donning and inflation problems, outweigh these advantages when the orthoses are used outside of an institutional setting.</p> <p>A study by Cerney, at Rancho Los Amigos Hospital, comparing energy costs for eight paraplegics walking versus using a wheelchair concluded "The average velocity for paraplegic walking was less than half of normal while oxygen uptake per minute was increased by 50 percent. These two factors combine to create an oxygen uptake per meter than is increased six times". Similar data for the same patients using wheelchairs, again compared to normal individuals, showed "only a two to six percent increase in the physiological factors and a ten percent decrease in velocity".</p> <p>Despite the poor track record I have documented, ambulation is still considered a goal for paraplegic patients in most rehabilitation settings. Obviously, the patient will fail to reach this goal in most cases, so why do most of us expend our energies in this area? I feel there are benefits to be gained by providing ambulation training. For one, nearly all new paraplegic persons believe they will walk again, and it is virtually impossible to convince them otherwise. These patients feel that they are being deprived of their chance for complete rehabilitation if they are never given the opportunity to try to walk. Psychologically, they must prove it to themselves. After these patients are convinced that walking is impractical, they will concentrate more heavily on becoming wheelchair-independent.</p> <p>A physician I worked with in Chicago told the story of an obese, bilateral above-knee amputee who wanted to be fitted with prostheses so he could walk again. They physician refused to prescribe a prostheses as he knew that the patient could never use them, and told the patient he would not be able to walk again. The patient immediately suffered a nervous breakdown in the clinic and required hospitalization. From that day on, the physician prescribed prostheses for patients with similar problems so they could convince themselves of the impracticality of ambulation and, more important, have a longer period of time to accept reality.</p> <p>A small percentage of patients do ambulate in orthoses (<b>Fig. 3</b>), especially those patients with pelvic or hip control or sensation. It is impossible to predict successful ambulators, and patients should be given a chance to succeed. Obviously, patients who lack motivation, are very obese, or who lack strength and endurance will never succeed and should be dissuaded from trying to ambulate.</p> <p>In this article I have attempted to back up my personal experiences with information from published reports, and then to justify why most paraplegics are given ambulation training despite the poor prognosis. We would appreciate your thoughts on this subject and therefore encourage you to complete the attached questionnaire.</p> <p><b>References:</b></p> <ol> <li>Abramson, S. A., <i>Bone disturbances in injuries to spinal cord and caude equina (paraplegia)</i>. J. Bone and Joint Surg. 30-A:982-987, October 1948.</li> <li>Edberg, E., <i>Bracing patients with traumatic paraplegia</i>. Phys. Ther. 47:9:818-823, September 1967.</li> <li>Hahn, Harry, Personal communication, March 1975.</li> <li>Hofstra, Peter C, <i>The clinical engineer and the spinal-cord-injured person</i>. Bull. Pros. Res. 10-22:37-40, Fall 1974.</li> <li>Hussey, Robert W., and E. Shannon Stauf-fer, <i>Spinal-cord injury: requirements for ambulation</i>. Arch. Phys. Med. Rehab. 54:12:544-547, December 1973.</li> <li>Ragnarsson, K. T., G. Heiner Sell, Margaret McGarrity, and Reuven Ofir, <i>Pneumatic orthosis for paraplegic patients: functional evaluation and prescription considerations</i>. Arch. Phys. Med. Rehab. 56:11:479-483, November 1975.</li> <li>Rosman, N., and E. Spira, <i>Paraplegic use of walking braces: a survey</i>. Arch. Phys. Med. Rehab. 55:7:310-314, July 1974.</li> <li>Rusk, Howard A., <i>Rehabilitation Medicine, Second Edition</i>. C. V. Mosby Co., St. Louis, Missouri, p. 503, 1964.</li> <li>Scott, Bruce A., <i>Engineering principles and fabrication techniques for the Scott-Craig long leg brace for paraplegics</i>. Orth. and Pros. 25:4:14-19, December 1971.</li> <li>Silber, Maurycy, Tae-Soo Chung, George Varghese, Catherine Hinterbuchner, Milton Bailey, and Nancy Hirvy, <i>Pneumatic orthosis: pilot study</i>. Arch. Phys. Med. Rehab. 56:1:27-32, January 1975.</li> <li>Warren, C. G., J. F. Lehmann, and B. J. DeLateur, <i>Use of the pelvic band in orthotics for adult paraplegic patients</i>. Arch. Phys. Med. Rehab. 56:5:221-223, May 1975.</li> <li>Cerney, Kay, R.P.T., <i>Walking and wheelchair energetics in spinal cord injury</i>.</li> <li>National Academy of Sciences, <i>Evaluation of the ortho-walk type B pneumatic orthosis on thirty-seven paraplegic patients. Washington, D.C., 1976, pp. 1-5</i>.</li> </ol> <strong>Footnote</strong><br />The Term 'pelvic control' used here refers to the ability of the abdominals to move the pelvis when body weight is on the crutches.<br /> <div style="width: 400px;"><br />*Michael J. Quigley, C.P.O.<br />Rehabilitation Engineering Center, Rancho Los Amigos Hospital, Downey, California.</div> Page Number(s) 4 - 6 Year 1977 Volume 1 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1977_04_004/1978_04_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_04_004/1978_04_005-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Should Functional Ambulation be A Goal for Paraplegic Persons? Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/aaf54c9164d3ee3f3a6a821a1f9a434f.jpg a6429c5baa0102fa521c3bd45043f877 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL https://www.shrinersinternational.org/ Contact Name/Title Yoshio Setoguchi M.D. - Director Address 3160 Geneva Street City Los Angeles State/Province California Countries Served USA Regions: Africa, North America, Middle East, Europe, AsiaCountries: Primary region is Southern California, Southern Nevada, Arizona & New Mexico. In addition Northern Mexico and work with 17 countries around the world. Children are referred to us for treatment through various organizations from around the world with specific areas in Russia, Lithauania, Middle Eastern countries of Turkey, Egypt, Pakistan, Africa and Iran. From the Far East Thailand, Cambodia, Vietnam, Phillipines, Korea and China.Specific cities, regions, or groups of people: We conduct outreach clinics in Las Vegas, Phoenix, Tucson, Albuquerque and Hobbs New Mexico, Tjuania, Ensenada and Hermosillo in Northern MexicoAge Group: ChildrenFees Charged: No Postal Code 90020 Phone (213) 388 3151 Fax (213) 387 7528 Email ysetoguchi@shrinenet.org Organization Type Including ID and tax status Non-profit Not-for-profit Type 501C-3 Services Provided Prosthetic Fitting, Orthotic Fitting, Education, Prosthetic Fabrication, Orthotic Fabrication, Medical / Surgical Care, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Accomodations for volunteers near or at the specified location. Need I Financial Assistance Need II Volunteers: Lay Persons Need III Materials, Components, and Equipment: New, Equipment 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 Shriners Hospitals for Children - Los Angeles 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL https://www.facebook.com/people/Simama-CBR/100064303555024/ City Mbeya Countries Served Mbeya, Tanzania Phone +255 755 696 432 Email mbycbr1762013@gmail.com Organization Type Including ID and tax status Non-profit Services Provided Education, Rehabilitation , Training Need I Financial Assistance Need II Volunteers Need III Materials, Components, and Equipment Mission We aim to provide high quality rehabilitative care to the community. State/Province Tanzania Facebook Page https://www.facebook.com/people/Simama-CBR/100064303555024/ 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 Simama Mbeya Community Based Rehabilitation Program https://staging.drfop.org/files/original/bca9b91aef7e3781b29df6181fc9502d.pdf 5d1adb8f6a4a251bfae87557108dcb7b https://staging.drfop.org/files/original/eba4db041582a948e7b8573f8171e55d.jpg d2d2b8d66e11f8576a2669c92ca431c9 https://staging.drfop.org/files/original/fd1e1b1fed23a83e0b989fbdbee7731c.jpg f2cfcea12c8494514b518ab14dc364a4 https://staging.drfop.org/files/original/02e3a3d141fd7f689df0f060da69142d.jpg 9b11833db8cba18b2e267287fd0b4381 https://staging.drfop.org/files/original/a5f74e0c94bba45447600513cce141f8.jpg 018efbb47c12a9ec5dd55890d76452de https://staging.drfop.org/files/original/cafd284bedbe85e23e4580df59846ea7.jpg 171443759e0f481de14918280826908f https://staging.drfop.org/files/original/98bb321dbfa2d34e578725fb1144ba2f.jpg 1b3540601d776f662c1f47f391614aec https://staging.drfop.org/files/original/eca5fce7b392bd0df7651f5c56ae05c4.jpg 85962872df45d132db9f927a8516721c https://staging.drfop.org/files/original/ab2922020f921ea9dc3260155c6b9855.jpg 4734cb468510d0554f5b80d449a9e507 https://staging.drfop.org/files/original/5efb5f8b47d417ecc3fb56b4e116ff85.jpg 8c2f5c4fa3b6df3b4341c0ec47f5af9b https://staging.drfop.org/files/original/0ff459c59890e9e3a392d35fd4d1a0bb.jpg ec9505e7eff0bdb1e3aad92c00d7e0b4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_004.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 4 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Skin Health and Stump Hygiene</h2> <h5>Gilbert H. Barnes, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Literally the word "hygiene" connotes a state or condition of health. But adequate hygiene, or good health, of the human skin presents a complex problem involving much more than a casual acquaintance with soap and water, the concept which usually comes to mind when hygiene is mentioned. The functional state of our human integument is pretty much taken for granted by most of us. We know that this two-square-yard covering will, in most cases, repair itself in event of local injury, provided infection is avoided. Cheerfully we dissolve it in strong chemical solutions. We broil it in the summer sun until it peels off like old birch bark. We allow it to be rubbed and blistered in tight shoes for vanity's sake. As a nation, we spend millions of dollars on elaborate sun-tan lotions guaranteed to produce in it the beautiful brown of the aborigine and at the same time an equal fortune on lotions and creams which promise to bleach it out to the shade of a sheltered lily.</p> <p>Even though the skin has remarkable powers of restoration, the conditions of use are occasionally too damaging, or the opportunities for healing between periods of use are too brief for repair and maintenance. In such instances, there may be an acute breakdown of the skin with a severe inflammatory reaction, or the process may be a gradual one, with a progressive deterioration of the skin and a loss of its protective properties. Among individuals in certain occupations, we frequently see both manifestations of such skin reaction. Housewives, mechanics, laboratory workers, and others whose work exposes certain areas of the body, particularly the hands and arms, to prolonged soaking in solutions and solvents, or even in plain water, are prone to recurrent skin irritation and breakdown. In such cases, the chemical and physiological properties of the skin are altered to such a degree that the skin's built-in protective functions are no longer effective. Even in the absence of prolonged soaking, the skin may be injured locally by contact with an irritant, such as a strong acid, or with a sensitizing agent, such as poison ivy.</p> <p>All of these considerations similarly pertain to amputees who wear some type of prosthesis (<b>Fig. 1</b>), most of which are attached to the stump by means of a snugly fitted socket which excludes circulating air and traps the accumulated sweat against the skin. In the lower-extremity amputee, the effect is aggravated by the added factor of weight-bearing and uneven loading on localized areas of the stump skin, especially in the adductor region of the stump and at other points of contact with the socket rim. Weight-bearing is attended by other mechanical stresses, especially intermittent stretching of the skin and friction from rubbing against the socket edge and interior surface. The latter results in two important and harmful effects on the skin- heat, and abrasion of the skin surface, which in time can, by steady attrition, become highly destructive. Over a long period of time, heat alone may be capable of causing profound changes in the metabolism of living tissues. The stump skin of the amputee is especially vulnerable to the possible irritant or allergic action of various materials that compose the socket of the artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Injury to the stump skin. The gremlins symbolize some of the common types of damage that may be inflicted upon the stump skin inside the socket of a prosthesis. Injury may be incurred mechanically when parts of the socket abrade the skin or burrow into it. The materials of the socket, coming in intimate contact with the skin, sometimes act as irritants or as sensitizing agents to create a local dermatitis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In this situation, then, the state of health of the stump skin is of the utmost importance in determining whether or not the prosthesis can be tolerated. If the skin cannot be maintained in a good functional condition in spite of daily wear and tear, then the weight-bearing prosthesis cannot be worn, no matter how accurate the fit of the socket may be.</p> <p>It is the purpose of this article to review some of the basic principles of skin biochemistry and physiology concerned in the maintenance of good hygiene in the stump area. Included are some remarks relative to the use of certain disinfectant agents in skin cleansing, and to some of the natural skin defenses against bacterial invasion, because these topics also are germane to the principal subject with which this article is concerned.</p> <h3>The Skin as a Vital Organ</h3> <p>Man cannot live without his envelope of skin any more than he can exist without his heart or his liver. It might seem at first thought that the cutaneous covering of the body performs about the same function as the leather cover of a baseball -and very little more. Actually, the biochemical and physiological activities of the skin are every bit as complex as are those of the liver. The respiratory rate of the main cellular portion of the epidermis, based on oxygen-uptake studies and glycolysis measurements, has been computed to be from two to ten times as high as the rates of other body tissues.</p> <p>The skin possesses many properties vital to health and life itself. Of particular interest to us from the standpoint of prosthetic design and use is the part it plays in mechanical support of the soft tissues of the stump. It provides a tough, elastic outer covering with a tensile strength of up to 2 kg. per sq. mm. Furthermore, this covering has a tremendous capacity for repairing itself after injury and for strengthening itself at points of mechanical stress, such as those occurring on the lower-extremity stump in association with the wearing of an artificial limb. A familiar example of this is the "lichenification," or leatherlike thickening of the skin over the ischial tuberosity and in the adductor region of the thigh. We know that "calluses," or localized thickenings of the horny outermost layer of the skin, will form at points of repeated pressure. Sometimes a BB-shotlike condensation of horny material will develop over a pressure point, producing the well-known "corn." All of these thickening processes illustrate the defensive reaction of the skin to abnormal mechanical stress by elaborating a natural cushion from its cellular elements.</p> <p>Mechanical protection, however, is only one of many important services which the skin performs. Its function in the conservation of water and electrolytes, those ionized salts which constitute an essential part of the body fluids, is nearly as indispensable as is the function of the kidneys. The skin is extremely important in the regulation of the body temperature within relatively narrow limits. It possesses certain important electrical and chemical properties. It is also the first barrier, and one of the chief defenses of the body, against infectious diseases.</p> <p>Many other properties of the skin that are of less immediate importance to the problem of stump hygiene nevertheless have a bearing on human health and welfare. For example, we rely on the sensory organs of the skin for a good part of our information about the world around us. Through nerve endings at or near the surface, the body receives the outside environmental stimuli of heat, cold, pain, and touch. Also important to health is the role of the skin in maintaining a highly complex system of pigment metabolism and in providing a source of vitamins important for growth and nutrition.</p> <p>Although there are other vital functions of the skin, those cited serve to illustrate the importance and variety of the services the normal skin performs. Some of these are described at greater length in the following portions of this paper.</p> <h3>The Anatomy of the Skin</h3> <p><b>Plate I</b> shows in semidiagrammatic form the principal structures of the skin concerned in stump hygiene. The skin is seen to consist of two distinct layers-the epidermis and the dermis, or true skin. These two layers are joined by a system of fingerlike projections, the rete pegs, which protrude down from the epidermis and interlock with the papillae, which project up from the dermis. This device furnishes a relatively large surface area at the dermal-epidermal junction, thus providing a strong bond between the two layers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Plate I. A section of normal human skin. 1, Epidermis; 2, true skin; 3, subcutaneous tissue; 4, horny layer; 5. clear layer; 6, granular layer; 7, germinativc layer; 8, capillary network; 9. artery; 10. vein; 11. lobules of fat; 12. nerve; 13, corpuscle of Vater; 14. sweat gland; 15, duct of sweat gland; 16, pore of sweat gland; 17, hair follicle; 18, hair shaft; 19, bulb of a hair; 20, arrcctor muscle; 21, sebaceous gland; 22, duct of sebaceous gland. Courtesy White Laboratories, Inc., KenilKorth, .V. J. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most superficial layer of the epidermis is the so-called "horny layer," consisting of a material called "keratin," which is very similar to animal horn. Scattered over the surface of the skin are numerous deep pockets, called "follicles," into which sebaceous, or oil, glands discharge their contents. From the follicles protrude the hairs of the skin.</p> <p>Two other types of glands in the skin have an important bearing on the subject of stump hygiene. They are the eccrine, or small sweat glands, which lie in coils near the base of the dermis, and the apocrine, or large sweat glands (not shown in Plate I), which are similarly situated but are more localized in distribution than are the eccrine glands. The watery sweat secretions pass to the surface of the skin by way of the sweat ducts, discharging on the surface through the sweat-duct opening, or pore.</p> <p>Deep to the dermis lies the subcutaneous zone. Here, cushioned in masses of fat cells, are the large blood vessels which serve the skin. From the arteries, smaller vessels rise, becoming narrower as they branch, until they terminate in fine capillary nets in the papillae of the dermis. Blood from the papillary nets returns again by a venous collecting system to the large veins in the subcutaneous tissue.</p> <h4>Relation of Skin Structures to Disease</h4> <p>All of these structures are vulnerable to damage from prolonged wear of a prosthesis. Injury to each different anatomical site results in a specific disease complex of the skin. For example, excessive heat and moisture may result in a local blocking of the sweat-duct pores. We are familiar with this condition in the form of what is known popularly as "prickly heat," a common malady in warm, humid climates; and the same disorder can occur over stump skin under similar environmental conditions.</p> <p>Prolonged use of negative-pressure sockets, and to a lesser degree of conventional sockets, may lead to engorgement of the small blood vessels of the skin, resulting in local areas of rupture and extravasation of blood into the surrounding tissues. The dark pigmentation often seen on the terminal end of the stump is the result of this bleeding under the skin. It is usually accompanied by some degree of edema, a state in which there is an abnormal collection of watery fluid in the soft tissues. Thus the skin disorder here is essentially focused in the circulatory system, whereas the previously cited condition of sweat-duct blockage affects primarily one of the glandular systems of the skin. It follows, then, that the over-all hygiene or good health of the stump skin reflects, among other things, the functional state of each of the anatomical components of the skin.</p> <h4>Skin Glands and Stump Hygiene</h4> <p>In the skin of the lower extremity, three different types of glands produce secretions that are discharged on the surface of the skin. These are the eccrine glands, the apocrine glands, and the sebaceous glands (Plate I). During daily use of a prosthesis, their secretions accumulate inside the socket, where they may become a serious hazard to local stump hygiene.</p> <p><i>The Eccrine Glands</i></p> <p>The eccrine glands, or small sweat glands, are distributed over the entire surface of the body. They are accessory structures that develop from the epidermis. They are true secretory glands, producing a clear, aqueous fluid, and their functioning is vital to the heat regulation of the body, since these glands are the principal source of sweat. It has been estimated that there are over two million of these glands in the skin of a normal adult and from 500 to 600 per sq. in. over the skin of the thigh and lower leg. It has been reported that the capacity for sweating is considerably less for females than for males. According to Weiner <i>{23), </i>roughly 50 percent of heat sweat comes from the trunk, 25 percent from the head and upper limbs, and 25 percent from the lower limbs.</p> <p><i>Sweat Deposits. </i>Eccrine sweat is a clear, watery solution containing 0.5 to 1.0 percent of solids. These solids play an important role in stump hygiene because, in the absence of adequate daily cleansing, their accumulation on the surface of the stump and in the socket interior may serve as a source of irritation and to some extent as a culture medium for the growth of harmful organisms. The eccrine sweat solids include urea (in at least twice the concentration found in blood plasma); creatine and creatinine in minute quantities; uric acid; a variety of different amino acids; ammonia; free choline; occasional traces of glucose; lactic acid and lactate (to the extent of more than 2 grams in 90 minutes of heavy physical labor); many of the water-soluble B-vitamins; traces of dehydroascorbic acid; and the minerals sodium, potassium, calcium, magnesium, sulfates, phosphates, and iron. In addition to the sweat solids, there are the secretions of local oil or sebaceous glands, plus a quantity of nitrogenous material made up of keratin shreds and other cellular debris which has been desquamated from the surface of the skin.</p> <p>This is the residue which collects on the skin and in the socket under normal conditions. If the skin has been damaged by abrasion against the socket wall, or if an eczematous skin condition is present, there may be "weeping" or oozing of serum over the surface, where it mixes with the sweat, oil, and skin debris. This serous material is deposited on the interior wall of the socket, where it dries and sets almost like glue. Successive laminations are added from each day's accumulation, until a considerable thickness may be attained (<b>Fig. 2</b>). Constant wearing and rubbing against the skin may produce a polished, glassy finish on the surface. In the interests of good hygiene, this deposit should be cleaned out of the socket interior regularly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Debris in the socket. Accumulation of waste in the socket is not favorable to good stump hygiene. Daily waste, consisting of sweat solids, oily secretions, and cellular debris, often combined with serous ooze, is deposited in successive layers that should be cleaned from the socket regularly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The innervation of eccrine sweat glands, pharmacologically speaking, is parasympathetic or cholinergic. Dale and Feldberg<a></a> demonstrated that the postganglionic nerve fibers liberate acetylcholine at their endings on the receptor cells of the sweat glands. Where excessive perspiration, or hyperidrosis, has been a serious problem, clinical application of this finding has been made by treatment of the patient with an anticholinergic blocking agent to diminish sweating. Drugs like methantheline bromide (Banthine) and diphemanil methyl sulfate (Prantal), which are anticholinergic, have been tried.</p> <p>Such treatment has proved sometimes very helpful, sometimes of slight benefit, and often discouraging. Even though excess perspiration may be reduced, there are not infrequently unpleasant side-effects, such as a sensation oi heat, dryness of the mouth and throat, headache, and urinary retention. In the amputee, who often has an overheating problem in the first place, any further impairment of his cooling mechanism may not be tolerated. In some cases, however, an effort to control excessive sweating may be worth a try; certainly any drying effect that such drug therapy may exercise in the stump area will contribute to the hygienic state of the stump skin.</p> <p><i>Eccrine Sweat Retention.</i> In profuse sweating, the sweat is expelled from the eccrine glands onto the surface of the skin at intraductal pressures ranging as high as 250 mm. of mercury. If the outlet at the surface of the skin becomes blocked by masses of keratin, local inflammation, or other obstruction, this pressure may be sufficient to cause rupture of the duct (<b>Fig. 3</b>). If the rupture takes place near the surface at the level of the horny, or keratin layer, the sweat collects in this layer in a raindroplike configuration of little blisters. If the rupture is deeper in the skin, there may be local inflammation, characteristic of "prickly heat." Where the duct is ruptured still more deeply, symptoms are few or none, and the only surface sign consists of small, noninflammatory elevations, or "papules."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Pressure in eccrine sweat glands. When an eccrine gland is actively secreting sweat onto the surface of the skin, the pressure in the sweat duct may rise to 250 mm. of mercury. If the opening of the gland becomes blocked, as symbolized by the gremlin, this pressure may be sufficient to rupture the gland duct and allow the sweat to escape into the skin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sweat retention may involve most of the skin surface of the body and may be accompanied by pronounced generalized symptoms of fever, headache, and exhaustion, a condition usually confined to tropical climates. More commonly it affects only a localized part of the body. It has been reported in many different types of eczema and in a variety of healing inflammatory lesions. Preliminary investigations of eczematous eruptions of the stump suggest that sweat retention occurs in this area also. The heat and humidity which prevail over the stump skin during use of a prosthesis are factors which encourage the development of sweat-duct blockage and localized sweat retention.</p> <p><i>The Apocrine Glands</i></p> <p>The apocrine glands, unlike the eccrine glands, develop from the follicular epithelium of the hair, as do the sebaceous glands. Apocrine glands are much larger than eccrine glands, and they are limited in their distribution to the underarm area, the breasts, the midline of the abdomen, and the anal and genital areas. Modified apocrine glands are also found in the external canal of the ear and in the vestibule of the nose.</p> <p>The apocrine secretion is a turbid, whitish-to-yellowish fluid which dries like glue to form a light-colored plastic. The total number of apocrine glands is greater in women than in men, and axillary sweating starts earlier in adolescent girls than in adolescent boys.</p> <p>The apocrine glands in the groin and axilla are occasionally the site of a chronic, extremely stubborn disease of the skin called "hidraden-itis suppurativa." This disease is characterized by large, burrowing, painful cysts which are filled with a foul discharge. These periodically break down and drain, then heal with scarring, and the process may be repeated indefinitely. Frequently the condition is so severe that surgical extirpation, followed by skin-grafting, affords the only means of controlling it. Rarely, hidradenitis suppurativa is encountered in amputees. In such cases it can cause a really serious handicap, making the use of a prosthesis or crutches impossible.</p> <p>Innervation of the apocrine glands is exclusively adrenergic, as compared with the cholinergic innervation of the eccrine glands. The apocrine system responds sluggishly or not at all to heat. However, it does respond promptly to emotional or painful stimuli. In the management of this aspect of the amputee's hygiene, therefore, it is important to bear in mind that pain or tenderness in the stump, or an emotional disturbance, may aggravate any existing skin disorders in the groin or underarm regions through stimulation of this specialized glandular system.</p> <p>Unfortunately, the apocrine glands occur in the areas upon which the amputee must depend for support in the use of a crutch or an above-knee prosthesis. The apocrine glands can be a source of considerable grief, if, through poor hygiene, infection, or other cause, these areas are allowed to become unserviceable for weight-bearing.</p> <p><i>The Sebaceous Glands</i></p> <p>The sebaceous glands occur wherever there are hair follicles. In addition, there are scattered, free sebaceous glands which are independent of the follicles. Their secretion is an oily liquid composed of fatty acids, alcohols, hydrocarbons, and certain vitamin precursors. This material, called "sebum," becomes solid at about 30 degrees C (86 degrees F), the prevailing skin-surface temperature.</p> <p>A unique feature of sebaceous-gland secretion is the capacity of the glands to secrete very rapidly onto a defatted skin surface, but at a rate which gradually declines until the new fat layer of the surface reaches a certain critical thickness. When this occurs, sebum production stops or falls to a minimum. If, however, the fat layer is removed, rapid secretion starts again. The more viscous the sebum becomes, the earlier the sebum expulsion is stopped. As a result, more oil is secreted per unit time at a high environmental temperature than at a low temperature.</p> <p>Presumably, the counterpressure of the oil film on the surface prevents further production by back-pressure in the gland. There is an interesting fact, however, which is not entirely explained by the back-pressure theory: if the duct of the gland is blocked by sebum only, no pathologic change takes place in the secretory cells of the sebaceous glands, but if the obstruction is caused by masses of keratin or other foreign matter, as in the case of comedones ("blackheads") and various types of follicular keratoses, degenerative changes in the gland set in relatively early.</p> <p>This phenomenon of controlled oil production is one in which a normal physiologic process appears to work with the amputee rather than against him in the wearing of a prosthesis. Here, the accumulating lipid film under the socket will serve as its own shut-off valve for further secretion, without damage to the sebaceous glands in the stump skin.</p> <p>Heat Control and the Healthy Skin Healthy skin exercises a vital role in the thermoregulation of the body, a function in which the skin of the lower extremities normally has an important share. This surface control supplements the central heat-regulatory center in the hypothalamus of the brain. At basal conditions, the heat balance of the normal body is maintained by cutaneous vasomotor adjustment through an environmental temperature range of 25 degrees to 31 degrees C (77 degrees to 88 degrees F), the so-called "zone of vasomotor control." Above this range, at 31 degrees to 32 degrees C (88 degrees to 90 degrees F), when cutaneous blood flow has reached its maximum, sweating sets in-the "zone of evaporative regulation." Between 31 degrees and 36 degrees C (88 degrees and 97 degrees F) and at low humidity, evaporative heat loss easily maintains normal temperature. Below the zone of vasomotor control, the skin temperature falls, and body temperature is maintained chiefly by chills (the "zone of cooling"). If environmental temperature is maintained below a critical level of 31 degrees to 32 degrees C, there is generalized, but grossly invisible, periodic sweating known as "insensible sweating." Consequently, although the principal thermoregulation in this temperature range is vasomotor, there is still an assist from the sweat glands in cooling the skin surface.</p> <p>The values cited are those reported for the normal. In the amputee, significant areas of cooling surface, along with the component sweat glands, have been subtracted from the total reserve of functional skin surface. In addition, the complex and important system of vascular shunts and arterioles in the amputated limb or limbs has also been lost from the total heat-regulatory mechanism. As a result, a number of characteristic and troublesome disturbances of temperature and heat control are associated with amputation.</p> <p>Among these is the phenomenon of the poikilothermic stump, which has been studied by staff members of the University of California Medical School <i>. </i><a></a> In this condition, the surface temperature over the distal part of the stump, and over a considerable portion of the stump proximally as well, tends to become stabilized at the temperature of the surrounding air, more or less independently of any vasomotor control. Thus it is seen that, in a lower-extremity amputation, not only is part of the original heat-control surface permanently lost but the remaining stump surface is no longer normally effective as part of the heat-control mechanism. Nevertheless, it is important to maintain the hygiene, or good health, of this remaining skin area in order to preserve whatever function it may still possess for heat regulating, and particularly for cooling.</p> <h4>Mechanisms of Heat Loss</h4> <p>Heat loss from the normal skin takes place by radiation, convection, conduction, and evaporation. All of these mechanisms are interfered with, if not entirely abolished, over the stump area when a tightly fitted socket is worn, Excessive local heating of the stump can result (<b>Fig. 4</b>), particularly during warm, humid weather, and a major hygienic problem can arise under such conditions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Overheating of the stump. Since air cannot circulate inside a snugly fitted socket, the stump is usually bathed in sweat. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Heat loss from the skin by radiation takes place in the form of infrared rays in the range of 5 to 20 m/u. Under normal conditions, radiation accounts for about 60 percent of total heat lost from the body. In the amputee, it seems probable that loss of heat from the stump area by this mechanism is greatly restricted by the socket of the prosthesis. We do not at present, however, have any data to confirm this supposition.</p> <p>Convection depends upon the transfer of energy by means of moving air and thus is negligible as a means of heat loss from the stump when a prosthesis is worn.</p> <p>Conduction, the transfer of heat between two media in direct contact, is of great importance to the amputee. As the socket becomes warmed to skin temperature, it acts as an insulator against further dissemination of heat from the surface of the stump. It appears probable also that in the vicinity of principal loading, especially along the medial, anterior, and posterior segments of the socket rim, heat is generated by the friction resulting from shearing action between the skin and the socket rim. The insulating effect of the socket would, of course, tend to maintain any such local elevation of temperature. We are initiating a clinical study of this question, employing thermistors for the direct reading of skin temperatures while the prosthesis is being worn under various conditions of normal use.</p> <p>Just how significant increased local heating of the skin may be in adversely affecting skin hygiene and metabolism over a long period of time we cannot say at present. It is known that an increase in environmental temperature elevates the oxygen and nutritional requirements of most tissues. At the same time, the blood supply to the skin of a lower-extremity stump, if changed at all by the active use of a prosthesis, is probably reduced. One might speculate here whether the predilection of these weight-bearing sites for the development of recurrent "pressure sores" may not be related to increased local heat plus diminished nutrition, as well as to mechanical damage and to maceration from sweat. Certainly this area of stump hygiene merits further investigation.</p> <h4>Reflex Sweating</h4> <p>If, in the normal person, the environmental temperature is raised above a critical level between 31 degrees and 32 degrees C (88 degrees and 90 degrees F), there is a sudden, visible outbreak of sweating over the whole body. A similar response, termed "reflex sweating," may be observed when only a portion of the body surface is heated. Whenever there is excessive heating of the stump, the conditions favor reflex sweating, even though the environmental temperature of the rest of the body is below the critical level necessary for visible sweating. Certainly a valuable contribution, both to the comfort of the amputee and to the improvement of his stump hygiene, would be the development of new socket materials and designs which would provide for more rapid heat transfer by conduction and radiation to the outside air.</p> <p>Loss of heat by evaporation from the stump is negligible in the case of the suction socket. Where the conventional socket is worn with a wool stump sock, however, the wicking action of the sock may well provide an avenue for evaporation and consequent cooling. A light stump sock for use with the suction socket may prove feasible. If so, the cooling effect, as well as the added support and protection afforded the stump skin, would be of benefit in maintaining a healthy stump.</p> <p>According to Rothman,<a></a> sweating which is elicited by exercise begins at a lower skin temperature than does sweating produced by external heat. Bazett<a></a> suggested that there may be, deeply situated near vascular plexuses, thermal receptors which are warmed by the working muscles. These receptors may in turn activate the sweat glands of the skin. Whatever the true explanation may be, the combination of excessive sweating (<b>Fig. 5</b>) and increased energy requirements for locomotion is all too familiar to the lower-extremity amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Excessive sweating. An amputee using an artificial leg may complain more of general bodily discomfort from heat and excessive sweating than would a normal individual undergoing similar exertion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Visible sweat secretion and heat loss can also occur independent of thermoregulatory needs. For example, sweating can be elicited with ease at air temperature below 31 degrees C (88 degrees F) by the ingestion of hot drinks, probably through a viscerocutaneous reflex. A variety of other nervous impulses unrelated to heat control may produce sweating. One of the most important of these is "emotional sweating," which may at times affect most of us to some degree. In dermatologic practice, we sometimes see patients in whom this condition has become so severe as to be almost incapacitating. Serious limitations affecting social contacts and employability result. The same disturbance of sweat mechanism may be experienced by amputees. Although the emotional factor may be important in some amputees who have a troublesome hyperidrosis, it is apparent from some of the known physiologic mechanisms for sweating that there may be other reasons for such an increase.</p> <h3>Stump Hygiene and Germs</h3> <p>It has been a matter of frequent observation that the normal skin is not a sterile skin. Such a condition simply does not exist. Normal skin teems with immense numbers of unseen organisms, some harmless and some pathogenic, that is, capable, under the right combination of circumstances, of causing an infection of the skin. Normally, the harmful bacteria and fungi are held in check by a number of different forces. Most of the time we live in some measure of harmony with this enveloping horde. But when resistance to infection is lowered by local skin damage, the presence of some generalized disease, a metabolic disturbance such as diabetes, or any one of numerous other causes, then this harmonious balance is destroyed and the avenue of invasion is opened. Two different classes of bacteria exist on normal skin under average conditions-the resident bacteria, which remain fairly constant, and the transients, which may be almost anything (<b>Fig. 6</b>). In addition, a variety of fungi come and go, chiefly members of the yeasts and molds, although other types, such as those which cause ringworm of the feet and body, may be present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Flora of the skin. Of the teeming numbers of microorganisms on the normal human skin, some are resident bacteria, which are found on the skin more or less constantly, while others are transient bacteria-only temporary visitors. Common among the residents are Corynebacterium acnes, the so-called "acne bacillus"; Micrococcus epidermidis; and Micrococcus pyogenes, a skin pathogen. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evans <i>et al. </i><a></a> have studied the resident bacterial flora in 146 sample scrapings from the skin of 17 adults over an eight-month period. They found that the anaerobic bacteria (those which grow in the absence of free oxygen) outnumbered the aerobic bacteria (those which require free oxygen) by a ratio that ranged between 10:1 and 100:1. In most of the cases, one species of anaerobic bacteria predominated, the so-called "acne bacillus," <i>Propionibacterium acnes (Corynebacterium acnes). </i>Of the aerobic bacteria, two species were observed regularly: <i>Micrococcus epidermidis </i>and <i>Staphylococcus albus {Micrococcus pyogenes), </i>the latter a skin pathogen The observation was made that, at least in cultures, some types of bacteria inhibited the growth of others. This finding might constitute one explanation for the overgrowth of certain bacteria, especially the acne bacillus, at the expense of the others. It was also found that the sebaceous glands were the major site of growth of bacteria on the skin and that exercise with sweating caused a transient minor increase in skin flora.</p> <p>What effect might the wearing of an occlusive prosthesis be expected to have on common skin pathogens trapped under the socket? How might the normal defenses of the skin be affected by the conditions attendant upon the use of a prosthesis? To answer these questions, let us consider four common groups of organisms which are likely to cause skin infections in the region of the amputee's stump-the gram-negative organisms like <i>Escherichia coli,</i> the staphylococci, the beta hemolytic streptococci, and <i>Proteus, </i>some strains of which are secondary wound invaders.</p> <p>We know that the normal skin surface has two important natural defenses against bacterial invasion-first, the ordinary drying action on the surface, facilitated, where the skin is uncovered, by the movement of air currents; second, the presence of unsaturated fatty acids (particularly oleic acid), which are components of the sebum, or oily secretion from skin oil glands.</p> <p>Gram-negative organisms, that is, those organisms which do not retain the selective blue dye used in the Gram staining technique, are particularly sensitive to drying. This alone is effective in killing or inhibiting their growth. Unfortunately, the dry state never exists for any length of time over the stump skin during the use of a prosthesis.</p> <p>Both the drying and the action of the fatty acids are slightly to moderately inhibitory against the staphylococcal organisms. In other words, neither factor offers sure protection against invasion by this group of germs, but both have deterrent value in the normal skin. Again, the moist state which usually exists under the socket tends to encourage the growth of staphylococci.</p> <p>Although the beta hemolytic streptococcus is unaffected by drying, it is destroyed by oleic acid. But streptococci will grow in serous exudate, such as may be seen in a weeping eczematoid dermatitis of the stump, because the albumin in the exuded serum neutralizes the oleic acid, the chief natural antagonist of the streptococci. This relation of exudative lesions of the skin to secondary infection underlines the importance of adequate hygienic care in routine management of minor abrasions and irritations of the stump area. Furthermore, it should be apparent that there are times when the continued use of a prosthesis on a stump which is the site of a dermatitis, especially where a serous discharge is present, will prevent healing and is almost certain to invite a secondary infection.</p> <p>The <i>Proteus </i>strains-the fourth group of organisms mentioned-multiply rapidly in a moist environment. Any occlusive dressing or cover, such as the socket, which tends to increase local moisture on the skin will favor a heavy overgrowth of <i>Proteus.</i></p> <p>Thus we see that, in all four of the examples cited, the use of a prosthesis may be expected in some measure to interfere with the defensive mechanisms of normal skin in its resistance to disease. This interference is augmented by prolonged or strenuous use of the prosthesis and by the presence of any pre-existing lesions, however minor they may seem to the amputee.</p> <h3>Electricity and the Skin</h3> <p>The electrical behavior of the skin plays an important part in the preservation of good health. Normally, there is a negative electrical charge in the superficial layers of the skin. When an alkaline condition prevails, this electrical negativity is increased owing to adsorption of negatively charged hydroxyl ions. An acid condition of the skin, however, causes a discharge of this normal negativity, which is complete between pH 3 and pH 4. As the relative acidity of the skin increases, there is eventually a reversal of the charge, the skin surface becoming electrically positive. Furthermore, investigators have reported that scarring of the epidermis<a></a> and prolonged soaking in water or concentrated salt solutions<a></a> tend to cause a discharge of the normally negative charge of the skin. Both of these abnormal conditions may develop over the stump as the result of use of a prosthesis.</p> <p>Just what effect socket wear has on the normal electrical behavior of the stump skin, or how significant this may be in maintaining a healthy condition in the stump area, we do not know at the present time. This is, however, another problem that should receive further investigation. We do know that the negativity of normal skin can be a factor in the defense of the body against pathogenic organisms, which are also negatively charged and which tend to be repelled from, or bound to, the surface of the skin according to variations in the electrical charge on the latter (<b>Fig. 7</b>). It is of interest, incidentally, to note here that in muscle the relationship of negative-positive electrical charges to normal and damaged tissue, as here described for the skin, is just reversed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Electrical charge on the skin as a defense against germ invasion. Germs, which are negatively charged, tend to be repelled from the normally negative surface of the skin but are attracted to the skin when this charge is reversed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Hygiene and Local pH or the Skin</h4> <p>Blank<a></a> has confirmed earlier observations that the pH of healthy skin is always on the acid side, falling usually between 4.2 and 5.6. Furthermore, both eccrine sweat and apocrine sweat are normally acid. These facts have given rise to the concept of the so-called "acid mantle" of the skin, which is cited by some investigators as one of the body's natural defenses against disease. Schmid<a></a> found a significant shift toward the alkaline side in the surface pH of the skin in cases of eczema and in seborrheic dermatitis, an inflammatory disorder involving especially the hairy and more oily regions of the skin. In general, an even greater shift toward the alkaline side takes place in these inflammatory diseases if the intact skin is broken and neutral in charge or if alkaline extracellular fluid diffuses through, as in any acute, weeping dermatitis of the stump. With healing, the original acid pH returns.</p> <h4>Buffering Action of Normal Skin</h4> <p>Another important property of the skin is its buffering action. If the skin surface is exposed to dilute acids or alkalies, there is normally a corresponding shift of the pH locally; but this is temporary, and the former acid pH is rapidly restored. This behavior represents the neutralizing capacity of the skin. Probably the most important agents in this neutralizing property are the sweat constituents, especially the lactic acid-lactate system and the amphoteric amino acids. Any local damage to the sweat mechanism, such as might be caused by socket irritation, could conceivably impair this important function of the skin in the involved areas. Burckhardt <i>{7,8) </i>and others have established that there is a definite correlation between the acid and alkali neutralizing capacity of the skin and its tolerance for acids and alkalies.</p> <p>Pursuing a discussion of acid-base balance brings to mind several unanswered questions with regard to the amputee's problem of stump hygiene. We would like to know, for example, what happens to the normally acid pH of stump skin during the daily wearing of an airtight socket. Does stump skin possess the same pH and buffering properties as the skin of an intact limb? What effect do different socket materials have on the pH of stump skin? Does an interior finish which gives an alkaline reaction necessarily cause more damage to the skin than does one with an acid reaction? These are questions which should receive further investigation in the light of their vital relationship to stump hygiene.</p> <p>It might seem from the foregoing that the cutaneous surface which gives an acid reaction denotes a healthy skin, resistant to invasion and disease, while an alkaline-reacting skin surface denotes the presence of some disease state. Unfortunately it is not quite so simple. Some organisms grow readily on an acid medium. Pathogenic fungi, for example, flourish on certain media at pH 4.9. Nonetheless, in general, it is desirable to maintain the surface of the skin at least slightly on the acid side.</p> <p>Washing, even with plain water, causes moderate hydration of the horny layer, with a drop, according to Szakall ,<a></a> from pH 6.3 to pH 5.3 in 30 minutes. This information may also have some application to lower-extremity prosthetics, since the stump skin becomes soaked with sweat in most cases shortly after the prosthesis is put on. Furthermore, a single washing with soap removes about 50 percent of the surface lipid film, thereby facilitating the outward diffusion of carbon dioxide, the acid reaction of which helps to neutralize an alkaline state on the surface of the skin.</p> <h4>Surface pH and Degerming of the Skin</h4> <p>Control of surface pH is also important in degerming the skin. Blank, Coolidge, and others,<a></a> in an extensive study of the surgical scrub, have investigated many different germicidal agents and techniques of cleansing. Among the agents studied were the quaternary ammonium compounds, like Ceep-ryn and Zephiran, which are widely used in surgical cleansing of the skin. While these compounds do exert a bacteriostatic or bacteriocidal effect, Blank<i>et al.</i><a></a> found that they also have the property of binding the bacteria to the skin. It was demonstrated that, at a pH a little higher than the isoelectric point of keratin, the quaternary ammonium compounds change the normally negative charge on the surface of the skin to positive. Since the bacteria are negatively charged, they are attracted to the skin. If the pH is then increased considerably, for example by rinsing with an alkaline soap, the charge on the skin will revert to negative and the bacteria will be released from the skin, as has been confirmed experimentally by analysis and culture of the rinse water.</p> <p>Another germicidal agent commonly used in disinfecting the skin is G-ll, or hexa-chlorophene. Chemically it is 2,2'-methyl-enebis (3,4,6-trichlorophenol): [pic1]</p> <p>This compound has the double advantage of accumulating on the skin when used daily and of not being inactivated, as most germicides are, when combined with a detergent. If used only at infrequent intervals, G-ll is no more effective as a disinfectant than any nonmedi-cated soap. If used regularly, however, within five to seven days there will develop in the skin a concentration sufficient to cause a definite reduction in the bacterial flora. One contraindication to the use of this agent is the presence of a serous ooze, such as we see not infrequently on the stump in various types of eczematous skin conditions. Seastone<a></a> has reported that as little as 1.0 percent of sterile serum will reduce the bacteriostatic effect of this agent.</p> <p>Hexachlorophene is available commercially in combination with various soaps and liquid detergents, in strengths varying from 0.75 to 3.0 percent. These include such brand names as Dial soap, Gammaphen soap, pHisoHex, and Septisol. Another useful preparation of G-ll is an alcoholic solution containing 0.1 percent of G-ll, with 0.5 percent of cetyl alcohol added as an emollient. This solution may be used as a two-minute rinse following soap-and-water cleansing of the stump.</p> <p>A useful cleansing agent for stump skin has been found to be pHisoHex, especially where superficial infection is a problem. It consists of an emulsifying agent known as pHisoderm, to which 3 percent of G-ll has been added. Chemically, pHisoderm is sodium octylphenoxyethoxyethyl ether sulfonate, plus lanolin cholesterols, lactic acid, and petrolatum. Its pH is 5.5, approximately that of normal skin. It lowers the surface tension of water and is an active emulsifier.</p> <p>There are many other agents for degerming the skin, many of which are too irritating for the type of regular use necessary to routine stump care. One of the more readily available of these is alcohol, which remains a useful bacteriocidal preparation. Isopropyl alcohol, for example, is germicidal up to 50-percent dilution. Too-frequent use of such solvents, however, will dry the skin excessively and may do more harm than good. Furthermore, any marked depression of bacterial flora over the stump skin cannot be maintained for long during use of the prosthesis.</p> <h3>Selective Absorption as a Protective Barrier</h3> <p>The healthy cutaneous envelope of the body is constantly active as a physicochemical barrier against the outside world, retaining some substances and passing others through (<b>Fig. 8</b>). As early as 1904, Schwenkenbecher<a></a> showed that the intact skin is permeable to fat-soluble substances and to certain gases but is practically impermeable to water and most electrolytes. Most substances which are soluble in both water and lipids penetrate the skin and pass into the general circulation at rates comparable even to gastrointestinal or subcutaneous absorption. Phenolic compounds, lipid-soluble vitamins, and hormones penetrate rapidly. This property of the skin conceivably could be of serious import in the indiscriminate use of socket materials or finishes capable of liberating absorbable toxic fractions which could be taken up by the stump skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The skin as a protective physicochemical barrier. The skin conserves in the body some substances like water and electrolytes by selectively barring their outward passage. Other substances, for example the gases carbon dioxide and oxygen, are passed freely through the skin. Lipid-soluble vitamins and hormones likewise readily penetrate the skin barrier. Unfortunately, certain materials which are potentially toxic, such as the phenolic compounds, may also be freely absorbed by the skin. Care should therefore be taken to avoid prolonged intimate contact with such materials. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In rare instances, individuals have demonstrated a peculiar sensitivity, known as an "idiosyncrasy," on first exposure to certain drugs and chemicals applied to the skin. Alexander<a></a> described a case of iododerma, a form of iodine reaction, resulting in the death of a 37-year-old woman following routine preoperative cleansing of the surface of the skin over the abdomen with iodine. This is not intended to suggest that any similar hazard exists in the use of present-day, conventional socket materials. It does, however, emphasize the fact that the skin may be, in certain rare cases, an open portal to the systemic circulation.</p> <p>Transfer of gases across the skin barrier may take place with ease in either direction. The biological significance of the movement of oxygen and carbon dioxide through the skin, which was once thought negligible, is given more importance now. Shaw and others<a></a> found that oxygen was given off through the skin when the oxygen content of the ambient air was reduced to about 2 percent and that it was absorbed more rapidly when the skin was surrounded by a gaseous mixture containing about 37 percent of oxygen than when surrounded by air. According to Chambers and Goldschmidt,<a></a> if the total skin surface is surrounded by nitrogen gas instead of air, there may be a compensatory, increased uptake of oxygen by the lungs.</p> <p>Hediger<a></a> reported that, from a water chamber containing the dissolved gas, carbon dioxide passed into the skin as long as the water contained more than 4 percent of carbon dioxide. When the concentration dropped below 4 percent, carbon dioxide diffused outward through the skin, as it does constantly under physiological conditions. Measurements cited by Rothman and Schaaf<a></a> showed that over a 24-hour period 7 to 9 grams of carbon dioxide escaped from the total skin surface, less that of the head, of an adult male. The amount suddenly increased when the temperature was raised to the critical temperature of visible sweat secretion.</p> <p>Cleansing of the skin with organic solvents such as ether, benzene, and, to a lesser degree, alcohol, enhances percutaneous absorption, that is, absorption across the skin barrier. Since such solvents are used frequently in the cleansing of the stump, as well as of the interior of the prosthetic socket, this effect upon the skin's absorption should be borne in mind. Moisture, almost constantly present in the wearing of a prosthesis, also promotes trans-epidermal absorption by an unexplained mechanism.</p> <h3>Summary</h3> <p>Through the use of improved prostheses, many amputees have been able to return to relatively normal physical activity and to take again their rightful place in business and social life. It must be remembered, however, that the use of a prosthesis places upon the leg amputee new and heavy demands, including not only muscular and emotional readjustments but also the infliction of unaccustomed wear and tear upon his stump skin. Daily, for the rest of the amputee's life, his stump will be subjected to an abnormal environment that combines heat, moisture, and darkness with chemical and mechanical irritation. It becomes imperative then, in restoring the amputee to full activity, to make certain that he understands the importance of systematic skin care. An adequate appreciation of the necessary requirements for good stump hygiene must be based on a knowledge of the functions and limitations of normal skin.</p> <p>The skin provides for the other tissues a highly effective, tough and elastic outer covering, which has a great capacity for strengthening itself at points of stress and for repairing itself after injury. But this capacity of the skin for mechanical protection, the limits of which are of special interest in prosthetics design, is only one of its many important functions. The skin possesses, in addition, a variety of anatomical structures, including the eccrine, apocrine, and sebaceous glands, the normal function of which is necessary for the preservation of good skin hygiene. The eccrine glands are indispensable in the heat control of the body. All of the glands produce secretions, some of which are exceptionally copious. This normal function poses an important sanitary problem for the amputee and makes routine cleansing of both the skin and the prosthesis essential.</p> <p>The natural defenses of the skin against germs depend upon good hygiene. Conditions inside the socket tend to impair the resistance of the skin to infection, but through adequate cleansing, frequent airing, and intelligent care of early lesions, serious infection may be avoided.</p> <p>Knowledge is increasing concerning the electrical and chemical buffering properties of the skin and their role in the maintenance of skin health. There is usually a negative charge in the superficial layers of normal skin. It is, however, discharged by injury or by prolonged soaking in water or salt solution. Similarly, normal skin is slightly acid, but in the presence of inflammation of the skin a shift to the alkaline side usually occurs. The sweat constituents contribute largely to the capacity of the skin to neutralize or buffer dilute acids and alkalies to which it is exposed. Whether or not these properties are retained intact by the stump skin of amputees and, if so, how they are affected by the conditions of use of a prosthesis are important areas for further research.</p> <p>Although the skin serves as a protective barrier, it is readily penetrated by certain substances. For this reason the stump should be protected from contact with materials potentially toxic. Similarly, the stump skin may be subject to a variety of local injuries- mechanical, chemical, or allergic in origin. Again the importance of early and close attention to minor lesions and to good preventive hygiene must be emphasized.</p> <p>There have been two chief aims in this discussion of basic principles. The first was to impart an awareness of the complex nature of the problem of stump hygiene and the second to emphasize that good stump hygiene, far from being an academic matter, is one of the utmost importance to the amputee. Like the proverbial dispatch rider whose horse was crippled for want of a horseshoe nail, the amputee may suffer discomfort and serious disability because of neglect of a seemingly insignificant lesion or failure to follow a simple cleansing routine.</p> <h3>Acknowledgments</h3> <p>A special acknowledgment is due Rothman's excellent sourcebook of dermatologic research, <i>Physiology and Biochemistry of the Skin , </i><a></a> which the author found to be a useful guide in the preparation of this article. The cartoons are the work of Tom Raubenheimer, medical illustrator at the University of California Medical Center, San Francisco.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Alexander, R. C, Fatal dermatitis following the use of iodine spirit solution, Brit. Med. J., 2:100 (1930).</li> <li>Bazett, H. C, Theory of reflex controls to explain regulation of body temperature at rest and during exercise, J. Appl. Physiol., 4:245 (1951).</li> <li>Blank, I. H., Measurement of pH of the skin surface. II. pH of the exposed surfaces of adults with no apparent skin lesions, J. Invest. Dermat., 2:75 (1939)</li> <li>Blank, I. H , and M. H. Coolidge, Degerming the cutaneous surface. I. Quaternary ammonium compounds, J. Invest. Dermat., 16:249 (1950).</li> <li>Blank, I. H., and M. H. Coolidge, Degerming the cutaneous surface. II. Hexachlorophene (G-ll), J. Invest. Dermat., 15:257 (1950).</li> <li>Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (1950).</li> <li>Burckhardt, W., Beilrage zur Ekzemfrage. II. Die Rolle des Alkali in der Pathogenese des Ekzems speziell des Gewerbeekzems, Arch. f. Dermat. u. Syphilol., 173:155 (1935).</li> <li>Burckhardt, W., and W. Baumle, Die Beziehung der Saureempfindlichkeit zur Alkaliempfindlichkeit der Haul, Dermatologica, 102:294 (1951).</li> <li>Chambers, A. H., and S. Goldschmidt, The influence of cutaneous atmospheric oxygen absorption upon the apparent total oxygen utilization of the body, Am. J. Physiol., 129:P331 (1940).</li> <li>Dale, H. H , and W. Feldberg, The chemical trans- mission of secretory impulses to the sweat glands of the cat, J. Physiol., 82:121 (1934).</li> <li>Evans, C. A., W. M. Smith, E. A. Johnston, and E. R. Giblett, Bacterial flora of the normal human skin, J. Invest. Dermat., 15:305 (1950).</li> <li>Hediger, Stephan, Experimentelle Untersuchungen iiber die Resorption der Kohlensaure durch die Haut, Klin. Wchnschr., 7:1553 (1928).</li> <li>Keller, Phillip, Die biologishen Grundlagen fur die elektrischen Potentiate der Haul, Arch. f. Dermat. u. Syphilol, 160:136 (1930).</li> <li>Rein, Hermann, Die Elektrophysiologie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:43 (1929).</li> <li>Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 1954.</li> <li>Rothman, S., and F. Schaaf, Chemie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:161 (1929).</li> <li>Schmid, Martin, Vergleichende Unlersungen iiber die Sdure-Basen-Verhaltnisse auf der Haul, Dermatologica, 104:367 (1951).'</li> <li>Schwenkenbecher, [A.], Das Absorptionsvermbgen der Haut, Arch. f. Anat. u. Physiol. (Physiol. Abt), p. 121 (1904).</li> <li>Seastone, C. V., Observations on the use of G-ll in the surgical scrub, Surg., Gyn., and Obstet., 84: 355 (1947).</li> <li>Shaw, L. A., A. C. Messer, and S. Weiss, Cutaneous respiration in man. I. Factors affecting the rale of carbon dioxide elimination and oxygen absorption, Am. J. Physiol., 90:107 (1929).</li> <li>Szakall, Alexander, Uber die Physiologie der obersten Hautschichten und ihre Bedeutung fur die Alka-liresislenz, Arbeitsphysiol., 11:436 (1941).</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</li> <li>Weiner, J. S., The regional distribution of sweating, J. Physiol., 104:32 (1945).</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>15.</b> </td><td class="clsTextSmall">Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 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>16.</b> </td><td class="clsTextSmall">Rothman, S., and F. Schaaf, Chemie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:161 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hediger, Stephan, Experimentelle Untersuchungen iiber die Resorption der Kohlensaure durch die Haut, Klin. Wchnschr., 7:1553 (1928).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Chambers, A. H., and S. Goldschmidt, The influence of cutaneous atmospheric oxygen absorption upon the apparent total oxygen utilization of the body, Am. J. Physiol., 129:P331 (1940).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Shaw, L. A., A. C. Messer, and S. Weiss, Cutaneous respiration in man. I. Factors affecting the rale of carbon dioxide elimination and oxygen absorption, Am. J. Physiol., 90:107 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Alexander, R. C, Fatal dermatitis following the use of iodine spirit solution, Brit. Med. J., 2:100 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Schwenkenbecher, [A.], Das Absorptionsvermbgen der Haut, Arch. f. Anat. u. Physiol. (Physiol. Abt), p. 121 (1904).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Seastone, C. V., Observations on the use of G-ll in the surgical scrub, Surg., Gyn., and Obstet., 84: 355 (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>6.</b> </td><td class="clsTextSmall">Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (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>4.</b> </td><td class="clsTextSmall">Blank, I. H , and M. H. Coolidge, Degerming the cutaneous surface. I. Quaternary ammonium compounds, J. Invest. Dermat., 16:249 (1950).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blank, I. H., and M. H. Coolidge, Degerming the cutaneous surface. II. Hexachlorophene (G-ll), J. Invest. Dermat., 15:257 (1950).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Szakall, Alexander, Uber die Physiologie der obersten Hautschichten und ihre Bedeutung fur die Alka-liresislenz, Arbeitsphysiol., 11:436 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Schmid, Martin, Vergleichende Unlersungen iiber die Sdure-Basen-Verhaltnisse auf der Haul, Dermatologica, 104:367 (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>3.</b> </td><td class="clsTextSmall">Blank, I. H., Measurement of pH of the skin surface. II. pH of the exposed surfaces of adults with no apparent skin lesions, J. Invest. Dermat., 2:75 (1939)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Keller, Phillip, Die biologishen Grundlagen fur die elektrischen Potentiate der Haul, Arch. f. Dermat. u. Syphilol, 160:136 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Rein, Hermann, Die Elektrophysiologie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:43 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Evans, C. A., W. M. Smith, E. A. Johnston, and E. R. Giblett, Bacterial flora of the normal human skin, J. Invest. Dermat., 15:305 (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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bazett, H. C, Theory of reflex controls to explain regulation of body temperature at rest and during exercise, J. Appl. Physiol., 4:245 (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>15.</b> </td><td class="clsTextSmall">Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 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>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Dale, H. H , and W. Feldberg, The chemical trans- mission of secretory impulses to the sweat glands of the cat, J. Physiol., 82:121 (1934).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gilbert H. Barnes, M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Instructor in Dermatology, School of Medicine, University of California Medical Center, San Francisco, and member of the Study Group on Dermatology, Lower-Extremity Amputee Research Project, University of California, Berkeley and San Francisco. Based on a lecture presented before the University of California Pilot School in Lower-Extremity Prosthetics, August 25, 1955, at the U.S. Naval Hospital, Oakland, California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_01_004/spring56-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_01_004/spring56-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_01_004/spring56-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1956_01_004/spring56-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1956_01_004/spring56-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1956_01_004/spring56-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1956_01_004/spring56-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1956_01_004/spring56-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1956_01_004/spring56-10.jpg Figure 10 http://www.oandplibrary.org/al/images/1956_01_004/spring56-09.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Skin Health and Stump Hygiene Creator An entity primarily responsible for making the resource Gilbert H. Barnes, M.D. * https://staging.drfop.org/files/original/b25b9a939b4d5c4ae9c2f2acedbd696c.pdf b30d583cd18be4ab29c7f0440219cbfc https://staging.drfop.org/files/original/085e246a53c62b03b6a70a4a5358313e.jpg 7e93897e87d2197f2f94cc38f6151bab https://staging.drfop.org/files/original/bf1d9342409ad283c4fc51fe85e5c428.jpg 8f49557f305b3f91b7b067d1d2fb37d8 https://staging.drfop.org/files/original/2401bf3d7149007a01025885d08d12ae.jpg c566cc861e0b9018fe1dc2d38a6f166f https://staging.drfop.org/files/original/c726ce3e24b0aade2c6e4dafa6f1bc65.jpg b0f4603259af940f59a613343b3209e6 https://staging.drfop.org/files/original/521e1b62356225f950ec5636d3aa0e99.jpg dba0a9cfe630f9f2342e23e916484200 https://staging.drfop.org/files/original/253df5a8e8ea95d454b65a3804d794f2.jpg bb1cae0e839a9c04e07cecb7754caece https://staging.drfop.org/files/original/e5705786f693a02943d04c1e21474ff9.jpg 36fc5cade6ee7836f0dad674628a3d63 https://staging.drfop.org/files/original/c93272788dcc12626615e966d1932254.jpg 43b0d4a687d08e1b229d409a604aeb7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_043.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 43 - 49 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_043.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_043.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Socket Flexion and Gait of an Above-Knee, Bilateral Amputee</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Many factors affect the gait of an above-knee, bilateral amputee as he walks on his prostheses. Among the factors are his general health and strength, the length and condition of his stumps, the alignment of his prostheses, his comfort, and the type of knee units employed.</p> <p>While some of these factors are difficult to observe accurately, others lend themselves to objective measurement and evaluation by means of current bioengineering techniques. Not long ago, the Bioengineering Laboratory of the Veterans Administration Prosthetics Center had occasion to evaluate the gait of an above-knee, bilateral amputee, and in the course of the evaluation developed records that show graphically the "before" and "after" effect of increased hip flexion of about 10 deg. in both sockets.</p> <h3>Background</h3> <p>An above-knee, bilateral, 26-year-old, male amputee veteran, who was fitted with two suction sockets and two Hydra-Cadence knee units, was referred to the Bioengineering Laboratory for gait evaluation. The amputations resulted from an automobile accident; the patient was a vigorous young man in good health, with well-muscled, strong stumps. He weighed 158 lb. with prostheses, stood 5 ft. 8 in., had 12-in. stumps, and had worn constant-friction knee units for two years. In May 1962, he was fitted with one Hydra-Cadence unit, and approximately three months later was fitted with a second Hydra-Cadence unit.</p> <p>After he had worn both units for three or four months, evaluation indicated that, although he managed two suction sockets adequately, the two Hydra-Cadence units produced a jerkiness in his gait which was tentatively attributed to the higher energy requirements of the hydraulic units.</p> <p>The clinic team recommended that both Hydra-Cadence units be replaced with constant-friction units and requested the Bioengineering Laboratory to obtain photographic records of his performance on the Hydra-Cadence units for subsequent comparison with records to be obtained of his performance on the constant-friction units.</p> <p>On May 15, 1963, the amputee appeared at the Bioengineering Laboratory for evaluation. Preliminary examination of the prostheses indicated only marginal-if not inadequate- initial hip flexion. Observation of the subject's gait tended to confirm this impression; he seemed exceptionally "stable" and found it necessary to jerk his knee forward to initiate the swing phase. This produced a marked lurching pattern in his gait.</p> <p>The Bioengineering Laboratory recommended realignment of the prostheses, with particular emphasis on increasing initial hip flexion as a step which might improve function and obviate the necessity for refitting with constant-friction knee units. The clinic team concurred. A biomechanical analysis of the amputee's performance with his unaltered prostheses was conducted at the Laboratory on May 15. On May 24, 1963, after the amputee's prostheses were realigned by procedures which did not involve refabrication of the sockets, his performance was re-evaluated.</p> <h3>Procedures</h3> <p>The purpose of the two biomechanical evaluations was to identify changes in the gait pattern of the amputee which might have occurred as a result of changing the attitude of both sockets so as to increase initial hip flexion (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Socket realignment to provide 10 deg. of initial hip flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the length of the amputee's stumps (12 in.) and the need to maintain cosmetic acceptability, the maximum increase of hip flexion possible was from 0 deg. to 10 deg. This change in attitude was intended to increase the amputee's functional range in hip extension and thereby improve his control of knee stability during stance, with potential effects upon his speed of walking, his stride length, the smoothness of the path followed by his center of gravity, the application of his body weight to the floor, the characteristics of his push-off, and his knee flexion at toe-off. Since the change was simply an increase of flexion, and only in one plane, it was accomplished without the use of the VAPC adjustable coupling.<a></a></p> <p>Although the amputee normally walked with the aid of canes, he did not use them during the two evaluations.</p> <p>For each evaluation, the amputee walked along a level walkway, first in one direction and then in the other, thus making two transits of the walkway on each occasion. Run No. 1 and run No. 3 were made on May 15; run No. 4 and run No. 5 on May 24. Because of equipment failure on run No. 2, no data are shown for that run.</p> <p>He was targeted with reflective tape at the head, elbow, hip, knee, ankle, and shoe for photography from the side by an interrupted-light camera during the transits. Also, as he proceeded along the walkway, he stepped on a set of force plates (thus providing a measure of the application of his body weight to the floor). Simultaneously, the tachograph (<b>Fig. 2</b>) measured and recorded his acceleration and velocity. Descriptions of these procedures and devices appeared in Artificial Limbs in 1954.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Schematic diagram of the tachograph, a system for recording linear velocity. The subject wears a lightweight belt, to which is attached a fine cable that turns the rotor of a direct-current generator. Voltage produced by the generator is proportional to the velocity of the subject. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Results</h3> <h4>Average Velocity</h4> <p>Average velocities, determined by integrating the tachograph curves, are given below in fiftieths of an inch of galvanometer deflection. An increase in velocity may reflect easier initiation of swing phase, an increased push-off force, or greater stride length. <b>(Table 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It can be noted that the patient's velocity was greater after realignment of his prostheses-substantially higher in run No. 4, and moderately higher in run No. 5. In <b>Fig. 3</b>, the velocity curves prior to realignment fall below the zero velocity level, indicating backward movement. In order to initiate the swing phase, it was necessary for the patient to incline his torso forward, with a consequent rearward thrust of the pelvis. The tachograph recorded this rearward thrust as a backward movement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Tachograph recordings. Run No. 1 and run No. 3 were recorded on May 15, 1963, prior to realignment of prostheses; run No. 4 and run No. 5 on May 24, 1963, after realignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Average Stride Length</h4> <p>Stride length is the distance between consecutive heel contacts by the same leg. In this case, increased stride length may be regarded as a result of greater control and strength in hip extension, increased push-off force, and easier initiation of the swing phase.</p> <p><b>Average Stride Length</b></p> <blockquote><p>Prior to Realignment of Prostheses: 17.0 in.<br />After Realignment of Prostheses: 19.4 in.</p> </blockquote> <h4>Smoothness Of Gait</h4> <p>In addition to measuring velocity, the tacho-gram reflected other elements of the gait pattern. Thus the smoother wave forms recorded after realignment of the prostheses (<b>Fig. 3</b>) indicate less lurching and jerkiness in the gait pattern.</p> <h4>Anteroposterior And Vertical Displacements</h4> <p>No significant differences were observed in the displacement of the head, elbow, hip, and knee after realignment of the sockets. However, the ankle displacement curve (<b>Fig. 4</b>) indicated a more rhythmic oscillation of greater amplitude after the realignment. This motion reflects more normal timing and range of knee flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pathways of targeted points on the amputee during ambulation, as determined by interrupted-light photography. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Knee Flexion</h4> <p>Knee flexion at toe-off and during the swing phase prior to realignment of the sockets was variable and at times very limited. After realignment of the sockets, the extent of knee flexion at toe-off and during the swing phase was more consistent and generally of more normal magnitude. <b>(Table 2)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Floor Reaction Forces</h4> <p>In view of the variability of the patient's performance on the four runs, vertical load and fore-and-aft shear forces do not show consistent differences. Nevertheless, reference to <b>Fig. 5</b> indicates that:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Force-plate data. Vertical forces applied by the subject to the force plate during the stance phase are shown in the upper curves. Less time was required to apply the full body weight to the prosthesis after realignment. Fore-and-aft shear forces shown in the lower curves indicate the pattern of push-off and toe-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient applied his full body weight to the prostheses faster after the sockets were realigned. <b>(Table 3)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full body weight was applied to the prostheses in a smoother, less jerky fashion, as indicated by a diminution of the oscillations in the patterns representing performance after realignment.</p> <p>The smaller amplitude of the oscillations in the vertical load curves after realignment indicates decreased lurching in the stance phase and perhaps a smoother initiation of the swing phase on the contralateral side.</p> <p>The fore-and-aft shear load curves indicate greater horizontal forces after push-off with the realigned sockets. Moreover, the increased magnitude of the aft shear loads after toe-off before realignment indicates a greater degree of toe drag.</p> <h4>Motion-Picture Analysis</h4> <p>Motion pictures were made of the patient prior to and after realignment of the sockets. Analysis of the gait patterns indicated the following positive changes:</p> <ul> <li>Somewhat less anteroposterior pelvic lurch.</li> <li>More symmetrical arm swing.</li> <li>Somewhat longer step length.</li> <li>Narrower walking base.</li> <li>Easier initiation of the swing phase with increased hip flexion.</li> </ul> <p>Analysis of the motion pictures did not bring out any significant improvement in stability. However, this may have been masked by the obviously improved mobility.</p> <h3>Summary</h3> <p>The performance of an above-knee, bilateral amputee in level walking with two suction sockets and two Hydra-Cadence knee units was compared before and after increasing initial hip flexion approximately 10 deg. Before realignment, he had worn the assembly three or four months. However, the second evaluation was conducted on the same day as the realignment; consequently, the comparison does not represent a reliable index to the significance of the change. The observations disclose only immediate reactions; another evaluation after at least three months of wear should provide a more conclusive analysis.</p> <p>In general, the patient's performance revealed marked variations from run to run, making it difficult to select a truly representative performance for each test condition. For this reason, "before" and "after" data describing performance during the runs have been presented.</p> <p>The increased initial hip flexion was undertaken to increase the amputee's range and strength in hip extension. Analysis of the data disclosed mild improvements in:</p> <ul> <li>Stability.</li> <li>Velocity and stride length.</li> <li>Smoothness of gait pattern.</li> <li>Initiating the swing phase by increased push-off forces.</li> </ul> <p>The only significant change which could be identified in the symmetry of the motions of body segments was a more normal ankle displacement, reflecting improved knee flexion in the swing phase.</p> <p>A follow-up inquiry on August 20, 1963, disclosed that the patient, who was employed in a summer camp, was wearing his prostheses daily. Because of the hilly terrain where he was working, he was using two crutches rather than the two canes previously used. Despite his comments that the limbs were heavy and he wanted to have the socket fit re-checked, he regularly wore the prostheses from 8:00 a.m. to 11:00 p.m. daily and did considerable walking.</p> <p>This experience illustrates a tendency toward excessive concern for stability when fitting and aligning prostheses for above-knee, bilateral amputees, thereby imposing needless functional limitation.</p> <p>In this particular case, more than 10 deg. of initial hip flexion could have been tolerated without significant loss of stability. However, even the increase of 10 deg., the maximum in view of stump length and cosmetic requirements, had several beneficial effects on the patient's performance.</p> <p><b>References:</b></p> <ol> <li>Contini, Renato, <i>Prosthetics research and the engineering profession</i>, Artificial Limbs, September 1954, p. 47.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artificial Limbs, Spring 1963, p. 31.</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">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, September 1954, p. 47.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artificial Limbs, Spring 1963, p. 31.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Laboratory, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-51.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-53.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-52.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-54.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-58.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-55.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Socket Flexion and Gait of an Above-Knee, Bilateral Amputee Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/995448e86e0b5f119a7459b183fd0e92.pdf b21593810340917c87578b184eb75be6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_004.pdf Text Any textual data included in the document <h2>Sockets, Linings, and Interfaces</h2> <h5>Eugene F. Murphy, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>A prosthesis, whose Greek source means "put to," must of necessity have contact with the residual limb or stump. The functions of this contact region or socket (perhaps supplemented with lining, sock, and further attachments or harness), are to allow the transmission of forces, bending moments, and torques between the amputee and the prosthesis to be as comfortable as feasible in order to sustain body weight and permit locomotion for lower-limb amputees, and to allow purposeful activities by upper-limb cases. Prolonged and vigorous use of a prosthesis should not cause pain, pressure sores, blisters or corns from friction, nor edema from restricted return circulation. Proper ventilation should also prevent such accumulation of moisture as to cause skin maceration.</p> <p>Challenging as these major tasks are, they should not lead to neglect of some of the less obvious functions of a prosthesis. The changing pattern of pressure distribution on the body from the prosthesis should provide important sensory feedback on external forces, on positions of remote portions of the prosthesis, and on events such as knee extension. Professor Ernst Marquartdt,<a></a> realizing the value of the limited sensory information transmitted to the residual limb of an upper-limb amputee by the older soft leather socket, was reluctant to change to rigid plastic laminates despite their other advantages. It should also be possible to control remote joints and locks or external sources of power by small reflex or voluntary motions of remaining muscles in the residual limb and through sensing of mechanical motion or myoelectric activity.</p> <p><i>Historical Notes</i></p> <p>Naturally there is a long history of attempts to meet these challenges, that is scattered in patents, papers, catalogs, and atlases.<a></a> There are records of wooden prostheses and peg legs since antiquity, which presumably were padded with fabric or leather. Medieval prostheses, made by armorers, probably had leather or other materials for liners. In the past century, molded leather shells or lacers supported by metal side bars and cuffs, adapted from orthopedic appliances, were used extensively. These allowed slow adaptation to radial displacement and deliberate readjustment of circumference, and provided some tapered flexibility of radial stiffness above and below the proximal and distal reinforcing cuffs. The typical American artificial limb carved out of wood was completely rigid, though it could be carved deliberately to produce enlargements as desired and could be lined, completely or in selected portions of the circumference, with leather.</p> <p>Felt, wax-impregnated materials slowly displaced under pressure at body temperature, and resilient or slowly compacted foam plastics or rubbers have been used by various developers. Diagonally woven straps or cords (sometimes called Chinese Magic Finger Grip in the U.S., or Nuremberg Witch's Finger in Germany) have been suggested repeatedly as resilient sockets and perhaps as suspension. Parallel vertical cords between upper and lower rigid frames have also been used for both flexibility and ventilation.</p> <p><i>End-Weight-Bearing</i></p> <p>Some early sockets attempted to provide direct end-weight-bearing on the unrestrained end of the amputated residual limb. Typically, the amputated end of the bone without deliberate plugging developed only a thin and flexible closure to resist transmission of end load to the medullary canal, causing discomfort or pain. In addition, the ring of bony cortex tended to produce painful direct loading on the skin at the distal end of the residual limb. Early attempts to leave flaps or pads of muscles or other tissues across the distal end merely led to atrophy. Grey, a former apprentice of James Potts who developed the coordinated-motion above-knee prosthesis later called the Anglesea Leg, was very critical of such misguided efforts to develop end-weight-bearing.<a></a> Except for the Syme,<a></a> the knee disarticulation, the Gritti-Stokes amputation levels, and some attempts to deliberately plug the end of a long bone<a></a>—all relatively rare—there were few attempts to attain any end contact, let alone end-weight-bearing.</p> <p>For generations most prostheses, especially the typical above-knee, caused considerable constriction in the proximal third of the socket, required trial-and-error fitting, and left relatively unsupported the distal end of the residual limb. Because the residual limb was considered "a bowl of jelly," it was constricted proximally but extruded distally in an attempt to secure a firm grip to assist both axial support and control of bending moments. Fortunately, the common firmly-knitted woolen stump sock between the limb and the prosthetic socket—folded over the socket brim and closed at the distal end—supported the skin, fascia, and internal tissues in resisting this distal extrusion and lengthening.</p> <p><i>Stump Socks</i></p> <p>One or more stump socks were typically worn between a hard socket wall and the residual limb. Stump socks were worn for reasonable as well as fallacious purposes.<a></a> Knitted fleece socks provided a slight degree of resiliency and thus redistribution of local radial pressure, especially when freshly laundered. Inevitably, there were mismatches between the residual limb and socket wall caused by slow changes in the limb with edema, atrophy, obesity, or sometimes growth or muscle development. Axial displacement, inaccuracies in the trial-and-error carving of a wooden socket, or even of modification of a plaster model of the residual limb before preparing a plastic socket also led to mismatches. Sock resiliency can overcome minor discrepancies and improve comfort and addition of a sock can help compensate for shrinkage of the residual limb.</p> <p>A major function of the sock is to cling to the residual limb but slide with respect to the socket wall if there are relative motions between stance and swing phases of walking or caused by discrepancy between the natural proximal joint and an external mechanical joint. (This important function is impeded if the socket wall is rough or if a perspiration-soaked sock can stick to the wall but chafe the skin.) The sock should also absorb perspiration, provide wick-like action, and allow for ventilation. The closed end or "toe" should provide some support of the distal tissue.</p> <p>Other than a circular cross-section, addition of one or more socks inevitably distorts the fit. In the triangular below-knee case, although the soft tissues in the posterior portion can change, the bony portions do not, so a spot liner is more appropriate than additional socks.</p> <p>Sometimes the stump sock was misused by patients to compensate for gross changes which required major refitting, or because of misunderstandings or lack of training. About 1947 Dr. John Young of Mellon Institute and this author met a below-knee amputee who wore five firmly packed socks. Though he did not believe in a "green sock," we finally persuaded him to purchase new socks in order to accompany a newly refitted prosthesis adapted to only one or two socks and to wash the socks daily. Such distortions, however, should not distract from the legitimate uses of stump socks.</p> <p><i>Suction Socket</i></p> <p>The suction socket above-knee prosthesis was and is routinely fitted with direct contact against the skin of the residual limb. The original suction socket of the Parmelee patent of 1863<a></a> may have been intended as total contact, though the evidence is not clear.</p> <p>A version of the suction socket which came from Germany in 1946-47, was routinely fitted with a "suction chamber" extending below the end of the residual limb. During donning, the tissues were pulled down through a snugly fitted proximal third by a tube of stockinet which was withdrawn through the valve hole in a side wall, thereby creating a significant distortion and elongation of the residual limb. In some cases, the distal end developed chronic edema or discoloration from disturbed return circulation or small hemorrhages.</p> <p>These problems, as well as basic principles, contact dermatitis, blisters and corns from friction, and cysts just proximal to the brim, were among the major difficulties discussed by Barnes<a></a> and Levy<a></a> in their classic treatment of dermatological problems of the amputee. They emphasized the importance of avoiding stasis in the distal residual limb in encouraging total contact and reducing proximal constriction.</p> <h3>Thoughts And Theories</h3> <p>After the issue of <i>Artificial Limbs</i> by Barnes and Levy was published in 1956, this author was appointed Fulbright Lecturer, based at the Orthopedic Hospital in Copenhagen. In an informal memorandum<a></a> based on years of observations and discussions concerning fitting of both dental and limb prostheses, three major themes were developed:</p> <ol> <li> <p>Minimize the stiffness gradient between the rigid socket wall and the flexible skin; i.e., taper flexibility of the socket brim.</p> </li> <li> <p>Approximately match wall stiffness to that of the tissue supported.</p> </li> <li> <p>Provide a porous wall capable of "breathing" slowly.</p> </li> </ol> <p>We may consider each theme in turn. Both theory and practice can be useful. Practice can develop to a considerable extent without theory; we walked before we learned about the biomechanics of locomotion, and Watt built steam engines before Carnot developed the basic cycle for all heat engines or Rankine the cycle for steam engines. Yet theory can guide our efforts toward improvements, show the areas where greatest progress can occur, and point out the ultimate limits so we do not waste our efforts.</p> <p><i>Tapered Flexibility</i></p> <p>The first theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett.<a></a> The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months.</p> <p>After the National Institute of Handicapped Research (NIHR) project at Moss Rehabilitation Hospital began working with polyethylene and polypropylene thermoplastics,<a></a> Bennett collaborated with that group on some attempts to develop more durable flexible-brim sockets using thermoplastics. These appeared to be promising, but the major focus of the project was on light-weight prostheses.</p> <p>There have been numerous recent efforts to produce a thermoplastic flexible (and often transparent) inner socket or liner supported by an outer shell or other structure. The Scandinavian Flexible Socket or the similar Icelandic-Swedish-New York (ISNY) Socket, and two recent designs from the New York University Institute of Rehabilitation Medicine<a></a> are examples. If, as in Figure 5 of "Flexible Prosthetic Socket Techniques" by Lehneis et al., the flexible inner liner projects proximally above the more rigid outer laminate shell, it helps to provide the tapered flexibility and transition from rigid socket to flexible skin which was suggested in theme I,<a></a> and which seemed desirable from Bennett's work.</p> <p><i>Matching Wall Stiffness to Tissues Supported</i></p> <p>First, consider the principles. The bony prominences near the surface are very stiff against radial indentation under load, but they do not bulge during walking or change appreciably in size or shape over extremely long periods. In contrast, soft tissues may change much more rapidly by brief displacement of body fluids or in moderate time periods (e.g., weeks) by growth or atrophy. Soft tissues are also much less stiff under loads from internal muscular or hydraulic forces, or from external pressure, provided they can be displaced.</p> <p>Conversely, if fluid-filled soft tissues are sufficiently trapped to avoid displacement, they will behave like an enclosed fluid under hydrostatic pressure. Within the limits allowed by connective tissue, unsupported soft tissue can be displaced a considerable amount, at the expense of distorting blood vessels from their usual circular cross-sections to oval shapes with the same perimeter but a smaller area. Such displacement can also stimulate nerve endings. These displacements may give the illusion of tissue "compressibility."</p> <p>Soft tissue can also accumulate excessive fluid, creating flushing and edema, if free to expand radially from the center of the body mass. External support will assist the "milking" effect from the pulsating action of muscles contracting within fascial compartments in pushing fluid into the veins and lymphatics, while on the contrary either external suction or restriction of the return ducts proximal to the tissue considered will favor edema. Similarly, a localized area, with little or no muscular activity that is free from support within a larger region otherwise firmly supported, will cause "window edema" with bulging of skin and tissue through the opening, as in a small opening in a large plaster cast.</p> <p>Many clinical observations and some systematic tests with sockets, plaster casts, and different designs of prostheses and orthoses relate to this problem of matching socket to residual limb, even though they have been viewed as specific rather than general. The direct comparison of two theories or designs is difficult because methods for preparing the socket and aligning it to the remainder of the prosthesis usually differ. It would seem useful to compare sockets with varying degrees and locations of softness or of flexibility, but similar as to cast, model, and alignment. If different methods or alignments really are needed to optimize results, the reasons should be studied.</p> <p>The original Navy "soft" socket for below-knee amputees of the late 1940's, provided a limited but equal degree of softness in all regions of the circumference. The cast was prepared with the residual limb dipped in relatively dense dental stone while it hardened. Weight was shifted to the cast after the impression was firm but not quite completely set. The socket was formed over a plaster model without modification or contact with the sock-covered distal end of the residual limb. The distal wall was intended to be tangent to the tapering residual limb. The later Navy "closed-end" socket also provided some additional thickness of cellular rubber in contact with the entire distal end of the residual limb, tapering toward the side walls, with the entire socket lined with vinyl. The Schindler soft socket was formed with gores of foam rubber tailored to fit the warped surface of the plaster model, more precisely than was possible with the single sheet wrapped around the model in the simpler Navy technique.</p> <p>The Blevens below-knee socket provided an oval pad of sponge rubber, with tapered edges, trapped between layers of stump sock over the calf region of the residual limb. After this pad was compressed and forced through a snugly fitted proximal portion, it could expand into an enlargement in the rigid socket wall below the popliteal region. It permitted both activity of the remaining remnants of calf musculature, which tended to atrophy in conventional hard sockets, and provided or assisted in support of the prosthesis in swing phase. Its possibilities for control signals remain unexplored.</p> <p><i>Fabrication Methods</i></p> <p>Carved sockets obviously required skill of the prosthetist and tolerance of the user, who was initially asked to try to fit the residual limb into an unduly tight space which was gradually enlarged until a tolerable fit was achieved. Did the residual limb become engorged or injured in the process? Did the amputee eventually tolerate a certain amount of discomfort as he "broke in " the hard limb—or perhaps broke down the soft tissues to conform more closely to the not-quite-perfect fit? Or did he become sensitized to discomfort, aware of its location and cause, and even more demanding?</p> <p>Sockets made over plaster models prepared from plaster casts seem more likely than those carved purely from measurements for an immediate accurate fit, or a fit with minimal trials and adjustments. Even so, the prosthetist usually considers that the manual distortion of the wet plaster during the process of taking the cast and "rectification " of the positive plaster model is necessary to avoid an unduly loose fit, often regardless of the resiliency of stump sock or foam lining. Could this view be the result of past experience in preparing casts from residual limbs which have become enlarged from being unsupported while below the body during the preparation period? Would little or no rectification be needed if the amputee were supine with the residual limb elevated for an "appropriate" period immediately before casting? Have a few anecdotal accounts of such attempts leading to excessively tight sockets reflected unduly long elevation times? Did the Navy dip impression allow the denser dental stone, while still fluid, to squeeze fluids from the tissues by an approximately correct amount before solidifying?</p> <p>Because the socket must transmit the necessary axial forces, bending moments, and torques described by Radcliffe<a></a> for all major levels of the lower limb, and Taylor<a></a> for the upper, the socket wall must be reasonably firm in at least some areas and the interior bone(s) must transfer forces through the skin to the wall in both proximal and distal regions.</p> <p><i>Retention of Fit</i></p> <p>A precisely made hard socket fit with direct contact (as in the suction socket) or with a single thin stump sock might be effective for a time, but it might encounter difficulties even with muscular activities or large motion of the proximal joint as in sitting and bending. More important discrepancies would occur over longer periods from edema, growth, or atrophy.</p> <p>Completely uniform softness might also be questioned because it does not match just those relatively limited areas which alter cyclically with muscular activity or over some time span. Perhaps more critically, uniform softness allows areas of high pressure, intended to match individual tolerance to high pressure, to sink into the soft material and thus to shift some load to areas where the designer desired lower pressure. Beginning in the prosthetics schools in 1957-58, emphasis upon socket planning based on anatomical and physiological considerations and upon avoidance of erratic constriction and looseness was a healthy development.</p> <p><i>Some Suggestions</i></p> <p>The local radial stiffness of the socket wall might be approximately comparable to the stiffness and physiological motion of the tissue which it touches, though changes should occur gradually from place to place to avoid high local shear stresses in tissue. Thus, the wall near bony prominences might be quite firm if precisely fitted to a nonedematous limb.</p> <p>Obviously this notion seems the opposite of the usual concept of cushioning the bony prominences. Much of the traditional objection to a hard socket wall in contact with a bony prominence may be due to two difficulties: (1) unduly concentrated pressure because of poor fitting or displacement from the correct position, or (2) slippage and friction from inadequate suspension or joint location, leading to formation of blisters and bursae.</p> <p>Relatively soft walls opposite soft tissue might allow muscle bulging or tendon tightening at every motion of the limb yet rebound to prevent window edema when relaxed. The stiffness might be chosen to allow deliberate gripping of the wall for control and suspension, somewhat comparable to the German "Haft-prothese"<a></a> with muscular bulging to grip a rigid wall to supplement an above-knee suction socket as well as to help support the Blevens below-knee prosthesis. Some softness opposite tissues which tend to change rapidly might also compensate for slight changes such as growth.</p> <p>Adequate, relatively firm areas must be found for biomechanically necessary forces, including those generating bending moments and torques. In the below-knee case, for example, counterpressure from the posterior wall is needed to hold the condyles anteriorly on their sloping supports. In the above-knee case, the distal lateral and the proximal medial aspects of the femur must generate, yet tolerate, substantial forces to oppose the moment created by body weight acting upon it through the center of gravity appreciably medial to the center of support of the prosthesis during stance phase.</p> <p>The soft tissues, usually present at the distal end, should be encased thoroughly to prevent displacement, extrusion, and edema, yet held precisely in a wall and floor soft enough to prevent localized painful loading. Page,<a></a> an engineer interested in dental prostheses, discussed with this author in 1946 the concept of "muco-static" fitting with tissues trapped so that, much like fluids, they behave almost hydrostatically. The tissues should not be distorted from resting position when the cast is taken, nor should they be displaced towards hollows left by grinding away apparent ridges actually needed to fit into folds in the tissue. Past failures to create end-weight-bearing simply by taking an impression under load or placing a pad of foam rubber on a flat socket floor need not eliminate the possibility of total contact or end-weight-bearing by more sophisticated methods.</p> <p>A socket of the style described might have variable but tapered thickness of resilient material, such as closed-cell foam rubber or plastic. Muscular bulging into such material might be developed as a control signal. Alternatively, but perhaps less precisely, a thin resilient liner might be supported by an outer shell providing firm support where needed but having rounded and outwardly flared windows where expansion should be possible. The thin resilient liner opposite the windows could improve heat transfer, awareness of adjacent surfaces, and comfort when seated. The sockets illustrated by Lehneis, et al.<a></a> seem reasonable steps, though one wonders whether "selected fenestration over pressure sensitive areas " would be as logical as carefully molded and slightly relieved or padded areas. Certainly the transparent socket materials are advantageous for checking fit, supplementing their value in the flared flexible brim.</p> <p><i>Porous Materials</i></p> <p>The skin, as Barnes<a></a> pointed out, normally excretes water, gases and various compounds. An impermeable wall pressed tightly against the skin for many hours at a time can lead to dermatological difficulties.</p> <p>Leather allows some absorption and passage of these excretions, but deteriorates from their presence. Organic materials trapped in the fine pores of leather tend to decompose. The Army Prosthetics Research Laboratory (APRL) developed a protective slightly permeable coating for leather consisting of a particular grade of nylon dissolved in isopropyl alcohol. It is not still commercially available, as it was not very widely used. Care had to be taken to avoid traces of oil on the leather in order to be coated.</p> <p>APRL also developed a "starved resin" process, producing a somewhat porous thermosetting plastic laminate. Unfortunately, the irregular holes tended to become plugged with debris from the stump sock, dead skin cells, etc., and no adequate cleansing method was found.</p> <p>Late in World War II, Quamco was developed for raincoats and aviation clothing to resist penetration by rain or sea water yet allow slow transfusion of perspiration. It received brief attention in the early suction socket program. In recent years, Gore-tex has become increasingly popular for sportswear. Though it is difficult to tailor Gore-tex to complex shapes, the recent availability of a molded sports hat may indicate the possibility of considering an individually shaped socket or at least gently warped segments to mount in a fenestrated socket.</p> <p>Simple mechanical perforations of the socket wall were used, for example, with aluminum sockets, particularly in England. The holes had to be small enough so that the tissue, presumably supported by a stump sock, did not bulge through them. At the other extreme, the mechanically or electrically perforated plastics, studied around 1949 by the Mellon Institute, sometimes had such tiny holes that organic materials became clogged in them as in leather.</p> <p>One could imagine a wick-like, minutely perforated liner—and perhaps wall—permitting rapid and effective cleaning and drying. Air flow must permit ventilation yet allow adequate suction suspension, perhaps assisted by muscular gripping as in the Haftprothese, or by a very flexible inner liner collapsing against and adhering to the residual limb, as in a Northwestern University design<a></a> tested upon both upper- and lower-limb amputees. Care must be taken to provide a suitable balance of wicking capillary pressure in excess of negative air pressure so that moisture is not drawn back into the socket during swing phase. Conceivably, a porous supporting liner within an outer supporting structure might provide total contact and biomechanical reactions for the residual limb, but for a small and slowly ventilated chamber between the two, perhaps serving as a suction chamber during swing phase.</p> <p>One hopes that a simple, inexpensive, individually moldable material with appropriate range of perforations will become available. Ideally it would be available in various thicknesses, stiffnesses, resiliencies, and strengths and in a choice of transparency or appropriate skin colors. Of course it must also be nontoxic, noncarcinogenic, and odorless.</p> <p>Until then, however, we must make do with the increasing array of compromise materials and our growing but imperfect understanding of principles of sockets, linings, and interfaces. Bit by bit, we can improve service to the severely disabled patients whom we serve.</p> <p><b>References:</b></p> <ol> <li>Marquardt, Ernst, Heidelberg, Germany, personal communication, 1961.</li> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic Appliances Atlas</i>, Volume 2, J.W. Edwards, Ann Arbor, Michigan, 1960, esp. Chapters 1, 5, and 6.</li> <li>Gray, Frederick, <i>Automatic Mechanism as Applied in the Construction of Artificial Limbs in Cases of Amputation</i>, London, [the NML catalog card did not indicate publisher], 1855 [1857, second edition]; a copy at National Library of Medicine, Bethesda. See also the advocacy of suturing of the deep fascial envelope, criticism of muscles pulled over the end of the bone, but presumption of no end-weight-bearing in Alldredge, Rufus H., and Eugene F Murphy, "The Influence of New Developments on Amputation Surgery," 11, in Paul E. Klopsteg, Philip D. Wilson, et al., <i>Human Limbs and their Substitutes</i>, Chapter 2, p. 19, McGraw-Hill, New York, 1954; reprint edition with additional bibliography, Hafner, New York, 1968.</li> <li>Harris, R.I., "The History and Development of Syme's Amputation," Artificial Limbs, 6:1, 4-43, April 1961; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</li> <li><a href="http://www.oandplibrary.org/al/1962_02_086.asp">Loon, Henry E., "Below-Knee Amputation Surgery," <i>Artificial Limbs</i>, 6:2, 86-99, June 1962; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li>Murphy, Eugene F., "The Fitting of Below-Knee Prostheses, " Chapter 22 in Paul E. Klopsteg, Philip D. Wilson, et al., <i>Human Limbs and their Substitutes</i>, McGraw-Hill, New York, 1954; reprint edition with additional bibliography, Hafner, New York, 1968.</li> <li>Parmelee, Dubois D., Artificial Leg, U.S. Pat. 37,637, Feb. 10, 1863. See also Murphy, Eugene F., "Patents, Patients, and Patience," commentary on centennial, <i>Artificial Limbs</i>, 7:2, 69-72, Autumn, 1963; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</li> <li>Barnes, Gilbert H., "Skin Health and Stump Hygiene," <i>Artificial Limbs</i>, 3:1, 4-19, Spring 1956; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</li> <li>Levy, S. William, "The Skin Problems of the Lower-Extremity Amputee," <i>Artificial Limbs</i>, 3:1, 20-35, reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</li> <li>"Murphy, Eugene F., "Some Thoughts on Fitting of Prosthetic and Orthopedic Appliances to be Checked and Refined," 10/11/57; mimeographed by Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, New York, 1957, 1961.</li> <li>"Murphy, Eugene F., "Transferring Load to Flesh- Part I: Concepts," <i>Bull. Prosthetics Res</i>. BPR 10-16: 38-44, Fall 1971.</li> <li>Bennett, Leon, "Transferring Load to Flesh," <i>Bull. Prosthetics Res</i>.; Series of Parts:<br />—Part II. "Analysis of Compressive Stress," BPR 10-16:45-63, Fall 1971.<br />—Part III. "Analysisof Shear Stress, "BPR 10-17:38-51, Spring 1972.<br />—Part IV. "Flesh Reaction to Contact Curvature," BPR 10-18:60-67, Fall 1972.<br />—Part V. "Experimental Work," BPR 10-19, Spring 1973.<br />—Part VI. "Socket Brim Radius Effects," BPR 10-20:110-117, Fall 1973.<br />—Part VII. "Gel Liner Effects," BPR 10-21:23-53, Spring 1974.<br />—Summary report at conference research project leaders, with title Transferring Load to Flesh, BPR 10-22, 13-143, Fall 1974.<br />—Part VIII. "Stasis and Stress," BPR 10-23:202-210, Spring 1975.<br />—(See also later progress reports on applying the same concepts under title "Stump Stress Analysis" in BPR 10-24:217-218; BPR 10-25:182-183-inadequate service life despite previous fatigue tests-; BPR 10-26:275-285-fatigue tests of various composites; problems of porosity.)</li> <li>Wilson, A. Bennett, Pritham, Charles, and Stills, Melvin, <i>Manual For An Ultralight Below-Knee Prosthesis</i>, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, and Drexel University, Philadelphia, Second Edition, 1979.</li> <li>Lehneis, H.R., Chu, Don Sung, and Adelglass, Howard, "Flexible Prosthetic Socket Techniques," <i>Clinical Prosthetics and Orthotics</i>, 8:1, 6-8, Winter 1983-84.</li> <li><a href="http://www.oandplibrary.org/al/1961_01_076.asp">Radcliffe, Charles W., "The Biomechanics of the Syme Prostheses," <i>Artificial Limbs</i>, 6:1, 76-85, April, 1961; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1962_02_016.asp">Radcliffe, Charles W., "The Biomechanics of the Below-Knee Prostheses in Normal, Level, Bipedal Walking," <i>Artificial Limbs</i>, 6:2, 16-24, June, 1962; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_01_035.asp">Radcliffe, Charles W., "Functional Considerations in the Fitting of Above-Knee Prostheses," <i>Artificial Limbs</i>, 2:135-60, Jan. 1955; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1957_02_029.asp">Radcliffe, Charles W., "The Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis," <i>Artificial Limbs</i>, 4:2, 29-38, Autumn 1957; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_02_022.asp">Taylor, Craig L., and Schwarz, Robert J., "The Anatomy and Mechanics of the Human Hand," <i>Artificial Limbs</i>, 2:2, 22-35, May 1955; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_03_004.asp">Taylor, Craig L., "The Biomechanics of Control in Upper-Extremity Prostheses," <i>Artificial Limbs</i> 2:3, 4-25, Sept. 1955; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York 1970.</a></li> <li>Hepp, Oskar, "Haftprothesen," Zeitschrift fuer Orthopaedic und ihre Grenzgebiete, Band 77, 1947-48, 219-279.</li> <li>Page visited the offices of the Committee on Prosthetic Devices, then at Evanston, Illinois, in 1946.</li> <li>ChiIdress, Dudley S., Billock, John N., and Thompson, Robert G., "A Search for Better Limbs: Prosthetics Research at Northwestern University," <i>Bull. Prosthetics Res.</i>, BPR 10-22:200-212, Fall 1974, especially p. 204 on "Self-Contained and Self-Suspended Devices," including atmospheric-pressure suspension. See also Progress Reports, BRP 10- 27:129, Spring 1977, and BPR 10-30, 177-178, Fall 1978.</li> </ol> <div style="width: 400px;"><em><b>*Eugene F. Murphy, Ph.D. </b> Retired, Veteran's Administration-Director, Office of Technology Transfer and Director, Research Center for Prosthetics<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 4 - 10 Year 1984 Volume 8 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sockets, Linings, and Interfaces Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/0833619f5e725925cd800c92714e217a.pdf f8cc7a22aa74728474f8dd18a422e13a https://staging.drfop.org/files/original/93b6e8e78d28f3a4b19219d5d0780629.jpg 04cc15ee28e53828d5d326dd88090b20 https://staging.drfop.org/files/original/345e28e78e61de9956f328db53407a53.jpg cc7d3094bd8e533f530e57c763d89156 https://staging.drfop.org/files/original/912b1afa69cacdf58a67897a83dcb315.jpg 7d3276d165a85f49bcaa170b6d63d8c2 https://staging.drfop.org/files/original/a336421d18e76b67aa3f15362a01a722.jpg 5424cf6316a027878c7cc16d28562dcd https://staging.drfop.org/files/original/ed019ac44a487f5a4d063bc3257f6613.jpg e0c695cdd2bdf121fba9bca5e8ec4b72 https://staging.drfop.org/files/original/6f79e7026b83de4890fedbf81936bf61.jpg 8829aadb1e7bf6c1a2f5b7ef81380d25 https://staging.drfop.org/files/original/f12ba0f6a5db975123a05a0ecc61bf8c.jpg d49c7e19a6ae87c07570043983a8154b https://staging.drfop.org/files/original/8111a6f2f5c9866102adc00d9369ba3a.jpg b550bebd56a8d3d8b5c4622eb2bfb636 https://staging.drfop.org/files/original/6f66c873f335c178a868bb081b408a99.jpg fee6486ffc1b68ab2e75eb9e394bfca2 https://staging.drfop.org/files/original/1e33291187b5f81e97bd34ef54e5ea18.jpg 0b0317c0877ceedfc4841a2f6b45464d https://staging.drfop.org/files/original/6d31a1a5146ef36443a7083f8fe0dce2.jpg 0e19dfad8f02ba4aba2378536fcc1854 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_067.pdf Text Any textual data included in the document <h2>Soft Molded Sandals for Insensitive Foot Care</h2> <h5>William C. Coleman, D.P.M.&nbsp;<a style="text-decoration: none;">*</a><br />Arthur Plaia, M.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In the United States, the most common cause of sensory loss on the foot is diabetes. Fifty to seventy percent of all non-traumatic amputations in this country are performed on diabetics.<a></a> In Atlanta, Georgia, the amputation rate was lower by half after a program of foot inspection, footcare, and shoe-fitting was instituted.</p> <p>A person with loss of sense of touch and pain in the feet should never walk barefoot. A single step on a sharp object or hot surface with bare feet often results in permanent loss of foot function or eventual amputation of the foot.</p> <p>A comprehensive program of medically-prescribed, therapeutic footware should address the patient's need for appropriate shoes at all times. Once the need for prescribed footwear has been identified, there is a period between the time the prescription is written and time when the definitive shoes are dispensed to the patient. During that period, the feet still need protection. A form of protective, temporary footwear, needs to be worn by the patient until those shoes are ready. There are a wide variety of devices used for this purpose around the country. The form of these devices is largely dependent on the available facilities and footwear expertise.</p> <p>A person with a plantar ulcer on an insensitive foot should never walk in shoes or sandals. The most important therapeutic consideration for a person with no sense of pain is to control the mechanical stresses during the healing of these wounds.<a></a> Shoes and sandals do not provide enough control over these forces.</p> <p>After a wound has been covered completely by skin, the healing and repair of the injury is not complete. A person with sensory loss needs very careful monitoring during this period immediately after closure, because they are at very high risk of reulcerating the area.<a></a> Temporary footwear, which provides a high level of protection, should be worn during this time.</p> <p>Usually, unmodified Plastazote®<a style="text-decoration: none;">*</a> shoes or postoperative wooden soled shoes are used as the temporary protection. Once they have served this temporary function, the shoes are discarded and only the definitive shoes are worn from then on. There are many other times, however, when protection of the insensitive foot is needed and custom molded footwear would be the best form of protection.</p> <p>Other times when protective footwear is needed are listed here.</p> <ol> <li> <p>Many people do not want to wear their street shoes around the house until bedtime. Since a person with insensitive feet should never walk barefoot, protective footwear, for use in the house, should be worn. Most commercial house slippers have thin soles which are not intended for walking on rough surfaces and do not provide any significant protection from sharp objects on the floor.</p> </li> <li> <p>Plantar foot deformity is often present when prescribed footwear is a necessity. With bony prominences or loss of plantar fat-pads, a person should never walk or stand barefoot on hard surfaces. This is a problem, particularly when this person showers and they stand on porcelain, concrete, or tile.</p> </li> <li> <p>A person who needs prescribed footwear should always have at least two pairs. Most people, who need them, do not. This is important during periods of time when these shoes are being repaired or the prescription is changed.</p> </li> </ol> <p>Plastazote® was first used for orthopedic purposes by William Tuck, in England, in 1967.<a></a> He notified Dr. Paul Brand in Carville, Louisiana and the first Plastazote® sandals were constructed soon after. Plastazote® provided a material which was easily molded directly on the foot so protective, interim footware could be quickly constructed.</p> <p>Prior to the introduction of Plastazote®, sandals at Carville were constructed of 5/8" thick microcellular rubber. Microcellular rubber is not a moldable material and foot conformity had to be accommodated by constructing microcellular pads and wedges.<a></a> This was imprecise and time consuming.</p> <p>Over the years, several people have contributed modifications to the design and construction techniques of the "Carville" sandal.<a></a> It has become an integral part of the total foot program.</p> <h3>Materials and Equipment Used to Construct the Sandal</h3> <p>The following is a list of the materials used to build the sandal.</p> <p><i>Materials for the Plastazote® Foot Bed</i></p> <ul> <li> <p>2 pieces of 1/2" x 6" X 12" Plastazote® #1 (medium)<a style="text-decoration: none;">*</a></p> </li> <li> <p>2 pieces of 1/2" x 6" x 12" Plastazote® #2 (firm)<a style="text-decoration: none;">*</a></p> </li> <li> <p>2 pieces of 1/4" x 5" x 12" Plastazote® #3 (rigid)<a style="text-decoration: none;">*</a></p> </li> <li> <p>2 pieces of Plastazote® #2, 5" x 10" X 1/2" thick to provide heel lift</p> </li> <li> <p>2 pieces of 1/4" x 3" x 33" Plastazote® #3 for wrapping the sides of the sandals</p> </li> </ul> <p><i>Additional Materials</i></p> <ul> <li> <p>Neoprene crepe soling (12 iron = 1/4") (24 iron = 1/2") (1" x 9") Spring steel cut to the full length of the sandal's length.</p> </li> </ul> <p><i>Webbing for Straps</i></p> <ul> <li> <p>2 pieces of cotton webbing 1" x 9"</p> </li> <li> <p>2 pieces of cotton webbing 1" X 8 1/2"</p> </li> <li> <p>2 pieces of cotton webbing 1 1/2" x 9"</p> </li> <li> <p>2 pieces of cotton webbing 1 1/2" x 8 1/2"</p> </li> <li> <p>2 pieces of cotton webbing 1" x 12"</p> </li> </ul> <p><i>Velcro® to be sewn to webbing</i></p> <ul> <li> <p>2 pieces of 1" x 2 1/2" Velcro® hook</p> </li> <li> <p>2 pieces of 1 1/2" x 2 1/2" Velcro® hook</p> </li> <li> <p>2 pieces of 1" x 2 1/2" Velcro® pile</p> </li> <li> <p>2 pieces of 1 1/2" x 2 1/2" Velcro® pile</p> </li> </ul> <p><i>Glue</i></p> <ul> <li> <p>Contact Cement or other adhesive</p> </li> </ul> <h3>Tools</h3> <ul> <li> <p>Skiving knife</p> </li> <li> <p>Ruler</p> </li> <li> <p>Scissors</p> </li> <li> <p>Polyfoam block (size 8" high x 12" wide x 18" long) cut at approximately 45° from the top to the base at the front of the block.</p> </li> </ul> <h3>Equipment</h3> <ul> <li> <p>Sewing machine or Patcher machine</p> </li> <li> <p>Finishing sander or grinding wheel</p> </li> <li> <p>Oven</p> </li> </ul> <h3>Pieces of the Sandal Prepared in Advance</h3> <p>Most of the materials used in the construction of a sandal are pre-cut and pre-sewn in the shop to speed the construction process.</p> <p>All pieces of Plastazote® are cut from large sheets into the rectangular sizes listed above. The cotton webbing and Velcro® are purchased on large rolls and cut to the sizes above in advance.</p> <p>A 1 1/2" x 2 1/2" patch of hook Velcro® is sewn to one end of a 1 1/2" x 9" piece of webbing. Approximately 1/2" of cotton webbing is left exposed on the very end so the end can be grasped by the patient to release the strap. A 1 1/2" x 2 1/2" piece of pile Velcro® is sewn to the end of a 1 1/2" x 8 1/2" piece of webbing. This procedure is repeated on the 1" x 8 1/2" and 1" x 9" pieces of cotton webbing.</p> <p>The oven should be preheated to a temperature of 140° Celsius (285° Fahrenheit). This is the temperature at which all polyethylene materials should be heated.</p> <p>Plastazote® is a closed-cell polyethylene foam material. If polyethylene foam materials are overheated, the cell structure is weakened and the material shrinks in all directions. To determine the amount of time a polyethylene foam should be heated, measure the thickness of the material in millimeters and multiply the thickness by twelve (10 mm x 12 = 120 seconds). The answer will be the time of heating in seconds.</p> <p>To mold the Plastazote® directly on the foot, the heated Plastazote® is placed between the foot and a thick foam rubber block. The foot is pressed into the foam and Plastazote®. The foam presses the polyethylene foam up around the sides of the foot and into every plantar hollow and the material cools and remains in this shape.</p> <p>The top/front of the foam a block is cut at a 45° angle to prevent obtaining a deep mold of the toes (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg"><b>Fig. 1</b>)</a>. A deep mold would create a ridge distal to the ends of the toes. During gait, the medial foot enlongates with pronation. This elongation could result in distal toe damage on an insensitive foot if this ridge were present.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg">Figure 1. The open-celled foam block used to mold the Plastazote® footbed is cut on the top/ front to prevent deep-molding the toes into the Plastazote®.</a><br /></strong><br /> <h3>Construction of the Sandal</h3> <p>Patients are seated in an adjustable chair to insure the knee and ankle can be maintained at right angles as the Plastazote® is molded to their foot. Patients with insensitive feet are asked to wear socks for heat insulation from the warm polyethylene foam.</p> <p>To begin the sandal, a piece of 6" x 12" x 1/2" thick, medium, Plastazote® #1 is heated according to the above formula. After the Plastazote® has been heated, it is placed on the foam block with the toe region hanging over the 45° cut of the foam block. The foot is aligned over the Plastazote® with the metatarsal heads positioned over the top edge of the cutoff section of the foam block. The patient's foot is then pressed into the Plastazote®.</p> <p>After the Plastazote® foot bed has cooled, but before the patient is asked to lift their foot, an outline is drawn to mark a reference for what will become the outer sides of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg"><b>Fig. 2</b></a>). Hold the pen marking this line in a vertical position. Purposely draw the toe area distal to the foot further distal to the toes than needed. Mark the toe of the sandal about 1" distal than the toes of the foot. Material used to wrap the sides of the sandal will pull the distal end of the sandal back.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg"><strong>Figure 2. As the first Plastazote® layer is cooling, a line is drawn to mark the outer edge of the sandal.</strong></a><br /> <p>Cut the molded piece of Plastazote® around the outside of the molded portion to remove excess material. Make this cut approximately 1/2" outside the drawn line. This will allow for better control of shaping the sandal during a later grinding process.</p> <p>Apply adhesive to the bottom (convex side) of the molded material and to one side of a 6" x 12" x 1/2" firm, #2 Plastazote® piece. Then heat the #2 Plastazote®. Set the heated #2 piece on the foam block and the molded #1 Plastazote® piece on top of it (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg"><b>Fig. 3</b></a>). Place the foot back into the molded #1 piece and then press down to mold the #2 Plastazote® piece to the bottom of the #1 piece. Plastazote® #1 and #2 are autoadhesive, but this characteristic of the material has not proven to form a dependable bond in these sandals.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg"><strong>Figure 3. The molded #1 Plastazote® is set on the glued surface of the heated #2 prior to molding the two together.</strong></a><br /> <p>Then cut the #2 piece to the edge of the # 1 piece and ground both pieces vertically to meet the line drawn earlier. At this time, ground flat some of the roundness on the plantar surface of the molded #2 piece and flatten by grinding the area under the metatarsal heads and toes.</p> <p>Use the 1 1/2" wide webbing to build the strap which will cross over the midfoot region just in front of the ankle. Use the 1" webbing for the strap which will cross over the top of the metatarsals just proximal to the metatarsal heads. Also use 1" strapping behind the heel.</p> <p>Place the patient's foot in the foot bed and "velcro" the straps together and hold them in place over the foot. Align the straps over the foot and mark the Plastazote® and straps (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg"><b>Fig. 4</b></a>). Glue together the Plastazote® footbed and straps, using the marks as a reference. Cut the straps under the sandal so they don't overlap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg"><strong>Figure 4. The cotton-webbing straps are held in place while the sandal and straps are marked for later gluing.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg"><strong>Figure 5. The straps are cut so they do not overlap under the footbed.</strong></a><br /> <p>Coat with glue the 5" x 10" x 1/2" scrap piece of #2 Plastazote® and the bottom of the molded footbed and heat the #2 piece. Glue the #2 piece under the heel arch and metatarsal heads. Ground down the bottom to form a 1/2" high wedge heel which tapers down to the metatarsal heads (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg"><b>Fig. 6</b></a>). This heel lift also serves to fill any remaining arch and curvature under the sides of the molded footbed.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg"><strong>Figure 6. The bottom of the sandal is ground flat under heel, arch, and metatarsal heads after the heel wedge is glued on. The area under the toe is ground up to form the rocker.</strong></a><br /> <p>The sole of these sandals should be absolutely rigid. On smaller patients the rigid Plastazote®, which will be added later, will be sufficient to accomplish this. But in larger, heavier patients, it may be necessary to include a rigid steel shank from the heel to the toe. For those patients, glue a piece of leather to the bottom of the footbed to prevent penetration of the steel through the footbed. Bend up the steel from the metatarsal heads to the end of the toe of the sandal in the form of a rocker. Glue the steel shank to the bottom of the leather, and shape and grind flat a filler material around the shank so bumps will not form in the outer sole of the sandal.</p> <p>If the steel shank is not used, coat with glue a piece of 5" x 12" x 1/4" rigid #3 Plastazote® and the bottom of the footbed. Heat the #3 piece and then attach it to the bottom of the footbed. This is done by adhering the heel of the sandal to the #3 piece first and then, in a rolling motion, elevate the heel of the sandal as the toe is pressed down onto the material piece<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg"> (<b>Fig. 7</b></a>). This creates a rocker sole with increased toe spring under the toes.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg"><strong>Figure 7. The heel of the sandal is lifted before the front of the heated #3 Plastazote® is glued to the footbed to help form the rocker sole.</strong></a><br /> <p>Skive back one end of a piece of rigid Plastazote® 3" wide by 33" long and 1/4" thick to a distance of 2" and at a shallow angle. Then apply glue over the 2" skived portion and the entire other side of the rigid Plastazote® piece. Coat the sides of the footbed with glue. Heat the rigid Plastazote® and glue it vertically around the perimeter of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg"><b>Fig. 8</b></a>). Glue the skived end to the medial arch area of the footbed first. This leaves the glue coated skived area facing out from the sandal. Completely wrap the #3 strip around it, overlapping onto the skived area, and cut off the excess. Trim the bottom flat and round the upper edge level with the top of the footbed by grinding. Then glue neoprene crepe soling to the bottom.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg"><strong>Figure 8. The sandal is made more rigid by gluing 1/4" #3 Plastazote® vertically around the footbed.</strong></a><br /> <p>Place the patient's foot into the sandal to fit a heel strap. The strap is 1" cotton webbing. Mark the location of the strap. Remove the sandal and sew the strap into place (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg"><b>Fig. 9</b></a>). Rivets can also be used to attach the strap.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg"><strong>Figure 9. The completed sandal with neoprene crepe soling and heel strap attached.</strong></a><br /> <p>For shortened feet, use only a single vertical, instep strap of 1 1/2" to 2" width and attach the heel strap to this single strap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg"><b>Fig. 10</b></a>). For more long-term use, construct the straps and sides of leather (<b>Fig. 11</b>). If the patient's skin is thin and atrophied, softer materials such as beta-pile can be used as straps.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg"><strong>Figure 10. For shortened feet a single, broad strap can be used across the instep.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.jpg">Figure 11. Leather can be used for sandals intended for long-term or outdoor wear.</a><br /></strong><br /> <h3>Considerations for Insensitive Feet</h3> <p>In a series of 41 diabetic patients with sensory neuropathy in their feet, when measured with pedobarograph, 51% had abnormally high pressure under their metatarsal heads.<a></a> This is compared to only 7% of non-diabetic patients displaying higher pressures. The skin under the metatarsal heads has been shown in many studies to be the most frequently ulcerated part of the insensitive foot.<a></a> The forefoot region of insensitive feet needs a higher level of protection than the rest of the foot. This can be accomplished in the Plastazote® sandal by making the sole rigid and creating a rocker effect in the sole design.<a></a> A rigid sole minimizes shear between the sandal and skin. It also eliminates flexion and extension at the metatarsal-phalangeal joints.<a></a> If the toes of the foot are rigid, a flexible soled shoe will press up into the toes during gait.</p> <p>Rocker soles have been shown to greatly reduce foot pressure during gait. The point on the sole where rocking begins should always be posterior to the metatarsal heads, but ideally would be placed near the middle of the sandal. These rocker styles of sole are also helpful in the rehabilitation of patients with fused ankles.<a></a></p> <h3>Conclusion</h3> <p>For 20 years at the Gillis W. Long Hansen's Disease Center in Carville, Louisiana, Plastazote® sandals have proven to be an effective form of interim footwear for insensitive patients. The technique is simple and highly adaptable to many types of foot therapy.</p> <p><b>References:</b></p> <ol> <li>"A Report of the National Diabetes Advisory Board," <i>NIH Publication No. 81-2284</i>, Bethesda, Maryland, November, 1980. p. 25.</li> <li>Boulton, A.J.M., M.D., C.A. Hardisty, M.D., R.P. Betts, Ph.D., C.I. Franks, Ph.D., R.C. Worth, MD., J.D. Ward, M.D., and T. Duckworth, M.D., "Dynamic Foot Pressure and Other Studies as Diagnostic and Management Aids in Diabetic Neuropathy," <i>Diabetes Care</i>, 6, June, 1983, pp. 26-33.</li> <li>Duckworth, T., M.D., A.J. Boulton, M.D., R.P. Betts, Ph.D.. C.I. Franks, M.D. and J.E. Ward, M.D., "Plantar Pressure Measurements and the Prevention of Ucleration; in the Diabetic Foot," <i>The Journal of Bone and Joint Surgery</i>, 67, January, 1985, pp. 79-85.</li> <li>Karat, S., M.D., "The Role of Microcellular Rubber in the Preservation of Anaesthetic Feet in Leprosy," <i>Leprosy Review</i>, 40, July, 1969, pp. 165-170.</li> <li>Milgram, JE., M.D., "Office Measures for Relief of the Painful Foot," <i>Journal of Bone and Joint Surgery</i>, 46, July, 1964, pp. 1095-1116.</li> <li>Pati, L., M.D. and F. Behera, M.D., "Metatarsal Head Pressure (M.H.P.) Sores in Leprosy Patients," <i>Leprosy in India</i>. 53, October, 1981. pp. 588-593.</li> <li>Price, E.W., M.D., "Studies on Plantar Ulceration In Leprosy VI, The Management of Plantar Ulcers," <i>Leprosy Review</i>, 31:3, July, 1960, pp. 159-171.</li> <li>Reed, J.K., RPT, "Plastazote® Insoles, Sandals, and Shoes for Insensitive Feet," <i>Surgical Rehabilitation in Leprosy</i>, Editors F. McDowell and CD. Enna, Williams and Wilkins, 1974, pp. 323-329.</li> <li>Ross, W.F., M.D., "Footwear and the Prevention of Ulcers in Leprosy," <i>Leprosy Review</i>, 33, February, 1962, pp. 202-206.</li> <li>"Selected Statistics on Health and Medical Care of Diabetics," The National Diabetes Data Group, 1980, pp. A-3.</li> <li>Tuck, W.H., C.P.O., "The Use of Plastazote® to Accommodate Deformities in Hansen's Disease," <i>Leprosy Review</i>, 40, July, 1969, pp. 171-173.</li> </ol> <p><em><b>*Footnote</b> The numerical identifications of the different densities of Plastazote® correspond with the designations assigned for these densities by Alimed Inc., 297 High Street, Dedham, Massachusetts 02026.</em></p> <p><em><b>*Footnote</b> Plastazote® is a trademark of BXL Plastics Limited, 675 Mitcham Road, Croydon CR9 3AL England.</em></p> <p><em><b>*Arthur Plaia, M.A. </b> Arthur Plaia, M.S., is Chief of the Orthotic Department, Gillis W. Long Hansen's Disease Center.</em></p> <p><em><b>*William C. Coleman, D.P.M. </b> William C. Coleman, D.P.M., is Chief of the Podiatry Department at the Gillis W. Long Hansen's Disease Center, Carville, Louisiana 70721.<br /><br /><br /></em></p> <div style="width: 400px;"></div> Page Number(s) 67 - 73 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Soft Molded Sandals for Insensitive Foot Care Creator An entity primarily responsible for making the resource William C. Coleman, D.P.M. * Arthur Plaia, M.A. * https://staging.drfop.org/files/original/2a26fa46a936952d7346630a4fddeb3b.pdf 9bf1d7ad81311e350ca58227aa8ef3e4 https://staging.drfop.org/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg 12316de41cb85404fa07f030884d0bbd https://staging.drfop.org/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg 5c959a25cd8c901d6983309deb9ae306 https://staging.drfop.org/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg aa82aa97958a91904276e94a5b918415 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_005.pdf Text Any textual data included in the document <h2>Some Comments on Cervical Orthoses</h2> <h5>Augustus A. White, III, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>The following was received past the deadline for the Spring C.P.O., for which it was intended. Because of the interest in the subject it addresses, we are printing these comments here. Anyone wishing to respond to the points the author raises may do so through letters to the editor. Our thanks to Dr. White for submitting his editorial.</i></p> <p style="margin-left: 10%;"><i>The Editor</i></p> <h3>Introduction</h3> <p>A classic history on the development of orthopaedic appliances, including some interesting material on cervical orthoses, has been written by J. W. Edwards (1952). A reading of this work quickly illustrates that many orthotic devices bear a striking resemblance to components of medieval armor. Particularly prominent in cervical orthotics is the work of Hugh Owen Thomas. This ingenious, chain-smoking, nineteenth century inventor developed a number of useful orthopaedic appliances, and is credited with the basic design of the cervical brace used today and known as the Thomas cervical collar.</p> <h3>Functions of Cervical Orthoses</h3> <p>Any cervical orthosis is really a device designed to apply forces to the cervical spine in order to control it in some way. The goal of that control is usually support, rest, immobilization, protection, or correction. The application of the forces restrains the normal or abnormal patterns of movement or alignment of the cervical spine. When the goal is to rest the spine, the device must assist or substitute for stabilizing muscle action. For example, a cervical collar may be used to prevent extension into a range that is painful or irritating to the patient. In another instance, the purpose of the orthosis may be to protect the vital spinal cord or nerve roots. This would be required when the spine has been rendered unstable by tumor, disease, surgery, or injury. A cervical orthosis can also function simply as a reminder and psychological "support." When the patient moves, he or she is made aware of the brace and therefore voluntarily restricts motion. In addition, the orthosis may provide warmth and physical support that is reassuring to the patient.</p> <p>After the physician makes a diagnosis, and elects to treat a particular problem with a cervical orthosis, it is helpful to identify the specific mechanical functions that are to be achieved with the orthosis (see <b>Table I</b>). Is the goal to support (rest), immobilize (protect), or correct the spine? It is helpful for the clinician to go through the process of determining which of various motions of the spine must be controlled. Is it flexion, extension, lateral bending, axial rotation, or some combination of these? By thinking through these questions, a more rational and precise orthotics selection can be made.</p> <strong>Table I. Systematic Analysis for the Selection of Orthoses</strong> <h3><img src="/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg" h3="" width="418" height="327" />Orthotics Evaluation Studies</h3> <p>Before discussing examples of cervical orthotics, it is helpful to review briefly the experimental work upon which we base our clinical recommendations. <i>In-vivo</i> cineradiography studies by Hartman and colleagues evaluated the effectiveness of immobilization of various orthotic devices on the cervical spine (Hartman et al. 1975). These studies compared five different cervical orthoses (Findings are shown in <b>Table II</b>). The investigators concluded that the motion that was most difficult to restrain was that between the occiput and C2.</p> <strong>Table II. Effectiveness of Cervical Spine Orthoses in Immobilization*<br /></strong><br /><img src="/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg" p="" width="568" height="192" /><br />An evaluation of cervical braces by Johnson and colleagues placed normal subjects in different orthotic devices Johnson et al. 1977). Photographs and radiographs were used to determine differences in range of motion with and without the subjects wearing various orthoses (Findings are shown in <b>Table III</b>). It was found that by increasing the vertical length and the rigidity of a given cervical orthoses, there is improvement in its ability to control motion. In general, it was found that controlling lateral bending and axial rotation is more difficult than controlling flexion/extension. The most effective conventional braces are able to restrict C1-C2 flexion extension by only 45% or normal. The halo apparatus restricts the motion by 75%. <br /><br /><strong>Table III. Efficiency of Cervical Braces in Immobilization*</strong><br /><img src="/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg" p="" width="422" height="254" /><br />In summarizing this experimental data, the following generalizations are valid. The soft collar does little in the way of immobilizing the cervical spine. The rigidity of the components at the chin and the occiput are the main elements in restricting motion. As one adds shoulder or thoracic fixation to the various conventional cervical collars, the immobilizing capacity of the orthosis is increased. When the added chest support is actually fixed to the thorax, the immobilizing efficiency is further improved.<br /><br /> <h3>Clinical Review of Some Specific Cervical Orthoses</h3> <p>To follow is a review of the major types of cervical orthoses. They are categorized on the basis of <i>effectiveness of control</i>. Thus, we have divided cervical orthotics into minimum, intermediate, and most effective control (<b>Table III</b>).</p> <p><b>Minimum Control</b>: The basic Thomas collar and numerous variations of it are examples of minimum control orthoses. These collars vary in height, contour and rigidity. They may be worn either forwards or backwards to increase or decrease the amount of flexion/extension possible. Generally, they are to be worn so that the chin rest, which is a convexity in the collar that points downwards, is anterior. However, some patients find it more comfortable to reverse this position, and certainly in cases where one is more interested in restricting extension than flexion, a reversal of this position will block extension more effectively. In other words, if a high portion of the collar is worn posteriorly there is relatively less extension. Although these collars probably do little or nothing in the way of immobilizing the spine, they do provide warmth as well as psychological comfort and support. They can be helpful to the patient in the treatment of a broad variety of conditions including some whiplash injuries, minor sprains and strains, cervical spondylosis, and some stable postoperative surgical constructs.</p> <p><b>Intermediate Control</b>: There are a number of orthotics that are appropriately classified in this group. The Philadelphia collar is a beefed-up version of a Thomas collar. It is more rigid, has an anterior and a posterior plastic reinforcement, a rigid chin support, and a significantly developed extension block posteriorly to support and restrict the occiput.</p> <p>In order to achieve a greater level of immobilization, some extension of the orthosis down into the shoulder and/or thorax is required. This lengthening of the orthosis provides a more effective anchoring, purchase, and immobilization. There are several braces that fit into this category, most notably the four-poster brace, the Duke brace, the Guilford brace, and the SOMI brace. The SOMI is the most effective immobilizer in this group. These orthoses are probably more effective in the standing and sitting positions. In the supine, prone, or side lying positions, relaxation and rotation of the shoulders and thorax minimize the effectiveness of these orthoses.</p> <p>We should also note that if we wish to prevent anterior displacement of C1 or C2 in a rheumatoid patient we cannot rely upon a soft cervical collar, a Philadelphia collar, a four-poster brace, or even a SOMI brace (Altoff and Goldie 1980).</p> <p><b>Most Effective Control</b>: If there is a clinical problem involving significant loss of clinical stability, the cervical orthosis hould provide the maximum amount of immobilization, unloading of the spine, and protection. Major control is needed in all of the parameters of motion. Depending on the particular clinical situation, it may be more important to control some particular motion or combination of motions.</p> <p>One option in this situation is a significantly more rigid version of the Thomas collar. The Minerva cast incorporates the concepts of extending the brace down towards the thorax and immobilizing the chin and occiput. This cast extends from the forehead down to the pelvis. The goddess Minerva was born by popping from the head of Jupiter, fully armored. From this Roman myth the cast has taken its name. This device, although not used very much currently, can be useful, especially in the protection of irresponsible patients. It should be kept in mind, however, that even with a well-applied Minerva cast, a few degrees of cervical spine motion are possible. Most of the motion occurs at the occiput-C1 region. The cast has to be open enough to allow an adequate range of motion for the mouth so that the patient can talk and chew. This same range of motion allows for motion at the occiput-C1-C2 joint complex. Thus, when your patients are in a Minerva cast but can talk and chew, you must be aware that they can move C1-C2.</p> <p>In difficult clinical situations, where there is extensive disease or surgery, or an injury has rendered the cervical spine unstable, use of a halo apparatus should be considered. This device is fixed to the skull with pins and is attached either to an individually molded plaster jacket or to a prefabricated jacket which comes in several sizes. Experimental studies generally agree that this device is the most effective immobilizer of the cervical spine. One should be aware that use of this device carries the risk of several complications. These include: penetration of the skull by fixation pins, brain abscesses, abducens, glossopharangeal and facial nerve palsy, and the development of cervical spondylosis. Facial complications can be recognized during the first few days after application by requesting patients to smile, roll their eyes, and stick out their tongue. If the patient is unable to do any of these three activities, careful neurological evaluation is indicated.</p> <h3>Resume</h3> <p>A rational approach to the use of cervical orthotics may be taken by posing several questions. What is the clinical condition of the spine? What are the therapeutic goals to be achieved by the brace? Is the goal to protect the spine, or to rest it? In what way should the mechanics of the spine be changed to achieve that goal? What kinds of forces are necessary in order to achieve these therapeutic aims?</p> <p>In the cervical spine, the standby orthosis for minimal immobilization is the Thomas collar. If one needs a high level of control, then an intermediate zone orthosis, such as the Philadelphia collar or any variety of collars that involve thoracic attachments, can be employed. The SOMI brace is the most effective in this intermediate group. If the therapeutic goal is to obtain maximum control and immobilization of the cervical spine, a halo apparatus with an individually molded plaster jacket is required. One should be aware that this apparatus carries the liability of exposure to complications. These complications can be minimized by diligent care techniques and follow-up evaluation.</p> <p><b>References:</b></p> <ol> <li>Altoff, B. and Goldie, I.F.: Cervical collars in rheumatoid atlauto-axial subluxation. A radiographic comparison. <i>Annals of the Rheumatic Diseases</i> 39: 485, 1980.</li> <li>Edward, J.W.: <i>Orthopaedic Appliances Atlas.</i> Vol. I, Ann Arbor, Michigan, American Academy of Orthopaedic Surgeons, 1952.</li> <li>Hartman, J.T., Palumbo, F., and Hill, B.J.: Cineradiography of the braced normal cervical spine. <i>Clinical Orthopaedics</i> 109: 97, 1975.</li> <li>Johnson, R.M. et al.: Cervical orthoses. A study comparing their effectiveness in restricting the cervical motion in normal subjects. <i>Journal of Bone and Joint Surgery </i>59A: 332, 1977.</li> <li>O'Brien, J.P.: The halo-pelvic apparatus. A clinical, bio-engineering and anatomical study. <i>Acta Orthopaedica Scandinavica</i> 163 (supplement), 1975.</li> <li>Victor, D.I., Bresnan, M.J., and Keller, R.B.: Brain abscess complicating the use of halo traction. <i>Journal of Bone and Joint Surgery</i> 55A: 635, 1973.</li> <li>White, A.A. and Panjabi, M.M.: <i>Clinical Biomechanics of the Spine</i>, Philadelphia, J.B. Lippin-cott, 1978.</li> </ol> <em><b>*Augustus A. White, III, M.D. </b> The Department of Orthopaedic Surgery Beth Israel Hospital and Harvard Medical School, and the Charles A. Dana Research Institute, Beth Israel Hospital, Boston, Massachusetts</em><br /><br /><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 7 Year 1983 Volume 7 Issue 3 Figure 2 TABLE II http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 TABLE III http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-3.jpg Figure 1 TABLE I http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Comments on Cervical Orthoses Creator An entity primarily responsible for making the resource Augustus A. White, III, M.D. * https://staging.drfop.org/files/original/3dc12ac74d007b30cd9ac2192ac0215c.pdf 5d7beccc83e107ade0d0749486469958 https://staging.drfop.org/files/original/a0a401a9b25d17513105126cb0e22659.jpg 0fcc33c1d8a6f3816a522919abb35777 https://staging.drfop.org/files/original/44c99f5d58723ecaa4e79eaf87cf3981.jpg 892fb6ec39817908bb4edc85e61acf13 https://staging.drfop.org/files/original/3ef2a0fe19537ad158c472f2949df71b.jpg 55a4929f1a78ab78e33373d5ea6ce3f9 https://staging.drfop.org/files/original/3612577ff647fd7ecd02f0df52948026.jpg 08f3fa9b0f6f0385168f6e324ceda5a0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_028.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 28 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Considerations in Management of the Above-Knee Geriatric Amputee</h2> <h5>Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Augusto Sarmiento. M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The gradual increase in the life span of people in the developed countries of the world has resulted in a tremendous increase in the number of amputees in the older age, or "geriatric," group. A survey by Glattly in 1962 <a></a> showed that approximately 52 per cent of all amputees fitted with prostheses for the first time were over 50 years of age. Of these patients, 82 per cent had had amputations as a result of disease, 2 per cent because of tumor, and 16 per cent because of trauma. Most of these, of course, were lower-extremity cases.</p> <p>As short a time as 10 years ago, only a relatively few geriatric amputees were provided with limbs, and not much attention was given to the special problems of older patients. However, it has now been demonstrated that, with expert care, older amputees can be fitted with functional prostheses and that the results obtained are well worth the extra efforts required. The below-knee case obviously presents fewer problems as a rule than does the above-knee case, but though surgeons are now saving more and more knee joints there will always be a certain number of above-knee cases that require attention.</p> <p>Just as in the case of younger amputees, geriatric patients should be fitted as soon as possible. The longer the patient goes without a prosthesis, the greater the possibility for the development of contractures, edema, and other undesirable conditions. If the patient is not provided with a prosthesis immediately after the amputation, he should be fitted with a preparatory prosthesis as soon as he is seen by the clinic team.</p> <p>When treating the geriatric amputee, the clinic team must keep in mind constantly that the patient's potential is far from that of an otherwise healthy person, and certain compromises must be made if optimum results are to be achieved. The primary factors to be considered are condition of the skin, muscle tone and strength, coordination and balance, and energy potential.</p> <h3>Anatomical and Physiological Factors</h3> <p>Skin loses its turgor and becomes more fragile as age increases, and although it does not necessarily become more sensitive to the touch it does become more subject to abrasion and breakdown. This is true especially for the below-knee amputee but also demands special consideration when fitting and training the above-knee patient, and every effort is made to limit relative motion and pressure between the socket and stump.</p> <p>The older a person becomes the more likely he is to collect a fair number of scars, some of which may become supersensitive. The patient who has had an amputation secondary to vascular occlusion may well have scars present in the femoral triangle or abdominal scars from previous sympathectomies (<b>Fig. 1</b>). Particular care must be given to socket fit and suspension in order to avoid undue pressure and abrasion of these scarred areas. The presence of abdominal or inguinal hernias must likewise be taken into consideration and appropriate relief given if necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sensitive scars in the inguinal area secondary to vascular reconstruction may require modifications in the quadrilateral socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Subcutaneous atrophy occurs in the elderly patient and may present difficulties with socket fitting. The loss of fatty tissue padding often gives rise to complaints of extreme discomfort in areas subjected to high pressure, such as the ischial tuberosity and the laterodistal end of the femur. It may also complicate socket fitting, because flabby tissues tend to roll and therefore provide less stability. Muscles also tend to atrophy with age and, in addition to becoming weaker, have correspondingly less tone and less bulk, as any surgeon knows who has operated through the muscles of an elderly patient. Loss of muscle tone and bulk further decreases the soft tissue padding over bony prominences and may contribute to socket discomfort. Loss of definition of muscle groups leads to loss of stump contour and hence less stability between socket and stump. The decrease in muscular strength which accompanies atrophy results in less strength for actuating the prosthesis; hence, the weight of the artificial limb becomes an extremely important factor.</p> <p>Coordination and balance definitely are affected by the process of aging and rapidly become impaired when any degree of cerebral arteriosclerosis is present. Studies have shown that vestibular function decreases steadily after 50 years of age and, in addition, there is a general slowing of reflex motor action to proprioceptive stimuli which is irreversible. <a></a> The prosthesis, therefore, must be modified frequently to provide increased stability.</p> <p>The energy expenditure in the elderly above-knee amputee has been studied only recently, and is highly significant in the management of this class of patient. Miiller and Hettinger showed that energy expenditure was 25 per cent greater in above-knee amputees than in normal people. <a></a> Bard and Ralston gave a figure of 20 per cent greater energy expenditure in the above-knee amputee over the normal person. <a></a> Later, Ralston studied 17 above-knee amputees, all over 50 years of age, and found that the average energy expenditure was 55 per cent greater than for a normal elderly person. <a></a> He further demonstrated that a normal subject walking at a comfortable speed consumed 580 cc. of oxygen per min., whereas the same subject at maximum walking speed consumed 715 cc. of oxygen per min. This figure coincided almost exactly with the figure of 700 cc. of oxygen per min. consumed by above-knee amputees walking at a slow speed. The average pulse rate in these elderly amputees walking at slow speed was 110 per min. From these studies it is obvious that energy expenditure is greatly increased when an elderly person must use an artificial limb instead of his own.</p> <p>The use of crutches without a prosthesis has been used in the past as a criterion for prescribing prostheses for the elderly. However, this not only demands more energy from the patient than the prosthesis itself, but also demands more balance and coordination, and therefore the use of this criterion has been discontinued. Many patients who are not able to use crutches without a prosthesis can achieve some functional activity with a prosthesis. Use of a temporary, or preparatory, prosthesis (<b>Fig. 2</b>) offers the best index to future function. <a></a> This is to be distinguished from a pylon, which has no articulated knee joint and no prosthetic foot. The temporary, or preparatory, prosthesis has a completely formed, quadrilateral, total-contact socket on an adjustable knee with a positive knee lock, an aluminum shank, and an articulated SACH (solid-ankle, cushion-heel) foot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical temporary above-knee prosthesis for determining the feasibility of a permanent prosthesis for the elderly amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Design</h3> <p>Hall has reviewed the principles which led to the development of the quadrilateral socket as we know it today: <a></a></p> <ol> <li>Actively functioning muscles should have relief.</li><li>Stabilization forces should be applied where no functioning muscles exist.</li><li>Functioning muscles should be placed at slightly greater than rest length for maximum power.</li><li>Properly applied pressure is well tolerated by neurovascular structures.</li><li>Force is best tolerated if it is distributed over the largest available area.</li></ol> <p>For these reasons, the quadrilateral socket is relieved anterolaterally for the functioning rectus muscles and postero-laterally for the functioning gluteus maxi-mus muscle; it is flattened along the lateral wall to provide the greatest surface area for the forces of abduction and along the posterior wall to provide a similar large area for the forces of extension, and is molded snugly into Scarpa's triangle to keep the ischial tuberosity displaced posteriorly on the ischial seat.</p> <p>Although it may seem like fitting a round peg into a square hole, the quadrilateral socket has provided the most satisfactory union between stump and prosthesis ever achieved for the above-knee amputee, because its shape permits proper function of the muscles which move the stump. At the same time, the forces generated by this muscular activity are distributed over relatively large areas.</p> <p>This is in contradistinction to the "plug-fit" socket which was used formerly and which did not take properly into consideration muscle action and the forces generated. The plug-fit socket, seemingly more compatible because it provides a round hole for a round peg, allows the ischium to slide inside the socket brim and the weight to be borne chiefly on the gluteal muscle mass and adductor region. Because the weight is borne chiefly by the soft tissues and because the socket is of a conical shape, there is a wedging effect of the stump in the socket and the distal tissues are pulled tightly over the end of the femur, frequently causing pain or stump breakdown. Stability about the long axis is poor because of its round cross section. In addition, the forces of abduction are distributed over relatively small areas as the femur is pushed out against the lateral wall.</p> <p>The use of the plug-fit socket has been largely abandoned today, but some of its features are useful at times for the geriatric amputee, particularly when pressure is to be avoided over Scarpa's triangle because of a femoral bypass graft or because of inadequate circulation. In some geriatric patients there is justification for modifying the quadrilateral shape in the direction of a rounded or plug-fit shape, retaining, however, certain characteristics of the quadrilateral socket.</p> <p>The quadrilateral socket is not made to a rigid pattern but is modified from a typical pattern in various ways to accommodate individual stumps. If the rectus femoris is unusually large, it may be accommodated by further relief. The same is true for the hamstring and gluteal groups. If the gluteal muscles are underdeveloped or atrophied, less relief can be given. In the elderly, because of tissue atrophy, ischial weight bearing is often uncomfortable and the posterior wall may be modified to distribute the load over the gluteal group. If it is necessary to have the Scarpa's-triangle area free from pressure, this can be accomplished by relief in this area, allowing the ischium to slide into the socket over a properly contoured posterior brim.</p> <p>We must also reconcile ourselves to the fact that, as much as we delight in rehabilitating the geriatric amputee to an ambulatory status, he will, nevertheless, spend much of his time sitting, and certain socket modifications must be made to provide comfort during prolonged periods of sitting. The thickness of the posterior wall may be decreased so that pressure neuropathy of the sciatic nerve does not develop, and the anterior brim may be lowered so that excessive pressure does not develop in the region of the femoral neurovascular bundle or the anterior superior iliac spine.</p> <p>There appear to be no contraindications to the fitting of total-contact sockets to the elderly above-knee amputee. With total contact, not only are the tissues supported evenly and edema and skin breakdown prevented, but a greater proprioceptive and kinesthetic sense is developed, a condition of even more importance to the geriatric amputee than it is to his younger counterpart. Total contact, however, is not as important with pelvic suspension as it is with suction suspension, and it is difficult to maintain, particularly when stump socks are used.</p> <h3>Suspension</h3> <p>There is uniform agreement that suction provides the best suspension available. Suction suspension, however, has a limited use in the geriatric amputee because of the exertion required in donning the prosthesis and the fact that many elderly patients have a limited ability to bend forward.</p> <p>The pelvic band is in wide use, but it has disadvantages. It is apt to create excessive pressure about the lower abdomen when the patient is sitting. It must be well padded to prevent the development of excessive pressure over the iliac crest and over any scarred areas on the abdomen. The location at the hip joint is critical.</p> <p>The preferred method of suspension in the elderly above-knee amputee is the Silesian bandage or one of its modifications. When used with the quadrilateral total-contact socket, it provides comfortable suspension and gives good stability. It may be modified to include a shoulder strap, or may be modified further to incorporate an elastic webbing band from the posterior portion of the belt to the posterior wall of the socket to act as a hip-extensor aid. <a></a></p> <p>The inability of most elderly above-knee amputees to don a suction socket properly has led to the development of a split-socket type of appliance at the University of Miami Prosthetic Laboratory (<b>Fig. 3</b>). In this type of prosthesis the intimate fit of the suction-type socket is obtained, yet it is donned easily by the geriatric amputee. [A complete description of the split-socket type of appliance will be published in the Spring 1969 issue of <i>Artificial Limbs.</i>-Ed.]</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The double-wall above-knee suction socket with anterior opening developed by the University of Miami Prosthetic Laboratory for easy application in the older amputee. The flexible inner socket is jointed to the outer by a lateral Velcro strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Alignment</h3> <p>The above-knee socket, in general, is adducted at least 5-10 deg. to restore the normal position of the femur and place the abductor muscles at their optimum functional length. Adduction of the socket also has the effect of narrowing the base of gait, an important factor in energy conservation. <a></a> If the abductor muscles are not placed in their optimum position of function, if the socket is abducted too far, or if the prosthetic foot is located too far laterally, the center of gravity of the body must shift over the supporting leg in order to gain sufficient stability during walking. Conversely, if the adduction of the socket is sufficient to hold the femur in a normal position of adduction and to keep the abductor muscles at their optimum length, these muscles will act to stabilize the pelvis with a minimum amount of contraction while dissipating the force of stabilization by femoral pressure against the lateral wall of the socket. This ideal cannot always be achieved in the elderly patient and the socket sometimes has to be aligned in the neutral or slightly abducted position in order to gain the required stability, at the expense of increased energy consumption.</p> <p>Aligning the socket in some degree of flexion increases the power of hip extension and voluntary knee stability. In general, the above-knee socket should be aligned in some degree of flexion, usually by 5 deg. in excess of the maximum amount of hip extension that can be obtained by the amputee while standing on his good leg without producing excessive lordosis. The amount of flexion will vary from 5 to 35 deg., depending on the length of the stump and the amount of hip-flexion contracture present. Alignment of the socket in flexion is limited by the length of the stump, and in the longer stump is minimal. As socket flexion is increased, the knee bolt must be moved somewhat more posteriorly in order to retain the same alignment stability at the knee. <a></a></p> <p>Although adduction of the socket is quite efficient because there is very little excursion of the femur outward toward the lateral wall of the socket in walking, flexion is not nearly so efficient because the large posterior muscle mass allows considerable backward shift of the femur in the soft tissues prior to its exerting significant pressure on the posterior wall. This has been documented by the senior author in a cineradiography movie of above-knee stumps in sockets (<b>Fig. 4</b>). Because of this backward excursion of the femur in the soft tissues as the thigh is extended, it is felt that the femur should be set in the maximum amount of flexion consistent with cosmesis to give greater voluntary control of extension to the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Frames from a cineradiography film of an above-knee stump in the socket. <i>Left, </i>The femur displaces posteriorly in the soft tissues a considerable distance before effective force can be transmitted to the posterior socket wall to stabilize the knee. <i>Right, </i>The limb is at heel strike prior to hip-extensor thrust. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the elderly patient with less voluntary control and deficiencies of balance and coordination, even a long stump may require the alignment characteristics of the medium or short stump.</p> <h3>Stability of the Knee Joint</h3> <p>Knee stability is usually achieved by a combination of voluntary control by the hip extensors and alignment of the knee axis so that it is posterior to the weight-bearing line (so-called alignment stability), or by a lock or brake. Voluntary control of knee extension is usually diminished in the geriatric amputee because of muscular weakness and poor coordination, and often an increased amount of alignment stability is necessary. This alignment stability, in combination with a single-axis constant-friction knee, the most standard type, is generally sufficient. However, there may be instances in which additional stability during weight bearing is necessary, and this can be provided by the use of a unit, such as the Bock Safety Knee, which gives a braking action during weight bearing. The chief disadvantage of this type of unit is the added weight of the mechanism.</p> <p>For the elderly amputee with extreme instability and insecurity, such as a bilateral amputee, or one in whom there is a severe flexion contracture, some type of positive knee lock is usually necessary. The knee is locked in extension throughout all phases of gait, producing obvious gait deviation, but as someone once said, "an abnormal gait is better than no gait at all," which would otherwise be the case.</p> <p>Hydraulic knee units can be used successfully by the elderly above-knee amputee, and offer many advantages when the amputee has sufficient muscle power to handle these necessarily heavier limbs. The chief advantage of the hydraulic unit in geriatric patients is that it allows more anterior placement of the knee joint without sacrificing stability, and less energy is consumed in hip flexion to initiate the swing phase of gait. The other primary advantage of the hydraulic knee unit, that of permitting rapid walking by faster and more reliable knee extension, is frequently lost on geriatric amputees as they usually walk with a slow, purposeful gait.</p> <p>Until recently it has been a most difficult task to provide the knee-disarticula-tion and long above-knee stumps with adequate swing-phase control. DuPaCo recently introduced a set up so that the DuPaCo "Hermes" unit can be used with these long stumps.</p> <p>Stability at heel strike is extremely important to prevent buckling of the knee or jack-knifing, which may occur in the elderly above-knee amputee with insufficient hip-extensor power. The less resistance to plantar flexion, the more stability there is at heel contact and shortly thereafter. Locating the foot anteriorly with respect to the knee also increases stability during the period just after heel contact.</p> <p>The SACH foot is generally satisfactory for use by geriatric amputees, although in cases where weight is a real consideration a wooden foot with an aluminum ankle joint can be lighter than the SACH feet available commercially. For the elderly amputee the heel should be relatively soft in order to act as a shock absorber and enhance stability of the knee at heel contact. A single-axis wooden foot in which the softness of the plantar bumper can be varied can give greater stability than even the softest SACH heel available. However, excessive stability results in unnecessary expenditure of energy.</p> <p>The foot must occasionally be outset more than usual to enhance lateral stability in the elderly. This again is another example of obtaining stability at the expense of increased energy consumption, for outset of the foot requires a greater lateral shift of the center of gravity in walking.</p> <h3>Ambulation</h3> <p>While it is desirable to return all elderly above-knee amputees to an ambulatory status, it is often not practicable. Nearly all bilateral above-knee amputees over 50 years of age will find the wheelchair an easier and more practical means of locomotion than the use of prostheses. One must carefully evaluate the patient in terms of strength, endurance, balance, and coordination prior to prescribing a prosthesis. The patient and his family or, more likely, the government will be saved unnecessary expenditure by proper selection of patients for fitting. Often, one must accommodate the patient's own desire to find out for himself whether or not he should be relegated to the wheelchair permanently. In the true geriatric amputee, once ambulation has been achieved it is best to continue the use of some type of external support, depending upon the patient. Usually a cane or single crutch on the opposite side will be sufficient support for the elderly amputee. In some extreme cases a walker may be used, which admittedly makes for poor gait pattern, but this is preferable to no gait at all. The use of external support not only gives increased mechanical stability but also provides the amputee with additional proprioceptive feedback from the terrain on which he is walking, thus leading to better balance. In determining the functional capacity of the bilateral amputee in the older age group, the use of "stubbies" is strongly recommended and the patient should graduate to nonarticulated pylons with increasing height, to a preparatory prosthesis, and, finally, to a permanent prosthesis. Needless to say, the bilateral above-knee patient must always use external support when walking, and a wheelchair should be considered the primary mode of locomotion.</p> <h3>Summary</h3> <p>In order to provide optimum function in the elderly above-knee amputee, one must consider thoroughly certain anatomical and physiological characteristics of the patient which may indicate the necessity for modifications of the standard prosthesis. The characteristics are individual and vary greatly from one elderly amputee to another, but include skin condition, condition of the subcutaneous tissue, muscle strength and tone, coordination, and general factors relating to energy consumption. Modifications based on these factors may then be made in the prosthesis to ensure optimum functional performance. These modifications may include changes in socket shape and alignment, changes in the suspensory apparatus, provisions for increased stability at the knee, and provisions in the ankle to ensure over-all stability. In every instance an attempt should be made to provide the amputee with a minimum prosthetic weight. The future level at which the amputee will function can best be anticipated by the initial use of a temporary, or preparatory, prosthesis.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., John J. Bray, and C. A. Hennessy, <i>Prosthetic principles-above knee amputations</i>, Charles C Thomas, Springfield, El., 1960.</li> <li>Bard, Gregory, and H. J. Ralston, <i>Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40, October 1959.</li> <li>Birren, J. E., <i>Age changes in speed of simple responses and perception and their significance for complex behavior</i>, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</li> <li>Glattly, Harold W., <i>A preliminary report on theamputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Hall, Cameron B., <i>Prosthetic socket shape as related to anatomy in lower extremity amputees</i>, Clin. Orthop., 37:32-46, November-December 1964.</li> <li>Muller, E. A., and T. Hettinger, <i>Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine</i>, Ztschr. f. Orthop., 81: 525, 1952.</li> <li>Radcliffe, Charles W., <i>Functional considerationsin the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputee</i>, Artif. Limbs, 4:1:41-75, Spring 1957.</li> <li>Ralston, H. J., <i>Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</li> <li>Staros, Anthony, <i>The temporary prosthesis for the above-knee amputee</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Functional considerationsin the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, M. H., John J. Bray, and C. A. Hennessy, Prosthetic principles-above knee amputations, Charles C Thomas, Springfield, El., 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>8.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Norman C. Johnson, and James Foort, Some experience with prosthetic problems of above-knee amputee, Artif. Limbs, 4:1:41-75, Spring 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">Hall, Cameron B., Prosthetic socket shape as related to anatomy in lower extremity amputees, Clin. Orthop., 37:32-46, November-December 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>10.</b> </td><td class="clsTextSmall">Staros, Anthony, The temporary prosthesis for the above-knee amputee, in The geriatric amputee, NAS Publication 919, 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>9.</b> </td><td class="clsTextSmall">Ralston, H. J., Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion, in The geriatric amputee, NAS Publication 919, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bard, Gregory, and H. J. Ralston, Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40, October 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>6.</b> </td><td class="clsTextSmall">Muller, E. A., and T. Hettinger, Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine, Ztschr. f. Orthop., 81: 525, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Birren, J. E., Age changes in speed of simple responses and perception and their significance for complex behavior, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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, Harold W., A preliminary report on theamputee census, Artif. Limbs, 7:1:5-10, 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>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento. M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. McCollough, III, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-04.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Considerations in Management of the Above-Knee Geriatric Amputee Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D. * Augusto Sarmiento. M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/d3e07ca0af0348fd4c2e920c106b4c65.pdf 809d9e3993c31bb21b2a8dc9b7031253 https://staging.drfop.org/files/original/222baa00904d46e2a3f74ce88ede3447.jpg c7b121f400393dc467ed647aeacdac4e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_061.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 61 - 63 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_061.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_061.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience in Harnessing Extreme Arm Cases</h2> <h5>Craig L. Taylor, Ph. D. <a style="text-decoration:none;">*</a><br /></h5> <p>With recent developments in shoulder prostheses, including that for complete removal of the shoulder girdle, it is possible to fit all upper-extremity amputees with useful arm substitutes. But of course it does not follow that all patients with high amputations can obtain from the available harnessing resources a uniformly good level of prosthetic function. It is appropriate to review present experience with such cases in order to establish realistic guides for the fitter. Although there is only a limited number of upper-extremity amputees with multiple amputations or with amputations at very high levels, the UCLA Case Study<a></a> has accumulated a sufficient number to make tentative conclusions possible.</p> <p>Limitation in the potentialities of shoulder harness begins with the unilateral shoulder case of the disarticulation type. Unilateral humeral-neck amputees with an intact shoulder girdle have, in every case known, been able to manage the shoulder dual control, and with any of several elbow-lock arrangements they have been able to carry out all of the operations of the prosthesis. Further unilateral shoulder losses, or losses of both shoulders at various levels, entail such impairment of harnessable shoulder mobility that it is impossible to attain the operating effectiveness ordinarily to be expected from the major prosthetic controls. A review of several types of fittings and the results obtained indicates the nature of these limitations.</p> <h4>Unilateral Shoulder Amputees</h4> <p> In the unilateral shoulder amputee, limitation begins with the disarticulation because the leverage on the amputated side is then so reduced that biscapular shrug no longer gives the necessary excursion. With most men of average to large build, however, the results usually are satisfactory (<b>Table 1</b>). In the case of M.W., pelvic control was required. T.M., a large and broad-shouldered man, obtained good function despite large, but not complete, clavicle and scapula losses. With the fore-quarter case, P.H., the sound shoulder could not manage the full control, and the functional regain was decidedly marginal.</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 /> <h4>Bilateral Above-Elbow/Shoulder Combinations</h4> <p> No case of bilateral humeral-neck amputation has thus far come to notice, but the bilateral above-elbow/shoulder combination is comparatively frequent. Five cases of this type can be cited. All save one are at least moderately successful. The unsuccessful case, C.B., has a number of stump complications that have prevented a satisfactory result. Otherwise, good operation, one prosthesis at a time, is provided by harnessing modifications in which the elements of the shoulder-disarticulation harness from one side and of the figure-eight from the other are combined. It should be noted that in all these cases both shoulder girdles are intact, and there is in addition one humeral stump. Hence, shrug and arm-flexion controls can be managed normally.</p> <p>The first case of this type, L.S., is a young man, age 29, with a right above-elbow stump of 10 in. and a humeral-neck amputation on the left side. The musculature and mobility of both shoulders and of the right stump are good. Amputee L.S. is tall and slender but of moderately broad-shouldered build. He is fitted on the right with an above-elbow dual control, on the left with a modified shoulder-disarticulation harness with nudge control for elbow lock. He is rated as a good wearer and is independent in nearly all activities.</p> <p>The second case, C.B., is an elderly man, age 60. He has a right shoulder disarticulation and a left short humeral stump supplemented with a tibial graft. Neuromata in the shoulder area and tenderness about the tibial graft have made fitting difficult; trial fittings with numerous types of harness have not been successful. The age of the subject, recurrent shoulder pain, and habits of dependence have together prevented satisfactory results.</p> <p>Another case, M.C., is a young woman, age 36, with a right short above-elbow and a left humeral-neck stump, the latter supplemented with a tibial graft not yet ready for fitting. Meanwhile, amputee M.C. is operating well with the right prosthesis only. She has acquired skill in eating, drives a car, does housework, and is rated a good wearer generally. Future addition of the left prosthesis is uncertain.</p> <p>Amputee R.G. is a young man, age 31, with a right short above-elbow and a left humeralneck amputation. He is tall and rangy with broad shoulders. Bilateral pectoral muscle tunnels had been constructed, but they were eventually closed at the amputee's request. When last seen he was fitted with short above-elbow dual control on the right side and shoul-der-disarticulation dual control on the left. For a while the left elbow lock was operated by the pectoral tunnel, but the method of elbow-lock operation after removal of the tunnel is unknown. Over several years of observation this amputee was rated as a moderately good wearer and was independent in most personal activities.</p> <p>Finally, J.L. is a man, age 40, with a right above-elbow stump 9 in. long and a left amputation at the humeral neck. Of fairly tall and rangy body build with good shoulder and stump mobility, he was fitted with a right above-elbow dual control and a left basic shoulder-disarticulation harness, the left elbow lock being operated by a nudge control After fitting and training he attained a good level of performance and as far as is known continues to be a good wearer.</p> <h4>Bilateral Shoulder Disarticulation</h4> <p> The reduced shoulder width associated with the bilateral shoulder-disarticulation case so impairs scapular abduction and shoulder flexion that complete control of the prostheses is not possible. Full operation of the terminal device at elbow angles above 90 deg. cannot be managed with the dual control, and a lower level of operation must be accepted. The pelvic control remains a possibility, but this expedient has so many disadvantages of inconvenience, awkwardness, and discomfort that few if any amputees accept it for continuous use. Shoulder control can at best be unilateral only.</p> <p>Nevertheless, an acceptable level of function may result. For example, J.G. is an elderly man, age 63, with bilateral shoulder disarticulations. Of medium build and with rounded chest, he has to date been completely dependent on help from others. Fitting and care have been sporadic because of infrequent visits to the laboratory. He last was fitted unilaterally with a right prosthesis and a reaction cap on the left shoulder. Thus far the fit has been promising. At the last visit he had managed eating and other activities.</p> <p>With the congenital anomalies, amelia and phocomelia, control functions usually are considered as being the same as those for the shoulder-disarticulation case. Shoulder girdles are narrow because of the absence of humeral heads or owing to loose and nonarticulated rudimentary elements, so that basic shoulder control may not be adequate for bilateral function. In phocomelia, with both forearm and hand or only hand elements, additional help may often be obtained for secondary controls such as elbow-lock operation. In any event, these congenitals early develop "manipulation" with the feet, and these capabilities have not been matched, so far as is known, by any upper-extremity prosthesis.</p> <p><b>References:</b></p> <ol> <li>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study, </i>Department of Engineering, University of California (Los Angeles), in preparation 1955.</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">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_061/tmp48F-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience in Harnessing Extreme Arm Cases Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph. D. * https://staging.drfop.org/files/original/ccbc8e8342b60cf117d2442be749ee76.pdf d2de9f9448bd61ff2b51f687800f4a75 https://staging.drfop.org/files/original/7f9444dc519a091e1db52b684898c6db.jpg 6afb0224ae498983295cf105bb24caa4 https://staging.drfop.org/files/original/ad7aeee90ad4b78b31d43fbf60f65bb5.jpg 1550d02824220fe557f6b80f17c281e0 https://staging.drfop.org/files/original/922c2880e12be056594b986dfdbd15a3.jpg a166685936c6108e3903c0431a34abd7 https://staging.drfop.org/files/original/3253f23949aff1f7c8b4ba003dd92266.jpg e59b2ac12c4f8f4acb25825f5c1d9fee https://staging.drfop.org/files/original/ecfadd74e96dda725a1a4968b7cd779c.jpg 7b83a2d864810382914b0008b234cb73 https://staging.drfop.org/files/original/96c1d8c5bbcd9e5572639a0399ccb2c4.jpg 7263f38aa629d269c19aa7052e919b85 https://staging.drfop.org/files/original/137df3362cb0370deeaedf5f2c513a9f.jpg d65819c948eccca57d976a570ce49d1d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_074.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 74 - 85 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_074.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_074.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Patellar-Tedon-Bearing Below-Knee Prostheses</h2> <h5>Frank A. Witteck, B.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the latter part of 1958, prothetists of the Limb and Brace Section of the U. S. Veterans Administration Prosthetics Center, New York City, were indoctrinated in the technique of fabricating the patellar-tendon-bearing (PTB) cuff-suspension below-knee prosthesis. Preliminary experience encouraged VAPC to institute in the spring of 1959 a form of clinical study. Selection of the patients fitted with the PTB prosthesis was not rigorous, potential wearers being recruited from among veteran beneficiaries having an approved request for a new or a spare below-knee prosthesis. Availability for follow-up examinations was an important consideration, and many patients otherwise acceptable were excluded because, as it turned out, they were unable, for one reason or another, to make themselves available for the several necessary one-hour follow-up visits to the VAPC clinic. Several patients sent to VAPC from other VA Regional Offices were included in the study even though the distance from residence to fitting facility posed problems.</p> <p>Although from the standpoint of fitting the study was concluded in November 1960, follow-ups continued through September 1961. During the 21-month period, 53 adult, male, below-knee amputees were selected for participation. With a few exceptions, all had been wearing conventional below-knee prostheses-carved wood socket, side joints, and leather thigh corset, or lacer. Two had only recently undergone amputation, and their initial fittings were with the PTB prosthesis. Fifteen cases out of the 53 were selected for discussion in some detail in this summary. They represent the types of adult male amputees seen in Veterans Administration clinics throughout the country. In addition to those amputees who present no problems and who are therefore fitted successfully with a minimum of difficulty, there are included those who had been wearing a prosthesis with a thigh corset that furnished either partial or full ischial weight-bearing, those whose previous prostheses had sockets of varying types (<i>i.e.</i>, soft, slip, suction, etc.), those who had worn a number of different types of prostheses over the years, and those who had worn the same prosthesis for 15 years. Included also are recent amputees who were to be fitted for the first time, as well as one typical bilateral below-knee amputee who benefited by use of PTB fitting concepts.</p> <h3>Fifteen Case Histories</h3> <h4>Case 5 (J. D.)</h4> <p>Case 5, a 43-year-old dock checker 5 ft. 11 1/2 in. tall and weighing 178 lb., lost his left leg below the knee as a result of a mortar-shell explosion. Simultaneously, he lost some muscle power in his left hand. While the patient was hospitalized from March 1945 to March 1947, a revision was performed on the stump, and first fitting was with a prosthesis having a wood socket large enough for two stump socks to be worn. A long thigh corset had a strap-and-buckle arrangement to facilitate harnessing with the right hand. Succeeding prostheses were of the same type. Gait was fair.</p> <p>When the patient was first seen at VAPC, his stump was 4 in. long and conical. There was evidence of chronic infection in the vicinity of the patellar tendon, the skin over the patella and over the medial tibial condyle was tender, and there was some scarring over the head of the fibula. In February 1960, a PTB prosthesis with side joints and thigh corset was delivered, but the patient did not report for follow-up examination until the following August. At that time he returned the prosthesis and requested fitting with the conventional type. Although he had worn the prosthesis only occasionally on weekends for a few hours at a time, he complained of excessive piston action and irritation of the skin in the popliteal area and claimed that he could not take time off from his job for the necessary socket modifications.</p> <p>The clinic recommended that a conventional type of below-knee prosthesis be fabricated for this patient because of his inability to cooperate through no fault of his own.</p> <h4>Case 9 (A. E.)</h4> <p>Owing to complications of diabetes, Case 9, a 44-year-old postal worker and part-time stevedore weighing 190 lb. and standing 5 ft. 10 in., underwent a left below-knee amputation in 1944. The prostheses issued over the years were always of the conventional type with carved wood socket, side joints, and thigh corset.</p> <p>When, in October 1959, the patient was first seen by the VAPC clinic, the 6-in. stump was in excellent condition, quadriceps and hamstring muscle groups were adequate. Gait was poor, and training was recommended. A PTB prosthesis was delivered in late October 1959, but the patient failed to report for any follow-up examinations until June 1960, whereupon it was discovered that the prosthesis had been worn during the first three months only. The patient claimed that during the following five-month period he had never been able to come in for socket modifications. Gait was still poor. A new PTB prosthesis was prescribed and finally delivered in October 1960, and the patient was cautioned to use it gradually until he could wear it for eight-hour periods without difficulty. When seen again in March 1961, the patient claimed that he could wear the prosthesis after work and on weekends with little or no difficulty but that he found the conventional prosthesis with sidebars and thigh corset better for the heavy labor in both his regular and his after-hours jobs. The clinic team felt that the use of the two different prostheses was a reasonable approach in this case. It was recommended that this procedure be followed until the PTB prosthesis could be worn full time without difficulty. A follow-up made several months later showed that the patient was able to put aside the conventional prosthesis and wear the PTB type comfortably.</p> <h4>Case 15 (D.H.)</h4> <p>Case 15, a 54-year-old information officer weighing 220 lb. and standing 6 ft. 3 in., had his right leg amputated in September 1944 as a result of wounds from shellfire. A final surgical revision was performed in December 1944 leaving a stump 7 1/2 in. long. The prostheses worn had all been of the conventional type- carved wood socket, side joints, and thigh lacer.</p> <p>The patient was fitted with a PTB prosthesis in November 1958 prior to the institution of the study. He received a second, or spare, prosthesis in the summer of 1959 and at that time accepted a job assignment in the Midwest. Thereafter his prosthetic needs were accommodated by a shop in his new location.</p> <p>The patient is extremely active and does not spare his prosthesis. The SACH foot, for example, required replacement after several months of use. Because of wear, at least four socket inserts were made within a six-month period. Although the horsehide linings were worn through in the areas of weight-bearing, there was no stump discomfort. According to a letter report, both the SACH foot and the socket insert had to be replaced again because of wear. Despite these difficulties, the patient was extremely pleased with the PTB prosthesis and continued to use it.</p> <h4>Case 17 (F. H.)</h4> <p>In June 1947, Case 17, a 42-year-old salesman weighing 185 lb. and standing 6 ft. 3 1/2<i> </i>in., had his right leg amputated below the knee owing to gunshot wounds. Because of pain in the stump, he later underwent surgery twice for removal of neuroma, and a sympathectomy also was performed. Referred to the VAPC clinic in March 1959 by another VA Regional Office, he complained of stump pain which could be relieved only by not wearing the prosthesis, a slip-socket type worn over three stump socks. Examination of the 6 1/2-in. stump revealed a reddened scar in the popliteal area and discoloration and sensitivity in the vicinity of the fibular head such that slight tapping with the fingers produced shooting pains in the stump.</p> <p>The initial prescription for this patient was a soft-socket prosthesis with a thigh corset designed for ischial weight-bearing. The prescription was filled in April 1959, but having worn the prosthesis only four hours the patient complained of pain and numbness in the stump. He felt that the thigh corset was cutting off circulation and "choking" the stump. Because the patient claimed that he could take weight-bearing on the stump, the thigh corset was loosened, whereupon he walked painlessly. Upon re-evaluation of the case, the prescription was modified to PTB fitting. But before the PTB prosthesis could be delivered the patient was hospitalized for pancreatitis, and delivery could not be made until June 1959. In the three months thereafter, several socket modifications were required-in the area of the tibial crest, about the medial tibial condyle, and in the region of the patellar tendon. Discharged from the hospital and back at work, the patient reported that he was comfortable and free of stump pain with the PTB prosthesis. But later, in February 1960, the patient was reported to have died, cause not given.</p> <h4>Case 19 (W.H.)</h4> <p>Case 19, a 41-year-old VA prosthetics specialist weighing 190 lb. and standing 5 ft. 8 in. tall, suffered irreparable damage to both legs in March 1944 as a result of gunshot wounds. Amputation of both legs below the knee was necessitated. Revision of the stumps was carried out in July 1944.</p> <p>This patient was able to tolerate almost full end-bearing on both stumps (3 1/2 in.), and accordingly conventional prostheses were made with closed-end sockets to take advantage of the ability to carry weight on the stump ends. Some years later, when SACH feet were used on his prostheses, the patient complained of insecurity and a poor gait pattern. Hence, the feet and ankles used subsequently were of the conventional type.</p> <p>A pair of PTB prostheses was provided in November 1959, the initial fittings being attempted without side joints and thigh corsets. But it was quickly determined that there was mediolateral instability and a tendency for the knee to hyperextend. Inasmuch as the patient obviously did not have to rely upon full thigh corsets for weight-bearing, whereas side joints were indicated, a combination of side joints with reverse thigh bands (<b>Fig. 1</b>) was tried. This arrangement was found to be effective both in providing mediolateral stability and in preventing hyperextension of the knee. When, on one of his infrequent visits to the Center, the patient returned to the shop for modification of the sockets, the distal ends of both were modified to permit insertion of additional pads for increased weight-bearing, the new inserts being prepared from a rubber of durometer higher than that used formerly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 19 Posterior view of bilateral PTB prostheses with side joints and anterior thigh bands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The modified prostheses are now worn for periods of five to six hours per day, but major use is still made of the older prostheses. The "weaning process" is a slow one.</p> <h4>Case 21 (J. M.)</h4> <p>Case 21, a 36-year-old, 140-lb. telephone coordinator 5 ft. 11 in. tall, suffered irreparable injuries to his right leg when he stepped on a landmine. Amputation of the leg below the knee was performed early in 1944. There was no further surgery. For eight years the patient had been wearing, with little or no difficulty, a conventional below-knee prosthesis with a modified thigh corset giving ischial weight-bearing.</p> <p>The stump, 6 3/4 in. long, was conical in shape. Pressure on a sensitive area over the posterodistal aspect of the stump just above the end radiated pain up the thigh, apparently along the course of the sciatic nerve. There was the usual atrophy of the thigh on the side of the amputation, but knee motion was good.</p> <p>Upon delivery of a PTB prosthesis in August 1959, the patient's initial comments referred to a change in gait pattern-to the inability to take a full step as he could with his old prosthesis. During the first 90 days of use, several socket modifications were made, relief being given about the medial tibial condyle, the crest of the tibia, and the distal end of the stump. To accommodate stump shrinkage, the patellar-tendon area was built up to restore proper weight-bearing. A spare socket insert, to permit change of liner every day, was provided in an attempt to alleviate a perspiration problem.</p> <p>The patient continued to wear his prosthesis without incident until June 1960, at which time a spare PTB prosthesis was prescribed. The major complaint after 30 days of wear of this limb had to do with excessive perspiration. The horsehide liner showed signs of cracking, and a vinyl plastic ("Doe-Lon") was substituted for the horsehide. Washing and drying this insert at the end of each day minimized the adverse effects of perspiration on the liner.</p> <p>At last report the patient was still wearing his new prosthesis and had no wish to return to the older conventional one. He was pleased with the coincident weight reduction of the prosthesis-from 7 1/2 to 4 1/2 lb.</p> <h4>Case 25 (S.M.)</h4> <p>Case 25, a 42-year-old retailer weighing 195 lb. and standing 6 ft., suffered irreparable damage to his right leg in October 1944 when he stepped on a landmine. Amputation below the knee followed. Numerous metallic foreign bodies remain in the left leg and in both hands.</p> <p>The first prosthesis worn by this patient was of the conventional type-carved wood socket, side joints, and thigh corset. Subsequent prostheses had soft sockets instead of the carved-wood type. Patient was always fitted with, and wore, two wool stump socks, and he was a frequent visitor to the shop for socket modifications and limb repairs. The stump was in excellent condition, conical, and 6-3/4 in. long.</p> <p>In March 1960, when a PTB prosthesis was made, it was noted that, as usual, the patient wished to wear two stump socks. The patient was insistent that the socket be made accordingly. With the new PTB prosthesis, he was able to sit more comfortably because he could now flex his knee to 145 deg. as compared with 80 deg. with his old prosthesis. The PTB prosthesis also felt lighter than any of those previously worn.</p> <p>In a follow-up examination three months later, the patient claimed that the fit was still good even though he had lost some weight. Some stump irritation was evidently due to excessive perspiration.</p> <p>The patient was seen again in September 1960, at which time a new cuff suspension strap was provided and socket modification was required to relieve pressure in the antero-distal area. The perspiration problem was alleviated by a change during the day of one of the two stump socks he was wearing. The fresh, dry sock was worn next to the stump. There had been no stump breakdown since application of the PTB prosthesis, and at last report the patient was still wearing his appliance comfortably.</p> <h4>Case 26 (W.O.)</h4> <p>Case 26, a 30-year-old claims adjuster and part-time professional golfer weighing 150 lb. and standing 6 ft., had his right leg amputated below the knee in November 1952 as the result of a landmine explosion. A surgical revision of the stump was done later the same year. The stump was cylindrical and 6 1/2 in. long, skin type was classified as tough, there was minimum distal padding, the quadriceps muscle group was strong, and there was only slight atrophy of the thigh on the side of the amputation.</p> <p>The first prosthesis had a soft socket fitted in a laminated fiber shank with side joints and thigh corset, the foot and ankle being of the Navy type (<i>i.e.</i>, with a two-durometer rubber ankle block). The second and third prostheses were similar except that the shanks were made of wood. The Navy ankle assisted in providing the pivoting action necessary in playing golf. Gait was excellent.</p> <p>In April 1960, a PTB prosthesis with SACH foot was delivered to the patient, but he returned after a week and asked to have the SACH foot replaced with a Navy-type foot and ankle. The SACH foot, he claimed, did not give him the function he desired-primarily the pivoting action or rotation at the ankle. Replacement was made to the patient's satisfaction.</p> <p>After the prosthesis had been worn five months, the socket was modified to provide additional relief for the medial hamstring area. Perspiration was not a problem. The patient was well satisfied and more comfortable. At last report the prosthesis had been in use for nine months with an average wearing time of 12 to 16 hours per day. A spare PTB prosthesis was fabricated.</p> <h4>Case 27 (C. Q.)</h4> <p>Case 27, a 43-year-old sheetmetal worker weighing 175 lb. and standing 6 ft. 2 in., had his right leg amputated below the knee in June 1945. In November 1947, a right lumbar sympathectomy was performed in an attempt to relieve intractable pain. Several weeks later a revision of the stump was carried out. But the patient continued to complain of pain in the stump and was again admitted to the hospital in June 1948, when the sciatic and saphenous nerves were sectioned. Stump pain persisted, and in January 1956 further surgery was performed. The remnant of the fibula was removed; the distal portion of the right deep peroneal nerve was identified, resected out, and divided high; and the stump was injected with 50-percent alcohol. Final diagnosis on discharge in January 1956 was "abnormal amputation stump characterized by pain, right lower extremity below the knee."</p> <p>From 1946 to 1957, the patient had received six conventional carved-wood-socket below-knee prostheses, six new carved-wood sockets, and two major repair jobs, including the addition of ischial-bearing thigh corsets. In February 1957, a soft-socket plastic-laminate below-knee prosthesis was prescribed and delivered by VAPC. Numerous complaints of pain and irritation made it necessary to deliver another prosthesis in October 1957. In September 1958, the patient was hospitalized for removal of a foreign-body granuloma from the right knee.</p> <p>In January 1959, the patient was again hospitalized for possible revision of the 6 1/2-in. stump to a Gritti-Stokes type of amputation, but it was decided that conservative management should be continued before institution of any further surgical procedures.</p> <p>In February 1959, the patient reported to the VA Prosthetics Center for delivery of a PTB prosthesis. At the time, he was wearing a prosthesis with a slip socket and long thigh corset. The patient spent ten days at the Center to assure a satisfactory fitting and returned in March 1959 for socket modifications. Contrary to advice given him he had tried to walk with the prosthesis without using the cuff supension strap. The results were predictable: prosthesis slipped off, patient fell and damaged his stump. A modification of the socket corresponding to the area of the tibial tubercle was made, and a spare insert was fabricated.</p> <p>In December 1959, the patient again reported to the Center with complaints of an ill-fitting prosthesis. Arrangements were made to fit and fabricate a new PTB prosthesis. As a stopgap measure, an insert using thicker rubber was provided, and the new prosthesis was delivered later in the month. When the patient was seen again after 30 days (mid-January 1960), he was experiencing pressure on the distal end of the stump. Suitable relief was provided by building up the socket in the patellar-tendon area. Because of excessive perspiration, a spare insert was furnished at this time.</p> <p>The patient has not been seen at the Center since January 1960. Reports indicate that the litany of complaints is again being recited. Patient's stump seems to be in good condition and is as well fitted as possible, but the case remains a problem. The consensus is that past objective difficulties, perhaps complicated by emotional overtones, have resulted in an unusually strict standard for comfort.</p> <h4>Case 42 (E. B.)</h4> <p>Because of a landmine explosion in 1945, Case 42, a 37-year-old accountant weighing 170 lb. and standing 5 ft. 10 1/2 in., was subjected to amputation of the left leg below the knee. A revision performed later that year left deep folds and scars on the end of the stump. The right ankle had been fractured, and with increased activity it became swollen and painful.</p> <p>The first, second, and third prostheses worn by this patient were of the conventional type- carved wood socket, side joints, and thigh corset. The fourth prosthesis substituted a "muley" type of suspension for the side joints and thigh lacer. The fifth and sixth prostheses were suction-socket prostheses<a></a>, a type worn by the patient for almost two years. The patient claimed to be comfortable in the suction socket but was concerned about the increasing edema at the stump end.</p> <p>The 9-in. stump had an hourglass shape, and the distal end was edematous and discolored (<b>Fig. 2</b>). There was evidence of many old ulcerations on the distal end, and during weight-bearing the tissue overlapped the socket brim (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 42. Anterior (left) and posterior (right) views of stump showing discoloration and hourglass shape. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 42 wearing suction-socket prosthesis. Note overlap of tissue above socket brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A course of whirlpool therapy was instituted to reduce the edema as quickly as possible, and a PTB prosthesis with a functional ankle was prescribed and delivered in July 1960. When, after 30 days, the patient was seen again, the edema had been reduced and the skin color was lighter. Three months later, in November 1960, the patient again reported to the clinic. The prosthesis had been worn routinely since delivery, and the hourglass shape of the stump was not as prominent. Discoloration was still evident but greatly reduced. The patient claimed that perspiration had increased so that the liner had to be dried each evening. Accordingly, a spare insert was furnished.</p> <h4>Case 44 (T. MCA.)</h4> <p>In February 1960, Case 44, a 38-year-old sheetmetal worker weighing 185 lb. and standing 5 ft. 10 in., had his right leg amputated below the knee because of chronic osteomyelitis. At the distal end the stump was slightly edematous, a condition not unexpected at eight weeks postamputation. The 7 1/2-in. stump was slightly bulbous. There were no sensitive areas.</p> <p>The prescription for the PTB prosthesis, this patient's first artificial limb, contained instructions that the socket was to be mounted on an adjustable pylon as a shank (<b>Fig. 4</b>). Because the amputation was so recent, considerable stump shrinkage was anticipated, and it was felt that the use of the adjustable pylon would facilitate socket replacement and the necessary alignment changes as anticipated. A PTB prosthesis was delivered in April 1960, the pylon shank being concealed by a plastic-laminate cosmetic cover. After 30 days of wear, the socket needed modification in the areas of the patellar tendon, the flare of the medial tibial condyle, and the crest of the tibia. Several alignment changes were required, and the patient complained of excessive perspiration of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 44. PTB socket mounted on an adjustable pylon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The pylon-type prosthesis, with modified socket and alignment, was worn until June 1960, at which time a new "permanent type" PTB prosthesis was delivered. A spare socket insert was furnished to help alleviate the perspiration problem. The new limb, lighter by 1 1/2 lb. than the pylon-shank prosthesis, added to the patient's satisfaction. Subsequent follow-ups revealed no new problems.</p> <h4>Case 46 (R.R.)</h4> <p>Case 46, a 58-year-old assistant director of athletics weighing 192 lb. and standing 5 ft. 10 1/2 in., had his left leg amputated in 1945 as a result of severe leg wounds suffered in 1944. No further surgery was necessary. Prostheses had all been of the conventional type-carved wood socket, side joints, and thigh lacer.</p> <p>The stump was 9 in. long and bulbous. A nonadherent, longitudinal scar, 7 3/4 in. long, extended up the back of the stump from the anterodistal aspect to the mid-posterior aspect. There was some sensitivity of the stump end to palm pressure. Skin type was classified as delicate.</p> <p>A PTB prosthesis was delivered in June 1960, and the patient returned two months later for socket modifications. During this period, the patient had done some mountain climbing and stream fishing, activities which probably expedited stump shrinkage. The weight-bearing areas were restored by building up in the areas of the medial and lateral tibial condyles and of the patellar tendon. After another 30 days, the patient returned with the complaint that the posterior scar had been irritated and opened up. Playing baseball did little to help the situation. Whirlpool treatment expedited healing. The socket was relieved to prevent a recurrence of this irritation, and a spare socket insert was provided.</p> <p>As of last report, the patient continues to wear the PTB prosthesis satisfactorily and without discomfort. He has requested a spare prosthesis of the same type.</p> <h4>Case 47 (H.H.)</h4> <p>Case 47, a 44-year-old sales representative weighing 160 lb. and standing 5 ft. 10 in., had his right leg amputated below the knee in 1944 as the result of severe wounds. Two surgical revisions were performed in 1947. The stump was 6 1/2 in. long, cylindrical in shape, and classified as redundant. Because of discomfort, all of his prostheses, though otherwise conventional, had been made with a modified ischial-weight-bearing thigh lacer.</p> <p>A PTB prosthesis was delivered in August 1960. At follow-up examinations it was learned that no difficulty had been experienced as a result of going from one type of weight-bearing to a radically different type. The patient preferred the intimate fit, and he expressed the opinion that the prosthesis seemed more a part of him rather than an appendage.</p> <h4>Case 49 (V.M.)</h4> <p>Case 49, a 43-year-old, 185-lb. VA contact representative 5 ft. 10 in. tall, suffered severe injuries to his left leg from a shell explosion. Amputation of the leg below the knee was performed in July 1944. Two surgical revisions were done in 1950.</p> <p>This amputee had worn the conventional type of below-knee prosthesis with carved wood socket, side joints, and thigh lacer. When seen at the VAPC clinic early in 1960, he was wearing a Blevens-type prosthesis<a></a> that had been issued him in 1956. He was satisfied with the prosthesis, but it was badly in need of repair. The stump, cylindrical and 7 1/4 in. long, showed evidence of multiple skin ulcerations and numerous areas of infection. A PTB prosthesis was prescribed and delivered in July 1960.</p> <p>Follow-up examinations showed great improvement in the condition of the stump. The prosthesis was worn routinely for 14 to 16 hours a day.</p> <h4>Case 51 (J.W.)</h4> <p>Case 51, a 43-year-old editor weighing 165 lb. and standing 5 ft. 11 1/2 in. tall, lost his right leg below the knee as the result of a landmine explosion. Amputation was performed in October 1944, and a revision was effected early in 1945. The patient's stump was in excellent condition, conical, and 7 1/2 in. long. Musculature was active.</p> <p>The prosthesis that the patient was wearing was the first one issued to him, some 15 years earlier. It had a leather socket in a fiber shank, side joints, and thigh lacer (<b>Fig. 5</b>). A second prosthesis had been made in 1950, but it had never been worn because the original prosthesis had been so comfortable and generally satisfactory. As a result of the clinic team's examination and recommendation, the patient was willing to try the PTB prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 51 wearing 15-year-old conventional prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In July 1960 a PTB prosthesis was delivered. At a follow-up examination made after 30 days, the patient reported great satisfaction with the prosthesis. He wore it 14 to 16 hours a day and felt it was lighter, more comfortable, and "easier walking" than his old prosthesis. He also appreciated the freedom from sidebars and thigh corset. Subsequent follow-ups merely confirmed earlier impressions.</p> <h3>Summary</h3> <p>Details covering these 15 cases, and also some information on the 38 others, are summarized in <b>Table 1</b>,<b>Table 1 Cont.</b>. Although the study was concluded in November 1960, wear-experience data were carried to September 1961. Experience has shown that as stump changes occur certain modifications are more prevalent than others. In 27 cases, modifications (build-ups) were required in the area of the patellar tendon and in the popliteal region. The necessity for this type of modification was evidenced by pressure at or on the distal end of the stump, and the discomfort could be alleviated by restoring the stump to its proper position in the socket by building up on the socket shell.</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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 Continued. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 24 cases it was necessary to modify the socket in the area of the flare of the medial tibial condyle, a modification also of the buildup type. Since the medial flare has excellent weight-bearing ability, a good fit in this area is essential.</p> <p>The medial hamstring area of the socket had to be relieved or lowered in 15 instances. In general, the socket brim was made lower for proper accommodation of the medial hamstring than for the lateral hamstring.</p> <p>Seven cases experienced pressure on the crest of the tibia, a condition that was relieved by building up the socket shell on both sides of the tibial crest.</p> <p>In 14 cases, stump shrinkage after one to three months of wear made it necessary to fabricate new PTB sockets. These amputees all had either fleshy or bulbous stumps and in some cases both conditions prevailed.</p> <p>Perspiration had been anticipated as a major problem with the PTB socket, but only 16 cases complained of excessive perspiration. For these cases spare inserts were provided. The facility with which inserts can be changed makes such a measure practical.</p> <h3>Conclusions</h3> <p>Experience in the fitting of PTB prostheses has led to some general prescription criteria. The amputee should have a sound, stable knee. Instability of the knee that cannot be corrected by physical therapy is a contraindication to the use of a PTB prosthesis without thigh lacer.</p> <p>Caution should be exercised in prescribing a PTB prosthesis for heavy individuals. They often cannot tolerate, for long, full weight-bearing on the stump and will often require the additional support of a thigh lacer.</p> <p>The amputee with a long stump (<i>i.e.</i>, with an amputation in the lower third of the leg) can, and does, present many problems. Often there are circulatory complications. Achievement of the required intimate fit is much more difficult. Proper fit and alignment can be arrived at initially but are difficult to maintain over long periods of time.</p> <p>Similar comments can be made regarding sensitive stumps and those that are badly scarred. These should be treated with particular care.</p> <p>The bilateral below-knee amputee presents another special situation. It is often feasible to limit the use of the PTB prosthesis to one side only. After a period of successful, problem-free wear, a fitting can be attempted on the other side. In general, one may say that prescription for bilateral fitting should be limited to young, slender amputees of average weight.</p> <p>Another factor of prime importance is the skill and ability of the prosthetist. His talents must be brought into full play to achieve a good socket fit. Use of an adjustable alignment device is mandatory. The old cut-and-try methods have no place in the fitting and alignment of the PTB prosthesis.</p> <p>Finally, the amputee should be oriented, or indoctrinated, by the clinic team even before fitting of a PTB prosthesis is attempted. In general, initial PTB fittings are much less troublesome to the patient than are initial fittings with a conventional carved below-knee socket. In the PTB case, therefore, the amputee may be lulled into an overly optimistic belief that the initial level of comfort will always continue. To avoid any disappointment on the part of the wearer, the clinic team should make clear the substantial possibility that stump changes and other factors may later necessitate socket modifications. Because, indeed, the usual indications for a change in socket fit are not as sharply defined in the PTB socket as they are in the conventional wood socket, it is essential that the clinic team plan for periodic follow-up examinations over a relatively long period until the stump reaches a comparatively stable condition. Similarly, the patient himself should be prepared to give adequate time for the examinations (and, if need be, for socket modifications), and he should be encouraged to be constantly on the alert for subtle but progressive changes that might signal impending difficulties. Persistence on the part of the team, together with investment of the amputee's time and interest, leads eventually to a significant return in the form of a comfortable, well-fitting, and functional prosthesis without the restrictions of sidebars and thigh corset.</p> <p><b>References:</b></p> <ol> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chap. 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954. Pp. 723-724.</li> <li>Murphy, Eugene F., <i>Lower-extremity components,</i> Chap. 5 in <i>Atlas of orthopaedic appliances, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 221.</li> <li>Murphy, Eugene F., <i>Lower-extremity components,</i> Chap. 5 in <i>Atlas of orthopaedic appliances, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 222.</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">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Atlas of orthopaedic appliances, Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 221.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Murphy, Eugene F., The fitting of below-knee prostheses, Chap. 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. Pp. 723-724.</td></tr><tr><td class="clsTextSmall"><b> 3.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Atlas of orthopaedic appliances, Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 222.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 A. Witteck, B.M.E. </b></td></tr><tr><td class="clsTextSmall">Assistant Chief, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience with Patellar-Tedon-Bearing Below-Knee Prostheses Creator An entity primarily responsible for making the resource Frank A. Witteck, B.M.E. * https://staging.drfop.org/files/original/d9df07ada71e9d7d83fffc2b3882605b.pdf dd5973e756028d4e9b05572ed933a126 https://staging.drfop.org/files/original/0f45aa6fc046dad209c2ecd2246d719d.jpg ef9ee0e2d6b75fb5a0f601219455c33c https://staging.drfop.org/files/original/d95df4afa4a2f4646ae80ab0c81b2c59.jpg eaf808db85894142fab323e6a395c193 https://staging.drfop.org/files/original/b6abea62fdee85f63c01f9f92f63427f.jpg 0cb011992156bd6cb8e3d2d0c7084ef2 https://staging.drfop.org/files/original/f0010ef48d7220a546c6825555e192d9.jpg 7d7fdedf615e168cb6806068e1c6ec9f https://staging.drfop.org/files/original/3b4551aa2727f7de686c9653c2e5a0a2.jpg 362acdaa1b00733aa29554d23964db97 https://staging.drfop.org/files/original/9d2755df918b9d45aa9be1ca6f563d0c.jpg 005f7f0338d752126218dd2d68eafbad https://staging.drfop.org/files/original/6c2c983e3d245d5c78f0820ce9ee4915.jpg 1d90a72444738f10f27abd1bac5c0faa https://staging.drfop.org/files/original/624b108ea7d5ee0507c22228b6f0d6a3.jpg 26f4ff3a54c4bccd797ca390cdf7ca5b https://staging.drfop.org/files/original/254ddecf8418d838cb6a8af9873a58de.jpg b4f775c186a69f8d2e53b158ac858068 https://staging.drfop.org/files/original/377df229bb696a03072dfd1c676bd050.jpg c0c4072b156f521d98c4f1354bbc325b https://staging.drfop.org/files/original/fd3e3ccdd2420ab18d0d0fffcbc9ab3c.jpg 0e72757a1dc47a5de48d7308461d5f6d https://staging.drfop.org/files/original/b5a660e0a92fcfe1dc39c8ff7fb409bf.jpg 2d614435d8ff3fe18ea8d22c8f3e3eb6 https://staging.drfop.org/files/original/bca83eadc2d6bdd1414a4a6220815d9b.jpg af655a4773be177a6f4c493d206128dd https://staging.drfop.org/files/original/a3377673f8480eff6b780ea492790238.jpg 31b69497a6c30f74af9e798ed25997b9 https://staging.drfop.org/files/original/14d1a5ad883e575f6f4ef41150d9abf1.jpg 3715824627641a0a6f1d6ee0636f59c2 https://staging.drfop.org/files/original/976df78ead28d770ef285a09c9bc0af9.jpg 423273a8db9972de7c0193e94f0f8bdc https://staging.drfop.org/files/original/cd85393dfea9ad19f0b6b560e893c1a6.jpg e2175b21b49484d983de253617cf5baf https://staging.drfop.org/files/original/59c142d232f6be2114140f4624655085.jpg 8e077cebc372f08ef05dd8002caf70d3 https://staging.drfop.org/files/original/efdc01af5dc1a7b942d551d17167eeca.jpg c00df2061434f0cde77ab3c22578b6b7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_041.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 41 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_041.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Prosthetic Problems of Above Knee Amputees</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br />Norman C. Johnson, M.D. <a style="text-decoration:none;">*</a><br />James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>For almost a dozen years the University of California has been active in prosthetics research. On the recommendation of the then Committee on Prosthetic Devices (now the Prosthetics Research Board) of the National Research Council, there was established in 1945, with the cosponsorship of the School of Medicine in San Francisco and the College of Engineering in Berkeley, the Prosthetic Devices Research Project (now the Lower Extremity Amputee Research Project), a program designed primarily for the purpose of conducting studies in several areas of importance to leg amputees, especially fundamental studies of the processes of human locomotion. Supported on a continuing basis with funds supplied by the Veterans Administration, the work has from the beginning been under the supervision of Howard D. Eberhart, Professor of Civil Engineering, and Verne T. Inman, Professor of Orthopedic Surgery.</p> <p>In the course of fundamental research, the need for experimental devices required the activation of an engineering design group, and consequently a small staff of design engineers, draftsmen, and technicians has been active since 1948. This group, working with the fundamental study groups, research prosthe tists, and amputee subjects, has designed improved prosthetic devices, developed mechanical aids to fitting and alignment, and assisted in the application of well known principles of engineering mechanics to the problems of fitting and aligning lower extremity prostheses.</p> <p>As correlation of the results of the various fundamental study groups progressed, and as the engineering design group developed improved devices, it became increasingly apparent that, in order to make their results useful to the members of the medical profession and to prosthetists serving amputees, a program of amputee application was indicated. Accordingly, there was organized in the spring of 1953 a Clinical Study aimed at providing increased opportunity for application of research results to the solution of typical prosthetic problems of leg amputees. The work in fundamental research had studied the "man"; the Clinical Study was needed to consider the 'man machine combination." Its objectives were to evaluate current prosthetic practice and to develop improved procedures where needed, to establish basic principles of fit and alignment for all levels of lower extremity amputation, to evaluate medical and prosthetic factors in the rehabilitation of amputees, and to develop methods for evaluation of lower extremity amputees and their prostheses.</p> <p>An immediate outgrowth of the Clinical Study was an increasing awareness of the need for additional research directed toward the solution of the medical problems of the amputee. At the present time, the Medical Division of the Lower Extremity Amputee Research Project, located at the Medical Center in San Francisco, includes groups active in the fields of stump dermatology, amputation surgery, skeletal changes, energy, neuroanatomy, psychology, and the physiology of pain. The Clinical Study provides an opportunity for the solution of the prosthetic problems associated with the medical studies and also of the purely prosthetics research problems connected with better materials and improved techniques of fitting. To date, most of the experience has been had with above knee amputees, as here reported, although more than 100 patients, presenting all levels of lower extremity amputation, are currently under study.</p> <h3>Procedures</h3> <p>Each amputee processed through the Clinical Study has certain unique problems, and each must therefore be considered on an individual basis. Initially, it was thought that it would be possible to process amputees in certain rather loosely defined groupings such as ''short stump above knee," "long stump below knee," and so on. But this procedure has not been found practical since each amputee is referred to the study as his particular problem arises. Largely because of the attendant requirements of time, travel, and inconvenience, it is difficult to induce an amputee to become a research subject when he considers his prosthesis to be comfortable and well fitted. The cases reported here have almost without exception been referred to the Clinical Study as "problem cases" and have had chronic difficulties upon referral. The sample does not, therefore, necessarily indicate a typical cross section of the amputee population. The prosthetic problems of the group as a whole, however, constitute what we believe to be a rather common group of problems facing above knee amputees.</p> <p>Each amputee referred to the Clinical Study is given a preliminary examination for the purpose of obtaining information as to the nature of his problems, if any. The preliminary examination includes:</p> <ol> <li>An interview with an amputee specialist <i>(i.e., </i>a trainer). The amputee specialist obtains a brief prosthetic history, explains the research program to the amputee, and records personal data.</li><li>Medical examination by an orthopedic surgeon. The orthopedic surgeon obtains a brief medical history and endeavors to classify the major complaints of the amputee.</li><li>Prosthetic evaluation by staff prosthetists and other specialists. A group consisting of three or more people examines the amputee's stump, his prosthesis, and his performance in order to analyze the fit, alignment, and functional behavior of the amputee with his prosthesis.</li></ol> <p>The results of each of these examinations are recorded in the form of a written memorandum report. Upon completion of the reports, a group discussion is held for the purpose of making recommendations as to the further handling of the case. For example, it may appear on preliminary examination that a particular amputee has a severe skin infection of unknown origin. In such a case, the recommendation might be to refer the patient to the Skin Study Group at the Medical Center in San Francisco before considering any work directed toward improving fit and alignment.</p> <p>Certain cases considered to be of interest to the research staff as a whole are referred to the Amputee Conference held at the Medical Center, San Francisco, on a regularly scheduled weekly basis. Amputees may be referred to the Amputee Conference by medical study groups as well as by the Clinical Study Group. Attendance at the conference is limited to University of California staff members, and not more than three amputees are presented for discussion at any one session. The Amputee Conference provides an opportunity for presentation of the results of the preliminary examination and, thereafter, a general group discussion. At this time a general plan of treatment, including broad research objectives, is formulated.</p> <p>If an amputee is accepted by the Clinical Study as a case of research interest, a more complete medical examination is required. Cases referred to the Clinical Study from the medical study groups or the Amputee Conference have usually been examined at the Medical Center prior to referral. The complete medical examination includes routine clinical tests, plus x-rays of the stump and pelvis.</p> <p>Before any actual treatment is undertaken, a plan of approach is worked out by a team consisting of an orthopedic surgeon, a pros thetist, an engineer, and an amputee specialist. The team discusses research objectives in detail, writes a prescription for one or more phases of prosthetic treatment, and lays out an estimated schedule. A report is then written summarizing the discussion and recommendations, and the team meets periodically, as necessary, to review progress and to make further recommendations. Each phase of the treatment of the amputee is reported in a memorandum which becomes a written record of progress. Permanent records embrace medical records, including x rays; evaluation records, including evaluation forms and 16 mm. motion pictures (100 ft. per evaluation); black and white still photographs; 35 mm. color transparencies; and memorandum reports on plans and progress.</p> <h3>General Principles of Above Knee Prosthetics</h3> <p>As already noted, one of the major objectives of the Clinical Study was to provide the means for additional amputee trials of certain principles of fitting and alignment which had been evolved during several years of fundamental research, evaluation of current practices, and amputee trials but which had been developed with a limited number of amputee subjects. The technique of fitting the suction socket prosthesis to an above knee amputee has been reported by the University of California in a series of publications<a></a> which have been revised periodically as new knowledge and techniques became available. The latest article<a></a> stressed the interdependence of the shaping and fitting of the socket and the biomechanics of alignment of the prosthesis. A rational basis for planning and fitting the above knee prosthesis was presented. All of the patients reported upon in the present paper were fitted in accordance with these principles. It is therefore well to offer here a brief summary of the more important considerations.</p> <p>The prosthetist is undoubtedly <i>the </i>person on the prosthetics team with the heaviest responsibilities. His skill with his hands is largely responsible for the eventual rehabilitation of the amputee. But in carrying out his assignment of providing the amputee with a satisfactory prosthesis, he is faced with something of a dilemma in the establishment of an order of procedure. In order of importance, he must provide the amputee with, first, comfort; second, function; and third, appearance. It can be argued that he should approach the solution of these problems in reverse order if optimum results are to be achieved. Actually, there are two separate and distinct phases of equal importance in the fitting of a leg prosthesis the planning phase and the construction phase. It is during the planning phase that the objectives listed above should be considered in the reverse order. One of the principal reasons for failure to achieve optimum results in the fitting of a suction socket above knee leg is lack of appreciation of, and hence failure to formulate, a working plan before beginning the construction of the prosthesis.</p> <p>In order properly to plan the fitting and alignment of a prosthesis, the clinic team must have in mind a rational sequence which will eventually result in a satisfactory fitting for the amputee. The order of the sequence is necessarily dictated by the type of problem to be solved at a particular stage. Let us consider, for example, the case of a typical leg amputee. During the medical and prosthetic examination by members of the clinic team, a careful analysis is made of the patient's potential as a wearer of a prosthesis. This analysis includes classification as to stump type, stump length, activity level, habit patterns, and special medical factors. It dictates in general terms the type of alignment to be incorporated in the amputee's prosthesis (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 1. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors. These figures serve as a guide to typical features of alignment once the amputee has been classified After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment of the prosthesis will in large measure establish the gait pattern of the amputee, assuming of course that he has been trained to use his prosthesis in a manner consistent with its alignment. A leg amputee can walk efficiently with a symmetrical, narrow based gait only if his prosthesis has been planned and constructed to achieve such a gait pattern. The type of alignment also affects the manner of fitting the socket. An amputee walking with a narrow base may require a distribution of contact forces between stump and socket entirely different from that of an amputee walking with a wide base <i>(i.e., </i>abducted gait).</p> <p>The distribution of stump socket contact forces is determined by the functions the socket must perform, the major functions of a typical above knee suction socket being as follows:</p> <ol> <li>Suspension of the leg in the swing phase of walking. This requirement dictates that an airtight seal be maintained between stump and socket, especially in the proximal third of the stump.</li><li>Vertical support of body weight in the stance phase. The only efficient areas of an above knee stump for weight bearing are the ischial tuberosity and the gluteus maximus. Attempts to use for weight bearing in a suction socket the attachments of the adductor musculature in the perineal area have been unsuccessful Almost without exception this procedure leads either to painful pressure on the pubic ramus or to skin irritation where there exists a definite roll of adductor musculature over the medial brim of the socket.</li><li>Stabilization of the ischial tuberosity on the posterior brim (ischial seat) of the socket. Failure to provide stabilization of the tuberosity will allow the pelvis to slide forward and down into the socket, a circumstance which causes chafing and irritation of the skin under the ischial tuberosity and, in addition, is a major source of crotch discomfort.</li><li>Provision of effective stump reaction points for utilization of hip musculature on the side of the amputation. Any attempt to use the hip musculature either for control of the torso above the hip joints or for control of knee joint movements below the hip joint will require that the stump transmit a moment, or torque. For lateral stabilization of the torso, there is required a pair of mediolateral reaction forces equal in magnitude but opposite in direction one acting on the lateral side of the stump, concentrated in the lower third, and a second acting horizontally against the medial side of the stump in the upper third. During those times when the stump acts to maintain knee stability by active stump extension, the reaction points are against the posterodistal and the anteroproximal areas of the stump.</li></ol> <p>On the basis of these functional requirements, the quadrilateral shape of suction socket shown in (<b>Fig. 2</b>) has been developed. It not only conforms to the anatomical skeleton and musculature but also provides the four functions already listed suspension, support, ischial stabilization, and torque reaction points.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Quadrilateral shape of suction socket, as developed at the University of California, showing anatomical features of an above knee stump in weight bearing. Cross section 1/2in. below ischial level. After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus far the objectives of appearance and function have been accounted for. It has been stated that appearance is determined by proper alignment and use of the prosthesis and that function is dictated by proper alignment accompanied by a rational design of socket to provide the necessary accommodation of stump socket forces. These concepts can be restated in the following two principles:</p> <ol> <li>Gait and alignment establish a definite pattern of stump socket forces.</li><li>The force pattern, in combination with anatomical proportions, dictates a rational design of socket of a generally quadrilateral shape.</li></ol> <p>The third objective is to provide a completely comfortable socket which will be consistent with the functional requirements and yet allow the amputee to use his prosthesis for long periods. Comfort is achieved by application of three additional principles:</p> <ol> <li>Relative motion or rubbing between stump and socket should be held to a minimum.</li><li>Stump socket contact forces can never be eliminated. Contact forces can be tolerated most comfortably if distributed over a large skin area.</li><li>Where a contact force must be transmitted in an area of the stump involving both soft and firm tissues, a uniform distribution of the contact pressure is accomplished by a proportionately greater distortion of the softer tissues.</li></ol> <p>Application of the three principles relating to comfort have resulted in four features of socket shape at the brim that are of particular importance:</p> <ol> <li>The anteroposterior dimension of the socket must be determined with considerable accuracy from skeletal measurements. Any error in this dimension will be reflected in improper placement of the ischial tuberosity on the posterior brim of the socket.</li><li>To ensure distribution of vertical support over the entire posterior brim <i>(i.e., </i>to achieve ischial gluteal weight bearing), a rather flat posterior contour with a flare in the gluteal area is required.</li><li>An anterior wall extending into the inguinal area (the high front), when used with the proper anatomical dimension, is extremely efficient in stabilization of the ischium on the ischial seat.</li><li>A definite protuberance into Scarpa's triangle (the adductor area extending downward into the socket), accompanied by a channel to fit the belly of the rectus femoris, is necessary to ensure a uniform pressure distribution and an airtight seal across the anterior brim of the socket.</li></ol> <p>The following cases have been selected as illustrative of typical problem cases and as being informative to others engaged in the rehabilitation of above knee amputees. Treatment was not completed in all cases because considerable improvement over the previous condition sometimes caused the individual to believe the optimum had been reached and to be reluctant to devote additional time. The cases are in general indicative of the kind of results that can be obtained under the team approach to the problem of amputee rehabilitation.</p> <h3>Some Above Knee Cases</h3> <h4>Case 1, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 1, a male, was 32 years of age, measured 5 ft. 8 1/2 in., and weighed 190 lb. His left leg had been amputated above the knee in October 1944 as the result of a wound. He was employed as a civil engineer. For two years after the amputation, he received intermittent physical therapy and exercise before being fitted with a conventional prosthesis with pelvic belt. The patient's second and third prostheses were similar. His fourth prosthesis, also a pelvic belt leg, was worn with fair results for 18 months. It was then converted to suction suspension in an unsuccessful attempt to increase comfort. The fifth prosthesis, also suspended by suction, was worn for a year with continuous stump trouble before the amputee was finally hospitalized.</p> <p>The patient was referred to the clinical study program in November 1953 following hospitalization for severe edema precipitated by his suction socket prosthesis. Treatment consisted of remaining off the prosthesis during and immediately following hospitalization.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 12 in. long, with limited tolerance to weight bearing on the end. Subcutaneous tissue was light and musculature soft, with some bunching of the hamstrings and slight atrophy at the distal end. X ray showed a healed but laterally displaced fracture of the distal 5 1/2 in. of the femur. The end of the femur was slightly rounded, was closed with new bone growth, and had a small medial spur. Approximately half an inch of muscle padding lay over the end of the femur. The ischial tuberosity was well padded, and the general health of the amputee was excellent.</p> <p>When the patient was admitted to the hospital, the end of his stump was severely edematous, open, and weeping. At the time of entrance to the study program, there was still some weeping and edema, and the end of the stump was discolored (<b>Fig. 3</b>). Follicular lesions were apparent in the area of the inguinal crease and of the crotch, and a small, healing abscess existed on the anteromedial portion of the stump 5 in. below the groin. Some rawness and irritation were still apparent in the crotch area. The distal area of the posterior aspect of the stump was tender, and there was a moderate adductor roll. Examination of the socket fit showed constriction of the stump, especially in the upper third. Weight was carried on a flesh roll at the brim of the socket (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 1. Condition of the distal end of the stump on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 1. Prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 1. Shape of socket of prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Interest in the case centered around the edema, roll formation, and skin problems, including discomfort in the crotch. Ischial gluteal weight bearing, with increased area of support at the anterior wall, particularly in the upper third, was expected to eliminate crotch discomfort, skin lesions and irritation, roll formation, and constriction of the proximal portion of the stump. A snug fit of the socket in the upper third was required to reduce the adductor roll, and a close fit of the distal two thirds of the stump was required to reduce remaining edema and to maintain fit as the edema subsided.</p> <p>The amputee was provided with a suction socket prosthesis using a Navy above knee set up,<a></a> including the variable cadence knee, the functional ankle, and the sponge rubber toe. The socket was made of willow wood reinforced with rawhide and finished inside with cellulose acetate lacquer, and an automatic expulsion valve with standard spring was used. A flat, leather covered, sponge rubber pressure pad was placed in the bottom of the socket to provide back pressure on the edematous tissue at the end of the stump.</p> <p>No special provision was made for relief of the adductor roll. The anterior wall provided no protuberance over the femoral triangle, and there was no special relief for the displaced section of the femur. The perimeter of the socket was 2 1/4 in. less than that of the stump at the proximal end, 3/4 in. less at the mid stump level, and equal to that of the stump at the end. The distance from the channel for the tendon of the adductor longus to the ischial seat was 4 1/2 in., the corresponding anatomical dimension being 3 3/4 in. This difference between medial socket width and anatomical measurement was subsequently found to be a major source of difficulty. Current practice is to have the medial width of the socket compare very closely with the anatomical measurement.</p> <p>Prosthetic evaluation showed some instability of the knee in ramp descent owing to reduced range of plantar flexion. Although there was drop off at the end of the stance phase because of the soft dorsiflexion stop and the soft, sponge-rubber toe, the amputee's performance was excellent.</p> <p>During the final fitting, the end of the stump turned red, but a sponge rubber pad placed in the bottom of the socket improved stump color markedly within two hours. One week after delivery of the prosthesis, the edema was reduced; three weeks after, there was no edema; nine months after fitting, some edema was evident at the distal end of the stump.</p> <p>Evaluation indicated that the ischial tuberosity was sliding anteriorly off the ischial seat so that the stump was settling deeper into the socket, with increased constriction at the proximal end. Several factors were involved. The stump had shrunk, and the anteroposterior dimension of the socket, especially in the medial third, which had been too great initially, had been increased in an unsuccessful attempt to relieve discomfort in the inguinal crease and in the weight bearing area of the stump. The edema was confined to the areas of the stump which extruded into the valve recess and into the gap between the pad and the socket walls. The valve recess was lowered, the pad was refitted so that more weight was carried on the end of the stump, and the space between the pad and socket walls was eliminated. The edema cleared up.</p> <p>Roll formation over the anterior brim of the socket was eliminated through extension of the anterior wall of the socket above the level of the ischial seat. The adductor roll was completely contained within the socket. Tightness of fit in the upper third was a source of minor discomfort immediately, but this problem decreased with reduction of the roll, which was complete within six months (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 1. Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Follicular lesions in the area of the crotch and the inguinal crease quickly cleared up with reduced forces from the socket brim and elimination of roll formation over the brim. One year after treatment began, the discoloration at the end of the stump was markedly decreased. Irritation of the skin over the posterior brim was a persistent problem directly related to decreased effectiveness of ischial gluteal weight bearing and wedging of the posterior aspect of the stump against the inside edge of the posterior brim of the socket. Attempts to increase weight bearing on the distal end of the stump showed that the amputee preferred ischial gluteal weight bearing because of discomfort experienced on the stump end with prolonged support of body weight.</p> <p>Reduced support on the ischial tuberosity followed stump and socket changes and caused discomfort on the ramus. The medial brim of the socket was lowered to provide relief. This expedient was partially successful, but the stump sank deeper into the socket after wear, and ramus discomfort has recurred.</p> <h5><i>Summary</i></h5> <p>The problems of edema, roll formation, skin lesions, and discomfort in the crotch were studied. Edema was originally caused by a tight fit of the stump with constriction of the proximal end. Definite ischial gluteal weight bearing, with increased area of anterior support, was the primary factor in clearing up the edema. A pressure pad under the end of the stump helped to reduce the edema. Stump and socket changes which allowed the ischial tuberosity to slide into the socket, with wedging of the stump proximally, caused edema to recur. Improved fit of the pressure pad, with increased end bearing, cleared up the edema. The adductor roll was brought about by weight bearing in the crotch on the tight socket. Ischial gluteal support, adduction of the femur in the socket with relaxation of the adductors, and extension of the medial brim to the level of the ischial seat, without provision of a relief pocket, eliminated the adductor roll. Discomfort due to tightness of fit for adductor roll reduction decreased as the roll reduced. The high anterior wall eliminated roll formation over the anterior brim of the socket. Skin lesions and irritation were caused by high force concentrations on the stump. Ischial Gluteal weight bearing, with increased area of anterior support, eliminated irritation and follicular lesions in the area of the crotch and the inguinal crease. Ramus discomfort following stump and socket changes was a sign of reduced effectiveness of ischial gluteal weight bearing, which allowed the stump to sink deeper into the socket. Discomfort in the weight bearing area posteriorly was caused by wedging of the stump against the posterior brim of the socket as the tuberosity slid inside the socket.</p> <h4>Case 2, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 2, another male, was 57 years of age, measured 6 ft., and weighed 187 lb. He was employed as a district manager for an insurance company. Amputation was through the right femur following a railway accident at the age of 17. He was referred to the clinical study in November 1953 by a local limbshop because of a history of problems. These included skin infections and irritations, fatigue, and low back pains which had persisted since amputation. At the time, the amputee considered his prosthesis satisfactory. The first prosthesis, with shoulder harness suspension, was fitted in 1913 and worn until 1928. Prostheses with shoulder harness suspension were worn until 1943, when a change was made to pelvic belt suspension. The pelvic belt was uncomfortable and aggravated the back pains, and prior to referral the prosthesis was converted to suction suspension.</p> <h4><i>Examination and Evaluation</i></h4> <p>General health and physical condition were good. The stump was 10 in. long and cylindrical, with light subcutaneous tissue and average musculature except for moderately prominent hamstrings. There was a lateral distal bone spur, a mass of redundant tissue at the lateral posterior end of the stump, and sensitive scar tissue which was adherent to the femur. Perspiration level was high. Skin irritations were present in the area of the crotch and the inguinal crease, and hard skin nodules existed in the ischial gluteal area (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 2. Lateral view of patient standing. Note scar on distal portion of stump over lateral and posterior aspects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis did not provide ischial gluteal weight bearing, and the tuberosity of the ischium was sliding inside the socket during weight bearing. This set of circumstances resulted in painful pressure on the ramus and wedging of the proximal portion of the stump against the anterior and posterior brims of the socket, with a high concentration of forces at the brim level. The medial brim had been lowered a half inch below the level of the ischial seat in an unsuccessful attempt to relieve the discomfort at the ramus. Walking with a narrow base increased the ramus discomfort because the femur was not adducted in the socket for stabilization of the pelvis. There was roll formation over the low anterior brim. Knee stability at the end of the stance phase was excessive owing to a long forefoot and posterior placement of the knee joint, which further increased the force concentrations at the socket brim. Insufficient security at heel contact was due to stiff plantar flexion action. A pelvic hike on the side of the amputation in the swing phase was noticeable, probably because of experience with shoulder harness and pelvic belt suspension.</p> <h5><i>Treatment</i></h5> <p>Problems of interest included skin lesions, horny nodules, ramus discomfort, fatigue, and backaches. It was decided that relatively standard procedures, including ischial gluteal weight bearing with increased support from the anterior wall, would be effective in eliminating roll formation and in reducing pressure concentrations on the stump, especially in the crotch, in the inguinal crease, and in the ischial gluteal area. Further reduction of vertical forces in the region of the crotch could be achieved by adduction of the femur in the socket, thus eliminating pelvic drop in the stance phase.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with single toe break. Segments of the prosthesis were willow wood reinforced with rawhide. The socket interior was finished with cellulose acetate lacquer, and use was made of an automatic expulsion valve with standard spring.</p> <p>Since the ischial tuberosity was not adapted to weight bearing, the gluteal channel was held shallow to increase gluteal support. In addition, this arrangement offered increased sitting comfort by allowing a thinner posterior wall. Definite hamstring relief was provided by channeling the posteromedial apex of the socket (<b>Fig. 8</b>). The medial brim was approximately 1/4 in. lower than the posterior brim to provide clearance for the ramus. The medial socket width was 4 3/4 in. as compared to an anatomical measurement of 3 3/4 in., a difference subsequently found to be a major source of difficulty. As already mentioned, current practice is to have the medial width of the socket compare very closely with the anatomical measurement. The anterior wall was extended 2 in. above the level of the ischial seat and was relieved slightly over the femoral triangle. But this idea, which was tried for fear that pressure in the femoral triangle would interfere with circulation, has since been abandoned in favor of a definite protuberance into this area. Such a shape gives considerable distributed anterior support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 2. Socket shape of prosthesis worn at present. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket was placed well forward on the knee block to allow initial flexion of the femur in the socket for increased voluntary control, reduced energy requirements, and decreased lordosis of the lumbar portion of the spine. Prosthetic evaluation indicated that there was excessive stability at the end of the stance phase owing to a long forefoot and the posterior location of the knee axis, the long forefoot having been dictated by the large foot size. In the swing phase, there was some whip, which was not removed during alignment trials on the adjustable leg,<a></a> but the gait was markedly improved on the new prosthesis. There was no ramus discomfort, no irritation, and no roll formation in the crotch or inguinal crease. The ischial tuberosity was close to the inside edge of the socket, so that the medial wall had to be lowered to prevent ramus discomfort.</p> <p>After stump shrinkage, ramus discomfort recurred. The medial brim was lowered, but this measure provided only temporary relief as the stump settled deeper into the socket. Skin irritations from the anterior brim were reduced but persisted, since wedging occurred owing to inefficient ischial weight bearing. Force concentration at the anterior brim was reduced somewhat by extension of the brim 2 in. above the level of the ischial seat. Undercut of the anterior wall over the femoral triangle reduced the effective area of anterior support.</p> <p>Skin lesions in the crotch cleared up initially but recurred with failure of ischial weight bearing. Formation of horny nodules in the weight bearing areas was unchanged because poor ischial support allowed the tuberosity to move in and out of the socket over the inside edge of the posterior wall, thus creating abrasive and wedging action. Excessive perspiration was considered a factor both in the formation of horny nodules and in stump irritation because of the deteriorating effect it had on the inside finish of the socket.</p> <p>Although the anterior and posterior brims were rolled and adjusted periodically to reduce discomfort from skin irritations in the inguinal crease and from nodules in the weight bearing areas, this expedient provided only temporary relief, since the forces involved were either unchanged or increased. Reduced alignment stability, with increased flexion of the stump in the socket, did not relieve the backache. Activity level was not noticeably changed, and fatigue also remained unchanged.</p> <p>In the course of treatment, redundant tissue at the lateral distal portion of the stump was a problem in fitting because of the sensitivity of the adherent scar tissue. A large pocket was provided to give relief. Doing so reduced the effective length of the femur available for stabilization of the pelvis.</p> <h5><i>Summary</i></h5> <p>Failure of ischial gluteal weight bearing resulted in ramus discomfort and skin lesions. Lowering the medial brim provided only temporary relief, since the stump settled further into the socket. With recurrence of vertical pressure in the crotch, skin lesions were again a problem. The need for effective anterior stabilization to maintain the ischial tuberosity on the ischial seal was definitely indicated.</p> <p>The high anterior wall eliminated roll formation and reduced skin infections in the inguinal crease. Undercut of the anterior wall over the femoral triangle reduced the anterior support area and increased the force concentration al the brim. Modifications of the anterior wall and of the posterior brim reduced discomfort temporarily only, since the force pattern was unchanged.</p> <p>Placement of the prosthetic toe break at the shoe crease provided excessive knee stability at the end of the stance phase. This result suggested that the conventional location of the toe break was too far forward.</p> <h4>Case 3, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 3 was another male, age 51, height 6 ft., weight 180 lb. He lost his left leg above the knee at the age of 17 after an injury sustained in a baseball game. Since his original surgery, he had had no further revision. For the first five years after amputation, he used crutches without a prosthesis. He had since worn three prostheses during his 34 years as an amputee. The first leg had a shoulder harness suspension. The leg worn upon his acceptance as a research patient had been converted in 1952 from an aluminum socket, pelvic belt leg to a wooden suction socket prosthesis a year and nine months previously. He was employed as an expediter in a shipyard, and the nature of his employment was such as to involve considerable standing and moving about over short distances. His chief complaint was concerned with persistent edema of the stump since conversion to suction suspension, and this was the reason for his referral to the clinical study program by a local limbshop in November 1952. The patient complained of occasional phantom pain but had no persistent local pain.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was in good general health, with normal reflexes and above average musculature. The stump was cylindrical, with 6 1/2 in. of femur below the perineum and 2 1/2 in. of soft tissue over the end of the femur (<b>Fig. 9</b>). Stump musculature was not abnormally prominent, and subcutaneous tissue was light. On contraction of the muscles, the redundant tissue pulled upward without bunching. A large scar, adherent to the distal end of the femur, extended 6 in. up the lateral side of the stump (<b>Fig. 10</b>). There was severe, nonpitting edema in the redundant tissue. The skin in the edematous area was without hair, distended, discolored, and scaly, with an orange peel texture. Small cysts and horny nodules were evident in this region as well as in the inguinal area and in the crotch. The patient said that these cysts frequently enlarged and broke down, producing a pinkish yellow discharge.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9 Case 3. X ray of stump, mediolateral view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 3. Lateral view of stump. Note large, adherent scar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>X ray revealed the usual finding that there was lessened bone density on the amputated side and that the femur tapered and curved medially toward the distal end, which appeared to be closed. Comparison of socket and stump perimeters showed the socket smaller than the stump by 1 1/4 to 2 in. at corresponding levels. The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2<i> </i>in., as compared to the corresponding socket measurement of 5 in.</p> <p>The suction socket the patient was wearing, although of the ischial bearing type, did not achieve ischial bearing. The anteroposterior dimension was too large, the mediolateral dimension too small (<b>Fig. 11</b>). The socket was too tight, especially in the distal half, and the proximal end of the stump was constricted because of a wedging action precipitated by failure to establish ischial gluteal bearing. Weight was borne on the medial brim of the socket, which was 3/8<i> </i>in. below the level of the ischial seat and generously flared. There was a small adductor roll, and the anterior brim of the socket was level with the posterior brim, with some roll formation in the area of the inguinal crease. The anterior wall was undercut, a feature that caused localized high pressure on the stump at the anterior brim. The patient was well adapted to the use of the prosthesis, although a number of undesirable characteristics of gait were apparent, including a 7 in. walking base, considerable sidesway, and exaggerated arm swing on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11, Case 3. Socket shape of prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>This patient's chief problem was the severe edema. It was felt that this disorder, as well as the skin lesions, could probably be controlled adequately by proper fit and alignment. The question of prime interest to the study group was whether or not suction suspension was the cause of the edema in this case.</p> <p>The amputee was provided with a suction socket prosthesis with conventional components, including a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were made of wood and reinforced with rawhide. An automatic expulsion valve with a strong spring was used to increase positive pressure in the socket during the stance phase.</p> <p>The socket perimeters were 1 1/2<i> in.</i> less than corresponding stump dimensions in the top third and equal to stump dimensions below that.</p> <p>The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2 in., and the corresponding socket dimension was 4 in. The anterior wall was relieved to avoid pressure in the area contacting the femoral triangle (<b>Fig. 12</b>), and a flat sponge rubber pad covered with soft leather was placed in the bottom of the socket to provide back pressure on the edematous tissue.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 3 Socket shape, present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the patient had worn the prosthesis for six weeks, the edema in the redundant tissue had decreased markedly. The improvement was maintained over a nine month period, although at no time was the condition completely eliminated. About the ninth month, there was a sudden increase in the amount of edema. Three factors seemed to be involved. There was increased activity. A weaker valve spring had been installed to reduce loss of suction. And there had been stump shrinkage, as indicated by the experience of ramus discomfort. The thickness of the control pad was increased, but doing so did not alter the condition. Next, a stronger valve spring was provided to increase the positive pressure in the stance phase, and there was then a marked and immediate improvement in the edematous condition of the stump. To provide increased ischial weight bearing by reducing the anteroposterior dimensions of the socket, liners were added in the area of the socket contacting the femoral triangle. Although ischial weight bearing was improved, as evidenced by the elimination of ramus discomfort, there was no change in the edema.</p> <p>The decision was then made to provide the amputee with a socket that would make total contact with the stump end, thus exerting greater back pressure on the edematous tissue. After a four day trial period, the patient found that accumulated perspiration irritated the stump acutely, and the socket had to be discarded. At present the amputee continues to wear the first prosthesis provided and still has moderate edema.</p> <p>Skin infections initially present in the crotch area were cleared with provision of ischial gluteal weight bearing, but with stump shrinkage the condition recurred because of decreased effectiveness of such weight bearing. Provision of liners over the area of the socket contacting the femoral triangle increased the effectiveness of ischial gluteal weight bearing and reduced the skin problems. Throughout treatment, there was irritation on the weight bearing area of the stump, especially around the ischial tuberosity. Provision of a section of nylon stocking, fastened to the outside of the socket and draped interiorly over the weight bearing area, improved comfort considerably by reducing shear between the skin and the socket. The skin irritations were due primarily to excessive anteroposterior socket dimensions, especially along the medial wall. This situation allowed the tuberosity to slip into the socket and the entire stump to settle deeper, with consequent wedging of the stump against the posterior brim and the anterior wall, thus creating a high force concentration on the ischial tuberosity. A pressure pad was found very helpful in controlling edema when other elements of the fit were satisfactory.</p> <p>Minor skin irritations resulted from deterioration of the inside finish of the socket, but refinishing the socket cleared them.</p> <h4><i>Summary</i></h4> <p>Although treatment was never completely successful in eliminating this patient's edema, function and comfort were markedly improved, and the course of his prosthetic treatment served to demonstrate several principles. Provision of ischial gluteal weight bearing eliminated ramus discomfort, reduced edema, and cleared skin infections anteriorly and medially where the stump contacted the socket brim. The posterior brim caused irritation of the stump when ischial bearing was indefinite, with the tuberosity near the inside edge of the socket, or when the radius of curvature over the inside edge was too small, or when the ischial area was not conditioned for weight bearing. Use of liners to decrease the anteroposterior dimension increased comfort. When there was stump shrinkage and decreased ischial support, edema increased, and a pressure pad alone was not successful in controlling it. Use of a stronger valve spring, to increase the positive pressure, decreased edema. In spite of the failure to control the edema completely, the patient was able to perform at a high level of activity.</p> <h4>Case 6, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 6, male, was 56 years old, stood 6 ft. <i>2 </i>in. tall, and weighed 142 lb. He lost his right leg above the knee as a result of a motor coach accident when he was 47. The patient's first prosthesis, fitted six months after amputation, used shoulder harness suspension. It was worn for two years. The next prosthesis provided pelvic belt suspension. It was being worn when he entered the Clinical Study in November 1953 (<b>Fig. 13</b>). Complaints included tightness of the socket, discomfort due to abrasion of the hip by the belt on the side of the amputation, and irritation in the distal lateral area of the stump. The prosthesis was in a state of general disrepair.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 6 Original prosthesis. Weight carried on adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>General health was good, and activity level was high both at home and at work. The stump was conical, with light subcutaneous tissue and very light musculature, muscular atrophy having been brought about by stump inactivity in the walking cycle. Tissue over the end of the stump was very thin. The lateral distal portion of the stump was scarred, and the ischial tuberosity was small, sharp, and lightly padded. Scars in the crotch area indicated periodic folliculitis and boil formation, and there was local pain posterodistally.</p> <p>A number of points were of interest in this case. They included a heavy adductor roll due to abducted gait and the plug fit; inexperience with suction suspension and ischial gluteal weight bearing; gait faults, including the abducted gait and pelvic hike on the side of the amputation; and the history of boils and folliculitis in the crotch due to weight bearing in that area (<b>Fig. 14</b>, <b>Fig. 15</b>, and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 14. Case 6, Relaxed position of stump prior to treatment </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15, Case 6. Adductor roll prior to treatment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case 6. Triangular shape of original socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were willow wood reinforced with rawhide (<b>Fig. 17</b> and <b>Fig. 18</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 6. New prosthesis, with ischial gluteal weight bearing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case 6. Shape of socket of new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the gluteus maximus was atrophied, the extensor channel and gluteal flare were fitted closely. No relief was provided for the heavy adductor roll, which was drawn completely into the socket as a part of the process of reduction. The socket perimeters at the brim of the socket were 3 in. less than stump dimensions. Two inches below the level of the ischial seat, socket perimeters were approximately half an inch less than stump dimensions. At the lower levels, socket and stump perimeters were identical. The distance from the ischial seat to the channel for the tendon of the adductor longus was 3 3/4 in., the corresponding anatomical measurement being 3 in.</p> <p>Adduction of the femur in the socket relaxed the adductors and permitted inclusion of the roll in the socket with less difficulty (<b>Fig. 19</b>). Initially a safety belt was provided to increase the amputee's sense of security, since he had a fear of losing the leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 6. Condition of subject one year after application of new prosthesis. Note reduced adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the first three months of treatment the prosthesis was worn three hours a day. During the next six months use of the prosthesis was increased to all day, the extended period of adaptation to use of the prosthesis being due to discomfort at the ischial tuberosity. After nine months there was marked increase in comfort, a circumstance which induced the amputee to discard the cane he had theretofore used regularly. A soft pad over the ischial seat reduced discomfort but was discontinued after two weeks in the expectation that adaptation would be accelerated.</p> <p>Tight fit of the proximal third of the stump for reduction of the adductor roll resulted in edema in the distal portion of the stump. But when the socket perimeters in the upper third were increased to reduce constriction, the edema cleared up. Two weeks later the adductor roll had shrunk, and there was loss of suction. A new socket was made and modified with liners at intervals for a period of a month as shrinkage continued. By this time, the perimeter of the stump at the perineum had been reduced 2 1/2 in., so that a new socket was required. The dimension of this socket from the ischial seat to the channel for the tendon of the adductor longus was reduced by half an inch, and a protuberance was provided over the area contacting the femoral triangle.</p> <p>Edema recurred after six months, and examination of fit showed considerable development of the hamstring muscles. Accordingly, the socket was opened at the posterior wall starting 2 in. below the ischial seat level; the edema cleared up.</p> <p>Further development of stump musculature resulted in edema at the end of the stump during the ninth month of treatment. Increased hamstring relief was provided, a stronger valve spring was installed, and a sponge rubber pad was placed in the bottom of the socket to increase back pressure on the end of the stump. Again the edema cleared up.</p> <p>Training was provided for a period of one hour a day for six weeks. Gait was excellent under observation, although there was some reversion to old habits when the amputee was not under supervision. Pelvic hike was particularly persistent. Those habits which were dependent on fit and alignment, including abducted gait, were gradually eliminated.</p> <h5><i>Summary</i></h5> <p>Problems studied included stump changes, particularly at the large adductor roll, adaptation to suction suspension, adaptation to ischial weight bearing, and gait faults. Boils and folliculitis did not recur during the process of treatment.</p> <p>Reduction of the large adductor roll formed in five years of weight bearing in the crotch with abducted gait required six months of treatment. During this period there was some edema owing to constriction of the proximal third of the stump. Edema was reduced by increasing the perimeters of the socket in this region. Edema resulted again owing to constriction following hamstring hypertrophy.</p> <p>Relief for this development, the use of a stiffer valve spring for increased positive pressure in the stance phase, and a sponge rubber pad in the bottom of the socket cleared up the edema.</p> <p>There was periodic loss of suction following stump shrinkage. The light subcutaneous tissue could be distorted very little. As a result, slight stump changes led to loss of suction.</p> <p>Initially some lateral instability and reduced control of the prosthesis, probably resulting from weakness of the gluteus medius, was experienced. With adaptation to suction suspension, there was increased stability and control as the gluteus medius became stronger. Adaptation was completed within the nine months required to stabilize the stump. The ischial tuberosity took more than nine months to condition for weight bearing, chiefly because of the lack of previous experience, the light padding over the tuberosity, and the especially sharp configuration of the bone.</p> <h4>Case 8, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 8, another male, was 42 years old, measured 6 ft., and weighed 175 lb. His right leg was amputated above the knee in December 1949 after a shotgun wound received in a hunting accident approximately a year previously. He had had only one prosthesis since amputation and was wearing it at the time he was accepted by the Clinical Study in January 1954. Although the prosthesis provided suction suspension, the components were conventional. The patient was dissatisfied with the prosthesis primarily on the basis of poor fit, but he felt that the alignment could be improved and that such improvement might give him more comfort and better function. He also complained of needlelike phantom pains in the ball or sole of the "foot," with persistent tingling.</p> <h5><i>Examination and Evaluation</i></h5> <p>General physical examination was normal. The stump was conical (<b>Fig. 20</b>), approximately 9 in. of femur remained below the perineum, and about an inch of tissue covered the end of the femur. Musculature of the stump was firm, but there was retracted muscle on the lateral side about 2 1/2<i> </i>in. from the tip of the femur. There was little subcutaneous fat. On the posterior aspect of the stump at the distal end was an inverted T shaped scar, and the distal end of the femur was sensitive to pressure. X ray showed a medioposterior spur arising from the end of the femur, curving upward, and tapering. There was edema and brown discoloration at the end of the stump (<b>Fig. 21</b>), and small follicular lesions were evident in the areas contacting the anterior and medial brims of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case 8 Stump molded by tight fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 8. Socket shape of original prosthesis. Note edema and brown discoloration at the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis had a wooden socket reinforced with rawhide, a single axis knee with constant friction for swing phase control, an ankle providing plantar dorsiflexion action, and a foot with a single toe break 5 in. anterior to the ankle axis. Weigh t was carried through a roll of flesh at the brim of thesocket (<b>Fig. 22</b>), and the amputee walked with a wide based gait owing to crotch discomfort and out set of the foot. Knee stability was excessive because of the long forefoot and the posterior position of the knee axis, which fell approximately 1 in. posterior to the tro chanter ankle reference line. The prosthesis was short, but this detail was not too apparent since the ischial tuberosity was 1 1/2 in. above the posterior brim of the socket. Because of insufficient knee friction and excessive kicker action, there was heavy impact at the end of the swing phase, and there was whip during the swing phase, probably owing to muscle activity within the socket and to the vigorous stump action required to break the prosthetic knee at the end of the stance phase. Rotation at heel contact was due to excessive stiffness of the plantar flexion bumper.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 8. Original prosthesis. Plug fit, with roll formation over the socket brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Problems of interest to the Clinical Study included the edema encountered with use of suction suspension, skin infections, the adductor roll, the time and circumstances involved in conditioning the amputee to ischial gluteal weight bearing, and gait training.</p> <h5><i>Treatment</i></h5> <p>Reduction of the edema required reduced constriction of the proximal third of the stump through provision of ischial gluteal weight bearing, extension of the anterior wall above the level of the ischial seat, and close fit of the distal two thirds of the stump. Reduction of pressure on the proximal end of the stump from the superior brim of the socket was required to clear up skin infections. At the same time, snug fit, with adduction of the femur in the socket to relax the adductors, was required for reduction of the adductor roll. Improved fit and alignment, with training, were planned to correct gait faults.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were of wood, reinforced with plastic laminate. The extensor channel was held shallow and flared minimally at the brim to increase gluteal weight bearing, since the amputee was not accustomed to ischial weight bearing. Xo relief was provided for the adductor roll. The anterior wall of the socket was slightly relieved over the area contacting the femoral triangle (<b>Fig. 23</b>). The toe break was cut 5 in. anterior to the ankle axis so as to coincide with the normal break of the shoe. To increase knee stability in the initial phase of the fitting, the knee axis was placed 3/4 in. behind the trochanter ankle reference line. Socket perimeters were 1 1/4 in.<i> </i>under stump perimeters at the proximal end and equal to stump perimeters at the level of the distal two thirds. The distance between the ischial tuberosity and the adductor longus tendon was 3 3/4 in., the corresponding socket dimension being 4 1/2 in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 8 Socket shape, new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evaluation following delivery of the prosthesis indicated that knee stability was excessive owing to the long forefoot and the posterior position of the knee axis. Training was required to improve balance and cadence symmetry and to overcome the vaulting as well as to reduce the width of the walking base. The ischial tuberosity was on the seat, and there was no ramus contact with the medial brim of the socket. The adductor roll was contained in the socket. Roll formation over the anterior brim of the socket was eliminated (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24 Case 8. New prosthesis. Note elimination of roll formation over the brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially there was some edema at the distal end of the stump owing to constriction proximally. As the flesh roll reduced, constriction and edema decreased, and finally the edema cleared up. After an illness which caused the patient to lose considerable weight, the stump settled deeper into the socket as the ischial tuberosity slipped inside. This circumstance allowed the ramus to contact the medial brim and caused the anterior and posterior brims to constrict the stump. But because the somewhat conical shape of both stump and socket maintained the snug fit over the entire stump as the latter settled down into the socket, and because, consequently, the pressure differential between the proximal and distal portions of the stump was not increased sufficiently, edema did not recur. Nevertheless, ramus discomfort decreased activity on the prosthesis. The problem was eliminated with provision of a new socket.</p> <p>Follicular lesions cleared up with effective ischial gluteal weight bearing but recurred when ischial support was decreased following loss of weight. Provision of a new socket with ischial gluteal weight bearing again cleared up the skin condition. With the first socket, poor stabilization of the ischial tuberosity on the seat contributed to skin irritation and to the formation of horny nodules in the weight bearing area. Comfort was greatly improved by reduced anteroposterior dimensions, with improved anterior support by provision of a protuberance on the anterior wall over the area contacting the femoral triangle.</p> <p>Gait training improved walking habits but focused attention on deficiencies of fit by forcing the amputee to walk according to a preconceived pattern rather than one that provided maximum comfort. Sixteen months after training was complete, evaluation indicated that, because of discomfort from loss of fit, gait was somewhat worse than before training. Since in any case the amputee adapted his gait pattern to provide maximum comfort, training was of doubtful value as compared with good prosthetic treatment. With the first prosthesis, excessive knee stability detracted from naturalness of gait, and this condition also was a factor in causing the discomfort in the ischial gluteal area and at the end of the femur anteriorly, where the stump showed the results of the force required to break the knee. Subsequent fit and alignment corrected these problems and greatly improved comfort. The length of the forefoot was reduced to approximately 3 1/2 in. to decrease knee stability, and the knee axis was placed on the ankle trochanter reference line.</p> <h5><i>Summary</i></h5> <p>The patient's edema on the prosthesis worn at the time of referral was apparently caused by constriction of the stump in the socket, especially in the proximal third. A contributing factor was weight bearing on the adductor roll over the medial brim. Provision of ischial gluteal weight bearing, with wide distribution of the pressure on the anterior aspect of the stump, had a number of consequences. The edema disappeared with the reduction of the adductor and anterior rolls and recurred only when fit and ischial support were lost with loss of weight from illness. Skin irritations in the crotch, along the gluteal fold, and around the ischial tuberosity were cleared up by reduction of shearing forces when positive support was provided. Reduction of alignment stability by shortening the toe break length and by moving the knee axis forward cleared up the skin irritation on the anterodistal aspect of the stump by reducing the force required to break the knee at toe off. Training appeared to have far less effect on symmetry of gait than did fit and alignment. When the patient was able to walk symmetrically with comfort, he did so. When last seen, the amputee reported a general increase in comfort and a corresponding increase in his level of activity.</p> <h4>Case 9, Bilateral Above Knee, Upper Third of Thighs</h4> <h5><i>History</i></h5> <p>Case 9, male, 27 years of age, weight 100 lb., underwent amputation at the age of eight as a result of crushing injuries to both legs sustained in a truck accident. He had had six pairs of legs since his amputation, the first pair having been fitted four months after surgery, without preliminary conditioning iherapy or exercise. That pair, employing shoulder harness suspension, was worn for four years. Between that time and 1948, he had had three sets of legs, all employing pelvic belt suspension and using conventional components. In 1948 he was fitted at the University of California with suction suspension. The prostheses were worn for two years and then discarded because of disrepair. New suction sockets, provided in 1950, were worn for two years. These were uncomfortable owing to tightness of fit. In 1953 a local limbshop fitted the patient with the suction socket prostheses he was wearing when referred to the Clinical Study in September 1953. The complaints included skin irritation with folliculitis, boils, and abrasion on areas of the stump contacting the socket brim; crotch discomfort; and edema in the ends of the stumps. Although working at essentially a sedentary occupation, he did a great deal of walking around his office.</p> <h5><i>Examination and Evaluation</i></h5> <p>There were no significant physical findings except as pertaining to the amputations. This young man was well nourished, healthy, and of average intelligence. The stumps were almost identical. They were approximately 6 in. long, measured from the perineum, and cylindrical, with approximately 2 in. of tissue over the distal ends of the femurs (<b>Fig. 25</b>). Hygiene of the stumps and prostheses was poor, perspira ation level high. There were boils, folliculitis, and abrasions on the stumps and the crotch areas, with boils and folliculitis in the inguinal creases. Both stumps had heavy, nonpitting edema and petechiae at the distal ends. The stumps were held in 28 deg. of abduction, but ranges of motion and muscle power were normal and equal. X ray showed medial curvatures of both femurs distally. The medullary cavities appeared to be closed, and there were no sensitive areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 9. Stumps relaxed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prostheses (<b>Fig. 26</b>, <b>Fig. 27</b>, and <b>Fig. 28</b>) had rectangular suction sockets on single axis knees with constant friction swing phase control, plantar dorsiflexion ankles, and wooden feet with single toe breaks. Segments of the prostheses were made of willow reinforced with rawhide. No auxiliary suspension or control straps were used. Although the sockets were intended to provide ischial gluteal weight bearing, the ischial tuberosities were down inside the sockets so that weight was carried on the medial brims, which had been lowered in an unsuccessful attempt to provide relief, with severe wedging of the stumps against the anterior and posterior brims. This situation was a cause of irritation and infection of the stumps in the areas contacting the medial and posterior brims of the sockets and promoted edema by restriction of circulation. Excessive alignment stability due to posterior placement of the knee axes increased forces on the posterior aspects of the stumps as the amputee attempted to break the knees to initiate swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 9. Socket shape of prostheses worn at time of referral, medial walls nearest patient's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Case 9. Prostheses worn at time of referral, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 28. Case 9. Pros theses worn at time of referral. posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient walked with a wide based gait, at least partially because of the abducted position of his stumps. He customarily used a cane but was able to walk without it. Because the amount of friction in the swing phase control units was adjusted to provide minimum resistance to rotation, there was impact at the end of the swing phase. Rotation at heel contact was due to excessive stiffness of the heel bumper of the left prosthesis. Torso and pelvic list were due to shortness of the right prosthesis.</p> <h5><i>Treatment</i></h5> <p>The objectives of treatment in this instance were:</p> <ol> <li>Elimination of crotch discomfort and skin problems by providing definite ischial gluteal weight bearing ;</li><li>Elimination of irritation and follicular lesions in the inguinal areas by reducing force concentrations in these areas through use of high anterior walls and definite ischial gluteal weight bearing;</li><li>Reduced wedging of the stumps proximally through provision of definite ischial gluteal weight bearing and high anterior walls for increased area of support;</li><li>Close fit oi the slumps along their entire lengths, with decreased wedging of the stumps proximally, for reduction of the edema;</li><li>Reduction in energy consumption by providing increased voluntary control with flexion of the stumps in the sockets and reduced alignment stability; and</li><li>Study of the effect of narrow and wide base alignment on lateral stability, within the limits imposed by the abducted positions of the stumps.</li></ol> <p>In March 1954, the patient was provided with two suction socket prostheses (<b>Fig. 29</b>). A light webbing belt was furnished to aid suspension. Single axis constant friction knees, plantar dorsiflexion ankles, and wooden feet with rocker toe breaks and foam crepe shoe sole material in the toes were used. The prostheses were reinforced with rawhide, the inside surfaces of the sockets were finished with cellulose acetate lacquer, and automatic expulsion valves with standard springs were used. For knee stability, the reference line joining the ankle axis to the point of contact of the greater trochanter passed 1 in. ahead of the knee axis on both prostheses. The ankles were provided with stiff plantar flexion bumpers to increase anteroposterior stability.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 9. Present prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Within approximately a month from the time of fitting the initial prostheses, there was substantial improvement in comfort and skin problems in the crotch areas. The medial brims were not appreciably lower than the posterior brims. Skin problems in the inguinal creases were relieved by ischial gluteal weight bearing, by high anterior walls, and by provision of a protuberance over the region of the femoral triangle (<b>Fig. 30</b> and <b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 9. Socket shape, present prostheses. Ischial seats are at bottom center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 9. Present prostheses, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Provision of ischial gluteal weight bearing and increased anterior support resulted in reduced wedging of the stumps proximally, and a close fit of the stumps over their entire length produced a prompt and marked reduction in edema. Irritation in the weight bearing area was a persistent problem in the early stages of fitting. At one point, the amputee had the sockets modified in a commercial limbshop in an attempt to relieve this discomfort. But these changes increased the anteroposterior adjusted to dimensions of the sockets medially in the upper third. The tuberosities slipped into the sockets, and edema recurred. New sockets were fitted to re establish ischial support. Irritation and discomfort in the area of the tuberosities disappeared after approximately two months of conditioning. Ischial gluteal weight bearing raised the stumps in the sockets and decreased voluntary control, but after four months the patient became this change. It was found that he could walk with adequate control and stability when using stiff plantar flexion bumpers, with the ischial seats well behind the projected lines through the ankle and knee axes, and with initial flexion of the stumps for voluntary control (<b>Fig. 31</b>). Because of long established habits of abduction, it was necessary to provide wide base a lignment of the second pair of prostheses. At the time of the final evaluation, the stumps were in excellent condition.</p> <h5><i>Summary</i></h5> <p>The patient's problems of edema and skin irritation in the areas of the crotch, the inguinal creases, and the gluteal folds responded well to the standard principles of fitting. Irritation in the weight bearing area was a temporary problem which cleared up with tissue conditioning. A wide walking base was required in this case for lateral stability. The stiff plantar flexion bumpers provided anteroposterior stability both standing and walking. Placement of the sockets well forward on the knees provided adequate security.</p> <h4>Case 10, Very Short Above Knee</h4> <h5><i>History</i></h5> <p>Case 10, male, was 51 years of age, weighed 150 lb., and was 5 ft. 7 in. tall. Amputation was through the left femur in the upper third. The original amputation had been carried out in December 1952 as a result of arteriosclerosis, and the stump had been revised in August 1953.</p> <p>This patient was referred by a local limb shop that was in the process of fitting him with a pelvic belt prosthesis converted from a suction socket because of failure to maintain suction. He was pessimistic about the use of suction suspension and was unwilling to attempt it except for the benefit of the research group. Because of pressure in the groin, insecurity at the knee, toe scuffing in the swing phase, and stump withdrawal when sitting, he was dissatisfied with the leg being fitted by the local shop.</p> <h5><i>Examination and Evaluation</i></h5> <p>Physiologically, the patient appeared older than his age, but he was alert and cooperative. The abdomen was severely scarred from surgical incisions for appendectomy and double sympathectomy, and scars also extended from the distal end of the stump up the antero medial aspect to mid groin. The medial scars were deeply adhered to underlying tissue. Subcutaneous fat was moderate and musculature firm, with prominent adductors and gluteus maximus. There were no sensitive areas. Skin was normal. The femur extended 1 1/2 in. below the perineum and 7 in. below the great trochanter (<b>Fig. 32</b> and <b>Fig. 33</b>). A spur extended upward on the medial side, and the stump showed some abduction contracture.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 10. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 10. Stump in 90 deg. of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient was of interest primarily because of the very short stump. Also of interest was the patient's inexperience, which offered an opportunity to study problems of adaptation and stump changes. Experience in prosthetic treatment of cases with circulatory impairment was also desired.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis. At first a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with single toe break were used. Segments were of wood, reinforced with plastic laminate. Later the knee was changed to a friction stabilized type. The final socket was made of plastic laminate, and a SACH foot (solid ankle, cushioned heel) was used instead of the conventional foot.</p> <p>Two sockets were fitted within the first two months. With the second socket, all requirements for the successful application of suction suspension had been met, but, because of obscuring factors related to the amputee's attitude, this condition was not altogether understood at the time. A remolding process had brought about elongation of the stump, a feature which made suction easier to maintain.</p> <p>Successful application of suction suspension depended upon undercutting the posterior, medial, and anterior walls of the socket below the ischial seat level, maintaining the lateral wall above the level of the ischial seat, and holding the fit close in the proximal part of the stump. Because of the undercut medial wall, bunching of the adductors did not break the suction. Suspension aids, valuable in providing increased sense of security in the initial phase of treatment, were unnecessary once the amputee was adapted to the use o'f his prosthesis. Because of the limited amount of femur available, and also because of the abducted position of the stump, no attempt was made to adduct the femur in the socket. Flexion of the stump in the socket was designed to meet the natural requirements of the stump and spine rather than to provide voluntary control of the knee, since stump power was limited and undercutting of the anterior and posterior walls of the socket reduced the effectiveness of the stump in controlling the knee (<b>Fig. 34</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 10. Rectangular socket provided for patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially the patient was provided with a conventional single axis knee with adequate knee stability. Fear of falling and buckling of the prosthetic knee due to weakness of the normal leg, inexperience, and other factors, however, led to use of a friction stabilized knee. But aligning the friction stabilized knee in accordance with the rules for the single axis conventional knee resulted in excess stability at the end of the stance phase. Accordingly, the knee was later aligned to provide decreased alignment stability with greater reliance on the friction mechanism.</p> <p>Although narrow based gait was not anticipated in the alignment of the limb, the amputee was able to walk with a 4 to 6 in. base. The prosthesis was made about 1 1/2 in. shorter than the normal limb (<b>Fig. 35</b>) because the amputee found that the shorter prosthesis permitted better control. Before prosthetic treatment started, the patient had back pains, and it was anticipated that the shorter leg might lead to recurrence. As a matter of fact, he had some recurrence of the back pains early in the fitting when a webbing belt was tried as a supplement to suction suspension. But this problem disappeared when use of the belt was discontinued.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 10. New prosthesis, posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump changes during the study were minimal. In the first two and a half months, stump shrinkage occurred, but the stump remained stable throughout the following two years of observation. After the patient had worn the first suction socket prosthesis a short time, the tissue of the stump started to extend, so that by the time the stump had stabilized there was an increase from 1 1/2 in. to 3 in. of tissue available below the perineum for effecting a suction seal. At no time was there more than a reddening of the stump in the weight bearing area, and, as the tissue became conditioned, the skin became dark and tough. There was no edema.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to attempt application of suction suspension to a very short, heavy, above knee stump. Suction proved to be a practical means of suspension. All walls were concave, and relief was provided for bunching adductors to prevent the stump from being forced away from the socket in the medial apexes with consequent failure of the suction seal. For increased control and reduced effort, the amputee preferred the prosthesis approximately 1 1/2 in. shorter than the normal leg. There were no back pains. The stump shrank slightly during the first two months, and there was elongation of the stump, particularly on the medial side. Because of insufficient knowledge for adequate prosthetic treatment of the patient, and because of the poor adjustment of the patient to his amputation and physical condition, rehabilitation was a lengthy process. Once the patient was successfully treated, no changes in fit and alignment were required over a two year period.</p> <h4>Case 24, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 24, female, was 41 years of age, stood 5 ft. 2 in. tall, and weighed 126 lb. She had undergone amputation at the level of the lower third of the left femur. There had been a congenital lymphangioma involving the tissues of the left leg from the knee down. Infection developed in the soft tissues over the anterior portion of the tibia, and subsequently there was an osteomyelitis of the tibia. Later a mass, which was diagnosed as carcinoma, appeared in the ankle. Amputation was performed in May 1954.</p> <p>The amputee had had only one prosthesis since amputation. It consisted of conventional components and a molded leather socket laced anteriorly (<b>Fig. 36</b>). When she entered the study program in January 1955, complaints included skin irritation and infection, with discomfort in the crotch, discomfort and restriction from the corset used to suspend the prosthesis, right sided backache, and excessive wear of hosiery.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 24. Prosthesis worn on referral. Note lateral displacement of the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Normally a very active person, the patient had a rather low activity level owing to limitations imposed by her prosthesis. General physical condition was good, except for very flabby abdominal musculature, but the patient experienced phantom sensations as though the "leg" were "falling asleep." Phantom pains in the form of cramps in the ''calf" and shooting pains on the medial side of the "ankle" also were present. They lasted only a few seconds and were less frequent since she had been fitted with a prosthesis.</p> <p>The stump was cylindrical and 9 in. long measured from the perineum, including approximately 2 in. of redundant tissue over the end of the femur. Subcutaneous tissue was heavy but firm. Musculature was of average strength, with no group particularly prominent. There was no significant edema or skin problem in the distal end of the stump, but follicular lesions existed in the crotch, and areas of irritation were present on the torso from pinching and bruising by the corset stays.</p> <p>The prosthesis provided weight bearing on a flesh roll around the brim of the socket, in the crotch, and against the side walls of the socket (<b>Fig. 37</b> and <b>Fig. 38</b>). A pressure pad in the bottom of the socket did not provide appreciable support, and the patient walked with a wide base and with torso and pelvic list owing to excessive length of the prosthesis, wide base alignment, and discomfort in the crotch. Stride length, cadence, and arm attitude were unsymmetrical because of excessive stability of the prosthetic knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 24. Socket shape at the brim, prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 24. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This amputee presented several problems of interest to the study group. They included skin infections, the relationship between redundant tissue at the end of the stump and edema with suction suspension, factors involved in changeover from corset to suction suspension, factors involved in changeover to ischial gluteal weight bearing, stump changes, the cosmetic problems of a female amputee, and use of the SACH foot with high heeled shoes.</p> <h5><i>Treatment</i></h5> <p>In September 1955, the patient was provided with a suction socket prosthesis consisting of a single axis constant friction knee, a SACH foot made for a high heeled shoe, and wooden segments reinforced with plastic laminate. An automatic expulsion valve with standard spring was used, and the inside surface of the socket was finished with phenolic resin varnish. A polyvinyl chloride acetate cosmetic cover was provided for the shank. Since the amputee was unaccustomed to ischial weight bearing, and also in order to increase sitting comfort, the gluteal flare and the extensor channel were fitted closely to provide increased gluteal support. The lateral wall was closed in over the stump above the ischial seat level, and the anterolateral apex was closed to reduce conspicuousness of the brim of the socket under the clothing.</p> <p>This socket was worn on the adjustable leg<a></a> for approximately a month and was then installed in a finished prosthesis. After a week, the redundant tissue at the end of the stump was moderately edematous. The only known difference between the prosthesis with the adjustable leg and the finished prosthesis was that the latter had five coats of "Platon" varnish on the inside of the socket. There were three possibilities related to the finish of the socket interior. The stump worked down into the socket through weight bearing, with increased effect of muscle activity on negative pressure and reduced positive pressure in the stance phase owing to reduced excursion of the stump in the socket. There was adherence of the stump to the walls of the socket and, hence, reduced massaging action at the distal end. Vacuum seal was improved so that negative pressure was maintained, especially during sitting.</p> <p>The edema cleared up after provision of a pressure pad in the bottom of the socket and after atrophy of the stump, which reduced constriction proximally. In addition there was, as a result of aging and lubrication of the surface finish by body oils, decreased adherence of the stump to the socket. Addition of liners to compensate for shrinkage did not cause edema with this socket.</p> <p>A second prosthesis was supplied in December 1955, the socket of this limb being fitted snugly in anticipation of further shrinkage of the stump. Six weeks after delivery of the prosthesis, examination showed edema at the end of the stump. A pressure pad was provided, but there was no reduction in the edema during the next two months. Pad thickness was then increased. When the amputee was examined next, six weeks later, the pad had been discarded owing to ineffectiveness in controlling the edema. Edema was reduced, and the stump had atrophied further. This development had reduced constriction of the proximal portion of the stump without reducing the effectiveness of ischial support, thus indicating that edema was caused by constriction of the proximal area and that the pressure pad was ineffective in reducing it so long as constriction persisted proximally. Six weeks later there was no edema, and the socket was looser. Liners were installed over the anterior and posterior walls to decrease perimeters of the socket in the upper third by one inch. Edema did not recur. Socket perimeters proximally were reduced another inch two months later as a result of stump atrophy. There was no edema before or after addition of the liners, and at no time was there failure of ischial support.</p> <p>The patient adapted very well to the changeover from corset to suction suspension and appreciated the comfort and freedom that resulted. Control of the prosthesis was excellent. Adaptation to ischial gluteal weight bearing was immediate, and skin lesions and discomfort in the crotch cleared up quickly. The shallow gluteal flare and extensor channel, with relief for hamstring attachments at the ischial tuberosity, provided sitting comfort. As the stump atrophied, proper weight bearing was maintained effectively by the addition of liners to the anterior and posterior walls of the socket as necessary (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Case 24. Socket shape, new prosthesis. Note liners added for shrinkage adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump atrophy due to heavy subcutaneous tissue was a problem, and the stump had not stabilized at the end of a year. It was found that initial fitting of the socket snugly, in anticipation of shrinkage, was satisfactory practice and did not produce a serious amount of edema. Such edema as was produced subsided as stump atrophy proceeded. As further shrinkage occurred, liners were added without complications.</p> <p>Closing the lateral wall over the stump above the ischial seat level and curving the anterolateral apex improved appearance of the prosthesis under clothing. The SACH foot provided a good cosmetic junction between the shank and the foot and permitted use of high heeled shoes. The polyvinyl acetate cosmetic covers used were sufficiently durable (<b>Fig. 40</b>) and were acceptable in appearance until they become discolored. Staining was objectionable within about six months.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Case 24. Anterior view of new prosthesis with cosmetic covering. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the cosmetic effect of the SACH foot was appreciated by the amputee, there was objection to the decreased plantar flexion action and to the damage this caused to spike heeled shoes. As a result, the patient requested a foot with an articulated ankle. It was found that the decreased plantar flexion action was a problem down ramps only.</p> <h5><i>Summary</i></h5> <p>In spite of the excessive amount of redundant tissue at the distal end of the stump, it was possible to use successfully suction suspension embodying the principles and techniques previously outlined. Problems of edema, skin changes, and loss of suction that occurred during fitting and wearing of the prosthesis were successfully treated by controlling the fit and alignment. Proper fit and alignment were instrumental in promoting stump reduction to a more firm and functional state and in eliminating skin lesions and discomfort in the crotch due to the heavy subcutaneous tissue and steady stump reduction. With a properly fitted suction socket prosthesis, the patient was able to assume a more satisfactory level of activity without discomfort, and it was possible without difficulty to adapt this type of prosthesis to the requirements of cosmetic appearance. Foot and ankle function were suitable for use with high heeled shoes, but frequent examinations and modifications to socket fit were required to maintain comfort.</p> <h4>Case 28, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 28, male, age 62, height 5 ft. 11 in., weight 121 lb., underwent amputation in the lower third of the left femur in June 1955 following circulatory failure. When he entered the Clinical Study in August 1955, he was wearing a plaster socket on a peg leg with shoulder harness suspension. He disliked the peg leg because of its appearance and because of discomfort in the crotch. Activity level postoperatively was very much less than prior to amputation and was a matter of great concern to the amputee, who had just retired to a small farm.</p> <h5><i>Examination and Evaluation</i></h5> <p>The amputee's physiological age was in advance of his chronological age. The stump was 11 in. long and cylindrical, with light subcutaneous tissue, average musculature considering the age of the patient, and full range of motion at the hip (<b>Fig. 41</b>). The end of the femur was adequately covered and tolerated considerable pressure. At the end of the stump there was persistent, mild pain not related to use of the temporary prosthesis, and there were diminishing shooting phantom pains. X ray showed a spur on the lateral distal end of the femur. Postoperative edema was slight. The plaster socket on the pylon leg had been furnished to aid in reducing the stump. As shrinkage proceeded, the number of stump socks used had been increased to adjust for it. Considerable stump shrinkage had occurred, a circumstance which, despite the added stump socks, allowed the stump to drop into the socket. Severe crotch discomfort was present, since ischial weight bearing was not used. The amputee walked with a circumducting gait, stride length on the prosthesis was shorter than that on the normal side, there was rotation around the pylon in stance phase, gait was abducted, and one cane was used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Case 28. Stump in abduction, slack tissue on medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of interest to the research group were the effects of the temporary plaster socket and the peg leg, stump changes, the rate of rehabilitation of the amputee, and evaluation of suction suspension on an elderly amputee with circulatory deficiency.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis which included a willow socket, a variable cadence friction controlled knee, a willow shank, and a SACH foot (<b>Fig. 42</b> and <b>Fig. 43</b>). Wooden segments were reinforced with plastic laminate, and the socket was finished inside with a phenolic varnish. The extensor channel was shallow, and there was minimal gluteal flare to ensure as much gluteal support as possible (<b>Fig. 44</b>). The anterior wall protruded over the area contacting the femoral triangle starting at the anterior brim and extending downward to a point one third the distance down into the socket. Evaluation of the finished prosthesis indicated that the forefoot was too long and that there was insufficient initial flexion of the stump in the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Case 28. Lateral view of new prosthesis. Note amount of initial flexion of the stump, as indicated by the angle between the shank and thigh sections Note also extension of the gluteus maxi mus over the brim of the socket, indicating weight bearing on the tendinous hamstring attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 43. Case 28. Posterior view of new prosthesis providing ischial gluteal weight bearing and narrow based alignment. Knee is friction stabilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Case 28. View of the crotch area of the stump and of the socket brim of the new prosthesis. Note the distance between the level of the ischial tuberosity and the very prominent tendon of the adductor longus. Note also the corresponding socket dimension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At first the amputee found it difficult to don the prosthesis, partly because of his age and partly because of the snugness of fit, which was intended to aid in stump reduction. The difficulty decreased as the patient became more accustomed to the limb and as snugness was reduced with stump shrinkage. Because of the patient's age and physical condition, it was necessary to maintain a comparatively low activity level during fitting and training, a matter which resulted in minimum discomfort or abrasion of the skin from impact between the stump and socket. The single axis knee offered sufficient stability under normal circumstances, but the amputee felt insecure at such activities as gardening. As a result, he was provided with a friction stabilized knee, and alignment stability was reduced. Initial indications were that the friction stabilized knee was an advantage, especially at heel contact. More supervision during fitting and training was required than is usually the case with younger amputees. Suction suspension offered good control, but had the patient been weaker this method of suspension might not have been practical because of the difficulty of putting the leg on.</p> <p>Gait evaluation showed two faults. One, circumduction of the prosthesis, was probably carried over from the peg leg. The other, which consisted of stepping from the prosthesis to the normal leg as soon as the resistance of the prosthetic forefoot was felt, may also have been related to the use of the pylon. Training reduced but did not eliminate these characteristics of nonsymmetrical gait.</p> <p>There was consistent stump shrinkage over the first six months of treatment. The initially snug fit of the socket was of limited significance since shrinkage was extensive. Addition of liners as the stump shrank was a successful means of maintaining fit, although it eventually affected alignment. Most extensive shrinkage occurred in the proximal third of the stump. Postoperative edema was not a significant factor, nor was stump hypertrophy. To avoid excessive enlargement of the socket during adjustments, it was necessary to apply a shrinker bandage before prosthetic treatment was started.</p> <p>There were no fitting problems related to the limited time lapse between amputation and prosthetic treatment. Adaptation was rapid, and the cane used with the plaster pylon was discarded before delivery of the permanent prosthesis. Use of the prosthesis as part of the reduction treatment introduced the difficulty of frequent examinations and adjustments but was less troublesome and more effective than applying the shrinker, especially at the proximal end of the stump, which the amputee found difficult to wrap properly.</p> <p>At no time were there skin or circulatory problems with suction suspension, but initially there was moderate discoloration at the distal end of the stump owing to the snugness of fit at the proximal end. Loss of suction, a matter related to the lightness of the subcutaneous tissue, was a frequent problem. Only a small amount of stump shrinkage produced loss of suction, since the amount of tissue distortion possible prior to shrinkage was limited, which is to say that stump fit had to be maintained close to optimal at all times.</p> <p>Some end bearing was provided on a pad of foam crepe shoe sole material in the bottom of the socket. When end bearing was increased periodically as the stump dropped deeper into the socket with stump shrinkage, the stump end became sensitive and even painful.</p> <h5><i>Summary</i></h5> <p>Problems studied with this amputee included those involving his age, his experience on the peg leg, stump changes, rate of rehabilitation, use of suction suspension where there had been circulatory impairment, and training. Prosthetics treatment was more time consuming, but stump discomfort was not a problem since activity level was low. At first the patient found the leg hard to put on, but this problem was overcome with practice. Fitting and training schedules were less strenuous than would be followed with a younger amputee. Use of the friction stabilized knee increased the amputee's confidence, and voluntary control was thus improved because it was possible to provide more flexion of the stump in the socket. Use of the temporary prosthesis with plaster socket and peg leg attachment introduced gait problems which could not be eliminated entirely, but the plaster socket was effective as a means of reducing postoperative edema. There was, for example, almost no postoperative edema when treatment was started. It was therefore not a problem. Suction suspension caused no circulatory difficulties.</p> <h3>Case 37, Very Short Above Knee</h3> <h5><i>History</i></h5> <p>Case 37, male, age 39, height 5 ft. 11 in., weight 180 lb., underwent amputation through the right femur, 1 1/2<i> in.</i> below the perineum, as a result of an injury sustained in World War II. At various times, but without success, attempts had been made to fit him with above knee prostheses, including suction (<b>Fig. 45</b>) and belt suspension. These circumstances led to a proposal by the referring agency to have the patient fitted as a hip disarticulation case using the Canadian type of prosthesis.<a></a> A plaster cast check socket had been fitted as a preliminary, with apparent success.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Case 37. Unsuccessful suction socket worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>The stump, though short, was powerful, and the end of the femur was covered by approximately 1 in. of muscle padding. Subcutaneous tissue was fairly heavy. The ischial tuberosity was broad and well padded, but there was pressure sensitive scar tissue on the lateral side of the stump and in the crotch (<b>Fig. 46</b>, <b>Fig. 47</b>, and <b>Fig. 48</b>). The distal end of the stump tolerated considerable pressure but, because of a trigger point on the anterodistal aspect, it was unsatisfactory for end bearing. Abduction and flexion contracture of the hip was typical of an above knee amputee with a short stump. Because of the habit of extending the knee when crutch walking, a practice which had reduced extensor control at the knee, the normal knee buckled occasionally under load in the flexed position. A triple arthrodesis of the normal ankle was an additional complication.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Case 37. Posterior view of stump. Note scar on posterolateral apex. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 47. Case 37. Anterior view of stump. Note scars in crotch and on lateral side of anterior aspect. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Case 37. Lateral view of stump in maximum flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The problem presented was how to fit an amputee who was on the borderline between the above knee case and the hip disarticulation. Were the patient fitted as a hip disarticulation, there would be loss of stump function, and, since the amputee lived in a hot summer climate, the socket would present a particularly acute heat problem. Joint placement with the hip disarticulation prosthesis would also be a problem, since, when the stump was flexed, it extended 2 in. ahead of the usual anterior contour for a hip disarticulation amputee.</p> <p>An above knee type of prosthesis offered the advantage of preserving stump function, particularly where suction suspension could be used effectively, since with the use of suction there is reduced excursion and piston action of the stump in the socket. At the same time, the shortness of the stump, with the reduced area for effecting a suction seal, and the large volume change in the stump between the relaxed and the tensed states, accompanied by prominent bunching of the adductors, could cause difficulty in achieving a reliable suction seal. Moreover, the possibility existed that the close fit required could cause discomfort to the sensitive scar tissue in the crotch.</p> <p>It was decided to treat this patient simultaneously as an above knee and as a hip disarticulation amputee, first to check the possibilities of using suction suspension on such a short stump and, second, to check the Canadian hip disarticulation prosthesis as a method of treating very short above knee stumps. The amputee was successfully fitted with a plaster hip disarticulation check socket and walked for two hours with a peg leg attached. The socket constructed from this check socket would have provided sufficient clearance for installation of the hip joint, but the hip disarticulation fitting was discontinued at this stage because of success achieved with suction suspension.</p> <p>Within five days of the beginning of treatment the subject walked successfully on the adjustable leg using suction suspension. The first socket failed from loss of suction through the posterolateral apex because the socket had been enlarged in this area in an attempt to compensate for the action of the gluteus maxi mus, which tended to force the stump away from the socket. The second socket, modified in view of lessons learned from the first, held suction and was comfortable (<b>Fig. 49</b>). It was provided in a finished prosthesis. A short above knee pelvic harness, as designed at the University of California (<b>Fig. 50</b>), was added to assist in swing phase control and to maintain the prosthesis on the stump in the sitting position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Case 37 Successful suction socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Auxiliary suspension for short stump above knee amputee (modified Silesian belt), as designed at the University of California. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Components incorporated into the finished prosthesis included a SACH foot, a wooden shank reinforced with plastic laminate, a friction stabilized knee, and a wooden socket providing definite ischial gluteal weight bearing. The tuberosity was located on the posterior edge of the seat, so that considerable weight was carried on the tendinous hamstring attachments, and the gluteal flare was fitted close to provide some gluteal support and to ensure a suction seal. The medial brim was held level with the posterior brim, while the anterior brim extended 2 1/2 in. above the ischial seat level. The socket protuberance into the area of the femoral triangle did not extend below the level of the ischial seat, and the lateral brim was held at the same level as the anterior brim. To aid in effecting a suction seal, the perimeter of the socket was enlarged below the brim level. The concavity of the anterior wall started 1 in. above the level of the ischial seat and extended downward, while the concavity of the lateral wall was above the ischial seat level. Concavity of the medial wall below the brim provided room for the prominent adductors, so that suction was not lost when the stump was tensed. At the brim, the socket perimeter was approximately 3 in. less than the stump perimeter. Alignment stability was reduced, inasmuch as a friction stabilized knee was provided.</p> <p>The short stump harness was successful in preventing loss of suction during sitting, the leg adhered firmly with tensing of stump musculature when the amputee walked, and there was no ramus discomfort. The scar in the crotch proved to be no problem in fitting and was not a source of discomfort. Except for a mild discomfort in sitting, which resulted in stretching of the skin, especially while sitting in soft seats, there was no discomfort from the posterior brim of the socket. Gait was satisfactory using one cane.</p> <p>Examination one month after treatment. was begun showed little change in the stump since the initial examination; it had simply elongated about 1/2 in. on the medial side. The ischial tuberosity tolerated weight bearing without difficulty, and the skin over that area was somewhat toughened. No edema, skin abrasion, or skin infection was evident. Six weeks after treatment started the amputee used the leg all day with one cane, but at a low activity level. Buckling of the normal knee was reduced as a problem when use of the knee increased with improved physical condition.</p> <p>Five months after treatment started the amputee wore the prosthesis from rising to retiring, and the stump was in excellent condition. Activity level was average, considering the level of amputation. One cane was used, although the patient was able to walk without it. There was some brownish discoloration in the weight bearing area. Stump shrinkage was not noticeable, and there was no further elongation of the stump. The tuberosity was firmly supported on the ischial seat, and there was no crotch discomfort, although there was slight skin irritation in the crotch due to roughness of the socket finish. The amputee considered the socket comfortable but wanted the leg lengthened. The rough area on the medial brim was covered with "Teflon" tape in an attempt to reduce friction. Elongation of the prosthesis by 5/8<i> </i>in. resulted in an improved gait appearance.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to define prosthetic requirements correctly. Suction suspension with the above knee type of prosthesis, in conjunction with the short stump pelvic harness, was successful and, since it preserved usable function of the stump, seemed to offer for this amputee a method of treatment to be preferred over the hip disarticulation prosthesis. Difficulties encountered were minimal owing to the previous experience gained with Case 10 (page 64).</p> <p>Gait, more natural with the use of one cane, improved markedly over the five months of study. Weight bearing on the gluteus maxi mus, ischial tuberosity, and tendinous attachments of the hamstring musculature was satisfactory. Use of the high anterior wall, without a protuberance of the socket wall over the area in contact with the femoral triangle, except above the ischial seat level, was satisfactory. For retention of suction, it was necessary to make all walls of the socket concave, especially below the medial brim because of bunching of the adductors.</p> <h3>Conclusion</h3> <p>From working with a group of amputees such as has been reported here, or from work with any similar group, many lessons are to be learned. One of the most obvious is that considerable "tincture of time" is required to solve chronic problems. The hope is that, as a result of the considerable amount of time devoted by a relatively small group of research subjects at the University of California, prosthetics clinic teams will gain some insight into possible methods of solving the problems of many other amputees.</p> <p>The most common prosthetic problems of above knee amputees as a group are edema, formation of an adductor roll, discomfort in the perineum (ramus pressure), and skin lesions. It has been found possible to control edema by maintaining a relatively uniform contact pressure between stump and socket. The proximal third of the socket need be fitted only slightly tighter than the more distal areas while still maintaining an airtight seal. In the case of an edematous stump, it is important to recognize the necessity for skillful application of socket liners to maintain a functional socket fit as the edema is reduced. Such liners are usually applied along the anterior and lateral walls only.</p> <p>The adductor roll which typically occurs with plug fit requires considerable time before the change can be made to an efficient, well fitting suction socket. Almost without exception, such a condition requires a second socket to complete the fitting.</p> <p>Ramus pressure is a thing of the past. Use of the higher anterior brim and the proper anteroposterior dimension from Scarpa's triangle to the posterior brim will eliminate completely this most troublesome complaint of above knee amputees. No longer need the above knee amputee suffer in silence because he just naturally expects his leg to be uncomfortable in this area.</p> <p>Provision of an efficient supporting surface along the posterior brim of the socket and of a proper fitting of the lateral wall of the socket to provide femur stabilization will relieve common areas of skin irritation, such as at the anterior brim, at the ischial seat, at the medial brim, and at the lateral distal end of the stump. The most common sources of skin difficulties are poor stump hygiene or rubbing and abrasion. Abrasion can be minimized by a functional fitting of the socket.</p> <h3>Acknowledgments</h3> <p>The group that worked on the patients presented in this article comprises in fact the whole staff of the Lower Extremity Amputee Research Project. Even more than amputee treatment must be, this study has been the product of many minds and many labors. Particular mention should be made of the staff members who were especially concerned in the study of the patients here reported. Dr. Henry E. Loon, Coordinator of the Medical Division, served as medical consultant to the group through much of the work. Jack C. Bates, Prosthetic Specialist, served in the vital function of trainer, in addition to making all arrangements with patients. And Jim C. McKennon and William H. Hoskinson served as prosthetists and faced the task of interpreting the plans of the research group as fully as possible to the patients in the fitting room.</p> <p><b>References:</b></p> <ol> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suction socket suspension of the above knee prosthesis</i>, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian types hip disarticulation prosthesis</i>, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and alignment jig for the alignment of above knee prostheses</i>, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower extremity prostheses</i>, Artificial Limbs, May 1954.</li> <li>Radcliffe, Charles W., <i>Alignment of the above knee artificial leg</i>, Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above knee prostheses</i>, Artificial Limbs, January 1955.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, 3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, <i>Functional considerations in fitting and alignment of the suction socket prosthesis</i>, March 1952.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in the fitting and alignment of the suction socket above knee prosthesis</i>, 2nd edition, August 1953.</li> <li>Wagner, Edmond M., <i>Contributions of the lower extremity prosthetics program</i>, Artificial Limbs, May 1954.</li> <li>Wagner, Edmond M., and John G. Catranis, <i>New developments in lower extremity prostheses</i>, Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</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">Foort, J., and C. W. Radcliffe, The Canadian types hip disarticulation prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 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>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 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>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Radcliffe, Charles W., Functional considerations in the fitting of above knee prostheses, Artificial Limbs, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suction socket suspension of the above knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above knee artificial leg, revised edition, April 1948.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above knee artificial leg, 3rd edition, April 1949.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in the fitting and alignment of the suction socket above knee prosthesis, 2nd edition, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, Lower Extremity Amputee Research Project, University of California, Berkeley; formerly with Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Norman C. Johnson, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopedic Consultant, Lower Extremity Amputee Research Project, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-39.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-46.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-47.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-48.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-49.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-50.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-51.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-52.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-53.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54b.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-55.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-56.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-57.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-58.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience with Prosthetic Problems of Above Knee Amputees Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * Norman C. Johnson, M.D. * James Foort, M.A.Sc. * https://staging.drfop.org/files/original/a7159063fb302b4a250573acb23abb85.pdf aa6c07bf41a25532666dc158ce0efc4b https://staging.drfop.org/files/original/c42f998e614f8cd33a557b45a09d067d.jpg 252589ddc51f2a80b7358f6974149b31 https://staging.drfop.org/files/original/8d6cfd7f8cac05cec1a7453dc79b69bd.jpg 4d64a6d4509dc6980e238a1a502d6547 https://staging.drfop.org/files/original/e6c5c23d894b219b103d507658c2b0ac.jpg 6e9ac58868a4f5e82d8a903c755fea21 https://staging.drfop.org/files/original/e91306e674a1c8947e9630148ddffd96.jpg ccb3e8403102657e330cce7186b530cc https://staging.drfop.org/files/original/68227ba109352f07e3866a1f452796c9.jpg 039bf222e5524b1352c7ab1b0ffd41a6 https://staging.drfop.org/files/original/19c1aad96069fabe0758187e646d1228.jpg e471fbdbef1ed11c58c71eff500781ba https://staging.drfop.org/files/original/2f07aa534dbd1584512f9c90809230d2.jpg 3570573c6cfd62aecaafbde8fbefc4ea https://staging.drfop.org/files/original/1a1fe4a37edcbe75d90b6ad73b8d0d4e.jpg c6ddc6b5a6d87db0bf2007ef5d8638b6 https://staging.drfop.org/files/original/75a33a9d6d5d0849ce7c12868685f1f9.jpg 1971a4230bd4ec28af875304f23a2cf6 https://staging.drfop.org/files/original/2617ce55fd29a20968da7d3e13766774.jpg 07a4a8a190d0f78932851483890b3b5d https://staging.drfop.org/files/original/c4d84385c58581f6533ec9d4e71f4fdc.jpg 30755fd905f1bc5e9d75566a928e222a https://staging.drfop.org/files/original/f6cffdc0a882bdda54350168a2222b6d.jpg a25624d88c7dadd9d6fa60f533badf24 https://staging.drfop.org/files/original/97eeaf86cf996280b7c14b0c5986553e.jpg 8268c26f3339dea97ccd44cdaba968a2 https://staging.drfop.org/files/original/015afe62ead49a74fb3a6f4162d7dc17.jpg cc0ba22ce6d1dbfee4a7d9bb8d429894 https://staging.drfop.org/files/original/9b82fe61ad066b08870be2171f256b77.jpg 36eccb8e1aac51332d921c634ede86be https://staging.drfop.org/files/original/e9359d5db4d7aafa657acee425a392c9.jpg 5b2005fd8445657c7504c01fe7a6773b https://staging.drfop.org/files/original/eec578b1c7b89a572f2f806882dda2fe.jpg ec67913ae1770d508da25e93c69258d2 https://staging.drfop.org/files/original/f69e7b05d484398ec53b97b665e4f948.jpg ac554dd86efbc1142de95f1fbca637b2 https://staging.drfop.org/files/original/fc43c4b25852b8cefa8ce6d8cccbb2cb.jpg 55676a5ab998ab1a06d8f6ea61c38fec DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_004.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 4 - 40 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Prosthetic Problems of Upper Extremity Amputees</h2> <h5>Marvin S. Gottlieb, M.A. <a style="text-decoration:none;">*</a><br />Robert L. Mazet, JR., M.D. <a style="text-decoration:none;">*</a><br />Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Marian P. Winston, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>The history of the upper extremity prosthetics program up to 1954 has been outlined in a previous article in this journal<a></a>. From 1950 to the present, the upper extremity research group established in the Department of Engineering, University of California at Los Angeles, has processed some 300 arm amputees: 72 during the Case Study Program<a></a>, an overlapping 250 during the 12 schools at the Prosthetics Training Center<a></a>, a small group of adult research amputees, and 104 children seen at the Child Amputee Prosthetics Project<a></a> prior to July 1, 1956. From the adult cases we have selected 23 of special interest to summarize in this article.</p> <p>First presented are five cases that responded well to standard methods, the purpose being to establish a baseline for comparison with the problem cases. Cases aided by the development of special equipment and by training in its use are grouped in one section because of the interrelationship between fitting, correct equipment, and amputee training. Under the heading of special equipment come the prototypes of several devices now standard in the armamentarium and also some modifications that remain unique to the individual wearer.<a style="text-decoration:none;">*</a> Cases aided by medical and biomechanical treatment are grouped together, again because of the interrelationship involved.</p> <p>Although some three fourths of all arm amputees encountered in the program have become consistent users of functional prostheses, we have chosen to present unsolved problems in nearly half of the case histories given here. The reason, obviously, is to draw attention to the areas of need. Apart from some unilateral wrist disarticulation and long below elbow amputees who operate easily and efficiently without prostheses (whom we do not consider to be problem cases), arm amputees who have the opportunity to be fitted properly, but who fail to use their prostheses, most often fall into one of three classes:</p> <ol> <li>Women of limited strength who object to the weight of forearm and terminal device.</li><li>Persons with severe biomechanical limitations, such as forequarter amputees.</li><li>Individuals suffering from disabling pain.</li></ol> <p>Just to show that arm amputees are no exception to the general orneriness of mankind, the closing section covers cases presenting unsolved psychosocial problems.</p> <p>It will be clear that several of the case histories might have been classified under some of the other headings. For example, in view of the drastic effects that the patient's postampu tation decrease in earnings had on his family life, Case 9, discussed from the viewpoint of special equipment, could as reasonably have been classified under psychosocial problems. Case 13, discussed under biomechanical treatment, represents also an achievement in equipment modification. And so forth.</p> <p>The expression "man machine combination" is a well worn phrase in contemporary bio technical research. In limb prosthetics, one might say, there is a "man equipment training combination" in which the man may be modified by medicine, by surgery, by physical or occupational therapy, by developments in the psychosocial realm, or by training in control and use of the prosthesis. The equipment must be compatible with all these and may have to be modified by redesign or special fitting to overcome the man's biomechanical limitations. Training may be either of negligible importance, as in Case 12, or crucial, as in Cases 7 and 11. Its usual importance tends to be somewhere between the two extremes.</p> <p>Finally, it may be noted that the standards, procedures, and techniques employed in fitting, fabrication, and training are all described in detail in the <i>Manual of Upper Extremity Prosthetics, </i>2nd Edition.<a></a> Similarly, all materials and most of the components mentioned are listed in the <i>Manual, </i>together with sources and characteristics. Of the components not otherwise referenced directly, all have already been described in previous issues of Artificial Limbs, in the collaboration by Klopsteg, Wilson, <i>et al. </i><a></a>, in manufacturers' catalogs, or in the general literature of the field. A number of the special components are described in recent reports of the Engineering Artificial Limbs Project at UCLA.</p> <h3>Cases Responding Well to Standard Methods</h3> <h4>Case 1, Forequarter</h4> <h5><i>History</i></h5> <p>Case 1, male, a 30 year old medical photographer, was first seen in the Case Study in February 1951, eight years postoperative. His left forequarter amputation, in which the left scapula and two thirds of the clavicle had been removed, followed injury in wartime Naval service. The Navy had provided him with a Navy Fitch<a></a> arm (double coupled flexion type with wooden forearm, leather socket, catgut cords, and double chest strap harness) but had not trained him to use it. Because of socket discomfort, he had worn no prosthesis for the preceding five years and was unable to operate his Navy Fitch arm at all for testing purposes. He was able to fulfill all his functional needs satisfactorily with one hand, did not believe that any functional prosthesis for his level of amputation was available, and sought only a cosmetic replacement.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was 6 ft. 4 in. tall, weighed 195 lb., was well muscled, and had good posture considering the extent of his loss (<b>Fig. 1</b>). The operative scar on the left shoulder girdle was well healed and not tender, but the area of the axilla was hypersensitive to touch. The subject was able to move the end of the remaining third of the clavicle only very slightly in flexion extension but was judged to have a good range of motion in elevation depression.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 1. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient's unusually good conformation enabled him to be fitted with a modified shoul der disarticulation prosthesis rather than with the usual forequarter type. Accordingly, a sectional type of shoulder prosthesis was prescribed, with emphasis on the cosmetic shaping of the shoulder cap. It included (<b>Fig. 2</b>) a chest strap harness with four attachment points on the shoulder cap, an opposite shoulder loop for dual control of terminal device operation and forearm flexion, and nudge control of the elbow lock since the patient had no desire for an actively operated elbow. The nudge control failed mechanically several times, a circumstance which led to a satisfactory redesign. Originally provided with a Dorrance hook, the patient later requested and received an APRL hand and hook. The pressure control feature of the APRL hook proved "invaluable" in his darkroom work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 1. Prosthesis provided at UCLA. The unusually good physical conformation and range of motion of this forequarter amputee enabled him to be fitted successfully with a modified shoulder disarticulation type of prosthesis rather than with the full forequarter socket. There was more functional regain than usual considering the patient's level of amputation. Compare with Cases 15 and 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training in use of the prosthesis was aided by the patient's wife, who was an occupational therapist. After training, the amputee passed nine out of ten activity tests and was judged to perform with extreme smoothness and remarkable ease and dexterity considering his level of amputation. When followed up a year later, the subject reported that he wore his prosthesis during most of his waking hours, sometimes as much as 120 hours a week, using the hand for most of his picture taking and public contact work and the hook in developing negatives and making prints.</p> <h5><i>Summary</i></h5> <p>In this case, better results were obtained than might reasonably have been expected. A unilateral forequarter amputee, the patient was interested only in a cosmetic replacement, did not seek functional regain, and did not believe that it was possible. Yet by proper fitting, followed by good training, he became an excellent prosthesis user.</p> <h4>Case 2, Wrist Disarticulation</h4> <h5><i>History</i></h5> <p>Case 2, male, a 38 year old machine operator and assembler of tools and outdoor furniture, was first seen by the Case Study in June 1952, seven years after amputation. His left hand had been lost by a shrapnel injury to the wrist while he was serving in a Polish French tank combat crew in Berlin. He had been fitted with a plastic socket with interchangeable Dorrance No. 8 hook and Becker wooden hand but had not worn the prosthesis for the preceding five months because the socket was broken. Prior to the breakdown, the patient had used the wooden hand 10 hours a day.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a screwdriver shaped stump with the styloids intact (<b>Fig. 3</b>). Physical condition was good, although forearm rotation was somewhat limited. The amputee had never received any physical therapy or prosthetic training.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 2. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>There is available no wrist cap that matches the elliptical cross section of the human wrist, and the wrist disarticulation socket must therefore be faired out to meet the round wrist caps used. In this case, an attempt was made to develop a manually operated wrist unit of elliptical cross section using rubber O rings to supply the friction necessary for resistance to rotation. But the resulting appearance was not satisfactory, the added length (1.3 in.) was too great, and frictional characteristics were not as desired. Rather than devote the time and effort necessary to redesigning the unit, the practical solution was adopted of using a Sierra Model C wrist cap instead and fairing out the socket accordingly (<b>Fig. 4</b>). Use of the Model C wrist cap decreased the length by half an inch and improved the functional characteristics.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 2. Prosthesis provided at UCLA. Because of required weekly cleaning and relative breakability in heavy work, the APRL hook shown here was later given up in favor of a Dorrance No. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In accordance with the patient's desire, he was supplied with an APRL hook. He preferred it because of the selective prehension and "better mechanism" and because he felt that exposed rubber bands, as in the Dorrance models, would accumulate grease in his work. But the hook required weekly servicing because of dirt accumulation, and when the patient ripped the stud off he requested a Dorrance No. 5 hook instead. After experience with the Dorrance hook, however, he reported that it tended to scratch the furniture he polished on the job. At the patient's insistence, an auxiliary prosthesis was constructed for use with the old Becker hand, which he considered ideal for the polishing operation. The patient's one remaining objection to his prosthetic equipment was that, with his limited pronation supination, the hook could not be positioned fast enough, but the length of his stump contraindicated use of a step up rotation prosthesis. At last report, the patient was wearing a prosthesis 10 hours a day, 70 hours a week.</p> <h5><i>Summary</i></h5> <p>Case 2 was a relatively uncomplicated case that responded well to standard methods of fitting and prescription. This particular case points up the unavailability of certain desirable equipment for the wrist disarticulation amputee and the importance of considering all the occupational requirements in prescribing a terminal device.</p> <h4>Case 3, Medium Below Elbow</h4> <h5><i>History</i></h5> <p>Case 3, male, a 48 year old butcher specializing in breaking and boning fore quarters of beef, was first seen in the Case Study in July 1951, nine months after amputation of his left arm below the elbow and one month after prosthetic fitting. He wore his new prosthesis at work but not otherwise, and he complained of stump soreness and pressure, a shoulder saddle that tended to slip under load, and awkward placement of the thumb of the Dorrance No. 1 hook. He had received no training in the use of his prosthesis.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a screwdriver shaped stump, 7.8 in. from epicondyle to tip, exceptionally finn and well muscled, with the radius approximately half an inch longer than the ulna (<b>Fig. 5</b>). The forearm flexors were markedly hypertrophied, and forearm flexion was limited to 120 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 3. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Because of the patient's heavy work, a heavy duty short below elbow type of prosthesis was prescribed (<b>Fig. 6</b>). The amputee specified modification in harness which called for replacing the leather shoulder saddle by one of washable webbing. In view of the patient's desire for selective prehension force, an <b>APRL </b>hook was prescribed experimentally, but it was badly damaged in the course of the patient's work and was therefore replaced by a Dorrance No. 1 hook. An F-M disconnect was tried. But after the patient's hard use broke the gear teeth of the disconnect three times, a threaded type of disconnect was prescribed instead. The first three sockets fabricated proved unsatisfactory the first because it interfered with circulation, the next two because of rubbing against the distal end of the radius and the ulna when the patient rotated his forearm. The fourth socket proved satisfactory, but the cables continued to fray with use and had to be replaced every few weeks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 3. Heavy duty prosthesis as prescribed for reason of occupation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This case emphasizes the importance of rugged equipment for heavy work in the manual trades and the shortcomings in this respect of many available components. The amputee made a contribution to limb prosthetics in initiating the washable webbing shoulder saddle. His experience with cable wear and frequent replacement indicates the problem which has since been very largely solved by swaged fittings and by the nylon cable housing liner.</p> <h4>Case 4, Below Elbow Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 4, male, a husky 18 year old student, first entered the Case Study in December 1951, six years after a right below elbow amputation that followed an explosion in a chemistry experiment in his home. About six months after the accident, he had been fitted with a laced leather socket and wooden hand, but he abandoned the device because he continued to break the fingers in the course of surf casting and other outdoor activities. About a year later, the patient obtained his second prosthesis, with a David work hook, and wore it daily until it became inoperable. He had received no prosthetic training.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 83 percent of forearm length, screwdriver shaped, and well muscled. The patient had a complete range of motion except for forearm rotation, which was limited to 30 deg. of pronation, no supination.</p> <h5><i>Treatment</i></h5> <p>Classified as a long below elbow type, the amputee was fitted with the standard prosthesis for his level of amputation, with an APRL hand and APRL hook. Operation of the voluntary closing device was learned readily, and the patient was judged an excellent user. In the trainer's judgment, the wearer's performance of test activities was as good as that of a normal person.</p> <p>Having heard of the increased range of motion and the freedom from shoulder harness made possible by the cineplastic procedure, the amputee returned to the clinic three months later as a candidate for biceps cineplasty under the experimental program. The operation was prescribed, and the biceps muscle tunnel was constructed in July 1952 without postoperative complications (<b>Fig. 7</b>). Six weeks after surgery, the patient returned to the clinic, where his below elbow biceps cineplasty prosthesis was completed (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 4. Patient after construction of biceps muscle tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 4. Patient wearing cineplastic prosthesis. Tunnel could develop 120 lb. of pull under 10 lb. of initial tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After fitting and training, the patient was tested, and his performance was found to be nearly as good as it had been with the harness controlled prosthesis. At that time, he experienced pain when the load on the tunnel reached 15 lb., but when this problem was overcome he proved to have a tunnel that could develop 105 lb. of pull when under 1 lb. of initial tension and 120 lb. under 10 lb. of initial tension. Two or three years later, the amputee modified his epicondyle clip by cutting it down in size and padding it deeply with foam rubber. Vinyl plastic was tried as a covering material, but the patient proved sensitive to it and went back to leather.</p> <p>After almost five years, this patient was wearing his prosthesis with APRL hook all of his waking hours. He had no interest in a hand and would not consider a voluntary opening hook, although he complained of the relative susceptibility of the APRL device to breakage. After several years' experience, he no longer broke his hooks, but the rubber linings wore off the hook fingers and required replacement every few months.</p> <h5><i>Summary</i></h5> <p>This case is an example of successful application of the below elbow biceps cineplasty. Although the amputee was an excellent user of a satisfactory harness operated prosthesis, he thought the increased range of motion and freedom from shoulder harness worth the surgery. This case also shows the amputee's insistence on using his preferred terminal device, even for activities for which he knew it was unsuitable.</p> <h4>Case 5, Above Elbow/Humeral Neck Combination With Bilateral Pectoral Cineplasty</h4> <h5><i>History</i></h5> <p>Case 5, male, a 31 year old Air Force fighter pilot and former ail American football player, entered the project in November 1950 on special leave from a military hospital. He had been under medical treatment since 1947, when the fire that followed a jet crash landing severely burned his head, the left side of his body, and both arms, resulting in bilateral arm amputation. Both pectoral muscles had been tunneled. The patient had been fitted with Navy Fitch double coupled flexion arms, the cineplastic tunnels being used for prehension control.<a></a> He complained of poor socket fit, restrictive harnessing, rotation of the sockets on the stumps, and the absence of an elbow lock and expressed a desire to learn to perform essential services for himself independently. Except for a six month program of exercise to strengthen the muscle tunnels, he had never received any training in connection with his amputations.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a right above elbow stump and a left humeral neck amputation, the two sides having the same pattern of scarring over the deltoid and the anterior and posteromedial aspects. There was limitation of humeral motion on the right side and no motion at all on the left. Exercises were prescribed. The patient appeared to be in excellent general condition, physically and psychologically. The right tunnel had a maximum excursion of 3 in. and a maximum force of 51 lb., the left 2.75 in. and 56 lb.</p> <h5><i>Treatment</i></h5> <p>To overcome the rotation of the sockets when the pectoral tunnels were contracted, to enable the amputee to don his prostheses independently, and to avoid the restriction of motion involved in force transmission through bilateral pectoral cineplasty, the right side (above elbow) was fitted and harnessed without use of the pectoral tunnel. The tunnel pin on the left side (humeral neck) was modified in an effort to improve efficiency of the power transmission system and to make it possible for the amputee to insert the pin either by means of the opposite prosthesis or by means of the mouth.</p> <p>Forearm flexion and prehension control were of the standard, harness operated dual type powered on the right side by humeral flexion and on the left by scapular abduction (<b>Fig. 9</b>), elbow lock on the left being operated by the left pectoral tunnel. After about three hours of training in the control and use of his new prostheses, the amputee was judged proficient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Case 5. Prostheses provided at UCLA. Use of the pectoral tunnel for elbow lock on the left side was later given up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The unused right pectoral tunnel was removed surgically, and about three years later the patient gave up use of the other tunnel but continued to use the prescribed arms without modification. He had had new prostheses made in 1953 but used them only for gardening and similar activities because he considered the upper portion of the right arm too long. In February 1957, more than six years after fitting, he was still wearing the prescribed arms and the same harness, although he had worn out four Northrop Sierra two load hooks and had been interchanging the two Northrop Model C elbows throughout the six years whenever service was required. He used the right prosthesis for most functions, with occasional help from the left. The patient did not bother with his own buttons or cutting his meat for himself, but he was active in the insurance business, took up hunting, and reported: "I write, drive, just like anyone else only thing, I ain't as pretty."</p> <h5><i>Summary</i></h5> <p>One of many cases in which pectoral tunnels did not work out as planned, this bilateral arm amputee was made independent through standard prosthetic fitting and training. He modified his bilateral prosthetic control system to emphasize unilateral function.</p> <h3>Cases Aided by Special Equipment and Training</h3> <h4>Case 6, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 6, male, a 23 year old office worker and preamputation bakery truck driver salesman, entered the clinic in September 1952, five months postoperative. His right arm had been disarticulated at the shoulder (<b>Fig. 10</b>) because of a malignant tumor.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 6. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed no medical contraindications to prosthetic fitting. Exercises to increase the range of motion of the shoulder girdle were prescribed.</p> <h5><i>Treatment</i></h5> <p>At first, a standard, sectional type of shoulder disarticulation prosthesis was prescribed and fitted, with dual control for forearm flexion and prehension and with nudge control of the elbow lock, a Dorrance No. 555 hook being used to keep weight to a minimum (<b>Fig. 11</b>). Later the patient was given a Northrop Sierra two load hook to evaluate; he adopted it enthusiastically.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Case 6. Pioneer fitting of a shoulder disarticulation, including prototype of the UCLA manually controlled, friction type shoulder joint The amputee refused to give up the prosthesis even when bodily changes due to illness made it irritating. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the amputee experienced difficulty in putting on a shirt or coat, he asked for a movable shoulder joint which would allow him to flex his prosthesis in the parasagittal plane. Designed to his satisfaction, this device proved to be the prototype of the UCLA manually controlled, friction type shoulder joint. At the patient's suggestion also, the nudge control was redesigned to cut down its protrusion and prevent clothing from catching in it. A month later, the subject reported that he wore his prosthesis 12 to 15 hours a day, that it was adequate for the needs of daily living, but that he would prefer a cosmetic hand of some kind for social occasions.</p> <p>In May 1955, the patient underwent surgery for removal of a large metastatic tumor mass in the right lung, and beginning in September 1956 he received x ray therapy for an inoperable lesion of the left lung. Loss of weight and atrophy of the shoulder girdle impaired the fit of the prosthesis, but the subject rejected medical advice that he wear only a shoulder cap to decrease the weight. He continued to wear the prosthesis until irritation of the bony prominences of clavicle and scapula necessitated prescription of a new soft socket liner in February 1957. At that time he was in good general health and working regularly.</p> <h5><i>Summary</i></h5> <p>This pioneer fitting of a shoulder disarticulation case resulted in devices now standard in the armamentarium. The satisfaction gained by the patient from his prosthesis is indicated by the fact that he insisted on wearing it even when bodily changes made it irritating physically.</p> <h4>Case 7, Bilateral Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 7, male, a 63 year old bridge and building construction foreman with bilateral shoulder disarticulations (<b>Fig. 12</b>), entered the clinic in November 1953, three months after the amputation of his right arm because of osteomyelitis. The left arm had been amputated 15 years earlier as an ultimate aftereffect of trauma in 1923. The patient had never worn a prosthesis. In addition to independence in self care, he particularly needed to be able to sign his name the one manual function required in his job.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 7. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a well healed scar in the left shoulder region but on the right some postoperative edema, encrustation, and weeping. Shoulder motion was limited, and strength was poor.</p> <h5><i>Treatment</i></h5> <p>After an interruption due to an unrelated operation (splenectomy), the amputee was fitted at the Prosthetics Training Center bilaterally and also unilaterally with a right shoulder disarticulation prosthesis. A year later, in 1955, he reported that he wore either the bilateral set or the unilateral prosthesis all his waking hours, usually the unilateral prosthesis, which had greater force and excursion and did not present the problem of interaction of controls. But he used this prosthesis only for picking up and carrying light objects and for nonprehension activities, such as pushing, pulling, striking, and hooking.</p> <p>In May and June of 1955, the patient spent seven days at the Prosthetics Laboratory for alterations, experimentation, and training. His shoulder turntable was modified by addition of a Belleville washer in order to maintain constant friction, and nylon cable housing liners were installed. Several experimental modifications of the elbow unit were tried in an attempt to secure smooth, reliable operation, but the final solution consisted of generous lubrication of the cable with paraffin, plus replacement of the housing by another long enough to allow an in line entry of the cable into the locking unit.</p> <p>The amputee's difficulties with the other components of his prosthesis resulted from lack of understanding of the mode of function, and he was therefore given intensive training. Patterns of activity feasible for this particular patient were worked out, and practice was supervised. Under this guidance, he learned to eat "all shapes and consistencies of food" with a fork, to write legibly, to unzip and zip his trousers (with a 3 in. elkhide thong attached to the zipper pull) for independent urination, to put on and take off a shirt or coat, to turn book and magazine pages, and to perform other activities. The therapist devised special equipment for his use, including a stand for his electric shaver and a simple trouser belt with a D ring buckle that he could tighten or loosen with one prosthesis.</p> <p>In January 1956, it was found that the patient had not been employing these techniques at home because it upset his wife to see him struggle and she preferred to do things for him. In March 1956, he was fitted with a unilateral prosthesis employing the UCLA manually controlled, friction type shoulder joint, modified arm rotation turntable, nylon cable housing liners, and a cable excursion multiplier (<b>Fig. 13</b>). He was the first of the amputees fitted with this system. Two months later, he wrote that he had leveled a building lot by hand and prepared it for planting, performed household chores, and worked in an office answering the phone, writing down messages, and checking workmen in and out with equipment. In December 1956, the amputee wrote, in his own shaky but legible penmanship, to report the prolonged illness of his wife, during which he had taken care of himself after years of dependence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 7. Successful unilateral fitting of the bilateral shoulder disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This complex case has been given in some detail because it highlights several different aspects of the problem of the severely handicapped amputee. The interrelationship of equipment and training is pointed up. When the patient was unable to operate his components, the solution resided in modification of some, realignment in one case, and better training in use of the others. The effect of oversolicitous family members in keeping the handicapped person dependent is shown. Given usable prosthetic equipment and training, this elderly bilateral shoulder disarticula tion amputee was able to operate independently when his wife was no longer able to help him. The case meets one of the prevailing standards of rehabilitation gainful employment at an appropriate task.</p> <h4>Case 8, Very Short Below Elbow</h4> <h5><i>History</i></h5> <p>Case 8, male, a 32 year old clerk, was first seen in the Case Study in November 1950. His very short below elbow amputation had resulted from machine gun fire during service as an Army rifleman in France in September 1944. Except for the insertion of the biceps, the forearm musculature had been lost. Several unsuccessful efforts at prosthetic fitting unsuccessful because of the limited stump motion had convinced him that he would have to undergo reamputation above the elbow in order to be fitted with a useful prosthesis. He came to the Case Study as a last resort before reamputation.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination revealed a 3.8 in. below elbow stump. A bony block in the elbow limited forearm motion to between 150 and 165 deg. of extension.</p> <h5><i>Treatment</i></h5> <p>A very short below elbow split socket prosthesis was prescribed, with an above elbow type of dual control for forearm flexion and prehension and with a special device which enabled the 15 deg. of stump motion to operate the elbow lock (<b>Fig. 14</b>). This was the prototype of the stump actuated elbow lock now standard in the armamentarium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Case 8. Amputee with very short (3.8 in.) below elbow amputation fitted with the stump actuated elbow lock. Reamputation previously considered, was avoided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the patient rated the prosthesis as excellent, he felt that more practice was needed in learning to operate the elbow lock with his stump and was found not to be wearing the prosthesis as many hours a week as he had reported. Three years later, however, he was wearing the limb constantly.</p> <h5><i>Summary</i></h5> <p>In this clear cut case, the design of a special device to meet a special situation solved the amputee's problem. The patient was saved from reamputation by the development of a device that is now standard. The history suggests, however, that the solution would have been still more successful, in terms of prosthesis use, had the amputee received more training and perhaps psychological counseling.</p> <h4>Case 9,Very Short Below Elbow With Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 9, male, age 40, was seen as an industry counseling case in October 1951, two and a half years after an amputation which resulted from an industrial accident while he was working as an elevator and control system installer. On the patient's return to work, after nearly two years' disability, the elevator company had transferred him to office work at slightly more than half his former salary. On the reduced income, he had been forced to give up his home. his wife suffered a nervous breakdown, and the two children had to live with relatives during a long period of readjustment. He had been provided in 1949 with a cosmetic arm and "Realastic" hand but had never had a functional prosthesis.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a left very short below elbow stump, badly scarred, with flexion limited to 90 deg. by a bony block in the elbow. Shoulder motion also was limited.</p> <h5><i>Treatment</i></h5> <p>The amputee was given a short below elbow prosthesis with an APRL hand and with the forearm set in 20 deg. of initial flexion. Five months later he reported himself satisfied with this limb and, although he said he was wearing it 12 hours every day, he desired a step up hinge to increase forearm flexion. In September 1953, a split socket prosthesis with variable ratio step up hinge was fitted, with both hook and hand as terminal devices. The new prosthesis increased the patient's maximum forearm flexion to 120 deg., and he was judged as being "very adept" with both hand and hook. After acquiring a functional prosthesis, the amputee was able to return to his skilled trade with another employer, although he had to start as an elevator mechanic's helper.</p> <p>Learning that still greater functional regain (ability to operate the prosthesis above shoulder level) was possible with biceps cineplasty control, the patient had his left biceps muscle tunneled in August 1954 as an experimental subject in the below elbow biceps cineplasly program (<b>Fig. 15</b>). Shortly after the surgerv, he was fitted with a below elbow biceps cineplasty prosthesis with split socket, variable ratio step up hinge, and UCLA control system. In March 1956, an experimental prosthesis was fabricated for him using the new UCLA 1.5 ratio step up elbow hinge (<b>Fig. 16</b>). With this limb he was able to lift 11 lb., nearly twice his previous maximum. It should be remembered that in this case slump flexion was not aided by the biceps because the biceps tendon had, of course, been severed The 1.5 ratio hinge gave 5 deg. more forearm flexion than did the variable ratio hinge. Although this increase in forearm flexion was of no importance to the patient, who had fell that the variable ratio hinge gave all the forearm flexion he needed in his left arm, he greatly appreciated the ease and smoothness of action of the 1.5 ratio hinge. By 1957 he had advanced to the position of elevator inspector.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Case 9. Patient after construction of biceps muscle tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case <i>9 </i>Patient fitted with UCLA below elbow biceps cineplasty system using split socket and the 1.5 ratio step up elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>This case highlights the contribution of new devices to the welfare of the amputee with a very short below elbow stump.. It also points up the socioeconomic value of a functional prosthesis in the manual trades. When this amputee was prevented from working at his highest level of skill, severe dislocation was experienced by an entire family. Fitting of a suitable prosthesis enabled him to return to gainful employment.</p> <h4>Case 10, Congentinal Below Elbow.</h4> <h5><i>History</i></h5> <p>Case 10, female, a 37 year old teaching nun, entered the clinic in January 1955. A congenital left below elbow amputee, she had worn cosmetic arms since the age of four She was wearing a cosmetic appliance 6 hours a day, 5 days a week, but desired more prosthetic function. Her particular desire was to be able to hold an open book while writing at the blackboard.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was of slight build (<b>Fig. 17</b>). Stump length was on the borderline of the very short below elbow type (3 in. below the epi condyles). Forearm flexion was limited to 90 deg., and strength was also limited. There was pain on pressure at the tip of the stump and along the anterior surface; x rays showed two bony spurs on the anterior surface of the ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 10 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient was first fitted with a short below elbow prosthesis with Hosmer PC 100 hinges, flexion range being sacrificed for simplicity. Three months later, another prosthesis was made, with outside locking elbow hinges as commonly used with the elbow disarticula tion type of prosthesis. For greater gripping surface, the Dorrance No. 555 hook was replaced by a Dorrance No. 5X. To help relieve pressure on the stump during forearm flexion, the therapist suggested use of humeral abduction, and the patient found this technique made many activities more comfortable and less awkward.</p> <p>For further relief from pressure, a polyure thane foam socket liner was made the following July. The seam coincided with a bony prominence, however, so that a new liner was necessary. At the same time, the socket was cut out to free the medial epicondyle.</p> <p>When nylon cable housing liner was installed in February 1956, the patient reported that:, although it afforded great mechanical advantage, it deprived her of the "vibration feedback" on which she had previously relied for information as to her cable tension and amount of hook opening. The final modification (<b>Fig. 18</b>) was made in July 1956, when a chest strap was added to the harness to prevent it from slipping off the shoulder when the arm was raised in upward and backward motions. Over the period covered, the patient tried several hooks, alternating between her needs for greater gripping surface and for lighter weight. Her final choice was the Dorrance No. 5XA. In February 1957 she was provided with three interchangeable socket liners for purposes of cleanliness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18, Case 10 Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient's desire to pass out papers to her classes was met by the technique of holding the stack of papers upright with the right hand and picking off copies with the hook.</p> <h5><i>Summary</i></h5> <p>This case indicates the experimental approach that must be adopted to meet the needs of an amputee with special physical limitations. It also suggests the use of the custom fitted soft socket liner when the amputee's stump configuration is too complex and painful to be made comfortable in the conventional plastic socket. The outside locking elbow hinge provided the needed stability for this short below elbow amputee with limited strength.</p> <h4>Case 11, Short Above Eelbow/Humeral Neck Combination</h4> <h5><i>History</i></h5> <p>Case 11, female, a 35 year old health educator and graduate dentist, entered the program in March 1953, 11 years after amputation. With right short above elbow and left humeral neck stumps, she had lost her arms as a result of electrical burns in a sailing accident. Before her marriage, she was self supporting as a teacher and lecturer. After marriage, she was an active housewife and mother of two small sons. She had been fitted with bilateral prostheses of modern type in 1947. Her second and third prostheses were for the above elbow side only, and the third, fitted in November 1952, was the first to incorporate an elbow lock. The family moved from Michigan to Los Angeles so that the patient could enter the UCLA program. They remained for two and a half years, during which various combinations of prosthetic equipment were tried.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a right stump extending 5.3 in. below the acromion, a left stump 3 in. below the acromion (<b>Fig. 19</b>). The patient was tall and broad shouldered, with excellent mobility of the shoulder girdles. The right stump required shrinkage, however, and in September 1954 the subject underwent surgery for excision of a neuroma, a spur, and a bursa. Simultaneously, excess fat and skin were trimmed off. About six months later, a fibular bone graft into the left humeral head was performed, but the stump thus produced was not functional, it projected at an awkward angle, and it proved sensitive to socket pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 11, Patient as seen on referal. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Before the bone graft, the amputee was fitted bilaterally (<b>Fig. 20</b>). She was trained to use each arm effectively, but because of interaction of controls she had great difficulty in coordinated activities and she found that the left arm was in the way in many functions. She was taught to drive an automobile (for the first time) using the driving ring, obtained her driver's license, and from that time continued to drive for herself and to take her turn at the wheel on long trips. She prepared the family meals and washed the dishes but did not feed herself because of limited forearm ilexion. Later, with the addition of a wrist flexion unit and with intensive training, she learned to use a fork effectively but found it an activity too fatiguing for everyday use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Case 11. Patient as fitted bilaterally. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1955, before the grafted slump was ready for fitting, the patient was fitted with a right prosthesis, with only a shoulder reaction cap on the left side (<b>Fig. 21</b>). Function was much better without cross controlling, <b>but </b>she stated that bilateral fitting was worth some sacrifices for the sake of body balance and prevention of spasm of the neck and back muscles.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 11. Patient as fitted unilaterally with opposite shoulder reaction cap. Properly aligned unilateral prosthesis gave body balance without counterweigh ting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The disadvantages mentioned were found to be due to subtle misalignment of the single arm and were corrected by fabrication of a unilateral prosthesis correctly aligned.</p> <p>In a final attempt to achieve successful bilateral fitting, the patient suggested a perineal strap. This change in harnessing, tried in January 1956, succeeded in separating the control motions but at the cost of limiting motion and preventing the wearer from putting on her prostheses independently. After this, the subject concluded that unilateral fitting without perineal harnessing gave her the maximum of function, especially with the aluminum Dorrance 5XA hook and a slightly shortened forearm. Several months after the family moved away, the amputee sent word that her final prosthesis was the lightest and most comfortable of all and reported that she fed herself quite nicely with the swivel "spork" (combination of spoon and fork).</p> <h5><i>Summary</i></h5> <p>The maximum comfort and function attained by this bilateral high level amputee was obtained with unilateral equipment. Even body balance was restored by careful alignment without further counterweighting of the opposite side. Intensive training, plus high motivation on the amputee's part, resulted in regain of many functions and the learning of some new ones <i>(e.g., </i>driving a car). The attempt to lengthen the humeral neck stump by a bone graft, while successful from a surgical viewpoint, was of no prosthetic value because of the angle of the resulting stump.</p> <h3>Cases Aided by Medical and biomechanical treatment</h3> <h4>Case 12, Shoulder Disarticulation With Weak Pectoral Tunnel</h4> <h5><i>History</i></h5> <p>Case 12, male, a 22 year old beekeeper, entered the program as an industry counseling case in February 1952, 18 months after the loss of his right arm in a mortar barrage during the Korean War. The small cineplastic pectoral tunnel that had been constructed was intended to operate the elbow lock of the shoulder disarticulation prosthesis with which he had been fitted. But when the patient was seen at UCLA, he was operating the elbow lock manually with the opposite hand because the tunnel pin excoriated his muscle tunnel and also because operation of the elbow required more excursion than he could produce (because of stretching of the nylon control cord).</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed the pectoral tunnel to be unusually narrow and superficially placed (<b>Fig. 22</b>). The maximum force developed during testing was 8 lb., less than one sixth the force normally available from a pectoral tunnel. Although the two shoulders were at the same height, the patient had developed a thoracic curve with compensating lumbar curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 12. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Prescribed physical therapy included posture instruction and practice, exercises to develop the left arm and right shoulder girdle, and DeLorme progressive pulley exercises for the muscle tunnel. After 20 half hours of supervised practice and eight hours of massage and irradiation, the maximum force available from the pectoral tunnel had more than doubled to 19 lb., still about a third of the normal amount but more than enough to operate the prescribed elbow lock. The tremor which had been evident on contraction had disappeared.</p> <p>A question mark muscle pin was prescribed to overcome the rubbing and pressure pain experienced with the straight muscle pin, and an adjustment turnbuckle was included. A larger shoulder cap (with circular cut out for the muscle tunnel) provided stability, and the modern cable transmission system lessened friction and increased efficiency (<b>Fig. 23</b>). Instead of the hinge joint which had allowed the patient to abduct his prosthesis by bending his body to the right, the prescribed prosthesis included the new UCLA manually controlled friction type shoulder joint, which allowed him to flex the humeral section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 12. Present prosthesis. By physical therapy and suitable adaptation of equipment, a weak, superficial pectoral tunnel was reclaimed for elbow lock operation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training results cannot be reported because the subject left for his home state as soon as his new prosthesis was checked out. The physical therapist, however, reported that the patient was "quite adept without instruction."</p> <h5><i>Summary</i></h5> <p>This amputee represents a case of a surgically inadequate pectoral tunnel which, by physical therapy and proper adaptation of equipment, was reclaimed for elbow lock operation.</p> <h4>Case 13, Female Congenital Below Elbow With Weak Biceps Tunnel</h4> <h5><i>History</i></h5> <p>Case 13, a 25 year old office worker first seen in March 1951, is the only female cineplasty case in the UCLA experience. A congenital left below elbow amputee, she had been fitted with her first prosthesis in October 1949 after biceps cineplasty and had never received any training. The patient reported that since graduation from high school she had been employed in secretarial work, bookkeeping, filing, sorting, operating "Mimeograph," running an "Addressograph," manning a PBX switchboard, and typing and that her amputation had not affected her earning power. She stated that her cineplastic Huffner prosthesis with magnesium forearm and metal hand was too heavy, fitted poorly, rubbed at the elbow joint, and caused damage to clothing. The tunnel pin was observed to slip to one side during operation, and the prosthesis rotated accordingly so as to require readjustment every 15 minutes.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a firm stump with a full range of forearm flexion. Curvature of the bones limited extension of the forearm to about 150 deg. The muscle tunnel showed a usable excursion of approximately 2.5 in. and a rest length force of 13 lb.</p> <h5><i>Treatment</i></h5> <p>Resistive exercises were prescribed to be performed at home, and tunnel exercise pins of increasing diameter up to 1/3 in. were given successively. Work on the prescribed prosthesis was started during the fifth week of exercise. Although there was a temporary gain of 1 in., tunnel excursion did not increase permanently as a result of exercise, but the force more than doubled to approximately 30 lb. While this value is markedly less than normal biceps cineplasty tunnel force in a male amputee, lack of comparative data on female cases prevents a judgment as to whether this relative weakness of the biceps is normal for the patient's sex.</p> <p>In any event, the tunnel was not adequate to operate the desired terminal device, the APRL hand. Accordingly the mechanical advantage of the lexer system of an APRL hand was doubled, thereby reducing the force requirements by one half but doubling the excursion requirements. The problem of slipping of the tunnel pin was eliminated by the development of the UCLA equalizing yoke, which also increased the available force by maintaining the tunnel ina slightly prestretched position (now the standard procedure). The new prosthesis (<b>Fig. 24</b>) enabled the patient to obtain 5 lb. of prehension force at 1 in. of opening, as contrasted to the 1 lb she was able to obtain with her old equipment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Case 1.3, Patient with new prosthesis Physical therapy, modification of equipment, and special training made useful an otherwise surgically inadequate biceps tunnel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately, family reasons required the patient's return to Chicago immediately after checkout, without any training. During the next two years she wore the prosthesis little. After two years, referral to Dr. Clinton L. Compere in Chicago resulted in the fitting of a new prosthesis, with proper training in its use, after which the amputee became a satisfied and consistent user When followed up three vears later, she continued to express satisfaction with her prosthesis and recommended cineplasty to other female amputees.</p> <h5><i>Summary</i></h5> <p>This case points up the interrelationship between considerations of surgery, physical therapy, engineering, and training. An essentially inadequate muscle tunnel (a surgical problem) was rendered useful by exercise, special individual modifications of equipment, and development of components which benefit all below elbow biceps cineplasty amputees. The results of physical therapy and engineering design were negated by lack of prosthetic training. When training became available, the amputee was changed from a virtual non wearer to an enthusiastic user.</p> <h4>Case 14, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 14, male, a 27 year old purchasing liaison representative with a paralyzed right arm, first appeared at the project in June 1952. A brachial plexus traction injury six years earlier had resulted in loss of arm control and virtual loss of forearm control.</p> <h5><i>Examination and Evaluation</i></h5> <p>A few intrinsic muscles remained in the hand, the forearm could be flexed very slightly, and a low level of sensation remained, but all the major arm and scapular musculature had atrophied. The patient was exceedingly anxious to have the flail arm removed so that he could wear a functional prosthesis. He said that the flail arm was useless and in the way. He was experiencing marital difficulties during this period, and the clinic psychologist suspected that the desire for amputation might be an emotional reaction to the home situation. The clinic strongly recommended against amputation until functional bracing had been tried. It prescribed such bracing. But this advice was not followed, and the arm was amputated.</p> <h5><i>Treatment</i></h5> <p>In August 1952, the patient reappeared at the clinic, a month postoperative, for fitting as a shoulder disarticulation amputee (<b>Fig. 25</b>). He was instructed in how to correct posture and was given shoulder exercises to do. Fitting and training in the use of a standard shoulder disarticulation prosthesis resulted in excellent use (<b>Fig. 26</b>). The amputee continued to serve the schools of the Prosthetics Training Center and the UCLA research program as an amputee subject, was considered an excellent user of his prosthesis, and stated three years after amputation that he had never regretted his decision. As far as the staff can judge, his emotional difficulties appear to have been resolved by the amputation and successful prosthetic fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 14. Patient as seen one month after voluntary disarticulation of a flail arm against clinic advice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 14. Successful shoulder disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Summary</i></h5> <p>It is difficult to prescribe the removal of an extremity that retains some sensation and some function, with a view toward replacing it with a mechanism. This patient knew what he wanted, obtained it against the advice of the clinic, and is apparently well satisfied with the results.</p> <h3>Cases Presenting Unsolved Problems of Biomechanical Limitation</h3> <p>The chief unsolved problem of biomechanical limitation in upper extremity prosthetics is the case of the forequarter (interscapulo thoracic) amputee, whose entire scapula and clavicle have been removed. In the UCLA experience to date, there has been no congenital forequarter amputee and only one caused by injury.<a style="text-decoration:none;">*</a> All the rest had undergone amputation because of malignancies. With the possible exception of one traumatic child case, which is still in question, within the knowledge of the staff no true forequarter amputee has become a successful user of a prosthesis.</p> <p>In forequarter cases, any functional regain is achieved at the cost of great effort because so little excursion is available by way of body control motions and because so much area must be covered by the socket for stability virtually the entire thorax and back to the mid line on the side of amputation plus a curved lobe that hooks around the neck onto the opposite shoulder. So far, none of our forequarter cases have considered the effort and discomfort worthwhile. Their attitudes may be influenced by a conscious or unconscious fear of stirring up malignancies, for the mortality rate among these cases has been high.</p> <h4>Case 15, Forequarter</h4> <p>Case 15, a 30 year old housewife, entered the project in June 1955, seven months after amputation for a recurrence of rhabdomyosarcoma. She was intelligent and anxious to cooperate. After a three month period of training and practice in use of the prescribed prosthesis, she doubted whether the functional regain was worth the effort and discomfort. Later, word of her death reached the clinic.</p> <h4>Case 16, Forequarter</h4> <p>Case 16, a 31 year old housewife, was seen in July 1955, about four months after amputation for a malignant synovial tumor. After prescription, fitting. and instruction, she was unable to operate the prosthesis enough to check it out for mechanical functioning. Because she was able to manage adequately with one hand all of her activities except sewing and knitting, and because she found the prosthesis hot, heavy, uncomfortable, and difficult to operate, she withdrew from the program and was referred to a maker of cosmetic restorations.</p> <h4>Case 17, Congenital Quadrilateral</h4> <h5><i>History</i></h5> <p>Case 17, male, a 27 year old congenital quadrilateral amputee 29 in. tall, entered the clinic early in 1951. Born without legs (bilateral hip disarticulations), he managed locomotion at home by hopping on his pelvic musculature. Away from home he was dependent on others for transportation; he could maneuver his wheelchair into the street but not across curbs. On the right was a below elbow stump, while the left stump was above elbow.(<b>Fig. 27</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Case 17. Upper extremities<b> </b>of patient<b> </b>as<b> </b>seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient operated a 24 hour telephone answering service at home with the help of his wife and one part time employee. He often worked the switchboard for eight hours without relief, writing down messages by means of a pencil inserted in a leather band worn on the below elbow stump. He also ran a baby sitting agency and from time to time recruited and managed telephone sales crews for special sales campaigns. His regular working day was 10 hours. His businesses were growing, but he felt handicapped by his inability to visit prospective clients. He had been fitted with artificial arms at the age of 21, but he found them in the way for the quick motions necessary in his work. Except for a wooden ladder used to reach chairs, toilets, and so on, he took care of all his vocational, avocational, and personal hygiene activities without the use of prostheses or special facilities.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed the above elbow stump to be limited lo 70 deg. of abduction, 95 deg. of flexion, and 5 deg. of extension, with no rotation at all. The arm on the below elbow side was limited to 80 deg. of abduction, 120 deg. of llexion, 15 deg. of extension, and 10 deg. of rotation, the elbow being fused at approximately 90 deg. The patient had never had physical therapy, and none was prescribed because his strength was satisfactory and it was felt that, in view of the fact that he was a congenital amputee, the muscles could not be stretched without severe pain.</p> <h5><i>Treatment</i></h5> <p>The new prostheses fitted to the patient (<b>Fig. 28</b>) were evaluated by him and shown by test to be excellent in relation to his old pair. But 20 hours of training led to the conclusion that interference with old habit patterns was insurmountable, especially because the subject wore the prostheses only six hours a week and was too busy to practice. At no time did his performance of test activities with the prostheses approach his performance with bare stumps. But he found the limbs useful for social occasions. His evaluation remained the same after a year of wearing the prostheses six hours a week.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Case 17 Prostheses provided Right prosthesis is cut out to accommodate characteristics of the below elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One benefit the patient received from his participation in the UCLA program was the design of a special pigeonhole device which served his filing needs far better than did the notebook system he had been employing. A specially designed prosthesis holder enabled him to put his arms on without help.</p> <h5><i>Summary</i></h5> <p>In the case of an amputee who combines severe limitations (by ordinary standards) with well established habit patterns that enable him to function quickly and efficiently without prostheses, training in the use of prostheses may be futile. This amputee, who in his vocation operated far better without prostheses than with, nevertheless appreciated prostheses for wear on social occasions.</p> <h3>Cases Presenting Unsolved Medical Problems</h3> <h4>Case 18, forequarter</h4> <p>Case 18, a 68 year old housewife, was seen in November 1953, seven months after her right forequarter amputation. The medical report obtained from her physician indicated that she had undergone a simple mastectomy of the right breast in October 1944, x ray therapy of the axillary areas in 1945 and 1947, and a left radical mastectomy for metastasis to the contralateral breast and axilla in 1950. Paralysis of the right arm had developed in 1952, and forequarter amputation was performed in March 1953.</p> <p>In view of the advanced age and history of malignancy, the clinic agreed that a functional prosthesis was contraindicated. A soft cosmetic shoulder cap was prescribed to meet the amputee's need for body balance and symmetrical appearance.</p> <h4>Case 19, Shoulder Disarticulation/Short Above Elbow Combinations</h4> <h5><i>History</i></h5> <p>Case 19, male, a 60 year old railroad pensioner, entered the clinic in November 1951. Ten years earlier, he had been run over by a boxcar. Shoulder disarticulation of the right arm, amputation of the left arm about 3 in. below the acromion, and application of a tibial graft to the above elbow stump had followed (<b>Fig. 29</b>). The stumps proved too sensitive to be fitted with prostheses, and the patient had been unemployed ever since, living on his railroad pension and dependent on others for his daily needs. Throughout that time, he had had intense sensation of phantom hands, with the "fingers" painfully pinched together and somewhat overlapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 19 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>In May 1952, the patient underwent with good results a partial resection of the pectoralis major tendon for the purpose of lengthening the above elbow stump. At the same time, three supposed neuromata, which turned out to be tender masses of scar tissue, were removed from the most sensitive areas. The operation was of some help, but the pain remained in the scar areas and in the distal 3 in. of the anterior aspect of the bone graft and prevented the amputee from sleeping and from wearing the prosthesis prescribed and fitted to him.</p> <p>Later in 1952, the patient was hospitalized for two weeks at the Pain Clinic at the University of California Medical Center in San Francisco. Under relatively mild sedation of phenobarbital and Seconal, he slept well and required only a few grains of codeine. Indefinite continuation of the mild sedation was recommended. The phantom pain disappeared after injections of sodium amytal, but the tender areas of the stump were not eliminated. Efocaine was ineffective, and treatment with a strong vibrator was not well tolerated. The intraspinous injection of sodium chloride solution as a counterirritant caused the trigger points to disappear only temporarily. Finally, in view of the patient's improved frame of mind, it was decided that minor pressure, such as would be exerted by the prosthesis, might be tolerated.</p> <h5><i>Treatment</i></h5> <p>Although pairs of prostheses of modern design were prescribed and fitted to the patient during the schools at the Prosthetics Training Center, his stump pain remained an unsolved problem. In April 1956, when the subject was 65 years of age, intensive research began on the case. The decision was made to fit the shoulder disarticulation side only and to make a reaction cap socket for the above elbow side rather than to make further attempts at bilateral fitting. Sectional plates were modified to form the UCLA manually controlled, friction type shoulder joint and skewed 20 deg. to the sagittal plane so as to enable passive flexion and abduction of the humeral segment. The arm rotation turntable was modified by addition of a Belleville washer for finer adjustment of tension, and a cable excursion multiplier was added. The use of nylon cable housing liners, which had been adopted as standard procedure at UCLA, greatly decreased cable friction and increased smoothness.</p> <p>Mechanically, the prosthesis enabled the patient to perform simple grooming and eating manipulations for himself. But pain under the left reaction cap intensified with the use of the prosthesis. Investigation showed that this problem was due partly to inadequate training. In addition to left shoulder flexion to stabilize the reaction cap, the amputee was employing flexion of the above elbow stump. Although training in the correct motion was given, it was not expected that the patient would overcome his faulty habit patterns, and a mechanical solution was sought.</p> <p>After several unsuccessful trials, a reaction cap was made from a wrap taken with the humeral segment snug against the body but with the distal end of the stump projecting slightly (<b>Fig. 30</b>). This expedient transferred the undesirable pressure to the anterior portion of the stump. To alleviate the pressure there, a cutout was made and margined with foam rubber padding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 19. Patient as fitted unilaterally with specially designed opposite shoulder reaction cap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Staff evaluation was that, while the mechanical results were very good, the potential functional regain would be somewhat limited by the patient's outlook and by his habits of dependence. It should be mentioned, perhaps, that this amputee supplemented his meager pension by earnings in part time employment at a men's club. With his prosthesis he carried a specially built tray for holding several drinks.</p> <h5><i>Summary</i></h5> <p>Here was a very complicated case in which intense phantom pain of 11 years' standing was eliminated but in which stump pain persisted. Mechanical problems were solved by the UCLA unilateral equipment for bilateral shoulder cases, but the amputee's habits and motivations limited full prosthetic effectiveness. At least this patient was enabled to earn some money for the first time in 15 years.</p> <h4>Case 20, Shoulder Disarticulation</h4> <h5><i>History</i></h5> <p>Case 20, male, a 26 year old Polish born Israeli plumber, well driller, and, after amputation, clerk, entered the project in August 1951. During the Arab Israeli War of 1948, when a jeep in which he was riding struck a land mine, he had suffered a crush injury to the left arm, which resulted in shoulder disarticulation. Afterward, the patient experienced intense and continuing phantom pain in the missing hand, in the distal third of the phantom forearm, and occasionally in the entire phantom arm. Usually the phantom hand was localized in the normal position, but sometimes it was perceived as telescoped to the phantom elbow.</p> <p>Paravertebral punctures had been employed, but the relief lasted only until the anesthetic wore off. Sympathectomy of the thoracic chain had no effect, nor did eight electric shock treatments administered by a psychiatrist. The patient was then sent by the Israeli Government to California for treatment.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed marked scoliosis (the left shoulder carried 1.5 in. higher than the right), an extreme anterior protrusion of the thorax, and lateral curvature of the spine (<b>Fig. 31</b>). The patient had never received physical therapy, and the left shoulder girdle was atrophied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 20. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Exercises to correct scoliosis and to increase range of motion were prescribed, the Sayre head sling was used to stretch tight neck musculature, and self corrective mirror instruction in posture was given. When last seen in May 1952, the subject was still performing his exercises, and his posture and shoulder mobility had improved markedly.</p> <p>Case 20 was fitted with a standard shoulder disarticulation prosthesis (<b>Fig. 32</b>), which he valued highly and which he wore all of his waking hours despite the discomfort of a perineal strap, which, because of unhealed operative wounds, he preferred to an opposite shoulder loop. But his phantom pain continued to be disabling. Two stellate ganglion blocks were attempted but failed. In October 1951, a neuroma of the left brachial plexus was removed, and a marked fibrotic scalenus anticus muscle was cut and allowed to retract. The patient was pain free for 10 days during the next month, but thereafter the pain returned with even greater intensity. In December 1951, therefore, he was referred to the Pain Clinic at the University of California Medical School in San Francisco.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 20 Standard shoulder disarticulation prosthesis supplied to patient, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On examination, the staff of the Pain Clinic found a strip of complete anesthesia below the left clavicle (thought to be related to the scalenectomy) and generally poor sensation on the left side of the entire body, with reduction of urinary and sexual function. These deficiencies were gradually eliminated during the weeks of the patient's treatment at the Pain Clinic. But no relief whatever of the phantom pain was obtained by counterirritant injection of sodium chloride into the intraspinous ligaments, by injection of sodium amytal into the trigger point in the neck, by vibration treatment, or by intravenous injection of ponto caine. The amputee was enabled to sleep, however, by the use of phenobarbital, plus almost daily intravenous injections of 10 percent sodium amytal to the point of slight drowsiness. The latter did not eliminate the pain but seemed to relax the phantom hand and lower the pain to tolerable levels. On the clinic's recommendation, these injections were continued, but within a few weeks the patient proved refractory to the sodium amytal. When he left Los Angeles in May 1952, he was resigned to living with his phantom pain and hoped only to keep busy enough to keep his mind from it.</p> <h5><i>Summary</i></h5> <p>This case was a success prosthetically but a complete failure from the standpoint of relieving the amputee's phantom pain. Neurosurgery, drug therapy, and psychiatry were equally fruitless; the first resulted only in the additional pain of multiple operative wounds.</p> <h3>Cases Presenting Unsolved Psychosocial Problems<a style="text-decoration:none;">*</a></h3> <h4>Case 21, Very Short Below Elbow</h4> <p><i>History</i></p> <p>Case 21, male, age 52, entered the clinic in October 1951, five years after the explosion of an enemy mine resulted in the very short below elbow amputation of his right arm. A revision had been performed five months after the amputation. Before his wartime service as a captain and major, the patient had worked for a railroad for 20 years, his civilian occupation being given as trainmaster. Since his amputation, he had been unemployed much of the time, living on rental income and Federal pension benefits.</p> <p>While in an Army hospital in 1946, the patient had been fitted with a modern prosthesis with polycentric hinges. He was wearing it five years later and at that time stated that he wore it 12 hours a day. But he was not satisfied with the limb. During the four years between 1947 and the lime of the patient's appearance at the clinic, the VA paid for three additional prostheses and also for an extensive series of modifications. Finally, in January 1951, convinced that the amputee was not wearing any prosthesis regularly, and under pressure from him for a satisfactory prosthesis, the VA representative referred him to the UCLA Case Study.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a stump 3 5/8 in. long measured from the medial epicondyle to the end (<b>Fig. 33</b>), the distal area of the stump being sensitive to pressure. The amputee had received physical and occupational therapy and prosthesis use training, all of which he evaluated as excellent. Strength and range of motion were good, and no exercises were prescribed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 21. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>After the patient's first UCLA prosthesis (<b>Fig. 34</b>) had been fitted, revised several times, and worn for a short period, and after the amputee had complained of the same pressure pain as before, a special study of his forearm flexion was made. Thereafter the clinic prescribed a prosthesis with flexible insert hinges, thus sacrificing flexion step up in order to provide a comfortable fit. To obtain a useful range of flexion, the socket was so formed and the hinges so aligned as to place the forearm in 20 deg. of initial flexion. After wearing the second arm a short time, the amputee rejected it with the complaint that the outer wall of the socket was bent laterally about 15 deg. from the normal plane of flexion, thus preventing him from using it in driving a car. He complained also that the prosthesis lacked a stop to prevent him from hurting his stump on full extension. The staff was unable to relate these complaints to any objective measurements, and no stump soreness or discoloration was found.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 21 First prosthesis provided at UCLA, using split socket and variable ratio step up hinges to increase forearm flexion Because the patient complained of pressure pain upon flexion, the step up hinges were later abandoned in favor of flexible insert hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Investigation of the patient's Army and VA records revealed no personality disturbance that might explain a hypercritical attitude toward prostheses. The UCLA staff psychologist examined all of the amputee's previous prostheses (which, except for the first, were in nearly new condition) and obtained the patient's relative ranking of each. It was found that the amputee's rankings were consistently related to the degree of misalignment between the epicondylar axis and the elbow axis of the prosthesis.</p> <p>When, in 1952, the prosthesis last prescribed was fitted, the relationship of the prosthetic elbow center to the epicondylar axis was measured as a function of forearm flexion, and the greatest discrepancy was found to be 1 in. with the forearm fully flexed. It was explained that this degree of misalignment was within the unavoidable error of the best techniques then available. As before, the prosthesis passed all checkout tests, was taken home, and returned with little evidence of wear. The amputee complained of the same pressure pain as before. Since the staff's resources had been exhausted, the case was closed. The staff psychologist was of the opinion that the patient was unconsciously rejecting a satisfactory prosthesis to retain a disabled state that absolved him from the necessity of working at a lower level of prestige and authority than characterized his preamputation history as safety engineer, trainmaster, and field officer.</p> <h5><i>Summary</i></h5> <p>Case 21 was a frustrating case for everybody concerned. It raised many questions and provided no answers.</p> <h4>Case 22, Below Elbow With Biceps Cineplasty</h4> <h5><i>History</i></h5> <p>Case 22, male, a 30 year old unemployed right below elbow amputee, appeared before the cooperating VA hospital clinic in October 1954 requesting a cineplasty operation, although he had never had personal contact with any cineplasty case. His amputation three years earlier had resulted from an automobile accident, and there had been a reamputation six weeks later. The patient had never had a prosthesis and stated that he could not get a job without one. His previous employment record was poor.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed a man 6 ft. 2 1/2<i> </i>in. tall, weighing 155 lb., with a normal range of motion and no conditions requiring medical or physical therapy (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 22. Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The patient was referred to the Prosthetics Training Center to observe cineplasty wearers. There he served as an amputee subject, was fitted satisfactorily with a conventional below elbow prosthesis (<b>Fig. 36</b>), and impressed the staff favorably by his cooperative attitude. He returned to the VA hospital with even greater enthusiasm for cineplasty, and with some misgivings a biceps tunnel was prescribed and constructed in November 1954. Postoperative convalescence was uneventful but was marked by a multitude of vague complaints with no assignable physical foundation, a demand for attention, and unwillingness to leave the hospital until forced to do so. The amputee returned to the next prosthetics course, where a cineplasty prosthesis was fabricated about seven weeks postoperative. During training, it became evident that his attention span was poor; disassociation of elbow flexion from biceps contraction was slow, and he was an inept student.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 22. Conventional below elbow prosthesis first fitted to patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>About three months after his operation, while in the laboratory, the subject induced an episode of hyperventilation during which he seemed to be choking. He was removed by ambulance to the Los Angeles County General Hospital, where a tracheotomy was performed, but he signed out on discovering that he was scheduled for a laryngoscopy. On his return, he informed all the laboratory staff that his tracheotomy was necessitated by cancer of the larynx. Thereafter he delighted in wheezing through his tracheotomy tube on every possible occasion until the tube was removed.</p> <p>It had previously been noted that the patient delighted in wearing short sleeved shirts and exposing his muscle tunnel to everyone with whom he came in contact. He also revealed himself as an inveterate fabricator, and psychiatric consultation disclosed him to be a dependent and insecure individual. About two months after the hyperventilation episode, he was admitted to the hospital with chest pain and unexplained fever. The hyperventilation was noted again in the hospital. His "fever" was explained when he was observed putting the thermometer on the radiator. Upon discharge, the patient disappeared.</p> <h5><i>Summary</i></h5> <p>The results of prosthetic fitting, which were in the main successful, were largely negated in this case by the extreme maladjustment of the amputee. Again the principle of careful selection in a cineplasty program was emphatically illustrated.</p> <h4>Case 23, Bilateral Below Elbow</h4> <h5><i>History</i></h5> <p>Case 23, male, an unemployed 31 year old bilateral below elbow amputee, was referred by the California State Department of Rehabilitation in October 1951. He had lost his hands in August 1949 in a punch press accident while learning to be a tool and die maker. He gave his previous work as coilspring winder and crane operator. He had been fitted with below elbow rotation prostheses (APRL Sierra) on both sides but with no wrist flexion device. He reported that he wore his prostheses 15 hours a day but that he found them inadequate for all but the simplest personal tasks and could not return to the trade he had been learning. He was anxious to dress himself, eat independently, drive a car, and so on.</p> <h5><i>Examination and Evaluation</i></h5> <p>Examination showed no postural abnormalities. The patient was well muscled and had a good range of motion. His right stump was 84 percent of estimated forearm length, his left 73 percent (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 23 Patient as seen on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Although the length of the left forearm placed the patient in the medium below elbow class, long below elbow prostheses were prescribed for both arms because both retained forearm rotation (160 deg. in the right, 110 deg. in the left). Wrist flexion units and Dorrance No. 5 hooks with rubber lined fingers were prescribed for both prostheses (<b>Fig. 38</b>). In mechanical tests, the new prostheses and the original pair made approximately the same scores.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 23. Bilateral prostheses as fitted at UCLA. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the amputee had had no prosthetic use training and was inadequate in the use of his original prostheses, after about four hours of training in the use of the prescribed prostheses he was judged proficient. His level of performance with either side was regarded by the trainer as excellent.</p> <p>Because the patient desired independence, much practice was given in opening doors and similar activities. When training was completed in October 1951, the subject stated that he felt independent and that he was going to move out of his parents' home and seek employment. After two weeks, he reported that he was totally independent and required no help in his everyday activities. He gave much of the credit to the wrist flexion units, with which he accomplished many activities formerly impossible for him.</p> <p>The day after the patient's discharge from the project in November, his picture was in the local newspapers under such headlines as <b>NAB HANDLESS BANDIT IN MARKET ROBBERY. </b>The stories revealed that he had had a brief notoriety as the "Paper Bag Bandit" in 1945, when a series of seven bank robberies in four months netted him approximately S10,000 and a 5 year to life term at Folsom Prison. There he had lost his hands in a license plate pressing machine. He had been on parole when referred to the clinic. To the humiliation of the UCLA amputee trainer, the subject was captured in the market parking lot as he struggled to open the door of the stolen stale vehicle he was using as his getaway car. The clinic staff which had discharged the patient with new prostheses one day earlier was surprised also to read his statement that he had turned to robbery because he ''needed money fast to replace a broken pull wire and a couple of rubber tips."</p> <h5><i>Summary</i></h5> <p>Does rehabilitation mean returning the patient to his former occupational status?</p> <h4>Conclusion</h4> <p>From the case histories given here, certain facts emerge. A primary feature is the individual nature of the problem, in which rules are only general guides. The amount of functional regain cannot always be predicted. Compare, for example, the results obtained with hree of the forequarler amputees (Cases 1, 15, and 16). Even in the abbreviated histories here, and far more in the actual case records, it is clear that the fitting of an arm amputee is a custom job usually involving a certain amount of experimentation and successive approximation before satisfaction is achieved.</p> <p>It is now obvious that by far the majority of arm amputees can be satisfactorily and usefully lilted with prostheses. The exceptions, as of this writing, are those amputees with long arm stumps who have so much residual function that they may not feel the need for mechanical assistance and, at the other extreme, amputees who are so handicapped that it is difficult to provide enough stability and body control motions. During the course of the UCLA study thus far, the titling of the shoulder amputee was raised from a marginal to a truly worthwhile procedure, as was the fitting of the bilateral high level amputee. The forequarler amputee remains, in most cases, an unsolved problem.</p> <p>At this lime, it appears that unilateral fitting of the bilateral high level amputee (shoulder and very shorl above elbow types) provides greater function than does bilateral fitting. A bilateral shoulder amputee can achieve considerable independence if equipped with the UCLA manually controlled, friction type shoulder joint, cable excursion multiplier, arm rotation turntable modified for constant tension by addition of a Belleville washer, and swaged cable fittings with nylon cable housing liner. The latter two apply to all arm amputees. Some cases of phantom pain are refractory to every therapeutic measure Yet painful pressure sensitive areas on the stump may often be dealt with by careful fitting techniques. In general, below elbow. biceps cine plasty cases were successful while other types involving cineplasty were not. The stories behind the development of now standard armamentarium components are drawn from the UCLA experience, and such background is therefore necessarily given only for UCLA developed items and not for the valuable developments of other agencies such as Northrop Aircraft, the Army Prosthetics Research Laboratory, and the commercial limb industry.</p> <h3>Acknowledgments</h3> <p>The authors wish to express their thanks both to the amputees whose records are presented here and also to the past and present members of the Engineering Artificial Limbs Project whose notations are found in the case files, particularly Tonnes Dennison, Jerry Leavy, Hyman Jampol, Gilbert M. Motis, Lester Carlyle, William R. Santschi, Harry E. Campbell, Jeannine F. Dennis, and William H. Henderson.</p> <p><b>References:</b></p> <ol> <li><p>Artificial Limbs, passim.</p> </li> <li><p>Canty, Thomas J., <i>Amputations and recent developments in artificial limbs</i>, Armed Forces Med. J., 3: 1147 (19S2).</p> </li> <li><p>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study</i>, Department of Engineering, University of California (Los Angeles), in preparation 1957.</p> </li> <li><p>Henderson, William H., <i>Artificial arms for child amputees fabrication and fitting developments to July 1</i>, 1956, Department of Engineering and School of Medicine, University of California (Los Angeles), October 1, 1956.</p> </li> <li><p>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human Limbs and their substitutes</i>, McGraw Hill, New York, 1954.</p> </li> <li><p>Navy Prosthetic Research Laboratory, U. S. Naval Hospital, Oakland, Calif., <i>Interim Progress Report</i>, Research Project NM 007 084.26, <i>Cine plastic above elbow prosthesis</i>, 1 November 1954.</p> </li> <li><p>Taylor, Craig L., <i>The objectives of the upper extremity prosthetics program</i>, Artificial Limbs, January 1954. p. 4.</p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1957.</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Two of the three problem cases included in this section are clear cut. That Case 21 is placed in the category of psychosocial problems represents a judgment on the part of the staff and of officials of the Veterans Administration; from Case 21s viewpoint, his problem related to inadequate fitting and alignment.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Case 1, although classified as a forequarter, is excluded from this discussion because he retained most of the clavicle, which had a good range of motion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Navy Prosthetic Research Laboratory, U. S. Naval Hospital, Oakland, Calif., Interim Progress Report, Research Project NM 007 084.26, Cine plastic above elbow prosthesis, 1 November 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Canty, Thomas J., Amputations and recent developments in artificial limbs, Armed Forces Med. J., 3: 1147 (19S2).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">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>8.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Since these case histories are drawn from the UCLA experience, the devices presented as solving problems are those designed by this particular project. We were in no position to present the stories behind valuable components which emerged from other laboratories and limbshops.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Henderson, William H., Artificial arms for child amputees fabrication and fitting developments to July 1, 1956, Department of Engineering and School of Medicine, University of California (Los Angeles), October 1, 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>1.</b> </td><td class="clsTextSmall">Artificial Limbs, passim.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 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>7.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper extremity prosthetics program, Artificial Limbs, January 1954. p. 4.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marian P. Winston, B.A. </b></td></tr><tr><td class="clsTextSmall">Editor, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles); formerly., Prosthetics Education Project, UCLA Medical 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>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Physiology, University of California (Los Angeles); Project Leader, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles); member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert L. Mazet, JR., M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Professor of Orthopedic Surgery, University of California Medical School (Los Angeles); Chief of the Orthopedic Service, Wadsworth Veterans Hospital; member, Committee on Prosthetics Research and Development, PRB, NRC; Past President, American Board for Certification of the Prosthetic and Orthopedic Appliance Industry, Inc.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marvin S. Gottlieb, M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Junior Research Engineer, Engineering Artificial Limbs Project, Department of Engineering, University of California (Los Angeles).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_004/1957-Spring-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience with Prosthetic Problems of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Marvin S. Gottlieb, M.A. * Robert L. Mazet, JR., M.D. * Craig L. Taylor, Ph.D. * Marian P. Winston, B.A. * https://staging.drfop.org/files/original/58b9ac3acbd103e06a1b89d3952822dc.pdf 0a1ffc6373173388efb41ba207d3695b https://staging.drfop.org/files/original/484b8daccf6ce6c0aece26201505c00e.jpg 0b54c5978606817a280da5a93803beba https://staging.drfop.org/files/original/c48afbc6a0c4b0e08fe65bc1293586dc.jpg 5610616274d318d4c61c5f823dccceb4 https://staging.drfop.org/files/original/7ad84a93475df636cf432dd2ed54559a.jpg 98eb6b4ed650868e68250eae91be6158 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_036.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 36 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_036.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Problems in the Management of Upper Extremity Amputees</h2> <h5>Frederick E. Vultee, Capt., USA (MC) <a style="text-decoration:none;">*</a><br /></h5> <p>Experience in the rehabilitation of upper extremity amputees in recent years has highlighted the advantages of many concepts not previously considered or else heretofore noted only superficially. Not only has the development of prosthetic devices assured a greater degree of rehabilitation of many more amputees, but consideration of the amputee as a whole also has played a major role. It is now well recognized that, in times past, attention was too often directed only to the amputation stump. After the wound had healed, the patient was referred to a prosthetist without benefit of a physician's final evaluation. The development of the clinic team approach<a></a> foreshadowed the end of such practices, and with the growth of the clinic team has come the all important factor of considering the patient as a whole.</p> <p>Implicit in such an approach is the concept that complete upper extremity rehabilitation can rightly be expected only when the amputee has been afforded adequate training in efficient utilization of the prosthesis with which he has been fitted. Incomplete or unsystematic training is, at best, responsible for improper habits in prosthetic usage and hence for awkwardness and inefficiency. In the extreme case, it may lead to discard of the prosthesis entirely even though the components involved may themselves be of the greatest utility to an accomplished amputee wearer. The therapist has thus come to be looked upon as an important member of every prosthetics clinic team.</p> <p>The importance of good health also has come to be realized. The patient who suffers from complicating injuries or diseases may not be able to cooperate fully, and when cooperation is limited, interest and motivation die rapidly. For example, the obese patient will profit by guided weight reduction and proper weight stabilization, and the anemic and allergic will benefit by proper corrective measures. Dermatological problems frequently are a serious complication for the amputee, especially when involvement of the stump is threatened or when harnessing excoriates areas of existing dermatitis. Here proper therapeutic measures may permit continued use of the prosthesis or ensure only a temporary suspension of its use. If, however, such conditions are allowed to continue unchecked, they may result in a prolonged period of inactivity.</p> <p>Equal in importance to good physical condition is a healthy mental attitude. Unless rehabilitation therapy includes consideration of the patient's mental outlook, the entire process of recovery may result in complete failure. Accordingly, some cases may require the assistance of specialists in psychiatry and related fields.</p> <p>With respect to the patient's mental condition, an important factor relates to vocational and avocational pursuits. Whether an amputee can engage successfully in work and recreation to his own liking, and whether he has a taste for such activities as are possible to him, may together spell the difference between success and failure in any given case. Proper attention by a qualified occupational therapist is therefore essential.</p> <p>Functional loss aside, a number of other problems arise from hand loss. In addition to the functions of grasp and tactile sense, the hand is used in many symbolic patterns in benediction, in supplication, in the salute, in the handshake. These are ancient and time honored functions denied the person who has suffered loss of the hand. In the rehabilitation of the upper extremity amputee, too much stress often is laid upon the restoration of functional losses relating to prehension, often forgetting the extraprehensile activities essential to the amputee's existence.</p> <p>In addition to these matters are the problems associated with the importance of early fitting and those involved in the special cases of multiple amputation. And finally, mention deserves to be made of the largely faulty but widespread notion that people are inherently right handed or left handed. In the rehabilitation of the upper extremity amputee, the popular concept of hand dominance leads to one of the most difficult problems to be overcome.</p> <p>Since each of these individual problems is closely interrelated with all the others, the order in which they are considered by the clinic team is of no particular significance. Of greatest importance is that they all <i>be </i>considered and that over all evaluation of the amputee's status take into account all the individual factors that, together, constitute total rehabilitation.</p> <h3>The Problem of Hand Dominance</h3> <p>Most people define handedness solely on the basis of whether the right or the left hand is used in writing, or in throwing a baseball, or the like. The less specific definition of a medical dictionary, which describes handedness as the preferential use of one hand over the other, is perhaps more acceptable, for handedness does not appear to be a flat case of one "necessary" and one "nice to have" hand but rather a case of two cooperating members either one of which could be trained as the leader. Nevertheless, the concept of dominance is so widely established that loss of the writing hand is considered by most compensation authorities to constitute severe disability, whereas loss of the other often is viewed lightly. Similarly, loss of one hand in the ambidexterous generally is considered to present no great rehabilitation problem.</p> <p>How do we determine whether an individual is right or left handed? When the average person is asked which is his dominant hand, he usually selects the writing hand. In the upper extremity amputee, we seemingly are presented with a case of "dominance" or "sub dominance." Simply to ask the patient whether he is, or was, right or left handed is, in most cases, a wholly inadequate method of determining the degree of dominant handedness. It produces premature evaluations of disability and of future rehabilitation problems, both of which may need complete revision before the patient is discharged from the care of the clinic team. The problem of handedness is of primary interest to those directly responsible for all phases of training the upper extremity amputee. It is during the preprosthetic stage that the real aspects of dominance present themselves, for during this period the patient is a one handed individual.</p> <h4>The Dictates of Convention</h4> <p>Judging from the design of many of the articles we use daily, it appears that society already has dictated that ours shall be a colony of right handed individuals. From the position of the knife and fork at the table to the placement of the gearshift lever on the modern automobile, we are reminded constantly that we are expected to use our right hand much more than our left. This decision of engineers and of authorities in etiquette causes no small concern to the parents of children who seem to use the left hand more than the right. Parents recall other left handed individualsindividuals who always find themselves crowded when seated at the dinner table (<b>Fig. 1</b>), or whose bodies assume the position of an animated corkscrew when attempting to write at a desk. For these and other reasons, parents try subtly to encourage the use of the right hand in the young child, despite some of the beliefs of medical science. Even the garmentmakers have conspired against the man who uses his left hand for some tasks. Commonly, a button is placed over the left hip pocket, where it seems understood the wallet will be placed, while the right hip pocket is free for easy withdrawal of the handkerchief. The man who uses the left hip pocket for the handkerchief has no protection for the wallet when it is kept on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The southpaw at dinner. Convention dictates the norm; habits in conflict with the established pattern usually lead to trouble. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Popular Fallacy</h4> <p>These elementary observations indicate that hand usage is dictated by habit patterns, possibly as a means of conforming to the norms of the society in which we live (page 9). It is important, however, to consider whether or not truly right or left handed individuals exist and, if so, to consider what is meant by the terms. As has been noted, when the arm amputee first is questioned about handedness, writing is apt to be the first thing considered, and the answer is likely to be made on that basis. Additional questioning usually reveals that, although the patient may have used the right hand for writing, many other tasks requiring delicate, coordinated movements might have been done with the left hand, or vice versa.</p> <p>Too many persons believe that the writing hand also is the only hand capable of performing all other smoothly coordinated tasks. As more probing questions are asked of the patient, it may be evident that the opposite hand also performs many functions. If the keys or small change are carried in the pocket opposite from the hand used in writing, bilaterality rather than simple dominance may well be indicated. Information in this connection can be elicited more readily with male patients by asking which pocket carries the handkerchief, which pocket holds the wallet, which hand holds the pipe or cigarette, and which hand is used to strike a match.</p> <p>It often is surprising to find that, with the exception of writing, almost all daily activities involve equal participation of both hands, one serving as a helper to the other with interchangeable ease. When loss of the use of a hand occurs, either temporarily or permanently, the most frequent problem stems not from the inability to write but rather from the inability to perform the tasks requiring use of both handstying shoes, buttoning clothes, cutting food, and so on. Hence, it is important that a prosthesis be designed to restore bilateral activity rather than dominance or the ability to write. When a patient loses a so called "subdominant" hand, he soon expresses some degree of surprise at the number of jobs formerly done by the missing member. He also notes, with as much surprise, that many tasks are quite difficult for the remaining hand alone, even though it be the dominant or leading hand. But the amount of time required to relearn all these tasks, including writing, with some degree of agility is quite short. Except in bilateral cases, the patient soon becomes reasonably independent. If allowed to continue as a one handed individual, the unilateral arm amputee soon learns short cuts that permit him to be more independent and ultimately to feel that he has no need for a functional replacement of the missing hand.</p> <p>Such a patient gives the greatest cause for concern. Perhaps the inability of some to recognize the absence of a true dominance or to understand the rapidity with which a one handed individual can adjust and become reasonably independent may, in some measure, account for a number of failures in upper extremity rehabilitation. Certainly there are other causesinadequate surgery, poor prosthetic replacement, inadequate training contributing to these failures. But only when all of these factors are considered and eliminated can full utilization of the prosthesis be expected.</p> <p>The patient who has learned to do reasonably well with one hand is the very patient most likely to be a failure when fitted with a prosthesis. His training will be most difficult and frustrating for all concerned simply because he cannot recognize the need for a prosthesis. Training for such a patient comprises largely a program of unlearning all of the grotesque contortions to which he has become accustomed. Because here the individual, having been pleased with his one handed accomplishments, must learn to be a two handed person again somewhat against his "better judgment," frustration becomes an important consideration. The more complicated the prosthesis, the lower is the frustration tolerance of the patient because he cannot accept the need for a device which seems to complicate rather than to simplify his life.</p> <h4>A Two-Handed World</h4> <p>One might now properly ask why so much concern should be shown for such a patient. Would it not be easier to permit his unilateral activities to continue and thereby eliminate all problems of fitting, training, and further care? Unfortunately, the solution is not so simple. We live in a two handed world. To maintain our place in society, two hands are needed, or at least substitutes for them. One need only consider the obvious difficulties encountered by the one handed individual when carrying a loaded cafeteria tray, serving himself at the table, or attempting to tie up a parcel (<b>Fig. 2</b>). In the effort to prevent similarly embarrassing situations, the one handed person may gradually seek less and less public contact, social and vocational, and with this self inflicted isolationism ultimate loss of his own security may develop. Despite all short cuts and self helps, the amputee who remains without a prosthesis must still require a degree of additional assistance for many tasks. A functional prosthesis offers independence. An unfitted stump usually leads only to a gradual but ultimate deterioration of self pride in all tasks, public or private.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The empty sleeve versus the upper extremity prosthesissome examples. Although the unilateral arm amputee may learn to perform well with the remaining sound hand many activities formerly conducted with the amputated member, and although the stump and other parts of the anatomy may be called upon to substitute in "two handed" activities, a great many essential functions are carried out awkwardly, if at all, by the arm amputee who remains unfitted. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Psychological Problems</h3> <p>When it appears that a patient has emotional complications that are not responding to treatment, he should be referred to other medical specialists. Such emotional problems may occur at any phase of the patient's course, and the use of proper specialists will, in many instances, permit the rehabilitation team to continue its work while the patient receives the indicated treatment. Prompt recognition and treatment of such unfortunate situations often will salvage the patient, where otherwise he might drift aimlessly through prosthetic fitting and training until the symptoms are so pronounced as to be recognized by everyone on the street.</p> <p>Initial interviews rarely, if ever, disclose an amputee's underlying feelings about his loss. As he advances through the rehabilitation processes, the amputee may feel that it is too late to open questions of fear and misgiving, in which case his feelings of insecurity are only perpetuated. Hence, it is wise for the physician to suggest possible questions and answers when the amputee is first interviewed. To focus attention upon likely questions may offer an opportunity for the patient to talk about his family's acceptance of his amputation, to discuss social problems resulting from his physical and mental condition, and to air any other problems peculiar to the individual. Unfortunately, no hard and fast rule can be applied; for no two amputees are alike, either in physical or mental make up or in social and economic status. In any given case, each question should be answered as frankly as possible, and, if the answer is not known, every effort should be made to provide one as quickly as possible. Although left to themselves most amputees ultimately find the answers to their own questions, the answers thus obtained usually come only after many frustrations and sometimes after severe emotional stress.<a></a></p> <h3>Medical Problems</h3> <p>The problems of pain, real and phantom, and of phantom sensation, sometimes are so difficult as to postpone actual fitting and training or even to suspend use of the prosthesis after it has been fitted. Recently, phantom pain and phantom sensation have been explored at length<a></a> and more complete concepts of etiology and treatment now are evident. When it is caused by thin or densely adherent scar tissue, neuromata, or bony spurs, stump pain is one of the most common causes for delayed initial fitting or for abandonment of the fitted prosthesis.</p> <p>In such cases it is futile to delay treatment in the hope that actual fitting, continued use of the prosthesis, exercise, or physical therapy may render a neuroma painless or reduce a spur so that it no longer is troublesome. As time passes and the pain or tenderness persists, the patient is entirely justified in questioning whether or not he ever will be able to wear a prosthesis. Specific difficulties that do not respond to conservative measures should be corrected surgically and with the least possible delay. When it seems wise to attempt a conservative approach to minor stump difficulties, an explanation will ensure the patient's continued confidence in the physician. During such a period, the patient's progress must be evaluated regularly. When and if the conservative treatment fails, more radical measures are in order.</p> <h3>Vocational Problems</h3> <p>All amputeesthose, like the housewife, engaged in the home as well as those employed in business and industryhave vocational problems at one time or another. Again, the patient requires much honest and factual reassurance. Although the trend in employment of the physically handicapped is much more gratifying now than it has been in previous years, rose colored pictures of industries seeking amputees for all types of employment lead only to false comfort and to eventual disillusionment of the patient. Although true vocational counseling has become a specialty in itself, the physician must never lose sight of the fact that the job of restoring the patient to useful function is his, the physician's, personal responsibility. Even though the patient may at some time be evaluated by a vocational counselor, the physician must regard the evaluation as a type of referral with continued follow up to ascertain the progress being made.</p> <p>Proper use of the social worker may prove invaluable in maintaining close liaison with the employer and the rehabilitation team.<a></a> The employer should be encouraged not to discharge the amputee patient until the possibilities of further employment have been fully explored. To the new amputee still in the hospital, nothing can be more devastating than a notice to the effect that he has lost his employment as a result of his newly acquired handicap (<b>Fig. 3</b>). Assurance that there is a reasonable chance of continued employment, or that efforts are being made to place the patient in some similar position, will do much to speed his total recovery and to provide motivation, the one factor without which there can be no genuine rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The pink slip versus the helpful proprietor. In total amputee rehabilitation, morale is important. Full cooperation of the employer is essential to the success of the prosthetics clinic team. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is fortunate that current trends in aiding the physically handicapped are toward providing vocational training and placement rather than monetary compensation and the subsequent opportunity to sit in the park and collect the pitying, sideward glances of the passers by. The amputee who formerly held a job requiring bilateral hand use very early recognizes the need for a prosthesis, accepts it readily, and receives training as quickly as possible. With the younger, inexperienced person, who perhaps has drifted aimlessly through several more or less unproductive jobs, the problem of prosthetic acceptance and use is more complicated. Such a person has yet to learn the true value of two hands.</p> <p>Unfortunately, some of the veterans of World War II and of the Korean conflict have been victims of such an experience. These men, many coming directly from high school or from odd jobs, had no opportunity to learn vocations or skills requiring use of two hands. Consequently, many of them accept a prosthesis, cooperate halfheartedly in training and follow up, and then discard the prosthesis to look the country over for a job they can do with one hand and sympathy. When an effort is made to offer these people vocational guidance, many indicate they are "going to school," apparently in the belief that one can get through school with one hand. But as a matter of fact the process of education more often than not demands bilaterality, and the inability to recognize the value of a prosthesis constitutes the principal reason why many amputees eventually withdraw from schools.</p> <h3>Training Problems</h3> <p>Although there can now be no doubt of the value of prosthetics training, it is interesting to note that many amputees, usually those who have worn a prosthetic device for many years, indicate that they see no need for training. The patient and prosthesis become one, and little tricks of operation and short cuts, all of which lead to increased efficiency, become second nature. From such a peak of efficiency it is difficult to remember the basic training required to perfect every motion, In the past, moreover, training rarely was conducted as intensively as it is today. Simple instruction in the use of the terminal device, usually by the prosthetist, was about all the patient could expect, and he depended on trial and error and the passage of time for the remainder of his training.</p> <p>A patient who has gone through such a procedure may scoff at the prolonged period of time now thought necessary to assure adequate training in prosthetic control. But the time thus spent really is immeasurably short because it saves the patient much false motion and wasted effort and prepares him to resume his place in society more quickly than the patient with no training. Of course, training must not be confined to the period of prosthetic wear; rather, it must start as soon as the condition of the stump permits.<a></a> Prepros thetic training includes maintenance of joint mobility and muscle strength as well as maintenance of cerebral patterns of motion.</p> <h3>The Problems of Multiple Amputation</h3> <p>The bilateral hand amputee presents both to the patient and to the medical staff a problem of the greatest difficulty. The patient who has lost both hands still possesses two stumps which afford some means of gross prehension. A pencil can be grasped for crude writing, an eating utensil can be held between the stumps for clumsy eating, and the stumps fill out the sleeves. But all delicate prehension, all discrete tactile senses, are lost. Initially, the bilateral amputee is apt to be deeply depressed, and he therefore usually responds poorly to the first rehabilitation contacts. He requires as rapid a fitting as possible, because otherwise he remains almost completely dependent for all necessities, not only economically but, more important, socially and in the home. The latter situation is the one usually most devastating and the one which unfortunately most often is brushed over when the patient first is met. He must have assistance not only in eating but in all toilet activities as well and finds himself relegated to a crude and almost infantile existence.</p> <p>Prosthetic training is much more detailed and prolonged for the bilateral amputee than for the unilateral because the patient has no remaining natural hand for a prosthesis to assist. All acts of dexterity must be accomplished by one or the other terminal device. The therapist cannot consider training complete when the patient meets the requirements of the unilateral amputee but must, in addition, cover use of the prostheses in all acts of everyday lifefeeding, toilet care, and dressing. It is fortunate that such activities are well within the realm of accomplishment for the bilateral hand amputee, especially when the stumps are comparatively long and the natural elbows are intact.</p> <p>An additional complication, usually resulting from trauma, involves amputation of part of a leg in addition to loss of an arm. In the light of present experience, neither amputation truly can be said to take priority over the other, and each case must be considered on an individual basis. In every case, body mechanics and sense of balance are impaired seriously. Gait training becomes more difficult when a part of an arm has been lost. Similarly, upper extremity training is made more difficult without the use of both normal lower extremities. The patient is necessarily confined to bed or uses a wheel chair or crutches for support. If one of the arms is artificial, crutches are used only with difficulty and often in a manner potentially dangerous. The patient may find his arm prosthesis so attached to the crutch that, in the event of a fall, he is unable to free himself rapidly and to discard the crutch. There is thus always the possibility of damage to the stumps or other parts of the body. Considering these potentials, it would seem best to undertake gait training first. When it can be instituted safely, this practice seems to present fewer problems to all concerned.</p> <h3>The Problems of Early Fitting</h3> <p>Early fitting of the prosthesis has come to occupy a major place in present day concepts of amputee management. To postpone fitting until maximum stump shrinkage has occurred often gives the patient those few extra weeks of one handed experience that lead him to believe he does not need a prosthesis. Although there is no known criteria for determining exactly when a stump has stopped shrinking, it now appears that the greatest incentive to maximum shrinkage is actual wear and use of a prosthesis. Once the patient is shown that early fitting and constant practice are the shortest roads to recovery, he usually cooperates willingly.</p> <p>With early fitting naturally comes the problem of continued stump shrinkage, which usually results in a loose socket. It is entirely possible that fabrication of a second socket may be necessary before complete adjustment has taken place. The patient should be made aware of this possible complication, and, when it appears that a second socket may be required, the added cost might be included in the price of the prosthesis. In a patient's decision to abandon a device, repeated expenditures for prosthetic adjustments often play as important a role as does a loose socket. But if initially the patient is told the reasons for possible additional expenditures, more than likely he will accept the conditions without protest and without discouragement.</p> <h3>Some Solutions</h3> <p>What can be done to solve some of the problems that are potential sources of failure in the proper utilization of an arm prosthesis? First, it must be realized by all concerned with the management of upper extremity amputees that the present concept of dominance is a relative one. The person who loses the so called subdominant hand is just as seriously disabled as is the one who loses the dominant hand, and he stands just as much chance of becoming a nonwearer. The remaining member often can be taught to perform many of the functions of the missing hand. If this situation is allowed to persist for long, the amputee begins to feel that prosthetic replacement is unnecessary.</p> <h4>The Education of The Physician</h4> <p>To the end that all upper extremity amputees shall be properly fitted and trained, it is imperative that the education of all physicians and ancillary medical personnel be continued and expanded. Current knowledge and new techniques must be passed on not only to those physicians and technicians who, because they are specialists, see amputees regularly but also to all general practitioners, especially to the family doctors who usually are first to see the amputee. The general practitioner must be brought to realize that new skills and devices are available to help his patients, and he also must be made aware of the fact that the longer assistance is delayed the more unlikely is the amputee to wear and use a prosthesis. Education must be carried to every level, ideally down to the county medical society, which in many instances is the only group in which the general practitioner can participate regularly. Information relating to amputee management should appear in <i>all </i>medical literature, for technical assistants also are responsible for extending any educational program devoted to the amputee. If complete success in total rehabilitation is to be expected, an amputee must be presented to the various specialized centers or clinics with the least possible delay after amputation.</p> <h4>The Education of the Amputee</h4> <p>Equal stress must be placed upon educating the amputee. If, for example, he has a short stump or some other problem requiring that he be fitted with a more complicated and hence less efficient device, the limitations of the prosthesis must be explained in detail. Too many patients are given the benefit of excellent surgery and fit but are not prepared for the shock that comes when they discover that the prosthesis is, at best, only a device to assist the remaining hand. Such a disappointment often produces discouraging results and sometimes complete failure. Many specialists and technicians are prone to be overenthusi astic about a particular prosthesis. What to them appears to be an excellent prosthesis well may be to the patient a hideous collection of bolts and ropes. As a result of some specialists' enthusiasm, many amputees envision a prosthetic device far more functional than actually is possible.</p> <p>When a patient is counseled for the first time, therefore, every effort should be made to point out all the factors involved in total rehabilitation. The limitations of the prosthesis should be explained at once, so that no false concepts or hopes are allowed to exist or to be perpetuated. Even if nothing more than a photograph is available, the patient should be shown a prosthesis similar to the one he eventually will use, and the necessity for training must be outlined so that the patient realizes that wearing the prosthesis and using it efficiently are two distinct functions. Many patients are astonished to find that training is necessary, and many look upon it as just one more stumbling block in an already confused amputee existence. Each step in the program must be explained fully, and the possible complications also must be outlined. Only in this way can the amputee be spared the bitter disappointments that often attend rehabilitation.</p> <h4>Training and Checkout</h4> <p>Adequate checkout procedures should assure efficient mechanical function as well as correct fit.<a></a> An inefficient cable system may, for example, render an otherwise satisfactory prosthesis so difficult or clumsy to operate that even the patient with a great desire to learn may find it impossible to use the device. The disinterested patient who does not appreciate the true value of prosthetic replacement may seize upon such a situation as the final excuse to give up training completely.</p> <p>Prosthetic training and final checkout complete the patient's initial steps toward rehabilitation, but unfortunately training can be responsible for failure. Therapists must be sympathetic with the patient's initial efforts, but they also must be firm in developing adequate control before actual use of the prosthesis is attempted. The patient's first desire after receiving the prosthesis is "to do something with it," and time spent in learning control techniques may seem worthless to him. Here again explanation of the reasons for the training steps is essential.</p> <p>If the patient is unable to demonstrate adequate control skill in a reasonable time, it often is wise to postpone or slow the training process rather than to provoke marked frustration in both patient and therapist. In such instances it is important that the therapist keep the prosthesis until sufficient basic skills are developed by the patient. If the amputee is permitted to wear the device immediately, he is likely to develop inefficient and sometimes weird methods of operation, thus negating all of the valuable time expended in fabrication and fitting. It is essential, however, that the patient understand the reasons for his sometimes difficult and slow progress in training and why it is necessary for the therapist to retain the prosthesis until basic skills are achieved.</p> <p>In some clinics there are to be found a standard below elbow and a standard above elbow prosthesis with split and laced sockets to permit adaptation to many different kinds of stumps. These so called "standard" prostheses are used in early training to prepare the patient for efficient operation of his prescribed prosthesis. When used with proper care and reasonable patient selection, they serve a valuable purpose, but such a procedure may be unwise if the training arm cannot be adjusted readily to the individual patient or if it contains undesirable components. Attempts to use an ill fitting training arm may be so difficult that the patient becomes discouraged and anticipates the permanent prosthesis with misgivings. Accordingly, training arms should be used only on the advice of the clinic team. Too much training can be as harmful as too little. The higher the level of amputation the less functional usefulness can be derived even from the best prosthesis. Realization of this circumstance can prevent the hypertensive episodes that occur in patient and therapist alike when too much is demanded of the amputee prosthesis combination. There is no personal defeat when, as is often the case, it must be admitted that the prosthesis can serve only as a "helper" hand. Under such circumstances, training, to be effective, must be guided appropriately. Overtraining only discourages the patient whose level of amputation is a basic factor in determining the degree of prosthetic function. Achievement tests should be used to measure and record the patient's progress and final skills, but such tests vary from level to level and from patient to patient and can serve only as a crude measuring stick, not as the final criterion as to whether or not a patient has achieved the maximum benefit of training. The answer to that broad question can come only with careful observation of the patient during activities of daily living and of vocational pursuits.</p> <h3>Conclusion</h3> <p>From these considerations, it is possible to formulate certain basic rules for the management of the upper extremity amputee. It is important first to know as much as possible about the patient besides the fact that he is missing a hand. It is necessary to understand him and to understand his disability. Too much faith must not be placed in the absence of either a so called "dominant" or "subdomi nant" hand as the sole measure of disability. In addition, the patient must be made to understand what is in store for him. Above all, no questions about any phase of his problem should be left unanswered. In some instances the amputee is reluctant to discuss problems not relating directly to his amputation, and the physician should be certain that, aside from the amputation, there are no other physical or mental problems that may affect total rehabilitation.</p> <p>For psychological as well as physical reasons, the patient should be fitted as rapidly as possible. Early fitting allows the amputee to realize the advantages and limitations of his prosthesis. Moreover, early fitting often eliminates the danger of the patient's coming to think that he can get along with one hand a situation which can complicate and prolong total rehabilitation. Finally, because overtraining can be just as harmful as are all the other "don'ts" of amputee management, no attempt should be made to train the patient to do more things than the level of his amputation and the nature of his prosthesis permit.</p> <p>When all of these individual problems are considered systematically by the respective members of the clinic team, over all management of the upper extremity amputee becomes a synthesis of cooperative effort. In no other way can so much success and satisfaction be afforded both the patient and those charged with his care.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee</i>, Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The principles of prosthetic prescription</i>, Chapter 6 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team</i>, Artificial Limbs, January 1954. p. 9.</li> <li>Carlyle, Lester,<i> Artificial arm checkout procedures</i>, Artificial Limbs, January 1954. p. 25.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues</i>, J. Bone and Joint Surg., 36A:981 (1954).</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>,Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Jampol, Hyman, and Jerry Leavy, <i>Training the upper extremity amputee</i>, Chapter 23 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Kuitert, J. H., and F. E. Vultee, <i>Prosthetic training for the upper extremity amputee with cineplasty</i>, Arch. Phys. Med. and Rehab., 34:367 (1953). </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee</i>, June 1952.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures, Artificial Limbs, January 1954. p. 25.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Jampol, Hyman, and Jerry Leavy, Training the upper extremity amputee, Chapter 23 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kuitert, J. H., and F. E. Vultee, Prosthetic training for the upper extremity amputee with cineplasty, Arch. Phys. Med. and Rehab., 34:367 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and Joint Surg., 36A:981 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs,Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 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>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frederick E. Vultee, Capt., USA (MC) </b></td></tr><tr><td class="clsTextSmall">Physical Medicine Service, Walter Reed Army Hospital, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-31.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-32.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-33.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Problems in the Management of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Frederick E. Vultee, Capt., USA (MC) * https://staging.drfop.org/files/original/6d21fba44b4c02b4c004bf63e1f63831.pdf cfe971bc146b39e11e97c79118b1a01c https://staging.drfop.org/files/original/b6e1c2c759ed57d301d37d5ab4b5dac1.jpg 1c533dccdbe487d7d7d5d410dad1110b https://staging.drfop.org/files/original/c4a8c9195afad4e3ca03898f003dee7a.jpg daa3d984879549cbfc42159eb222089a https://staging.drfop.org/files/original/9f6daaddd1106d9cbe983c2033775d25.jpg becab7587312a262eb82597586a55b32 https://staging.drfop.org/files/original/362bb85952cc606295a9d63a6b958884.jpg bc9f5510398c4a397e38835cfa659c6b https://staging.drfop.org/files/original/3df3d00f10722335a631d5d506bce3e9.jpg 1438d406cb4650e0b21cc5cd159ab4d4 https://staging.drfop.org/files/original/3c515a6e746ee9da332077965f79f130.jpg eeaa58e7d94c89adda2a30a56fce67e6 https://staging.drfop.org/files/original/c14f2585925462148b4dc438c9c27a32.jpg d44e67466a5e9abea7791e13cea64868 https://staging.drfop.org/files/original/f76954679dfd8b87f5df527a3c7d892b.jpg 7ac7d32a7aec4d1aec8fd653c346fbc1 https://staging.drfop.org/files/original/1993fdd6c16310f6c51fb0a4ac52babe.jpg 3404b478edcf7b6daea295ec18b64db0 https://staging.drfop.org/files/original/5699bab2e0bc22f0d0c338f1fe253c49.jpg dd7be1022a55d231aecf0c0506683d10 https://staging.drfop.org/files/original/7edc77d5b01a38b55dc8a930df01f1a9.jpg d1de7bf09a288dccc2a1dbaa6f857c5e https://staging.drfop.org/files/original/19b07e847745ca927903c374fcdd08b3.jpg 329601d54d376428eddccdf1c99743e2 https://staging.drfop.org/files/original/35cb88c8107f12d1e13e4f66aeb734d0.jpg 50819e7dac33551723a15d6e26c1d066 https://staging.drfop.org/files/original/1cb6915c5fcaae6c2d352544442ba21e.jpg 0bcc34a21662a964b18d6bcb72c0e2ed https://staging.drfop.org/files/original/4ac29010338a64c8712eb4fcef376384.jpg ae72774766d287aff0fe5353562f75a3 https://staging.drfop.org/files/original/e7e2686a60c6518befb80b03771e5f80.jpg 9f8d304788a8729cacce1bfeb40979a6 https://staging.drfop.org/files/original/affd9f9bd75a9a20f20ca57f8be4e3c3.jpg 4a1273b17bd7fa3518107c0cfa7fe4de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_026.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 26 - 33 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_026.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee</h2> <h5>Liesl Friedmann, O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Considerable information is available concerning the treatment philosophy, prosthetic prescription, and training of the child with a unilateral upper-limb deficiency<a></a>. However, there are few published data on adapted equipment for the child with a bilateral upper-extremity deficit. To help remedy this lack, this article presents a brief discussion of the current treatment philosophy at the Institute of Physical Medicine and Rehabilitation in the New York University Medical Center and describes some of the adapted equipment and training procedures that have been found useful for children with congenital bilateral upper-limb deficiencies.</p> <p>The presentation is essentially confined to children fitted with conventional prostheses. Experience with unilateral and a few bilateral amelic children at the Institute of Physical Medicine and Rehabilitation has led to the conclusion that these patients obtain inadequate benefit from conventional fitting and might do better with externally powered prostheses. However, these prostheses pose their own unique training problems which are not considered here.</p> <p>Bilateral Fitting Recommended The child is fitted as soon as he sits independently. If there are lower-limb deficiencies or other conditions which delay the achievement of sitting balance, assistive devices and training programs are used to facilitate this accomplishment.</p> <p>It is believed that all children with bilateral upper-limb deficiencies should be fitted bilaterally at the outset for the following reasons:</p> <ol> <li>To encourage the performance of bimanual activities and, hopefully, to assist in the development of an appropriate body concept by providing bilateral extremities of equal length.</li><li>To aid balance and prevent scoliosis.</li><li>To increase prosthetic tolerance.</li><li>To prepare for later bilateral prehensile function.</li><li>To promote eye-hand control of the prostheses.</li></ol> <p>The considerations listed above outweigh the disadvantages of lack of sensory input from the covered stumps. Since the prostheses are not worn full time by any of these children, ample sensory stimulation of the deficient limbs can be achieved.</p> <h3>Training Considerations</h3> <p>In the training program, the longer stump is developed as the dominant member unless the child shows a strong preference for the shorter limb. If both sides are equal in length, the child's preference is determined by observation.</p> <p>If the child has lower extremities which can assist in the performance of activities of daily living, use of the feet is encouraged, with loafer-type shoes recommended for easy removal.<a></a> However, exclusive use of the feet should be discouraged. Pedal skills should be used to assist prosthetic function or in emergencies when the prostheses are not available. Thus, the feet should be used primarily for activities that cannot be performed with prostheses, although strict rules cannot be applied. The degree to which the lower extremities are used must be a matter of judgment based on the individual case. It should be remembered, however, that if the child becomes too dependent on his lower extremities he will have to learn to reduce foot usage when he reaches the age of social consciousness.</p> <h3>Fitting Modifications</h3> <p>In general, the same standard fitting procedures are used for the bilateral limb-deficient child as are used for the unilateral patient with the following modifications:</p> <ol> <li>A 12P hook is fitted immediately but is not activated . Passive mitts are not used.</li><li>During the passive phase of training (inactive terminal device), a figure-eight harness is used, with a chest strap connecting the two axilla loops added for retention. To prevent the harness from riding up in the back, a vertical strap from the cross of the figure-eight is attached to a waist belt.</li><li>The usual developmental sequence in a child's perception of the prehensile function of a hook is well known<a></a>. In bilateral amputees, the developmental sequence is the same, but is sometimes extended over a longer period. The therapist will usually be able to detect the child's readiness for cable attachment and active use by noting the typical signs of frustration arising from inability to function independently; for example, a sudden, sustained increase in crying, temper tantrums, refusal to wear the prostheses, and similar otherwise unexplainable manifestations. Occasionally, the child will verbalize the desire to do things independently without the prostheses. A reasonable attention span is an imperative requisite.</li><li>When the child reaches the age of four or five years, bilateral wrist-flexion units are provided.</li><li>For the very young above-elbow amputee, friction-lock elbow units, which have recently become available, are useful.</li></ol> <h3>Training Procedures</h3> <p>Patients with bilateral limb deficiencies below the mid-humeral level present less of a fitting and training problem than bilateral amelic patients. Nevertheless, they still require specialized training. It is recommended that they be taught the use of one hook at a time and learn pre-positioning of the terminal device by use of the opposite hook, the knee, elbow, chin, or any available hard surface. Training in changing the position of wrist-flexion units by pushing against a hard surface or the opposite prosthesis needs to be given. These patients must also learn to don and remove their prostheses <a></a> and perform the activities of daily living.</p> <h3>Assistive Devices</h3> <p>The pattern of the training program in the New York University Medical Center follows the developmental scale of the normal child as far as possible.<a></a> However, it must be remembered that the "child amputee" will eventually become a teen-ager and then an adult. Thus both the physical and psychological aspects of growth should be taken into account in special training programs.</p> <p>Most of the special training devices used by adults for independence in activities of daily living can also be used by the young teenager. However, since training must start at a very early age if independence is to be obtained, devices specifically designed for the very young child must be used initially. The items described in this article are some that have been developed for the patients at the Institute of Physical Medicine and Rehabilitation.</p> <h3>Self-Feeding Aids</h3> <p>The first level of activity training is self-feeding. A swivel spoon<a style="text-decoration:none;">*</a> possibly with a flat, built-up handle to prevent slipping (<b>Fig. 1</b>) is useful. Initially, the therapist places the spoon into the hook. Later, the child learns to pick up the spoon from the rim of the plate or from the table without assistance. Usually, the child can push the food against the rim of a bowl or against a plateguard. At about four years of age, the child is introduced to the use of a "pusher," a utensil (<b>Fig. 2</b>) commonly used by normal children in Europe. The pusher has been found to be a good pre-knife-and-fork feeding aid. The pusher, which can be made from a flattened and re-shaped teaspoon, is placed behind the "thumb" of the hook on the nondominant side by the therapist. At this stage it is also likely that the child will be able to use a regular teaspoon with a flat handle, bent at an angle which is a compromise between that needed for scooping and the angle needed to get the food to the mouth without spilling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Straight spoons. The one on the right illustrates a method of building up the handle to prevent slipping when grasped by a prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Top, metal pusher formed from flattened spoon. Bottom, spoon flattened to make pusher. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At six to seven years of age, knife-and-fork usage can be started (<b>Fig. 3</b> and <b>Fig. 4</b>). At first, both utensils are placed behind the "thumbs" by the therapist, but with practice the child learns to do this independently. Bilateral wrist-flexion units are very useful for proper positioning of the utensils as they are maneuvered for insertion into the terminal devices and then for cutting. To prevent plate movement, it is frequenth" helpful at this stage to use a damp, flat foam-rubber sponge, wet paper towel, or adhesive foam rubber attached to the bottom of the plate. Correct table height is important in reducing shoulder abduction during eating. With the prostheses in complete abduction, the elbows should barely touch the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of knife and fork for cutting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Use of knife and fork for peas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When teaching drinking with a cup, a plastic, flat-handled cup<a style="text-decoration:none;">*</a> should be used initially. If necessary to prevent spilling when the cup is placed on the table, a lid (<b>Fig. 5</b>) may be provided. At this stage, the child can grasp and release actively but has not yet learned to pre-position the hook. This must be done by the therapist. When the child is able to preposition the hook (three to four years of age), a regular plastic or paper cup can be introduced. Such cups must be held by the upper rim from above (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cup equipped with cover to avoid spilling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Plastic cup held at rim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the public schools of New York City, children are provided soup and a sandwich for lunch. These items are most difficult to handle with a prosthesis. Soup should be sipped from the cup or through a straw, but the child cannot control his prosthesis well enough to prevent mutilation of a sandwich. At the Institute of Physical Medicine and Rehabilitation, a sandwich holder has been devised which is used successfully by some children. The teacher or a parent must insert the sandwich, but the child can then eat it from the holder (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Sandwich holder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Dressing Aids and Adapted Clothing</h4> <p>The amount and type of dressing activities performed by the bilateral upper-extremity amputee vary greatly from one child to the next. For these patients the combined use of feet and teeth may be required.</p> <p>To don his prostheses the child must first put on his stump socks and then maintain them in position as he maneuvers his stumps into the sockets. This feat is not very difficult for the bilateral below-elbow amputee, but if one or both of the limbs are deficient above the elbows, the socks tend to fall off. Others<a></a> have described a bilateral stump sock which is useful. At the Institute of Physical Medicine and Rehabilitation, a connecting piece has been added to this bilateral stump sock to protect the back and axillary skin from irritation (<b>Fig. 8</b>). There is no commercial source for this item at present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Bilateral stump socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Adolescent girls frequently find a front-opening brassiere useful. The standard item can be easily converted into a front-opening type by sewing up the back, opening the front and fastening it with a long Velcro strap and D-ring (<b>Fig. 9</b>). To close the top, a supplementary smaller strap with Velcro or a large hook on an elastic strap may be used. Sleeveless dresses split below the waist and with an open back are helpful.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Front-opening brassiere. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major training problem is toileting, which is particularly difficult for females. If a female child does not have normal lower extremities or at least toes able to function sufficiently in grasping clothing or toilet paper at the proper body level, life-long dependency in this function may have to be accepted. In using bilateral upper-extremity prostheses for assistance in toileting, it is a problem to get the prostheses close enough to the body to adjust the underpants while wearing a dress, even with elbow turntables and bilateral wrist-flexion units.</p> <p>Some children have successfully used modified underpants which do not have to be removed. The crotch of the undergarment is split and refinished with binding (<b>Fig. 10</b>). The opening should close when the child is in the erect position. When the patient sits on the toilet seat, with the trunk flexed on the thighs and the lower limbs abducted, the opening is sufficiently wide to prevent soiling of the garment. With practice, the use of toilet paper can usually be mastered without special devices. Sometimes, however, the solution of this problem requires the development of special reaching devices which are highly individualized. Female patients usually find tampons much superior to sanitary napkins.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Modified underpants. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Schoolwork Aids</h3> <p>For the bilateral amputee to function effectively in school, adaptation of equipment is required in many activities. For example, cutting with scissors is an impossible task with the standard item. <b>Fig. 11</b> illustrates a simple and very satisfactory adaptation in which one handle of the child's scissors is embedded in a small piece of wood 1-1/2 in. X 1 in. X 1/2). The lower handle of the scissors is placed in a groove made with an X-acto knife and held in place with plastic wood. When the scissors are positioned in the wood block, the tip should touch the table. The axis of the two blades should not be tight and the blades should fall open with ease. The child holds the upper handle of the scissors with the hook tines pointing downward. As the handle of the scissors is pulled up and down, the block of wood rides flat on the table surface. In learning to use the adapted scissors, the child should start with straight lines on paper and then include gentle curves and corners and, finally, complex figures. Such scissors are effective only with paper; cloth cutting requires the use of electric scissors (<b>Fig. 12</b>). For cutting thread on a sewing project, a seam ripper is verv useful (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Scissors with one handle embedded in wood. Plastic wood holds the handle in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Electric scissors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Seam ripper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Writing can be facilitated by the use of a clipboard or attaching the paper to the table with masking tape, rather than letting the child struggle to hold the paper steady with his non-dominant prosthesis. Chalk holders which prevent the chalk from breaking and improve blackboard writing efficiency are available commercially<a></a>. A pencil holder has also been described<a></a>. A simpler crayon-holding device has been used for very young patients at the Institute of Physical Medicine and Rehabilitation (<b>Fig. 14</b>). This holder consists of a wood block (6 in. X 2 in. X 2 in.) with a series of holes drilled at angles to enable the child to withdraw and reinsert the cravon without having to pre-position the crayon. Unless the child presses down very hard, the crayon will not slip from the hook. If a thin layer of foam rubber is glued to the bottom of the wood block, it will not slip on the table. Some older children cannot use their other hook to insert a pencil behind the ''thumb" for stability. When clamped to the edge of the table, a simple block of wood with a single deep hole (<b>Fig. 15</b>) is effective in holding the pencil so that it may be properly grasped. In time, the child learns to pick up and position the pencil without special devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Crayon holder fashioned from wooden block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pencil holder clamped to edge of tray. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sewing and Knitting Aids</h3> <p>It is possible for a bilateral upper-extremity amputee to learn knitting and sewing. One needle with the knitting on it can be inserted in a vise (<b>Fig. 16</b>), while the other needle is held behind the "thumb" in the dominant prosthesis. The wool is laced around the needle by the nondominant hook. Thick needles and wool should be used. Sewing can be made easier by use of a frame mounted on a pivot with ball bearings (<b>Fig. 17</b>). Many four- and five-year-old children enjoy sewing cards or doing simple cross-stitch work. This is an excellent activity for training the child to achieve minimal opening of one hook at a time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Small vise used to hold knitting needle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Frame to hold sewing card, mounted on ball bearings to swing freely on pivot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Constant Modification Necessary It is hoped that other therapists will find these suggestions useful and that they will report special devices that they have used successfully. Finally, it should be emphasized that, although a variety of assistive devices, including the feet, are used by young children with bilateral upper-extremity deficiencies in performing the activities of daily living, the problem changes as the child grows older. The physical growth and social consciousness characteristic of the teen-ager may preclude the use of techniques that were acceptable in the younger child. Constant alertness to the need for modification of techniques is required to meet the changing physical and psychosocial needs of the developing child.</p> <p><b>References:</b></p> <ol> <li>Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</li> <li>Deutsche Vereinigung fur die Rehabilitation Behinderter (Heidelberg-Schlierbach), Information on measures for rehabilitation of children with dysmelia, 1962.</li> <li>Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bulletin, April 1965, pp. 7-16.</li> <li>Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</li> <li>Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</li> <li>University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Baby Cup, KT5, with flat double handle and lock lid (50 cents); Kayware Corp., 2731 North Crawford Ave., Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Sta-Lcvel Baby Training Spoon ($1.00); Price Industries, Ltd., 815 East Talmadge Ave., Akron, Ohio.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 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">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 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>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 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">Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 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">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 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>Liesl Friedmann, O.T.R. </b></td></tr><tr><td class="clsTextSmall">Therapist-in-Charge, Children's Division, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 400 East 34th St., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_026/autum65-53.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_026/autum65-54.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_026/autum65-55.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_026/autum65-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_026/autum65-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_026/autum65-58.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_026/autum65-59.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_026/autum65-60.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_026/autum65-61.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_026/autum65-62.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_026/autum65-63.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_026/autum65-64.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_026/autum65-65.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_026/autum65-66.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_026/autum65-67.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_026/autum65-68.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_026/autum65-69.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee Creator An entity primarily responsible for making the resource Liesl Friedmann, O.T.R. * https://staging.drfop.org/files/original/627090118e7550aef32b928f5cfc5097.pdf c7c3671e2f62151182aae56f91f5d70f https://staging.drfop.org/files/original/c7e92f6d5fe85c8d6ef8544614a97aa3.jpg e468493086048ce57199f393dee24774 https://staging.drfop.org/files/original/04ce23f2e2248f3d1d49330516618203.jpg 5ad71da0cd2407e65b1be1093f9dad0d https://staging.drfop.org/files/original/37a6c5bccac772225e463355b7ce5b99.jpg 5fdd10eb7e82869440f88ddc8281c621 https://staging.drfop.org/files/original/1df47c562dff18af23aea5737e89ad4f.jpg d057a4335966a37fed05ecf311b6fa49 https://staging.drfop.org/files/original/66602a6f594faa462098d6e7eae66228.jpg b1e3ac1eed82d64494c9acf1af76bd6f https://staging.drfop.org/files/original/beceed2ac3ba9eecfcc08cf2abe51169.jpg 9ae2a1c0df624061372096332c5fce03 https://staging.drfop.org/files/original/d308ea30b792e6fb6e57c9d43f2f66f5.jpg 8be6fb5bd0b864a1f0104a3e23affdd6 https://staging.drfop.org/files/original/5e8c8f8672d073a25e049c5a392e5ef1.jpg 5774196adae9a8c9364a6e9134b7bde9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_029.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 29 - 39 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_029.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Status of the Above-Knee Suction Socket in the United States</h2> <h5>Chester C. Haddan <a style="text-decoration:none;">*</a><br />Atha Thomas, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The above-knee suction socket constitutes a means of attaching an artificial leg to the stump of an amputee without necessity for the conventional pelvic band, a metal hip joint, or other types of suspension harness (<b>Fig. 1</b>). The leg is held on by the slight vacuum created in the socket each time the leg is lifted from the ground, the pressure usually being controlled by a valve installed in the lower portion of the socket. Accurate functional fit of the socket, as distinguished from the conventional "plug" fit, permits the creation of negative pressure, gives a wider range of muscular control of the leg, and provides comfort while walking or sitting. Because the conventional belt and hinge joint are eliminated, the suction socket gives the above-knee amputee more freedom and less interference with clothing. The leg feels more like an integral part of the body, a feature which tends to decrease the sensation of dead weight and to improve sense of position. Reduced piston action of the stump in the socket results in greater toe clearance during walking. No stump sock is necessary. Any adductor roll is corrected. And finally, active use of the stump muscles causes them to develop instead of becoming atrophied. For a complete discussion of the prescription, fabrication, fitting, alignment, and use of the above-knee suction-socket prosthesis, reference may be had to Bechtol,<a></a> to Eberhart and McKennon<a></a>, and to the so-called "suction-socket brochure" of the University of California.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical above-knee suction-socket leg before application of the usual rawhide finish. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Early History</h3> <p>The earliest known reference to the suction socket is in the form of a patent issued by the United States, February 10, 1863, to Dubois D. Parmelee<a></a> of New York City. Subsequent patents have been issued to George Beacock and Terence Sparham<a></a> of Brock-ville, Ontario, Canada, in 1885; to Justin K. Toles<a></a> of Stockton, California, in 1911; and to Ernest Walter Underwood<a></a> of Birmingham, England, in 1926. The fundamental principles of the Beacock and Spar-ham suction socket differed but little from those of the Parmelee method. Toles' description was basically the same but with the addition of a rubber lube and bag lining which could be inflated by air to assist in holding the socket on. The socket described by Under- wood had smooth helical grooves, which he claimed ventilated the stump as well as assisted in holding the socket in place.</p> <p>A search of the literature on above-knee suction sockets has revealed only a few articles prior to the last few years. In 1925 Muirhead Little<a></a> of England reported favorably on 11 amputees fitted with the suction socket after the design of Blatchford,<a></a> made of metal, and containing a smooth helical groove of a little more than one turn around the circumference of the socket. Some 30 cases were reported as fitted at Roehampton, England, following World War I using a metal socket with a helical groove as described by Blatchford.<a></a> It is not known whether these 30 cases included the 11 reported by Muir-head Little, but it is considered doubtful since during this period several different groups were using the suction socket in England. Use of the suction socket has been practically dormant in England since that time, although it has been revived in recent years.</p> <p>Pfau<a></a> of Berlin says the suction socket has been known in Germany for 30 years but that it was not popularized until Oesterle, in Ulm, started his work in the early '30s. Felix,<a></a> a surgeon of Diisseldorf, reported on above-knee sockets in 1941. He stated that the suction socket had been used in Germany to some extent since World War I but that it was not popularized until a satisfactory suction-socket valve had been developed in 1932. After this accomplishment, numerous selected cases were successfully fitted in Germany.</p> <p>As a result of the apparent reported success with artificial limbs in Germany, early in 1946 the Surgeon General of the United States Army sent to Europe a "Commission on Amputations and Prostheses" to observe foreign practice. One principal item of interest was the successful use in Germany of suction sockets for above-knee prostheses. Because of the favorable report<a></a> issued by the commission, the Advisory Committee on Artificial Limbs instituted, as one activity of its general plan of providing information on the best possible prostheses, a program to determine the possibilities and limitations of the suction-socket type of suspension for the above-knee leg.</p> <h3>Clinical Research in the United States</h3> <p>After extensive trials and studies in their own laboratory, workers at the University of California, Berkeley, prepared instructional material and started a nation-wide program to determine the feasibility of use of the above-knee suction-socket technique under field conditions in the United States. By September 1947, 52 subjects had been fitted in 10 widely separated localities by local prosthetists in their own shops with materials and devices normally employed but making use of supplementary information and supervision by University personnel.</p> <p>The success of this program led the Advisory Committee on Artificial Limbs, in October 1947, to recommend to the Veterans Administration the use of the suction-socket technique for above-knee amputees, its use being limited for the time being to further field tests within the VA under the direction of qualified surgeons. The recommendation was accepted and, from December 1947 through January 1949, 20 schools, each of one week duration, were held throughout the country to provide 250 orthopedic surgeons and 200 prosthetists with sufficient knowledge of the fabrication and application of the suction socket to introduce it on an experimental basis.</p> <p>By October 1949 comprehensive records had been made of over 500 cases, and ACAL felt that sufficient experience had been gained in the use of the suction socket to warrant its general application. Accordingly, a recommendation was made to the Veterans Administration, and the above-knee suction socket has since been in use routinely. The Orthopedic Appliance and Limb Manufacturers Association and the Veterans Administration, in a cooperative effort, have sponsored suction-socket schools from time to time to permit surgeons and limbfitters to gain sufficient knowledge in this field to qualify them to prescribe and fit the suction socket.</p> <h3>Surveys Of Amputee Acceptance</h3> <p>The enthusiasm with which the suction-socket above-knee leg has been accepted in the United States is indicated by the results of a number of surveys. Among them are the surveys of selected groups made by Thorndike and Eberhart <i>, </i><a></a> by Mazet, McMaster, and Hutter <i>, </i><a></a> and by Canty and Asbelle.<a></a> Results of three surveys, two by the Orthopedic Appliance and Limb Manufacturers Association, are shown in <b>Table 1</b>. The earliest data are from a University of California report<a></a> of April 1948. The 52 cases reported at that time had been carefully screened, selected, and fitted under the supervision of representatives of the Advisory Committee on Artificial Limbs. The results were carefully recorded. At the termination of this initial experimental program on April 15, 1948, of the 52 subjects fitted, 40 had been wearing their suction-socket legs routinely for 4 to 20 months. All were satisfied and had no intention of returning to the type of prosthesis worn previously. Six of the subjects, owing to improper fittings, nervous disorders, or lack of cooperation, were still alternating between the suction-socket leg and their previous legs. Six had been dropped from the program and were considered as failures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In February 1949, the Orthopedic Appliance and Limb Manufacturers Association, in an effort to determine the extent of acceptance of the suction-socket leg in the United States, mailed questionnaires to approximately 200 limbshops. Of these, 159 shops reported. Eighty of those reporting had made no suction sockets at all; 79 shops had at that time fitted 1262 men, women, and children, with an amazingly small number of complete failures. A comparatively small group of 46 were converted to pelvic-belt-controlled legs, but many of these continued to use the suction-socket shape and some the suction valve, thus retaining many of the advantages of the suction-socket leg. The 1954 survey, also conducted by OALMA, with 72 firms reporting on 5882 cases, indicates similar conclusions. The 1954 OALMA questionnaire includes those firms reporting as few as three cases fitted and those reporting as many as 500 cases or more.</p> <p>Many of the limbshops reporting in both the 1949 and the 1954 OALMA questionnaires indicate that they have adopted the suction-socket method of fitting (that is, ischial bearing) as standard practice even though the amputee cannot actually wear the suction socket as such. Auxiliary supports, such as the Silesian bandage (<b>Fig. 2</b>), are used almost routinely by some limbshops. One of the most widely known and reputable shops in the United States reports the use of auxiliary supports on 300 out of 322 cases fitted. Another reports auxiliary supports applied in 300 out of 373 cases fitted. Another highly successful shop, in fitting 181 cases (of which 91 were children), used auxiliary supports on 90 cases. It is interesting to note that the firms reporting the largest number of cases also report the largest percentage of cases fitted with auxiliary supports.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two forms of the Silesian bandage commonly used as an auxiliary support for the suction-socket leg, both in the United States and in Europe, particularly in Germany, where, according to Pfau, Hepp, and others <i>(13), </i>it is used almost routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The surveys indicate that over 96 percent of all suction sockets fitted since the introduction of the program were fitted to stumps over 3 in. long. In the one shop that reported 90 children fitted, not a single one was fitted with a stump shorter than 3 in. It is to be noted that most of those fitted with the stump shorter than 3 in. were women; and some reported that, although they did not believe the fitting of a stump shorter than 3 in. to be practical, they were almost forced at least to attempt it because of pregnancy, a condition which precludes wearing the conventional pelvic belt.</p> <p>It may therefore be assumed that, except in very rare instances, generally it is impractical to prescribe the suction socket for stumps less than 3 in. long. A further observation is that of the large number of apparently quite successful cases of Gritti-Stokes amputations fitted, no failures whatever being reported in the case of amputation at this level.</p> <p>Another interesting feature brought out is that, while in 13 percent of the cases reported edema was present in the early stages of fitting, in only two cases did the edema persist and become a contributing cause of failure of the suction-socket leg. It is obvious from these data that, while edema may be common, it need not be considered a serious problem.</p> <p>An effort was made to determine the number of bilateral above-knee amputees fitted successfully with suction sockets, but reliable data were not obtained on this question. From the information received in the survey, however, it is believed that the number will probably be about 100, the percentage of failures being approximately the same as in the case of unilaterals.</p> <p>The overwhelming reason given for failure in the use of the suction socket comes under personality factors. An effort has been made in the surveys to obtain reliable data as to the definite reasons for failure. Personality factors are found to be predominant, with physical factors next in line, the condition of the stump third, and social and economic considerations fourth in importance. Thus tabulated, the causes of failure look about like this:</p> <blockquote><p> <i>1. Personality Factors</i><br />Unfavorable temperament<br />Poor cooperation<br />Inability to adjust<br />Discouragement<br />Lack of interest<br />Low order of intelligence<br />Insecurity<br /><i>2. General Physical Factors</i><br />Skin trouble<br />Age<br />Change in weight<br />Circulatory difficulties<br />Inability to bear weight on ischium<br />Buerger's disease<br />Overweight<br />Perspiration<br />Allergy<br />General weakness<br />Loose abduction<br />Unsocial noises<br /><i>3. Slump Characteristics</i><br />Inadequate length<br />Bone spurs<br />Interfering scars<br />Undue length<br /><i>4. Social and Economic Considerations</i><br />Insufficient time for proper fitting<br />Excessive distance from shop<br />Undue sales influence<br />Employer disapproval<br />Occupational requirement </p> </blockquote> <p>Another question asked the reporting firms was: "What percentage of above-knee amputees could, in your opinion, be fitted with a suction socket?". While the answers to this question range from a low of 30 percent of all amputees to as high as 100 percent, the average is 73 percent, a figure thought, in the opinion of the authors, to represent a realistic approach.</p> <p>Another question, asked because of the unusual amount of interest in children and the older age group on the part of the Committee on Artificial Limbs, was: "Is the socket suitable for amputees under five and over seventy?". Almost without exception the suction socket was said not to be suitable for the very young or the very old.</p> <p>Again, the question was asked: "When is the suction socket a practical approach to prosthetic fitting?". The following list of conditions, in the order of frequency with which they were mentioned, indicates the thinking prevalent among the reporting firms on this particular question:</p> <blockquote><p>Right personality factors and willingness to cooperate<br />Healthy, unscarred stump over 3 in. long<br />Under 65 years of age<br />New amputees not conditioned to suspenders or pelvic control<br />Easy access to facility<br />Good muscular reaction<br />Patient's enthusiasm<br />Good circulation<br />Good balance and coordination<br />Available training and therapy<br />Reasonable occupational demands</p> </blockquote> <h3>Factors in Suction-Socket Technique</h3> <p>Accumulated experience with fitting the suction-socket above-knee prosthesis over a period of seven years has clearly demonstrated its many advantages and its desirability over the conventional belt- or shoulder-suspended leg. On the other hand, the experience of the authors during the same period has convinced them that the suction socket is not suited for all above-knee amputees. This belief has been confirmed further by reports of survey studies previously conducted by others and by the results of the surveys reported here. In our opinion, there is considerable question as to the validity of the statement made by some to the effect that the suction socket can be used profitably by any thigh amputee who can wear the conventional type of prosthesis successfully. Experience has shown that there are certain amputees who cannot wear a suction-socket prosthesis successfully. If failures are to be avoided, all cases should be studied and screened carefully before a suction socket is prescribed.</p> <p>The factors to be considered are divided roughly into two groups, each often affecting the other-those relating to characteristics of the prosthesis itself, and those relating to the characteristics of the amputee. Chief among the mechanical considerations of the leg are alignment and socket shape. Factors relating to the amputee are the general physical and mental condition, the condition of the stump, and the condition of the opposite extremity.</p> <h4>Factors Relating To The Artificial Leg</h4> <p><i>Alignment</i></p> <p>With the suction-socket leg, which is controlled entirely by the stump muscles, alignment becomes much more critical than in the case of the pelvic-band suspension and therefore must be correct for proper control and comfort. If alignment is incorrect, there is a definite whip or rotation of the prosthesis during the swing phase. The problem of alignment has not yet been solved completely, and opinions differ a little as to what constitutes the ideal alignment of the prosthesis. Theoretically, it is desirable to incorporate as much adduction of the stump within the socket as is possible mechanically, since to do so tends to suppress body sway and to place the iliotibial band (or that portion of it which may remain intact) under tension.</p> <p>In the normal, the centers of hip, knee, and ankle joints coincide in the frontal plane with the mechanical axis of the lower extremity as a whole (<b>Fig. 3</b>). After amputation through the femur and fitting with a prosthesis, however, the body weight is no longer borne through the center of the hip joint but on the ischial tuberosity, which lies medial to the center of the hip joint. This would indicate, then, that the mechanical axis of the well-aligned above-knee prosthesis would more nearly coincide with a vertical line extending from the ischial tuberosity through the centers of the knee and ankle joints (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Normal alignment in the frontal plane, showing how centers of hip, knee, and ankle joints coincide with the mechanical axis of the lower extremity as a whole. From Thomas and Haddan (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Forces acting on the stump and pelvis of an above-knee amputee during the stance phase. In the well-aligned prosthesis, the heel of the foot and the center of the knee should fall approximately on a vertical line (A-A') through the point of contact of the ischium (a). The tendency of the pelvis to rotate downward on the normal side owing to the body weight can be reduced by keeping the dimension (b) as small as possible. This is accomplished by an upward force through the ischium (a). Lateral rotation of the pelvis and side-sway in the shoulders and torso can both be minimized if the force in the abductor muscles (c) is sufficient to balance the body weight by lever action about the ischial seat <i>(a). </i>The stump must be anchored firmly and comfortably by pressure along the entire lateral side <i>(d). </i>Failure to do this results in discomfort at the crotch (e). From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Posterior view of the above-knee prosthesis showing position of the socket in relation to the rest of the leg. The medial line (a) should be approximately vertical. The lateral line (b) is sloped downward and inward. From Had-dan <i>(8).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the sagittal plane, the weight line in the normal person is a vertical line drawn through the centers of the shoulder, hip, knee, and ankle joints (<b>Fig. 6</b>, left). After amputation and fitting of a prosthesis, however, this vertical weight line must be shifted forward in order to obtain alignment stability (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Normal posture and two postural deviations which must be compensated for in fitting and aligning the prosthesis. Left, normal; center, slight deviation from normal presenting few difficulties in prosthetic fitting; right, extreme postural abnormality which, unless corrected by postural exercises, would present almost insurmountable alignment problems. From Gocht (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Alignment in the sagittal plane. The stump should be oriented in the socket with several degrees of initial flexion <i>(a) </i>to allow the stump to control knee stability over the widest range of hip motion possible. The ankle may be positioned either in front of or behind the knee. The dimension (i) will depend upon the individual amputee, his age, range of motion in the stump, stump musculature, and prevailing terrain. From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee is young and agile, with no stump deformities and with strong and well-developed muscles in the back of the stump, the dimension <i>b </i>in <b>Fig. 7</b> may be reduced to zero. On the other hand, in the presence of flexion contracture in the stump, or weak musculature, this dimension may have to be increased to give sufficient stability. But to do so may result in the sacrifice of a normal gait and cause a tiring and awkward one. Similarly, postural abnormalities (<b>Fig. 6</b>, center and right) can make proper alignment very difficult to achieve.</p> <p>Such deviations in the weight line have upon postural stability and body alignment a biomechanical effect that is obvious. To complicate matters further, the amputee is deprived of a number of those sensory cues upon which every normal human being depends for the autonomous control of posture and motion. These include touch and pressure sensations from the soles of the feet and the never-ending bombardment of proprioceptive impulses that emanate from sensory receptors in the muscles, tendons, and joints of the weight-bearing limbs and sweep upward to the cerebellum. In the aggregate, these physiological and biomechanical deviations from normal appear formidible. Yet with proper fitting and alignment of his prosthesis, and with adequate training in the proper gait and posture, the average amputee can compensate for them to an amazing degree.</p> <p><i>Socket Shape</i></p> <p>Exactly what constitutes the most successful socket shape has not yet been fully determined owing to the many variables involved in the use of this technique. Several successful designs have been fully described in the literature <i><a></a><a></a><a></a><a></a>. </i>In these designs, weight-bearing occurs chiefly about the top posterior portion of the socket, particularly in the region of the ischial tuberosity, with a lesser amount on the gluteal muscle. The addition of a well-defined . . ischial seat reduces pis- ton action of the stump in the socket to a minimum and allows for a looser fit at the top of the socket. Incorrect shape, size, or location of the ischial seat leads to definite discomfort and frequent loss of suction, particularly when the wearer is sitting. In some very muscular stumps, the ischial seat may be reduced in size and in some cases removed entirely. Such amputees bear weight on their well-developed muscles, with the load distributed around the top portion of the socket. The socket is shaped the same except for the reduction or removal of the ischial seat.</p> <h4>Factors Relating To The Amputee</h4> <p><i>General Physical and Mental Factors</i></p> <p>A complete history and physical examination is the first step in determining the desirability of fitting the suction socket. Age is an important consideration, and as a rule elderly amputees are poor candidates for the for this reason it requires considerably more effort and muscular skill to learn to use it. If, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has indicated that children as young as seven years can be fitted successfully.<a></a> The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to suction socket. But old age <i>per se </i>is not a contraindication. Amputees over 70 years of age have been fitted successfully. As already noted, the suction-socket prosthesis is activated almost entirely by the muscles of the stump, and for this reason it requires considerably more effort and musulcar skill to learn to use it. if, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has Indicated that children as young as seven years can be fitted successfully<a></a>. The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to psychological or emotional difficulties. Learning to wear and use a suction-socket prosthesis requires cooperation, effort, patience, and perseverance. If the amputee is impatient, resentful, undependable, easily discouraged, unreasonable, or otherwise emotionally unstable, he most likely will be uncooperative and is apt to be a poor subject for the suction socket. Many failures can be attributed to the fact that the amputee is either unwilling or unable to devote the necessary time and effort to obtain a satisfactory fitting. As experience has been gained by the prosthetists, and with the additional aid of the recently developed alignment devices (page 23), the time required for construction and fitting has been considerably lessened in recent years. The interesting observation has been made that, when an amputee has to purchase his limb himself, he is likely to be much more cooperative than if he is given one by some agency.</p> <p><i>Slump Considerations</i></p> <p><i>Length. </i>Stump length is not so important a consideration as might be thought. Contour, muscle tone, and mobility are important determining factors in deciding whether or not a short stump can be fitted. Naturally, the longer the stump the better is the muscular control and the easier is the fitting and training problem. But stumps as short as 3 in. (measured from the crotch) have been fitted successfully. Usually the shorter stumps require the addition of an auxiliary suspension belt (such as the Silesian belts shown in <b>Fig. 2</b>) in order to stabilize the socket on the stump.</p> <p>End-bearing supracondylar and Gritti-Stokes amputation stumps can be fitted successfully with the suction socket, although in such cases the mechanical knee joint usually has to be placed at a level slightly below that of the opposite knee.</p> <p><i>Stump Contour. </i>With the conventional socket, a conical-shaped stump has always been considered desirable. Such is not the case with the suction socket. A stump of more cylindrical shape, with only slightly tapering sides and a fairly broad end, seems to maintain better suction and friction than does the conical or pointed stump. Most undesirable is a long, redundant, flabby mass of skin and fat extending beyond the bone end. Such a mass of tissue not only offers fitting problems but is prone to become edematous and swollen, thus making it difficult to don the leg or to remove the stump from the socket. In such cases, surgical revision is advisable before a suction socket is prescribed.</p> <p>Excessive subcutaneous fat or extreme flabbiness of stump muscles frequently results in marked changes in the contour of the stump after the suction socket has been worn for a while. Repeated modification of the socket thus becomes necessary. With excessive subcutaneous fat, the stump may shrink considerably after wearing the socket, necessitating the insertion of leather liners or even the making of a new socket. Muscles that are atrophied and flabby and of poor tone will develop and increase in size with the use of the suction socket, necessitating enlargement of the socket.</p> <p><i>Muscle Control and Strength. </i>Good muscular control and mobility of the stump are essential for successful use of the suction socket. Fixed deformities due to muscle contracture are very common in amputations above the knee, particularly in the older age group, and they not only present very serious fitting and alignment problems but also handicap the amputee in walking. Flexion and abduction deformities are the usual ones, and the shorter the stump, with resulting greater muscle imbalance, the more likely are they to occur. Once they do occur they are very difficult to correct. It is imperative, therefore, that every effort be made postoperatively to prevent such deformities. Studies in alignment conducted at the University of California<a></a> indicate that the most efficient gait with the suction-socket prosthesis is obtained by fitting the socket with the stump in adduction and slight flexion (<b>Fig. 7</b>). Severe flexion-abduction deformity of the stump makes such alignment very difficult, if not impossible, without producing marked tilting of the pelvis and excessive pressure on the stump.</p> <p>The adductor and hamstring muscles are important not only in controlling the limb but also in preventing flexion-abduction deformity by overcoming muscle imbalance. The shorter the stump, the less power remains in these muscles and the greater the tendency to deformity. It is well known that, in order for muscles to function at maximum efficiency, they must have a fixed insertion. In amputations through the thigh, the major muscles are sectioned well above their insertions, and all too often these muscles are allowed to retract upward, no attempt being made to fix their cut ends to fascia or over the end of the bone. Failure thus to fix the free ends seriously impairs muscle function in controlling the stump. In considering an amputee for a suction socket, the stump should be carefully examined to determine how well the thigh muscles are functioning and whether there are any fixed deformities. If any are present, active and passive exercises should be carried out to correct them as much as possible before the socket is fitted.</p> <p><i>Scars. </i>Deep linear scars near the socket brim may interfere with maintenance of suction. Tender, adherent scars in the weight-bearing area beneath the ischial tuberosity and over the buttocks may cause pain sufficient to prevent the wearing of a suction socket. Deep, folded, adherent, or puckered scars over the end of the stump, which so often cause difficulty with the conventional socket, rarely offer any problem with the suction socket. In fact, it has been observed repeatedly how often these scars smooth out and become more pliable after a suction socket has been worn for some time.</p> <p><i>Ulceration and Infection. </i>Open ulcers, draining sinuses, and active deep infection of the soft tissues of the stump, as well as active osteomyelitis, are definite contraindications to the use of the suction socket. With adequate surgery and use of antimicrobial drugs, these conditions can usually be eradicated readily.</p> <p><i>Bony Spurs. </i>Although in many thigh stumps bony spurs develop at the end of the femur, they rarely offer any difficulty in the fitting or wearing of a suction-socket prosthesis. Occasionally, however, a large spur will develop on the lateral side of the bone in a stump with a fixed abduction, thus producing painful pressure against the side of the socket. Relieving the socket at point of pressure, realigning the socket, or surgical removal of the spur usually solves such a problem.</p> <p><i>Skin Disturbances. </i>Skin sensitivity, irrita- tion, and infections are not uncommon in amputation stumps, and there appears to be considerable variation in the skin's resistance to pressure, friction, and irritation among individual amputees. Some are constantly troubled, while others have no difficulty. Der-matological complications are cited as a fairly common cause of failure in the use of the suction socket. Usually they can be prevented by proper hygienic care of the stump and good fitting, or else they can be relieved by derma-tologic treatment. Skin allergy and contact dermatitis, of rare occurrence with the suction socket, usually can be controlled readily. The troublesome adductor roll, with recurring "pressure boils" (suppurative hydroadenitis and folliculitis), so commonly encountered with the use of the conventional socket, rarely if ever occurs with the well-fitted suction socket. In fact, when such a condition exists with a conventional socket, and the socket is converted to a suction one, usually the roll and cysts rapidly disappear. This is one of the great advantages of the suction socket.</p> <p><i>Perspiration. </i>One troublesome problem occurs in individuals who perspire excessively and who also have a high bacterial count in their perspiration. Irritation or skin friction in such a situation leads to suppurative hydro-adenitis and furunculosis. Excessive perspiration is not uncommon when the suction socket is first worn, but it usually subsides after varying lengths of time. In alleviating these superficial skin infections, x-ray treatment is often of value. Autogenous vaccines have also been used with some success. Before any suction socket is discarded as a failure, every possible effort should be exerted to treat and eradicate such troublesome skin conditions. Some of them can be anticipated from previous history and careful examination and can be eliminated by proper treatment before the socket is fitted.</p> <p><i>Condition of the Opposite Extremity</i></p> <p>During the experimental program, and in the early suction-socket schools, abnormalities and disabilities in the opposite extremity were considered as constituting an important factor—and even as a probable contraindication—in determining the suitability of the amputee for a suction socket. Subsequent experience has shown that abnormalities in the opposite extremity, while still to be considered, are not necessarily contraindicative. Amputees with disabilities so great as to require permanent bracing of the opposite limb have been fitted successfully with suction sockets; many persons with below-knee amputations on one side are wearing above-knee suction-socket prostheses with ease and comfort on the other. In fact, in such cases the suction-socket leg appears to have several advantages over the conventional above-knee leg. Survey studies also reveal that some bilateral above-knee amputees have been successfully fitted with suction-socket prostheses. But of course it is apparent that all such cases must be selected only after a very thorough analysis of individual problems.</p> <p>Peripheral vascular disease which has necessitated amputation is in itself no contraindication to use of a suction socket, provided the opposite limb is not too seriously affected by the disease.</p> <h3>Conclusions</h3> <p>On the basis of the surveys reported upon, it appears quite definite that the suction-socket prosthesis has many advantages over the conventional belt- or shoulder-suspended leg. Approximately 75 percent of all above-knee amputees can be fitted successfully with the suction socket. Chief causes of failure, listed in decreasing order of importance, are psychological difficulties, general physical factors, stump abnormalities, and social and economic factors. Teamwork between physician, prosthe-tist, therapist, and amputee is an essential requirement in the successful fitting and wearing of the suction-socket prosthesis. Meticulous attention to fitting and alignment techniques is important, as is also adequate training.</p> <p>Research studies in gait and principles of alignment, and the development of new alignment devices and duplicating jigs, have been of great value in reducing the time involved in construction and fitting by eliminating, to a great extent, trial-and-error methods. Although many limb manufacturers in this country still do not appreciate the advantages of the suction-socket above-knee limb and make no attempt to fit it, the wide acceptance of the above-knee suction-socket prosthesis in the United States today indicates that it can no longer be considered an experimental device, its use limited to a few selected amputees. Use of the above-knee suction socket is now so prevalent that it can be safely stated—and fairly stated-that the majority of above-knee amputees can successfully be fitted with the suction-socket prosthesis.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>The juvenile ampu-tee, </i>J. Bone and Joint Surg., 35A:659 (1953).</li> <li>Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</li> <li>Bechtol, C. 0., <i>The suction socket, </i>J.A.M.A., <b>146:625 (1951).</b></li> <li>Canty, T. J., and C. C. Asbelle, <i>Above knee suctionsocket prosthesis. </i>Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954,</li> <li>Felix, W., <i>Praktische Erfahrungen mil der Saugpro-these, </i>Ztschr. f. orthop., 72:352 (1941).</li> <li>Gocht, H., <i>Kunstliche Glieder, </i>Berlin, 1920.</li> <li>Haddan, C. C, <i>Alignment principles, </i>paper readefore a meeting of AAAS, Sec. M., Philadelphia, 1951.</li> <li>Little, E. M., <i>A new method of fitting artificial legsockets, </i>Brit. Med. J., 2:896 (Nov. 14, 1925).</li> <li>Mazet, R., P. E. McMaster, and C. G. Hutter<i>Analysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, </i>J. Bone and Joint Surg., 33A:618 (1951).</li> <li>OALMA Journal, 3(3) :36 (Spring 1949).</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</li> <li>Pfau, Heintz, personal communication.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation pros-thesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thorndike, A., and H. D. Eberhart, <i>Suction socketprosthesis for above knee amputations, </i>Am. J. Surg., 80:727 (1950).</li> <li>Toles, Justin K., U. S. Patent 980,457, January 3,1911.</li> <li>Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</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>20.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (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>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Canty, T. J., and C. C. Asbelle, Above knee suctionsocket prosthesis. Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Mazet, R., P. E. McMaster, and C. G. HutterAnalysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, J. Bone and Joint Surg., 33A:618 (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>15.</b> </td><td class="clsTextSmall">Thorndike, A., and H. D. Eberhart, Suction socketprosthesis for above knee amputations, Am. J. Surg., 80:727 (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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Felix, W., Praktische Erfahrungen mil der Saugpro-these, Ztschr. f. orthop., 72:352 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pfau, Heintz, personal communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Toles, Justin K., U. S. Patent 980,457, January 3,1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (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>Atha Thomas, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, University of Colorado School of Medicine, Denver; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Chester C. Haddan </b></td></tr><tr><td class="clsTextSmall">President, Gaines Orthopedic Appliances, Inc., Denver, Colorado; Past-President, Orthopedic Appliance and Limb Manufacturers Association; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-25.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-26.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-27.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-28.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-29.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-30.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-31.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-32.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Status of the Above-Knee Suction Socket in the United States Creator An entity primarily responsible for making the resource Chester C. Haddan * Atha Thomas, M.D. * https://staging.drfop.org/files/original/db74232ff919eba50ae953fc5d8e15df.pdf 4106376d5c34e536f4d1f88cbe77c124 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_001.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Still a Long Way to Go</h2> <h5>D. S. McKenzie, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is probably a common experience to those of us who work in the field of artificial limbs to receive odious comparison between the relatively primitive prostheses and the sophisticated hardware deriving from space technology, nuclear physics, and the like. The implication usually is that, if similar expenditure on research were made in our field, similar dramatic advances would be made. I do not think that the problem is as simple as this reasoning would imply, and there is some evidence to support my view. I am told that, once upon a time, a great American aviation company undertook to develop an artificial arm and that, some years and a million or two dollars later, they reverted with relief to the relatively simple matter of designing aircraft.</p> <p>And yet we must acknowledge that the externally powered upper-extremity prostheses of today are poor things. It is very doubtful indeed whether the unilateral arm amputee can obtain from them any functional or emotional gain over that deriving from the conventional body-powered prosthesis; indeed, in some respects there may be a loss. It is even doubtful whether any bilateral amputee with measurable humeral stumps would be improved, except perhaps by making it possible to superimpose an additional degree of freedom such as pronation-supination on the existing body-powered prostheses. Indeed, I would go so far as to say that the amelics and bilateral shoulder-disarticulation patients would be better off functionally if they only had sufficient sites available for harnessing with sufficient power and excursion for body-powered control. Currently available externally powered limbs are acceptable to these patients only because a little function is better than none at all. How little that is, is exemplified by the readiness with which the children with upper-extremity amelia and normal lower limbs revert to using their feet for prehension and manipulation.</p> <p>It is of more than passing interest to attempt to analyze why these things should be so, and I think there are a number of reasons.</p> <p>First, the power-weight ratio of available actuators and power storage components is still not advantageous enough for us to provide truly acceptable responses.</p> <p>Second, we have not yet discovered enough control sites capable of providing a sufficient number of degrees of freedom to position the hand or terminal device in space, to put it in the optimum attitude in relation to each task to be performed, and still leave an adequate reserve for prehension.</p> <p>The problem of simulating normal prehension has not been solved, nor, in my opinion, has a truly acceptable compromise been attained. Most writers agree that a well-designed hook is more functional than any of the many so-called functional hands, and yet few would claim that the hook contributes anything to cosmetic restoration or that it is likely to be emotionally satisfying to more than a small proportion of patients. Various ingenious hands purport to provide a selection of different types of grasp, such as the power grasp, precision grasp, "three-jaw chuck," and so forth, and some even achieve this. But none of them, nor of the hooks for that matter, is capable of manipulation within the grasp. This results in the exasperating experience for the user that any object he picks up is seldom immediately in a position of function; he is unable to manipulate it into such a position and has to resort to inelegant procedures such as transferring the object to the mouth and back to the hand again. Furthermore, many tasks that we do are achieved by manipulation-screwing, modeling, squeezing, and a host of others--which, for the amputee, have to be done by energy-consuming gross arm movements or even gross body movements, and he cannot feel what he is doing. It is not surprising that the unilateral amputee elects to use his remaining hand, and the amelic his toes.</p> <p>The foregoing difficulties apply in the main both to externally powered and body-powered prostheses, and I have said little about sensory feedback, a degree of which is available to the users of the latter systems. The control cable offers a built-in position servo, while a great deal of information about the forces applied at the output can be derived from the reactions of the harness against the body and those of the socket on the stump. When external power is used, these afferent channels either cease to exist or are severely attenuated, and it becomes necessary to consider the provision of artificial sensory loops which in their turn introduce difficulties in interpretation.</p> <p>We are thus confronted with what I believe to be the main barrier to progress in externally powered prostheses-the man-machine interface. This should be taken to mean not only the physical attachment of the prosthesis to the wearer, but also the boundary through which all command signals from the biological system of the wearer must pass to the mechanical system of the prosthesis and through which all information relating to the output of the prosthesis must return to the biological system if the wearer is to make the best use of such information to modulate performance.</p> <p>It is on these channels of communication that the effective control of externally powered devices depends. I am quite certain that we do not know enough about their mechanism to exploit them to best advantage. No one has yet attempted to measure the "goodness" of the channels-for example, in terms of communication theory-and yet I believe that effective systems design would follow on such data as surely as night after day.</p> <p>One of the greatest virtues of biological systems is that they are highly adaptive. The human control system-and in particular the computer as represented by the central nervous system-is no exception to this. The pattern of manual activity which we require in order to enjoy a full life is so infinitely variable that I have very serious doubts whether any form of programmed operation within the prosthetic system will satisfy a user for any length of time. The concept of programming the trajectory of the terminal device so as to limit the decision-making demand upon the user to commanding the system to move it from <i>A </i>to <i>B </i>is open to this criticism. Even if provision were made for the user to override the program and revert to voluntary control, I suspect that the switch would soon be left permanently in the override position. In any event, the case for this sort of programming seems to me to be accepting that the interface is inevitably poor in a communications sense. It may be that a better understanding of the interface will make this an unduly pessimistic view.</p> <p>Reverting to the adaptive properties of the biological system in general, and of the central nervous system in particular, it seems to me that significant progress in externally powered limbs will be made only when it becomes possible to link the central nervous system "on line" with the prosthetic control system. Servo loops crossing the interface would make an integrated and adaptive system. It might be said that a start had already been made on this by exploiting the myoelectric discharges for control. In such an integrated system, however, the command signal is being derived by tapping the middle of the efferent loop. Such sensory information as returns by afferent channels is derived from the muscles and their tendons. Essentially, this is a backwater of the main stream of the afferent channel of the man-machine complex. It follows that information about the output of the man-machine system can only be inferred rather than known. In my view, Simpson's position-controlled servos and Bottomley's pressure-demand pneumatic valve have more prospects of achieving a truly adaptive output and might be regarded as among the first breaches in the man-machine interface.</p> <p>Taking all these matters into consideration, besides many other difficulties which I will not discuss for reasons of space, we are in no position to be complacent about externally powered arms. Indeed, the state of the art is so relatively primitive that the only overriding indication for prescribing them at this time is bilateral high-level amputation or the equivalent-only a handful of patients out of the total upper-extremity case load of any prosthetic service and an even smaller proportion of the total case load. The difficulties are so great, and the amount of fundamental information lacking is so formidable, that one is continually surprised at the surge of interest in the field and the amount of effort that is going into it. Indeed the budget for prosthetics research and development in Great Britain for next year envisages that over 30 per cent of the total expenditure will go to work on external power. From what I saw when I visited the United States in May 1967, I would think that a similar proportional expenditure is being made there. Taking into account the tiny number of immediate beneficiaries-although admittedly they are among the most severely disabled-it is proper to take stock and consider whether this level of expenditure of money and effort is justified. Have we got our priorities right? Of course, there is much common ground in the orthotics field, and many developments arising from purely prosthetics requirements would have direct application here. This would increase the number of potential beneficiaries, but they would still be a small proportion of the total disabled population. I think the justification as well as the reason for the interest in the subject is the fact that we believe the possibility of introducing a new order of function to <i>all </i>upper-extremity amputees lies in external power and possibly to lower-limb amputees as well.</p> <p>May I use these pages to make a plea, if not that hardware development should cease, at least that some of the effort should be put into fundamental research into problems such as those I have indicated? Indeed, all of us already engaged in such work should devote sufficient time to discovering what the patient really needs, rather than to providing him with what we think he ought to need.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>D. S. McKenzie, M.D. </b></td></tr><tr><td class="clsTextSmall">Director, Ministry of Health, Biomechanical Research and Development Unit, Roehamp-ton, London, S.W. 15, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Still a Long Way to Go Creator An entity primarily responsible for making the resource D. S. McKenzie, M.D. * https://staging.drfop.org/files/original/128a4ee02ba99ec2b2f3383ebf4c5ee1.pdf 1d58a741d5b899bf3165aaee4a30b867 https://staging.drfop.org/files/original/2d1139a7a8b381922d685cedf6c247d6.jpg b1b7bf385524209a364b2a5d706e69f1 https://staging.drfop.org/files/original/0b625e54797b43090410315f51bb8d4d.jpg 5a4a4b7273c3c08e58009c0f1d7ac1c4 https://staging.drfop.org/files/original/6af1f53cf4a83727f1442c98daaf6325.jpg e59a5dce109a736b1220cea93df1d532 https://staging.drfop.org/files/original/ef39aec52d3f6f89d396d8de9b904348.jpg 43eb5113c3c8357bc66c5661da85c546 https://staging.drfop.org/files/original/43f4c2cfada99345789b214972118bb4.jpg 53c3f83b5e1afba21df1b455a5cf3d6b https://staging.drfop.org/files/original/cf564e482b2e846fe2bf016c153528c5.jpg 16165f4e12ab933aa6a4134f395ceaf4 https://staging.drfop.org/files/original/94ddb01505c6fd91d498912976af3048.jpg 9f4e4824217f753bbfc090061b775b86 https://staging.drfop.org/files/original/c3e6400840337b90c6265d9fdb31ba05.jpg 6c5c72cce2507fd840d11e5b01c72499 https://staging.drfop.org/files/original/5fe4651c4989ad661077ef728ce3dfc2.jpg f4589d3c099abf5c832d2f368ac04110 https://staging.drfop.org/files/original/c95654d14fbc139044f4f2c1d95cf838.jpg 02cf0e94fb1afe4a88464f018b0407b3 https://staging.drfop.org/files/original/50f3d635111e4062bd949a25d13d93b8.jpg f7f75243050a5c11088831cc5677c2d1 https://staging.drfop.org/files/original/defb3aa2f95589f1d808e5bbcdb5f068.jpg 92e2681beb7f96b1aafc78a0ee712bde https://staging.drfop.org/files/original/18540ad87543021e8ea0daf13b66a934.jpg 884df0195a3f5e4beba928039b604b8f https://staging.drfop.org/files/original/973afd8b16f8e2b86200850467e47aa9.jpg da85192551a55f89ecb5f68fbfba2f86 https://staging.drfop.org/files/original/8f08a4840fdbccaad732de3cf86c6656.jpg aa1650fd1dee2a737800610dea67e78e https://staging.drfop.org/files/original/b29824f38251a82718c4ee9151c706c1.jpg 0493e10fdd34899b9d3d60972263341f https://staging.drfop.org/files/original/babc4d6089681d0e63053e41f2891aad.jpg 45827d84a72fd1e1c6c812877bbfa404 https://staging.drfop.org/files/original/b80b8ef48cb874db384cb2177426b857.jpg 644927a521638fa7a65d2a0059ca0925 https://staging.drfop.org/files/original/6be0ab9c948daa999fee159e98b18731.jpg ff93ed94477dc598a4d1bdf910d8f292 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_057.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 57 - 72 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_057.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper Extremity Amputee II. The Population (1953-55)</h2> <h5>Norman Berger, M.S. <br /></h5> <p>The number of upper-extremity amputees examined during the "Survey Studies" conducted by New York University probably represents the largest sample of a single type of disabled individual any research group has thus far had the opportunity to study. The size of the sample (1630 cases) offered a unique opportunity for assessing the status of the upper-extremity amputee on a nationwide basis during the years 1953-55 just prior to the widespread introduction of the devices and techniques promulgated by the Artificial Limb Program. The information that will allow us to form a picture of the arm-amputee population during those years is presented in the following pages under the headings:</p> <blockquote><p><em>General characteristics.</em> This section presents identifying data (such as age, height, weight, and educational level) as well as some general findings concerning causes of amputation, amputee types, and amputee vocations.</p> <p><em>Stump characteristics.</em> Here are found data concerning the strength and range of motion of various stump movements, characteristics basic to the control and use of a prosthesis.</p> <p><em>Extent of use of prostheses.</em> Under this heading is presented information dealing with the extent and type of prosthetic use in the common activities of daily living, data which permit inferences concerning the functional value of prostheses.</p> <p><em>Prosthetic components.</em> This section presents a description of the prostheses worn by arm amputees throughout the country.</p> </blockquote> <p>Within this outline, the data gathered are presented, where applicable, by amputee type, an arrangement which permits comparison of attributes between below-elbow, above-elbow, shoulder-disarticulation, and bilateral arm amputees.</p> <p>One should note at the very outset that this entire study deals with male amputees only. No female patients are included anywhere. It will also be noted that the tables and graphs which present the data contain a varying number of cases. Owing to such limitations as the fact that some amputees were not wearing their prostheses or could not remember details about their prosthetic experience, full information was not available for each case. Accordingly, the totals approximate, but are usually somewhat less than, 1630.</p> <h3>General Characteristics</h3> <p>Below-elbow amputees only slightly outnumber above-elbow amputees in the general population. This observation may be somewhat surprising in view of the widespread belief that below-elbow amputations occur much more frequently than do other types. Apparently, the latter is not the case, and it would therefore be unwise to direct research and development toward the one area at the expense of the other. The relative infrequency of shoulder disarticulations and of bilateral arm amputations also is noteworthy. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Classification of arm amputees is based on stump length expressed as a percentage of the length of the same arm segment on the sound side. For example, a below-elbow amputee whose stump measures 6 in. from medial epicondyle to end and whose sound forearm measures 12 in. from medial epicondyle to ulnar styloid has a remaining stump length of 50 percent. The system of classifying arm amputees is thus based on percentage categories, each category indicating a progressively greater amount of loss of function. Because the remaining percentage of the length of the corresponding normal arm segment is an indication of the amount of functional loss occasioned by the amputation, the figure is an important one. (<b>Fig. 2</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the NYU survey, the number of amputees in each category was as indicated in the accompanying charts. Nearly half (45 percent) of all below-elbow amputations fall in the medium below-elbow range, while more than half of the above-elbow cases (66 percent) fall in the standard above-elbow category. Extremely short stumps tend to outnumber extremely long types in both above- and below-elbow cases. Of the below-elbow stumps, 10 percent are very short as compared to 8 percent that are wrist disarticulations; in the above-elbow group, 12 percent are shoulder disarticulations as compared to 7 percent that are elbow disarticulations. (<b>Fig. 3</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A very substantial portion of the amputees contacted during the survey studies were veterans whose amputations were service-connected and who were receiving prosthetic treatment through the Veterans Administration. This preponderance of veteran amputees should be borne in mind, since it may tend to affect the data in some respects. (<b>Fig. 4</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the large number of veterans in the sample, it is not surprising that over half of the amputations were caused by combat injuries. Aside from wartime casualties, most upper-extremity amputations result from trauma, less than 5 percent being either of congenital origin or due to disease.</p> <p>The average age of the group (<b>Table 1</b>) is 36 years, but in view of the large number of veterans in the sample it is difficult to say whether this age distribution is representative of the entire amputee population. It is likely that significant numbers of cases in the older age groups are not included in these data.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 2</b> and <b>Table 3</b> give respectively the heights and weights of the subjects studied. <b>Table 4</b> gives the residence of the subjects by state.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Almost four out of five of the amputees in the survey group were married (<b>Table 5</b>). There has been speculation about a possible relationship between the extent of handicap and marital status. In this regard, the following breakdown may be of interest: (<b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While there is some indication of a trend in these figures, their significance must await additional data bearing on this point.</p> <p><b>Table 6</b> presents the educational level of the subjects, but here again the data may be biased by the fact that a large portion of the group was eligible for educational benefits through the Veterans Administration or State Vocational Rehabilitation Divisions. The effect of these influences on the data cannot be assessed without further study.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputation in the upper extremity apparently results in a definite occupational shift primarily away from agricultural and other forms of manual labor at all levels of skills and toward managerial, clerical, sales, and office work. Prior to amputation, professional-managerial, clerical, and sales jobs accounted for 14 percent of the sample's vocations, while agricultural, skilled, semiskilled, and unskilled jobs accounted for 64 percent. In contrast, the former groups of jobs include 41 percent of the postamputa-tion occupations (an increase of 27 percentage points), and the latter groups include 27 percent (a decrease of 37 percentage points).</p> <p>Another marked shift occurs in the rate of unemployment. Whereas only 1 percent of the group was unemployed prior to the loss of an arm, 19 percent were not gainfully employed when seen at amputee clinics.</p> <p>It is interesting to note that those amputees who were employed were occupied in a wide variety of jobs including agricultural and skilled vocations. This fact leads us to speculate as to the reasons for these occupational shifts. Are these trends actually caused by the physical inability of the amputee to perform and compete, or are there perhaps other social or psychological reasons for the occupational shift? Doubtless, a combination of factors is operative, but the relative importance of each is still unknown. (<b>Fig. 6</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stump Characteristics</h3> <p>The stump characteristics with which we are concerned in this section are strength and range of motion. Information about these characteristics was obtained through gonio-metric measurements and standard muscle-testing techniques.</p> <p>In general, the below-elbow amputee retains somewhat more range of pronation than of supination (<b>Table 7</b>). The average amount of residual pronation in the entire sample is 38 deg., the average amount of supination being 33 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides retaining somewhat more range of motion in pronation than in supination, the below-elbow amputee tends to have somewhat greater strength of pronation (<b>Table 8</b>). The strength of pronation was rated good or excellent in 57 percent of the cases while 51 percent were rated good or excellent in supination. (<b>Fig. 7</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the total group, 75 percent were able to flex their elbows actively to an angle of 130 deg. or more (<b>Table 9</b>). Among below-elbow amputees, then, approximately three out of four cases retain a normal amount of elbow flexion on the side of the amputation. On the other end of the scale, however, it should be noted that a significant number of amputees have a restricted range of motion and require special prosthetic or medical attention in order to achieve a more normal flexion angle. Whereas somewhat more than 50 percent of the cases had good or excellent strength in pronation and supination, 90 percent had equivalent strength ratings in elbow flexion (<b>Table 10</b>), as would be expected since amputation through the forearm interferes less with the muscles and joints related to elbow flexion than with those related to pronation and supination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When wearing a prosthesis, the above-elbow amputee rarely has occasion to move his stump beyond an angle of 80 deg. either in elbow flexion or in abduction of the humeral stump. On this basis, the majority of above-elbow amputees have more than adequate range of motion for present conventional prostheses. The data indicate that 94 percent of the cases had 80 deg. or more of flexion; 91 percent had 80 deg. or more of abduction (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The motion of extension at the shoulder joint is used primarily in locking and unlocking the prosthetic elbow. To perform this operation, an extension range of 40 deg. is more than adequate. In our sample, 82 percent of the cases could achieve an extension angle of 40 deg. or more.</p> <p>The majority of above-elbow amputees have no significant problem with regard to the strength of motions at the shoulder joint. In the total group, 90 percent of the cases had good or excellent strength in flexion, 81 percent had good or excellent strength in extension, and 90 percent had good or excellent strength in abduction (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Extent of Use of Prostheses</h3> <p>In assessing the extent of prosthetic use, information was obtained as to the length of time the prosthesis was worn, if at all, and as to the specific activities for which it was used in dressing, eating, work, and recreation. These data permit inferences to be made concerning the usefulness of the prosthesis in everyday life.</p> <p>A surprisingly large portion (62 percent) of the amputees indicated that they were prosthesis wearers at the time of the survey, but this figure may be deceivingly high because of the large number of veterans in the sample. Moreover, the term "present wearer," while it indicates daily wear, does not indicate the actual amount of time the prosthesis is worn. Some of these "present wearers" may use the prosthesis only a short time each day. Further information bearing on this point is to be found in the accompanying chart dealing with the number of hours per week the prosthesis was worn. (<b>Fig. 8</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is perhaps more informative to notice how the wear status varies with increasing severity of loss. While 75 percent of the below-elbow amputees were classified as present wearers, this figure drops to 61 percent for the above-elbow amputees and to 35 percent for the shoulder-disarticulation cases. Clearly there are considerably fewer unilateral arm amputees wearing prostheses as the level of amputation moves proximally.</p> <p>The same trend is found among amputees who had worn prostheses before but who had given them up and were nonwearers at the time of the survey. Among the below-elbow amputees, 9 percent were nonwearers although they had had previous prosthetic experience. Among the above-elbow amputees, this figure rises to 21 percent and reaches 35 percent among the shoulder-disarticulation cases.</p> <p>From these data, the inference is inescapable that, while the below-elbow prosthesis was a fairly widely worn device, the prosthetic replacement for the above-elbow case and that for shoulder disarticulation left more to be desired.</p> <p>A significant portion of those amputees who wear prostheses apparently use them full-time, i.e., 80 or more hours per week, which is about the equivalent of 12 hours a day, every day. In this respect there are, however, significant differences among the several amputee categories. For example, 71 percent of the below-elbow amputees were full-time wearers. But for the above-elbow and shoulder-disarticulation groups, this figure drops to 53 percent and 54 percent, respectively. Among bilaterals the figure rises to 88 percent; the bilateral is obviously more dependent on his prosthesis than is the corresponding unilateral amputee.</p> <p>The conclusion that the amount of wear decreases significantly as the level of unilateral amputation becomes higher is reinforced by the data pertaining to the percentage of amputees who wear their prostheses for relatively short periods each week. A wearing time of less than 40 hours per week was reported by 11 percent of the below-elbow group, 20 percent of the above-elbow group, 27 percent of the shoulder-disarticulation group, and 6 percent of the bilaterals. Judging from these data, individuals with amputations above the elbow do not receive sufficient value from their prostheses to wear them consistently.</p> <p>We come now to a consideration of the degree of actual use to which arm prostheses are put by those who wear them. The activities listed in the four accompanying charts have two important characteristics. First, they are extremely common, being performed several times daily by almost every active individual. They are an inescapable and integral part of normal daily life. Secondly, they are bimanual in nature, either requiring two hands directly or else necessitating the use of one hand while the other is occupied in an auxiliary role. For these reasons, the use or nonuse of the prosthesis in these activities can properly be considered an indicator of the value of the replacement.</p> <p>We have already seen that some amputees had never worn a prosthesis and that others had given one up after some trial period. While the situation is quite complex, these facts point out that, at least for a certain number of amputees, the prosthesis did not offer sufficient functional advantage to compensate for any inconvenience or discomfort involved in its use. But what of those amputees who did wear their appliance? Did they use their artificial arms to assist in the accomplishment of these common activities? (<b>Fig. 9</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the activities of dressing, we find that 42 percent of the below-elbow amputees did use their prostheses in tying shoe laces and in holding up the trousers while the sound hand adjusted buttons, zippers, or belts. This figure, however, is considerably reduced in the case of the above-elbow amputee and is even smaller for the shoulder-disarticulation cases. The information can be summarized by saying that, first, significantly less than half of those amputees who wear arm prostheses use them in dressing activities and, second, that use of an arm prosthesis in dressing decreases markedly the more proximal the level of amputation. (<b>Fig. 10</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although it is customary for the normal person to use a knife and fork in cutting food, apparently most arm amputees adopt some other method. It should be recalled that the use of two hands for eating activities is mandatory in only a few instances, such as in cutting tough meat or in buttering bread. The amputee can try to avoid these situations, can receive help from another person, or can use a special tool such as a combination knife-fork. At any rate, it seems clear that, in the area of eating, the prosthesis was not of great functional value to the sample group. The highest rate of use was only 23 percent (among the below-elbow and the bilateral subjects, who reported holding a fork in the prosthesis). (<b>Fig. 11</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Light grasp is differentiated from heavy grasp not only by the weight of the object but also in that precision is the essential feature of the former while strength of grip is paramount in the latter. Holding papers and writing implements are examples of light grasp; handling tools exemplifies heavy grasp. The word "support" is here used to indicate holding an object up, as in carrying a topcoat, not by grasping but by placing a terminal device or prosthetic forearm underneath it. "Weight" implies holding an object down in the fashion of a paperweight, again without grasping. (<b>Fig. 12</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As regards work activities, the data on use of an arm prosthesis present much the same picture as we have seen in connection with dressing and eating. The majority of the group still report no use of their prostheses, and again the amount of use at work declines at the higher amputation levels. It is interesting to note, however, that in this area there is much less decrease in use among above-elbow and shoulder-disarticulation amputees than is the case in the other two areas (dressing and eating). That is to say, the above-elbow and shoulder-disarticulation prosthesis was used more often for work tasks than for eating or dressing. This may be accounted for by the social and competitive pressures in job situations, or perhaps by the fact that work tasks are extremely varied as compared to the restricted number and type of activities in dressing and eating.</p> <p>As for activities involved in recreation, the number of amputees reporting use of the prosthesis for grasp of heavy objects is more than double the number reporting light grasp. This reversal of the data dealing with use of the prosthesis at work raises a number of questions. Does the amputee find himself placed in jobs whose demands are quite light physically? And, if so, is this a real or an imagined limitation, since apparently the amputee is able to and tends to do heavier activities for his own recreation than he does on the job? It may be that there is an existent prejudice, not in accord with the facts, concerning the kind of activity that an arm amputee can perform. Such a misconception, on the part either of the amputee or of other persons such as vocational counselors, could lead to placement in jobs requiring activity levels lower than those which the amputee is capable of producing. (<b>Fig. 13</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prosthetic Components</h3> <p>In this section we are concerned primarily with the types of prosthetic equipment worn by arm amputees throughout the country just prior to the research studies. For convenience, we shall deal first with those prosthetic components that are common to all prostheses and then proceed to components that are specific to below-elbow and to above-elbow arms.</p> <p>At the time of this survey of upper-extremity amputees, the voluntary-opening Dorrance No. 5 was by far the most widely used hook. Over 32 percent of the group wore it. In all, the Dorrance hooks, of which there are numerous types, were worn by 70 percent of the subjects, the No. 8 and the No. 7 following behind the No. 5 in popularity. Other hooks that had a fairly widespread use were the APRL voluntary-closing hook (10 percent of all the amputees) and the Trautman hook (9 percent).</p> <p>The three hands that had been most widely dispensed were the Miracle (31 percent of the group), the APRL (24 percent), and the Becker (21 percent). In addition to the relative numbers of the various types of hands, it is interesting to note that 84 percent of the sample used active hands as compared to 16 percent who wore passive hands. Also, as one would expect, the total number of hands worn (728), while quite high, is substantially less than the total number of hooks (1010). Many amputees owned both a hand and a hook. (<b>Fig. 14</b>, <b>Fig. 15</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that at the time of the survey the great bulk of arm amputees (70 percent) used friction wrist units. The positive-locking type of wrist unit was worn by 20 percent of the group, and approximately three out of four of these units were of the Hosmer WD-400 type. The proportion of positive-locking wrists remained fairly constant in all groups except that of the bilaterals, who would be expected to have difficulty in operating this unit. Among the arms worn by bilaterals, only two were equipped with positive-locking wrists.</p> <p>The remaining 10 percent of the sample wore the quick-change Dorrance "Butterfly" type of wrist, which is essentially a friction unit with provision for quick interchange of terminal devices.</p> <p>Considering the group as a whole, plastic sockets were used most extensively. Forty-three percent of the subjects wore this type as compared to 37 percent who wore sockets made of leather, 12 percent whose sockets were made of wood, and 9 percent with fiber sockets. Since plastic is the standard socket material today, it is interesting to note that 57 percent of the entire group did not wear plastic sockets at the time of the survey.</p> <p>There was, however, considerable variation among the below-elbow, above-elbow, and shoulder-disarticulation groups. The leather socket was used by a substantial portion of the below-elbow population (47 percent) but by smaller segments of the above-elbow and shoulder-disarticulation groups (23 percent and 35 percent respectively). Approximately half of this latter group (above-elbow and shoulder disarticulation) wore plastic sockets. (<b>Fig. 16</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to note that at the time of the survey there was still fairly prevalent use of wood for the above-elbow socket (19 percent of the cases) and of molded leather for the shoulder-disarticulation socket (35 percent of the cases). The data also indicate that over 79 percent of the below-elbow and over 86 percent of the above-elbow sockets were of single-wall construction. Double-wall sockets, which have many functional and cosmetic advantages, were not in general use. (<b>Fig. 17</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The harnesses worn by arm amputees at the time of the survey present quite different pictures in the below-elbow and above-elbow groups. The bulk of the below-elbow population (63 percent) used standard figure-eight harnesses, and an additional large group (25 percent) wore a single axilla loop. These two types of harnesses differ only in that the axilla loop does not contain the front suspension strap (commonly in the form of an inverted F) of the figure-eight harness. The other major style of below-elbow harnessing is the chest strap and shoulder saddle, which was worn by 12 percent of the sample.</p> <p>Turning to the above-elbow population, we find the situation reversed. Fifty percent of this group wore a shoulder saddle and chest strap, while another 24 percent wore the same harness plus an axilla loop to which the control cable was attached. Thus, three quarters of the above-elbow sample had shoulder saddles and chest straps as their basic suspensory harness. The remaining one quarter of all above-elbow amputees wore figure-eight harnesses, either with or without the over-the-shoulder strap. (<b>Fig. 18</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most universally used elbow joint was the poly-centric rigid joint. It was found in 57 percent of the below-elbow arms (<b>Table 13</b>). If we add to this figure the three other types of rigid hinges listed in the accompanying table, we find that 70 percent of the below-elbow sample wore rigid elbow joints. The remaining 30 percent wore flexible or semi-flexible joints.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Beginning with the triceps pad, a relatively small section of leather located on the posterior side of the humerus, each type of upper-arm cuff is progressively larger. The half cuff covers approximately half of the upper-arm circumference, the full cuff completely encircles the arm, and the three-quarter cuff is between these two in size.</p> <p>A principle generally agreed upon is that the less cuffing used the more comfortable and convenient is the prosthesis, provided that stability and control are not impaired. It is noteworthy, therefore, that the smallest cuff, the triceps pad, was worn by only six percent of the cases. The half and full cuffs were worn almost exclusively (48 and 41 percent of the sample, respectively).</p> <p>Almost all of the half and full cuffs were worn with one or two billets. One of the factors accounting for the large number of full cuffs and supportive billets, which contrasts markedly with present practice, may have been the previously noted prevalence of the axilla-loop harness, which has no front suspension strap.</p> <p>Slightly more than half of all above-elbow amputees did not use automatic, harness controlled elbow units, which are considered standard equipment today. Of this group, 42 percent were manual locks operated by the remaining sound hand, while the remainder (12 percent) wore Fitch-type elbows, which do not contain a locking mechanism. (<b>Fig. 19</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the slightly less than half who did wear harness-operated elbow-locking units, 25 percent used Hosmer units (primarily the E-300 elbow) and 21 percent used Sierra units (the Model C elbow).</p> <h3>Summary</h3> <p>The past five years have witnessed a rapid change in the field of upper-extremity prosthetics, partly as a result of the education program and of the studies reported in this issue of Artificial Limbs. As a step in the measurement of the progress that has been and will be made, the survey studies were designed to provide a baseline describing the state of upper-extremity prosthetics prior to the introduction of new techniques, devices, and concepts of amputee management. (<b>Fig. 20</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To establish this baseline, information has been presented about a sample of 1630 amputees observed during the years 1953-55. The character and status of the entire upper-extremity amputee population in 1953-55 can reasonably be inferred from these data. The extremely large number of all types of male amputees who participated, the nationwide scope of the survey, the inclusion of wearers and nonwearers, and the wide variety of occupations represented make for confidence in the accuracy with which the state of the art has been depicted.</p> <p>The primary limiting factor in these data is the large number of veterans among the group, which undoubtedly influences the results. In addition, the data tend to characterize those amputees who reside in urban areas or within a 100-mile radius of the major metropolitan centers where the participating clinics were located. Hence it is likely that the rural resident is not fully represented.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-17.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-18.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-21.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-22.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-16.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-23.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-20.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-26.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-24.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-27.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-28.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-29.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-30.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper Extremity Amputee II. The Population (1953-55) Creator An entity primarily responsible for making the resource Norman Berger, M.S.