15 20 371 https://staging.drfop.org/files/original/6a14887dccb6af6e9e26ce87123196dd.pdf 9c0426c05e766c9fea1f2d8fdf087e6b https://staging.drfop.org/files/original/842bf0cf5047f21bfbb1f5b67b405d57.jpg c5929c69483ba3a3674295e9c05e2798 https://staging.drfop.org/files/original/b69258705c1c1029fea89e959a20461f.jpg 8d3adecc23bb719325e7f3b757b2bbfb https://staging.drfop.org/files/original/44354ad5672e786cb22286eed8615f9a.jpg 4be40ceee37e10c8210384107aa5a06c https://staging.drfop.org/files/original/ee5d5da90ccb3fbaba84f056609ca61a.jpg 2d5d7cd8183cb4aefac4c723e16fd1d7 https://staging.drfop.org/files/original/840cc38fe69fc89973c3ca0430b6b333.jpg de4df5209df76fb80f081dc30f4a582d https://staging.drfop.org/files/original/ec31e35fa05e26ac2dc2d20061e34567.jpg 0643a7a42d9b832e42cb92f8de360af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_076.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 76 - 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/1961_01_076.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_076.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of the Syme Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <blockquote><p>*A contribution from the Biomechanics Laboratory, University of California, San Francisco and Berkeley, aided by U. S. Veterans Administration Research Contract VAm-23110.</p> </blockquote> <p>The purpose of any limb prosthesis is to replace, to the reasonable satisfaction of the wearer, as much as possible of the normal form and function lost through amputation. To provide a suitable prosthesis in any particular case, therefore, the several cooperating professional persons-physicians, prosthetists, therapists, others as appropriate-must have an intimate knowledge of just what losses have been incurred and just what new circumstances, if any, have accrued as a result of the losses. Among these are the losses of structural elements, of joint motion, and of muscle function; the decrease in proprioceptive sense as well as in sensory perception; the development of persistent or recurrent pain in one form or another; the impairment of circulation; and the losses of what in the normal would be the weight-bearing areas; not to mention numerous other matters purely medical and not necessarily associated with the amputation. Any one of these factors, or any combination of them, may influence the way in which an amputee will use a given type of limb prosthesis-that is, a device intended as a limb substitute.</p> <p>In the case of the Syme amputee, where the patient has suffered loss of the foot and ankle while retaining essentially the full length of the shank and more or less of the typical weight-bearing characteristics of the normal heel, the obvious problem is to restore foot and ankle function (or to supply the equivalent of foot-ankle function), to extend the stump so as to accommodate the loss of the tarsus and of the calcaneus, to furnish adequate support for the body during standing and during the stance phase of walking, to provide suitable suspension for the prosthesis during the swing phase, and to do all these things in such a way that the final result is acceptable to the wearer under both static and dynamic conditions. As with prostheses for other levels of amputation in the lower extremity, determination of the requirements of the Syme prosthesis takes its departure from a review of the normal pattern of locomotion and proceeds toward assessment of the means through which such a pattern may best be reproduced by application of inanimate devices. Discussion is here limited to the pertinent features of straight and level walking in the normal person and to the corresponding circumstances in a Syme amputee enjoying good general health, using a prosthesis, and having a stump itself free from any inherent medical complications such as excessive scar tissue, or neuromas, or skin disorders, or sensitive joints, or other conditions ordinarily beyond control of the limb designer.</p> <h3>LOCOMOTION PATTERNS</h3> <p>In any analysis of bipedal locomotion such as that of man, it is common practice to divide the walking cycle into the two obvious phases through which the lower limbs pass alternately-the stance phase and the swing phase. <b>Fig. 1.</b> and <b>Fig. 2.</b>, based on averages from tests on four normal young males during straight and level walking,<a></a> show five different kinds of data-angular motion at the knee and ankle joints, moments about the knee and ankle joints as a result of muscle activity, muscle activity as measured by electromyographic techniques, energy level at the knee and ankle joints at a given instant, and change in energy level. Correlation of the energy data <b>Fig. 2.</b> with motions of the joints <b>Fig. 1.</b> provides an insight into knee-ankle interaction in normal human locomotion and is useful in determining the compensation required to make up for the losses incurred by Syme's amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Correlation between joint action and muscular activity in normal locomotion in man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Energy levels and work done at knee joint and ankle joint during normal, level walking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The terms "work done on/' "work done by," "input," and "output" used in describing energy requirements can best be defined by citing examples. In the simplified sketch of musculoskeletal joint action <b>Fig. 3.</b>, the musculature exerts an internal moment <i>M </i>which resists the load <i>W. </i>If the load <i>W </i>is sufficient to overcome the moment <i>M </i>and thus to cause the joint to rotate in opposition to the muscle action, then work is done <i>on </i>the joint, <i>i.e., </i>the joint absorbs energy. If the moment <i>M </i>is sufficient to cause the joint to rotate in the same direction as the muscle action and thus to move the load <i>W </i>in a direction opposite to its sense, then work is done <i>by </i>the joint, <i>i.e., </i>the joint provides an energy output.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Energy input and output at a typical joint. Left, equilibrium; center, energy in at knee joint, i.e., work done <i>on </i>the joint; right, energy out at knee joint, <i>i.e., </i>work done <i>by </i>the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE STANCE PHASE</h4> <p>Comparison of the stance phase of the normal with that of the Syme amputee wearing a prosthesis reveals an excellent example of compensation by one joint (the knee) for loss of a second joint (the ankle) in the same extremity.</p> <h4><i>Shock Absorption</i></h4> <p>During the subphase designated "shock absorption" (<b>Fig. 1.</b> and <b>Fig. 2.</b>), the ankle in the normal subject undergoes plantar flexion while the knee flexes, both under load. Thus, an energy input results at both knee and ankle (work is done <i>on </i>both joints during the first part of the stance phase). As summarized in the bar graph of <b>Fig. 2.</b>, the work done on one joint is approximately equal to that done on the other. It could therefore be stated that in bipedal walking the knee and ankle contribute equally to the cushioning of the shock transmitted to the body at the beginning of the stance phase when the leg first assumes its function of support.</p> <p>In the Syme amputee, ankle function has-been lost and some way of compensating for it must be found. Because of the inherent space limitations in conventional Syme prostheses,. use of articulated ankle joints and elastic compression members has been for the most part unsuccessful. It is known that, in order to keep stresses in elastic bumpers within reasonable limits, the bumpers must contain a certain minimum volume of material. Otherwise the energy-absorption requirements per unit volume are excessive, and overheating and fatigue occur rapidly. The alternatives are to increase the volume of shock-absorbing material so as to reduce the unit stresses, or to transfer shock absorption to some other area, or both.</p> <p>The volume of shock-absorbing material can be increased by eliminating the articulated ankle joint and using in the heel the greatest possible volume of suitable sponge-rubber cushion-as in the SACH foot.<a></a> In general, function may be improved over that supplied by an articulated joint, but owing to the space limitations the Syme amputee cannot be given the same degree of shock absorption as can be afforded the above-knee or below-knee amputee wearing a SACH foot.</p> <p>To compensate for the lack of adequate function in the artificial foot, the knee joint on the side of the amputation must assume a greater proportion of shock absorption by increasing the amount of knee flexion under load just after heel contact. If the knee does not assume this function, the amputee must tolerate a definite impact force from prosthesis to stump and must also accept the deviation from normal gait that might be expected to accompany such a circumstance.</p> <h4><i>Roll-Over</i></h4> <p>The roll-over portion of the stance phase in normals may in turn be subdivided into three parts corresponding to the direction of knee motion. During the first part, the knee continues to flex under load and thus prolongs the period of its function as a shock absorber for the initial support of the body weight. The ankle, acting as a controller, is required to supply energy during this time, as indicated by the rising curve of energy level and the positive bar for the ankle <b>Fig. 2.</b>. In the Syme amputee, the heel cushion of the modified SACH foot contributes some of its energy of compression and thereby simulates normal ankle action, but again the knee joint must compensate for the shortcomings of the prosthetic foot-ankle unit. Because of the lack of active plantar flexion in Syme amputees, maximum knee flexion during this subphase is in general less in persons wearing a Syme prosthesis than it is in normal persons.</p> <p>While in normal locomotion the body continues to roll over the foot, which for the time being continues in full contact with the floor, the knee begins a second period of active extension, a circumstance that results in work being done on the body as a whole (<i>i.e., </i>the knee exhibits energy output). Meanwhile, the ankle absorbs about half the energy output of the knee. In a typical Syme amputee wearing a prosthesis, the foot-ankle unit is neither absorbing nor supplying energy during this period, and the energy requirement of the knee during this interval is thus reduced as compared with that of the normal person.</p> <p>During the third part of normal roll-over, the knee is forced into full extension and maintained there by the external forces acting upward on the ball of the foot. The ankle continues to absorb energy as the tibia rotates forward over the stationary foot. To compensate for the inability of the prosthetic ankle to absorb energy during the last part of rollover, the prosthetic foot must be designed so that the forward point of support corresponds to the ball of the foot, an arrangement which maintains the knee along a path corresponding to that of the normal. In other words, the knee should move forward smoothly, and no sensation of vaulting over the fore part of the foot should be experienced. In the amputee wearing a Syme prosthesis with a properly aligned SACH foot, knee action at the end of roll-over should be almost the same as it is in a normal person.</p> <h4><i>Push-Off</i></h4> <p>The push-off portion of the stance phase begins when the heel is lifted from the floor. During the first part of this subphase in normal persons, both knee and ankle contribute energy-the knee by virtue of energy that has been stored by passive stretching of the hamstring ligaments and the ankle by virtue of active plantar flexion which continues throughout the push-off phase. In the Syme amputee, the ankle substitute cannot contribute energy by active plantar flexion, and accordingly other means must be found to maintain a smooth path of the center of gravity of the body. In the SACH foot, a comparatively simple keel contour, with a cylindrical or spherical surface on a 2-in. radius at the end of the keel, has been found practical for most adults. Under these circumstances, the hip and knee joints serve as the active elements in the kinematic chain which controls the pathway of the center of gravity.</p> <p>In the second part of push-off, the normal knee absorbs about half as much energy as is supplied by the normal ankle joint, energy absorption by the knee being associated with the maintenance of a smooth path for the center of gravity of the body as a whole. At toe-off, for example, the knee in normal persons has flexed 40 deg. of the total of 65 deg. achieved at the point of maximum knee flexion. Energy absorption by the normal knee continues at about the same rate after active plantar flexion of the ankle has started to slow down. Since the foot-ankle unit in the Syme prosthesis must maintain the pathway of the knee by proper keel contour rather than by active plantar flexion of the ankle, the amount of energy absorption required of the knee is less in the Syme than it is in the normal. The need to initiate knee flexion before the end of the stance phase remains, however, and the socket must therefore be designed to permit maximum control of knee motion by the stump in preparation for the swing phase.</p> <h4>THE SWING PHASE</h4> <p>Since in the patient with Syme's amputation the knee and hip joints are usually undisturbed, it might be assumed that the swing phase of the Syme amputee would always appear relatively normal. But the role of the ankle joint at the end of the stance phase must be considered. In normal locomotion, the knee starts to flex before the foot leaves the ground, and the controlled knee-ankle interaction provides a major source of energy for the forward propulsion of the knee. If this motion is smooth and precisely controlled, the thigh-shank-foot combination enters the swing phase normally. Anything that tends to disturb this smooth transition from stance to swing has a noticeable effect throughout the swing phase.</p> <p>For the patient who has undergone Syme's amputation, poor function in the prosthetic foot and pain in the weight-bearing areas of the stump are the two most common sources of unstable or erratic action during transition from stance to swing phase. When, however, the prosthetic foot has been properly designed, aligned, and adjusted to allow the knee and hip to provide normal-appearing control of knee motion at the end of the stance phase, the amputee should, in general, have the ability to exercise complete control of his prosthesis during swing phase.</p> <h3>SOCKET DESIGN</h3> <h4>ANALYSIS OF STUMP-SOCKET FORCES DURING THE STANCE PHASE</h4> <p>Analysis of the distribution of contact pressures between stump and socket at various times during the stance phase is useful in the design of a socket that will be comfortable for the amputee. Since pressure distribution varies during each of the three subphases-shock absorption, roll-over, and push-off-each must be analyzed separately.</p> <h4><i>Shock Absorption</i></h4> <p>If it be assumed that body weight is supported at the distal end of the stump, it can be seen clearly from <b>Fig. 4.</b>A that during the shock-absorption subphase the major functional forces between stump and socket occur in the anterodistal and posteroproximal areas. During roll-over, the need for posteroproximal pressure decreases, and the contact pressure at the end of the stump shifts toward the center of that area. If the force system is to be in equilibrium, the paths of the forces <i>P, D,</i>and <i>F </i>must intersect at <i>M </i>and their vectors must form a closed polygon. Use of this principle makes it possible to estimate the relative magnitudes of the three forces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stump-socket forces during the stance phase. A, Shock absorption; B, push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4><i>Push-Off</i></h4> <p><b>Fig. 4.</b>B shows the force system that develops as the Syme amputee rolls over the ball of the foot in the push-off subphase. At the instant shown, the hip joint is being used to help flex the knee against the force acting upward on the ball of the foot. Again, the principle of force equilibrium can be applied to estimate the magnitude of the forces. A posterodistal and an anteroproximal contact force between stump and socket are seen to be necessary to resist the floor reaction against the ball of the foot. It is essential that the anteroproximal force against the tibia be kept at as high a level as possible. Shortening of the distance <i>a </i>results in increased inclination of the line of the posterodistal contact force and in a transfer of the force away from areas surgically prepared for end-bearing.</p> <p>Since some change in the inclination of the distal stump-socket force is unavoidable, it must be anticipated during the fitting procedure. If the line of the floor reaction is kept in a particular position relative to the knee, the amputee can use some voluntary control in shifting the distal contact point. Moreover, the anteroproximal force at push-off will be several times the posteroproximal force at heel contact. For this reason, the prosthesis must be strong enough to resist the large bending moment in the ankle region during push-off. Suppose that in a 180-lb. man there is an increase of 30 percent (as compared with body weight) in the dynamic force against the ball of the foot during push-off and that dimension <i>b </i>is 4 in. Then the structure must resist a bending moment of 1.30 X 180 X 4 = 936 lb.-in.</p> <h3>SOCKET MATERIALS</h3> <p>Because of the bulbous form of the typical Syme stump, any prosthesis devised for it will be bulky in appearance. To provide the least bulky socket requires that the thickness of the wall be kept to a minimum commensurate with structural demands. Plastic laminates with high strength-weight ratios that can be molded easily over a plaster model seem ideally suited for construction of sockets for the Syme prosthesis.</p> <p>Since a snug fit throughout the length of the stump is necessary if proper function is to be expected, a cutout must be provided in the narrow section of the socket to permit entry of the bulbous end of the stump. The question arises as to where to locate a cutout, which in any case obviously should not interfere with the functional characteristics of the prosthesis nor affect its structural properties unduly. Several possibilities have been suggested. Among others are the posterior cutout used at Sunnybrook Hospital in Toronto and the medial cutout proposed at the Veterans Administration Prosthetics Center (page 57). Some predictions as to the relative structural strengths to be had from the several approaches may be arrived at through the techniques of engineering stress analysis.</p> <p>From a review of data on normal human locomotion it has been determined that in level walking maximum forces are brought to bear on the shank at the time of push-off. At this point in the walking cycle the center of pressure is eccentric with respect to the shank. Obviously the highest unit stress will occur at the level of the shank where the cross-sectional area is smallest. The relationship at push-off between the center of pressure acting upward on the ball of the foot and the minimum cross-section at the ankle is indicated in <b>Fig. 5.</b>, where the ankle is approximated by a circle of radius <i>R </i>and where all dimensions are expressed in terms of <i>R. </i>If the same loading conditions be assumed to be present when a Syme prosthesis is worn, the result is a combination of three different types of stresses in the structure of the prosthesis: compression stresses resulting from the direct thrust load carried by the structure, bending stresses resulting from a tendency for the structure to bow laterally, and bending stresses resulting from a tendency for the structure to bow posteriorly. If the loading conditions and the dimensions of the cross-section are known, the magnitudes of the stresses can be calculated, as indicated in <b>Fig. 6.</b>A. In such calculations, a plus sign indicates that a fiber of the material would be in tension at the point being investigated. A minus sign shows that the fiber would be compressed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Center of pressure as related to minimum cross-section of the ankle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Summary of stress calculations for various socket cutouts. <i>A</i>, Sample stress analysis for Canadian-type posterior cutout, ø = 210 deg. <i>B, </i>Comparison of stresses at edge of cutout for varying degrees of cutout at three locations about the circumference; <i>P, R, </i>and <i>t</i> constant. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Summarized in <b>Fig. 6.</b>B are the results of a number of calculations based on stresses in a hypothetical Syme prosthesis with a circular cross-section of radius <i>R, </i>with a material thickness <i>t, </i>carrying a load P, and with a constant eccentricity. An interesting feature is that, even when the values for direct compression as a result of proximal weight-bearing are included, in general the posterior cutout results in tensile stresses at critical points whereas the medial cutout results in compressive stresses at critical points. The posterior cutout with <i>ø = </i>210 deg. and the medial cutout with <i>øT = </i>270 deg. are perhaps most nearly representative of actual conditions.</p> <p>These results would indicate that, when Syme prostheses are constructed with a posterior opening in the socket (tensile stresses at critical points), a material with the highest possible tensile strength should be used. A laminate of Fiberglas cloth with epoxy resin, such as is used by Canadian makers of Syme prostheses, would be an efficient material, particularly when reinforced with roving along the edge of the cutout. A laminate of Fiberglas cloth and polyester resin would also be satisfactory if fabricated carefully. Either material would provide great strength and minimum thickness with more than sufficient tensile strength. Nylon stockinet with polyester-resin laminates has lower tensile strength, and the lamination would have to be thicker.</p> <p>When the stresses at critical points are compressive, such as in the case of medial opening, a material with the greatest compressive strength should be used. In situations involving compressive loading of thin-walled columns (as in a proximally loaded Syme prosthesis), failure may be due either to failure of the laminate at the area of direct compression or to buckling of the material in a localized area, such as near a free edge carrying a compression stress. The sides of the cutout in the Syme socket with medial opening would constitute free edges of this type. To increase resistance to local buckling, the wall thickness of the laminate should be increased. Doing so will also increase resistance to direct compression because the area of the cross-section will be increased proportionally.</p> <p>Since in practice it is more convenient to use nylon stockinet as a laminating material, and since the thickness must be increased to overcome the effects of buckling, nylon stockinet is probably the material of choice for the medial opening. Although theoretically Fiber-glas laminates would have sufficient direct compressive strength even with thin walls, resistance to local buckling would be lower than in the case of a thicker nylon laminate. Moreover the compressive strength of a structure made of thin-walled Fiberglas laminate depends mainly on the quality of the laminating technique.</p> <p>It should be pointed out that in Syme prostheses direct end-bearing has been used more often in Canada than in the United States. Since end-bearing tends to increase the critical tensile stress in the posterior-opening socket by eliminating the direct compressive stresses due to proximal loading, the need for an extremely strong laminate such as one of Fiberglas cloth, Fiberglas roving, and epoxy resin is obvious. When direct end-bearing is used with the medial opening, the critical compression stress is reduced, sometimes to the extent that it is converted into tension of some low value. Nylon stockinet and polyester resin should be an adequate material for the medial-opening socket, although such a socket is more bulky in appearance.</p> <h3>CONCLUSIONS</h3> <p>To ensure a satisfactory period of use, the ankle of any prosthesis must be so designed that the elastic members resisting dorsiand plantar flexion have adequate volume to provide sufficient fatigue strength. Furthermore, the foot must be designed to permit the knee and hip joints to move smoothly through space during the roll-over and push-off phases. The SACH-type foot, with its sponge-rubber heel wedge and a keel of proper proportions, has proved useful in meeting most of the requirements for use in a Syme prosthesis, but, like all other known foot-ankle units, its inability to provide energy at push-off requires that the remaining musculoskeletal system compensate for functions lost in amputation.</p> <p>To satisfy the requirements of a comfortable transmission of functional stump-socket contact forces, the socket must provide the following features:</p> <ol> <li>Comfortable support of the body weight on the distal end of the stump or on the proximal part of the socket brim or both.</li><li>Firm support against the anteroproximal surface of the leg at the time of push-off. Careful fitting against the wedgelike medial and lateral surfaces of the tibia can satisfy this requirement.</li><li>Similar support against the posterior surface of the leg at the time of heel contact. This requirement can be satisfied by pressure in the region of the gastrocnemius. Here the main interest is to prevent lost motion between socket and stump as the reaction point shifts from the posterior to the anterior surface of the leg.</li><li>Provision for shifting of the center of pressure against the distal end of the stump, as indicated by the force analysis. If a cuplike receptacle is provided for the stump end, it must extend around and up the sides of the bulbous stump far enough to prevent relative motion between stump and socket in the anteroposterior direction. It is particularly important to provide for the horizontal component of the force against the posterodistal region of the stump during push-off.</li><li>Adequate stabilization against the torques about the long axis of the leg. A three-point stabilization against the medial and lateral flares at the anteroproximal margin of the tibia and a flattening of the postero-proximal contour can be highly effective in providing the necessary torque resistance. If the needed stabilization is not provided, torques acting on the distal end of the stump will result in skin abrasion and other associated difficulties in more proximal areas.</li></ol> <p>Either the posterior cutout of the socket favored by the Canadian workers or the medial cutout proposed by the VA Prosthetics Center will result in a socket of adequate strength if a laminate of the correct type is used. When a posterior cutout is incorporated, the laminate must be capable of resisting high tension stresses. Fiberglass-epoxy laminates are therefore indicated. When a medial cutout is used, particularly in those cases where a large proportion of proximal weight-bearing is provided, the critical stresses are compressive. When compression stresses are involved, the thicker nylon-polyester laminate may have advantages.</p> <p><b>References:</b></p> <ol> <li>Bresler, B., and F. R. Berry, <i>Energy and power in the leg during normal level walking, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</li> <li>New York University, Prosthetic Devices Study, Research Division, College of Engineering, <i>Evaluation of the solid ankle cushion heel foot (SACH foot)</i>, May 1957</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</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">New York University, Prosthetic Devices Study, Research Division, College of Engineering, Evaluation of the solid ankle cushion heel foot (SACH foot), May 1957</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy and power in the leg during normal level walking, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Mechanical Engineering, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_076/d001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_076/d002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_076/d003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_076/d004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_076/d005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_076/d006.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Biomechanics of the Syme Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/3bd373d7b71c5da2b6a9a46f7a8b1a61.pdf 0902badc0f53cd23ac3d290e99214489 https://staging.drfop.org/files/original/4a95db85b24a9753157d2091a3a2a5ec.jpg c7bc89ef10dd6110b7b5107695947e36 https://staging.drfop.org/files/original/873ca0c36463fdee471bc415f3db6a30.jpg fb11174d4492e099d8c5bf4ada23cb5a https://staging.drfop.org/files/original/cc5c394b9babc8c66452d969e0ec3360.jpg 6002758e2fce5cc2c9cb4a78a4673074 https://staging.drfop.org/files/original/f4d6246ae5163ec9fd33ac86c230a674.jpg 5efe317f898eb54a61e9af475e49b444 https://staging.drfop.org/files/original/80d686ca496322d9bab4e840a41d9ed5.jpg 90254103541c6ed9430f948a568504ee https://staging.drfop.org/files/original/7522225df64cd7f5a947c3ae9914c2eb.jpg f6a79e27bd830681dec524c398cdb24b https://staging.drfop.org/files/original/658e23dc8166ab586faa2bf8eace64e1.jpg b155747e7c2e83cd2fdd9ca2e2ed8fde DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_016.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 16 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_016.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_016.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of Below-Knee Prostheses in Normal, Level, Bipedal Walking</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Human locomotion involves the transformation of a series of controlled and coordinated angular motions occurring simultaneously at the various joints of the lower extremity into a smooth path of motion for the center of gravity of the body as a whole. Though largely taken for granted, it is an extremely complicated process, the complexity becoming evident when one considers that the path of motion is influenced by six major factors: knee-ankle interaction, knee flexion, hip flexion, pelvic rotation about a vertical axis, lateral tilting of the pelvis, and lateral displacement of the pelvis. A thorough study of walking in the orthograde attitude would therefore include not only the influence of each of these factors on the total displacement pattern but also a complete analysis of the action of major muscle groups of the lower extremity. The present discussion is limited to a consideration of the hip, knee, and ankle joints and of their interaction during level walking-first in the normal person and then in the case of the below-knee amputee wearing the patellar-tendon-bearing prosthesis with and without additional impedimenta in the form of thigh corset and sidebars.</p> <h4>Phases of the Walking Cycle</h4> <p>The upright, bipedal walking cycle may be divided into two phases-the stance (or weight-bearing) phase and the swing phase. The stance phase of any given leg begins at the instant the heel contacts the ground, ends at toe-off when ground contact is lost by the foot of the same leg. The swing phase begins at toe-off and ends at heel contact. The two feet are in simultaneous contact with the walking surface for approximately 25 percent of a complete two-step cycle, this part of the cycle being designated as the "double-support" phase.</p> <p><b>Fig. 1</b> gives a graphic account of the interaction between the knee and ankle joints and of the phasic action of major muscle groups during a typical walking cycle. The particular curves shown represent the average of actual measurements recorded during studies<a></a> of four male college students considered to be representative of a larger population sample. The sequence of events is arbitrarily started at heel contact and followed until the next heel contact of the same foot. The term "knee moment" refers to the action of the muscle groups about the knee which tends to change the knee angle, either in flexion or extension. Similarly, "ankle moment" refers to the muscular action about the ankle joint which may cause either plantar flexion or dorsiflexion. The mechanics of major muscle groups of the lower extremity is indicated in <b>Fig. 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Correlation between joint action and muscular activity in the lower extremity during normal, level walking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Major muscle groups of the normal lower extremity (schematic), showing the major mechanics in the parasagittal plane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Eevents Just Prior to Heel Contact</b></p> <p>In reference to <b>Fig. 1</b>, and particularly to the curves in the region corresponding to the end of the swing phase (about 95 percent of a complete cycle), it may be noted that the knee joint reaches its maximum extension just prior to heel contact and that a period of knee flexion then initiated continues on into the stance phase. As seen in the curves of muscle activity, this decrease in the rate of knee extension at the end of the swing phase, in preparation for the contact of the foot with the floor, is due primarily to the action of the hamstring muscle group, which is attached to the pelvis behind the hip joint and to the tibia and fibula below the knee joint. Tension in the hamstring group may cause either hip extension or knee flexion or the two simultaneously.</p> <p><b>Heel-Contact Phase</b></p> <p>As the heel makes contact, the hamstring action tends to bring it forcibly backward into contact with the floor, while the knee continues to flex rapidly. The activity in the hamstring group continues, but with decreasing magnitude, while the quadriceps action begins to build up quickly. The quadriceps group, acting anteriorly about the knee joint, and the pre-tibial group, acting about the ankle joint, serve to control the knee-ankle interaction and thus to effect a smooth motion of the forepart of the foot toward the floor. The major function of both knee and ankle during this phase is smooth absorption of the shock of heel contact and maintenance of a smooth path of the center of gravity of the whole body. Although the function of the knee as a shock absorber is often overlooked, energy studies<a></a> have shown that the knee and ankle contribute equally to shock absorption.</p> <p><b>Mid-Stance Phase</b></p> <p>The controlled knee flexion of the heel-contact phase continues into the mid-stance phase (between foot flat and heel-off), and the maximum angle of knee flexion, approximately 20 deg., occurs in the first part of the mid-stance phase. As the body rides over the stabilized knee, the upward thrust of the floor reaction moves forward on the sole of the foot, thus gradually increasing the dorsiflexion of the ankle and causing the knee to begin a period of extension. In this period, control of the leg is through ankle-knee interaction, there being only minimal muscular activity in the groups acting about the hip and knee. The knee reaches a position of maximum extension about the time the heel leaves the ground, the calf group providing the resistance to knee extension and ankle dorsiflexion. As the heel leaves the ground, the knee again begins a period of flexion, chiefly because of muscular action about the hip joint. This sequence of controlled flexion at heel contact, release to allow gradual extension in mid-stance, and controlled flexion preparatory to swing is important in accomplishing a smooth and energy-saving gait in normal persons.</p> <p><b>Push-off Phase</b></p> <p>During the push-off phase, a phase complex and often misunderstood, the knee is brought forward by action of the hip joint, and a sensitive balance is maintained by interaction of hip, knee, and ankle joints. The combined action has two purposes-to maintain the smooth forward progression of the body as a whole and to initiate the angular movements in the swing phase that follows. As the knee begins to flex (about the time the heel leaves the ground), the knee musculature must first resist the external effect of the force on the ball of the foot which passes through space on a line ahead of the knee joint. Then, as the knee is brought forward by hip-joint action, so as to pass through and then anterior to the line of the force acting upward on the foot, the knee must reverse its action to provide controlled resistance to flexion by increasing quadriceps activity. Some inconsistent hamstring activity is noted as an antagonist. The calf group continues to provide active plantar flexion during the entire push-off phase. At the time the toe leaves the floor, the knee has flexed 40 to 45 deg. of the maximum of 65 deg. it reaches during the swing phase. In normal persons, knee flexion in the swing phase is not due primarily to hamstring action, as might be supposed. Complete prosthetic restoration of normal function in the push-off phase is difficult, if not impossible. A proprioceptive sense of knee position by the amputee is necessary, as well as an active source of energy in the ankle. Because of lack of an active source of ankle energy, initiation of knee flexion in amputees wearing a prosthesis must come from active hip flexion.</p> <p><b>Swing Phase (Quadriceps Action)</b></p> <p>The over-all objective in the swing phase is to get the foot from one position to the next in a smooth manner while clearing the usual obstacles of terrain. At the start of the swing phase, the leg has just completed a period of rapid increase in kinetic energy caused by the active extension of the ankle and flexion of the hip during the push-off phase. The knee is flexing and continues to flex after toe-off. During rapid walking this would result in excessive knee flexion and heel rise were it not for the action of the quadriceps group in limiting the angle of knee flexion to approximately 65 deg. and then continuing to act to start knee extension. Knee extension continues as a result of a combination of pendulum effects owing both to muscle action and to the weight of the inclined shank and of the foot. Little quadriceps action is required, since other factors are of equal importance. For example, the iliopsoas muscle contributes by developing active hip flexion, which in turn accelerates the knee forward and upward.</p> <p><b>Mid-Swing</b></p> <p>During mid-swing there is a period of minimal muscular activity, and the leg accelerates downward and forward like a pendulum with forced motion of its pivot point.</p> <p><b>Terminal Deceleration (Hamstring Aaction)</b></p> <p>Near the end of the swing phase, the rate of knee extension must be reduced in order to decelerate the foot prior to heel contact. This "terminal deceleration" of the normal leg is due primarily to the extension resistance of the hamstring group.</p> <h4>Knee Action in Amputee Gait</h4> <p>In the past a common cause of difficulty in the use of the so-called "muley" below-knee prostheses<a></a> has been the "breakdown" of the stump, in particular of the knee joint on the amputated side. It has been due in part to overstraining of the ligamentous structures of the knee by excessive hyperextension under load. In order to protect these ligamentous structures on the amputated side, it is necessary to maintain within safe limits the forces and moments about the knee which tend to force it into hyperextension. In normal individuals a precise sense of knee position limits the hyperextension moment by maintaining the knee center close to the line of the force transmitted through the lower extremity. Since in many below-knee amputees the knee action is unaffected by amputation, it is reasonable to expect such an amputee to walk with a normal knee action. When this potential is anticipated and accounted for in the fitting and alignment procedure, a below-knee amputee of average-to-long slump length can make use of the controlled flexion-extension-flexion sequence of knee action required in absorbing shock and smoothing the path of motion of the center of gravity (<b>Fig. 1</b>). The socket must be fitted to accommodate the dynamic forces, and the amputee must contribute voluntary control of the knee by action of the musculature.</p> <h4>Analysis of Stump-Socket Forces</h4> <p>The contact pressures between the stump and socket of a below-knee amputee are influenced by a combination of factors. In the case of the patellar-tendon-bearing prosthesis (or of any other below-knee prosthesis without thigh corset and sidebars), the two major factors are the fit of the socket and the alignment of the prosthesis, <i>i.e., </i>the location of the foot with respect to the socket. When the thigh corset is used, there are certain modifying effects even when optimum alignment of sidebars and corset with respect to the socket is obtained. In discussing the relationship between fit and alignment, it is often helpful to discuss alignment factors first, since the method of fitting a socket to an amputee's stump is dictated largely by the manner in which he can be expected to perform while wearing his prosthesis. His performance, in turn, is influenced considerably by the structural relationship between the elements of his prosthesis, <i>i.e., </i>the alignment. The patellar-tendon-bearing cuff-suspension below-knee prosthesis, without side joints or corset, is here discussed first. Thereafter the modifying influences resulting from the addition of the side joints and corset are considered.</p> <p>The following analysis is based on the assumption that a below-knee amputee with a stump of at least average length can be expected to walk in a manner similar to that of a normal person. That is, if the prosthetic foot is properly designed to minimize the effects of the loss of normal ankle function, the amputee can compensate by hip and knee action so as to achieve a gait which closely approximates the normal. Accordingly, he should be expected to go through the following sequence of knee motions:</p> <ol> <li>Control of knee flexion from the time of heel contact until the foot reaches a stable position flat on the floor.</li><li>Control of knee flexion-extension during roll-over. The foot-shank serves as a firm base during this portion of the stance phase. The position of the knee relative to the force acting on the foot can be gauged accurately by properly trained amputees. The muscular moment about the knee required to maintain a particular knee position serves as an excellent source of proprioceptive sensation if the socket fit is intimate enough to reduce lost motion to a minimum.</li><li>Control of knee flexion during the push-off phase as an aid in accelerating the prosthesis forward in the swing phase.</li></ol> <p><b>Mediolateral Forces, Cuff-Suspension Below-Knee Prosthesis</b></p> <p><b>Fig. 3</b> is a front view of a below-knee amputee in a position corresponding to the mid-stance phase. Two force systems are shown. Figure <i>3A </i>shows the forces exerted on the amputee. These forces are of two types- the body weight due to the effect of the earth's gravitational pull and the forces applied through contact with the socket. <b>Fig. 3B</b>shows the forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Mediolateral force diagram for a below-knee amputee wearing the patellar-tendon-bearing prosthesis with supracondylar cuff only. <i>A, </i>Forces on the amputee; <i>B, </i>forces on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If, as seen from the front, the prosthesis is considered as a means of supporting the body, it must be capable of providing both vertical support and mediolateral balance. It is apparent that vertical components of pressure are applied against the surfaces of many areas of the stump, but for purposes of simplified analysis the combined effect of all these forces is shown as the single support force <i>S.</i></p> <p>Considering the point of application of the support force <i>S</i> as a balance point, the lateral force <i>L </i>times the distance <i>b </i>equals the body weight <i>W </i>times the distance <i>a, </i>or, in equation form:</p> <p><i>Lb = Wa </i>and <i>L = Wa/b </i>  (1)</p> <p>Unfortunately, the effect of the horizontal acceleration of the center of gravity cannot be ignored in this case, and hence in neglecting the horizontal acceleration equation 1 is incorrect.</p> <p>As indicated in <b>Fig. 3</b>, the horizontal acceleration of the body in a medial direction, due to the medial inclination of the total floor reaction <i>R, </i>results in a lateral inertia force which tends to oppose the acceleration. This inertia force must be included when consideration is given to balancing moments about the point of support. The correct relationship is therefore <i>Lb </i>+ <i>Ic = Wa:</i></p> <p><i>L </i>= (<i>Wa</i> - <i>Ic</i>) / <i>b</i>   (2)</p> <p>Equation 2 shows that the magnitude of the required lateral stabilizing (balancing) force <i>L </i>can be reduced in one of two ways-by increasing the horizontal inertia force or by increasing the effective lever arm <i>b. </i>Increasing the horizontal inertia force requires that the horizontal acceleration be increased or, in other words, that the foot should be moved laterally so as to increase the medial inclination of the total floor reaction.</p> <p><b>Effect of Foot Iinset-Outset on Mediolateral Forces</b></p> <p>The effect of changing the inset or outset of the foot is shown in <b>Fig. 4</b>, where it is possible under special conditions, as shown in <b>Fig. 4B</b>, to eliminate the need for the lateral stabilization force <i>L, </i>since in this case the weight and inertia force are seen to be in balance:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Change in mediolateral force diagram owing to inset or outset of foot from optimum position, PTB prosthesis with cuff only, as in Figure 3. <i>A, </i>Inset; <i>B, </i>outset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wa </i>= <i>Ic </i>  (3)</p> <p>The force on the lateral aspect of the stump has shifted to the region of the head of the fibula.</p> <p>Complete elimination of the lateral stabilizing force <i>L </i>by outset of the foot is generally undesirable, for the resulting wide-based gait is abnormal and unnecessary. Actually, a narrow-based gait with a definite need for the lateral force <i>L </i>(and corresponding lack of pressure on the head of the fibula) is definitely indicated for stumps 4 in. or more in length, the wide-based alignment being then reserved for very short below-knee stumps. It must be remembered, however, that planning the fit and alignment of a below-knee prosthesis to accommodate a narrow-based gait requires that the need for a definite lateral stabilizing force be recognized and accounted for in the fitting of the socket.</p> <p><b>Effect of Thigh Corset and Sidebars on Mediolateral Forces</b></p> <p><b>Fig. 5</b> shows the modifying effect of the thigh corset and sidebars on the pressures between stump and socket. If the sidebars are stiff enough it is possible to develop against the medial thigh a force <i>T </i>which acts in cooperation with the lateral-distal socket contact force <i>L </i>in providing mediolateral stabilization. In fact, with judicious use of bending irons the lateral pressure can be greatly reduced. In the past, this has been done to compensate for uncomfortable lateral-distal stump pressure. With a good socket fit against the lateral aspect of average-length stumps, however, the need for lateral stabilization by the thigh corset is minimized. Use of a thigh corset is indicated only for amputees with very short stumps or those in whom other medical factors require reduction in stump-socket contact forces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Effect of thigh corset and sidebars on medio-lateral stump-socket forces, PTB prosthesis. When the thigh corset applies a force against the medial side of the upper part of the thigh, the effect is similar to a force on the laterodistal side of the stump. Corset adjustment constitutes a possible means of modifying the magnitude and distribution of forces against the lateral side of the stump. This circumstance suggests that if the lateral sidebar is constructed with sufficient stiffness it may be of assistance in relieving excessive pressure on the laterodistal end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Anterposterior Forces, Cuff-Suspension Below-Knee Prosthesis</b></p> <p><b>Fig. 6</b> shows a side view of a below-knee amputee and the cuff-suspension prosthesis under three conditions-at heel contact, during the shock-absorption portion of the mid-stance phase, and during push-off. At the instant of heel contact, and for a short time corresponding to about 5 percent of the walking cycle, knee stability is maintained primarily by active extension of the hip joint. The tendency of the external load on the prosthesis to extend the knee is resisted by hamstring action. During this phase, forces are acting as shown in <b>Fig. 6A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anteroposterior force diagrams for a below-knee amputee wearing the patellar-tendon-bearing prothesis -with supracondylar cuff only. <i>A, </i>At heel contact; <i>B, </i>during shock absorption (foot flat in midstance); <i>C, </i>during push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of the forces acting during the shock-absorption portion of the mid-stance phase shows that it is typical for the floor-reaction force <i>R </i>to be acting along a line which passes posterior to the knee center. Under such circumstances, a completely relaxed knee would buckle, but the amputee is able to resist this tendency by active knee extension. The resulting force pattern on the stump (disregarding end-bearing) is as shown in <b>Fig. 6B</b>,where the forces are concentrated in three areas-around the patellar tendon, on the anterodistal portion of the tibia, and in the popliteal area. The socket fit must be designed to accommodate the resulting functional pressures.</p> <p>During the push-off phase, the floor reaction continues to pass behind the knee, and the anteroposterior forces are concentrated in the same three areas, as shown in <b>Fig. 6C</b></p> <p><b>Effect of Thigh Corset and Sidebars on Anteroposterior Forces</b></p> <p>If a below-knee amputee is fitted with a thigh corset and back-check so that he relies on the mechanical action of the back-check to resist knee extension, the force pattern is altered considerably. <b>Fig. 7</b> shows the effect. The floor reaction <i>R </i>must now be assumed to pass anterior to the knee, since otherwise the knee would not be extended against the back-check. If the knee joint is considered as a moment center, the effect of the force <i>R </i>is resisted by the back-check moment <i>Mo </i>and the two forces <i>A </i>and <i>P </i>exerted by the stump within the socket. Under the proper conditions, it is possible for the mechanical back-check to provide the total resistance to the floor reaction, the stump being suspended freely in the socket. This would indicate that, by proper adjustment of thigh corset, sidebars, and back-check, it is possible to modify the pattern of anteroposterior stump-socket contact pressures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Effect of thigh corset, sidebars, and back-check on anteroposterior stump-socket forces, PTB prosthesis. Shear force, <i>Sh, </i>is absorbed by mechanical side joint. Moment reaction forces on the stump are reduced through absorption of moment by knee stop. Without a knee stop, the stump would have to resist moment due to floor reaction passing ahead of knee joint. The resulting high pressure on the patellar tendon can be eliminated if the knee is allowed to flex (Fig. 6) instead of being forced into full extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Summary</h4> <p>Thus it may be seen that, while normal skeletal and neuromuscular structure of the lower extremity is so organized as to accommodate the complex and precisely phased performance needed for erect, bipedal locomotion, the below-knee amputee, even though provided with a well-fitting prosthesis of the patellar-tendon-bearing cuff-suspension type, is unavoidably destined to experience in walking a continually changing set of stump-socket forces in both the anteroposterior and the medio-lateral directions. Successful fitting of the below-knee amputee means, therefore, the resolution of stump-socket forces in such a way as to provide both comfortable support and adequate stabilization throughout the walking cycle. Whenever addition of thigh corset and sidebars is required, there occurs a change in the pattern of motion, and hence a change in stump-socket forces to be anticipated, and accordingly suitable modifications are required. Allowance for such factors calls in every case for the sound judgment of the prosthetist if fully satisfactory results are to be obtained.</p> <p><b>References:</b></p> <ol> <li>Bresler, B., and F. R. Berry, <i>Energy and power in the leg during normal level walking, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</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., The fitting of below-knee prostheses, Chapter 22 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>1.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy and power in the leg during normal level walking, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 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">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Mechanical Engineering, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-7.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 The Biomechanics of Below-Knee Prostheses in Normal, Level, Bipedal Walking Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * 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/4adf69aec72e4ae9b5f3bf92fb6ac8b3.pdf e0839880f8ec1ac27ea3e70c4edbdfd1 https://staging.drfop.org/files/original/98fe795c88fad17b1d74cc108c160e00.jpg 6a34b2e11bcae6cff2d976d346aacbc6 https://staging.drfop.org/files/original/14cf27cb8f5d81a47a7cdb8e6e214bce.jpg 3e5046beb80d00399c476ce991aba40d https://staging.drfop.org/files/original/4e626be5b3789221a3412f6af707dc27.jpg d7655bf11d81815becaf73e0db4bf62c https://staging.drfop.org/files/original/2fd9c9228f2c808801f701cc1a7d7b4d.jpg 43a265c5f229dad91a709b0c2e9f55f4 https://staging.drfop.org/files/original/1d59bded42f11085ee1da15a0877dad4.jpg 212923d2b7ef13ff8f521e29fdd1f5c4 https://staging.drfop.org/files/original/0ade1458ed51fa5f108d5b082568fdab.jpg 69820b21e500e18a75685ae782e8bbce https://staging.drfop.org/files/original/35d6d2556399148c9040f819b52e0a3b.jpg 82fcf4c1287fe7b335a8ed1da803ffe6 https://staging.drfop.org/files/original/81650d70907f304a16ab8defe11f7f60.jpg 3eb5943b2e2f96e74e96a92daf651c64 https://staging.drfop.org/files/original/f08db7f605fcd5595c184552c44e456e.jpg 599058d9e0aacadff3ce8baef49af00e https://staging.drfop.org/files/original/1d67bc6ae3ad9cbc0f6efc141f40cb13.jpg b86b89038edb944943cd90a2d336b82a https://staging.drfop.org/files/original/13d1cabd8d9f654969ba2b555d3d8dbc.jpg 404c4855866586a67f87b86a472d8c4b https://staging.drfop.org/files/original/1c87598af401dbf72d1d1d6649168efb.jpg c22e01cc312817431faf39508cc6eb4c https://staging.drfop.org/files/original/2ad5c4af43e2a75bade795051925730d.jpg 1d026a103663cb520c6fa6258ee3016c https://staging.drfop.org/files/original/d30525d8fcd51ba1c3970ba3ab2d2341.jpg ff652c1d6b200c7720ed45b3b7d8e8f5 https://staging.drfop.org/files/original/ccc86a0851bcad4c2f6c5eb0c6aeaf60.jpg 8da98cb540c35edd945fd7d842777491 https://staging.drfop.org/files/original/59877e8b7291ec5abdf5713e6e331a77.jpg 0139dfaba0fae4e4298266965017153a https://staging.drfop.org/files/original/03ba66d1000443a30f2de37b2ae3c698.jpg 39756cb1dceb16189fffde46ca165728 https://staging.drfop.org/files/original/7448bd0d7c079138df3101f8ed65e8b4.jpg 374c47d5ffc47c6009dd51df02816f30 https://staging.drfop.org/files/original/0f0a175b1c6c3f79e4d2767c9c0ca6d9.jpg 5536596629ec9f258ad85c1291617a29 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_025.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 25 - 73 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_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_025.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>Construction of the Patellar-Tendon-Bearing Below-Knee Prosthesis</h2> <h5>Bryson Fleer <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The first and most obvious requirement of any below-knee prosthesis is to furnish a suitable extension of the stump to the ground in such a way as to provide adequate support for the body weight with as little involvement as possible of other parts of the residual anatomy. In the interest of appearance as well as of function, there is a need secondarily for some reasonably faithful simulation of the normal leg, otherwise known as the "shank." Each of these requirements may be met in either of two ways. In one the structural member may be endoskeletal (the pylon), in which case the skeletal form may be covered with some suitable camouflage designed to give natural appearance. In the other, the structural element may be exoskeletal (crustacean), in which case the shell-like supporting member may itself be so shaped as to provide the desired appearance of naturalness. In either case, there is needed some acceptable means of attaching prosthesis to stump in a way that will satisfy the additional requirements of weight-bearing, comfort, and stability both in standing and in the stance phase of walking. As has been found through several centuries of observation and experiment, this is best accomplished by attaching the prosthesis via the medium of a sleeve, or socket, so shaped and so fitted as to accommodate prevailing features of local anatomy and physiology and into which the stump may be inserted.</p> <p>Of all the methods, and variations of methods, that are available for the construction of sockets advantageously fitted to the irregular surfaces of the below-knee stump, most fall into one or another of three classes.<a></a> One of these involves the forming, or shaping, of materials (such as aluminum or other metals). A second involves the negative carving, or excavation, of some suitable material (such as wood). And the third involves the molding of some material (such as leather). Because the hand-shaping of metals, like the hand-carving of wood, is at best difficult and time-consuming, and also because the skill needed for doing either may be developed only through long periods of apprenticeship, metals and wood have in recent years both been on the decline as materials of choice in the fabrication of sockets. Although the molded leather socket has persisted owing to its comparative ease of fabrication, it too is being displaced because of undesirable properties (such as its tendency to deform under load and its inclination toward perspiration absorption and consequent odor). Profoundly encouraging this transition has been the advent of plastics technology and the introduction of plastic-laminating techniques into the field of limb prosthetics. The lighter, cleaner, stronger sockets of plastic laminate, much more easily made and with considerably more precision, have now all but replaced other types of sockets in new fittings of below-knee prostheses.</p> <p>Fabrication of the plastic-laminate below-knee socket involves the taking of a suitable impression (the negative cast) of the particular stump concerned; the preparation of a positive model (male replica) from the negative mold; modification of the model in such a fashion that in the final socket (to be made from the rectified model) the weight of the body will be distributed over the respective areas of the stump according to their relative tolerance, or lack of tolerance, for weight-bearing; and, finally, the layup, lamination, curing, and finishing of the plastic socket itself. Should liners or other special features be wanted for particular cases, they are incorporated in the layup, as will be seen later.</p> <p>While the method of construction described here is applicable in the fabrication of a variety of below-knee sockets, it is intended more specifically for the construction of the plastic below-knee socket in which the purpose is to utilize to fullest extent the patellar ligament as one of the principal weight-bearing areas.</p> <h4>Construction of Socket and Liner</h4> <p><b>Taking the Negative Cast</b></p> <p>Unlike numerous other below-knee sockets heretofore recommended, the socket for the patellar-tendon-bearing (PTB) prosthesis is intended to remain at all times in intimate contact with the entire surface of the below-knee stump. The stump is therefore contained firmly in the socket throughout its length, and accordingly the cast is taken not while the patient is bearing weight on the stump (as has sometimes been done in the construction of certain "open-end" sockets) but while he is seated, relaxed, the leg hanging naturally over the edge of the support (say a table), and the knee flexed naturally about 30 deg. Whatever special effects are induced by the hands of the operator as he takes the cast are intended not to produce a "weight-bearing shape" but to emphasize the special points of weight-bearing to be anticipated in a PTB socket.</p> <p>Although of possible impression materials there is available a substantial number, the most suitable, the least expensive, and the most workable for the present purpose is the old orthopedic standby, plaster of Paris. Judging from past practice, and from long usage in limb prosthetics generally, one may suppose that there are a number of satisfactory ways of taking a plaster impression, each perhaps with certain advantages and disadvantages peculiar to itself. Experience seems to suggest that for PTB sockets the most useful and practical means of cast-taking is to wrap the stump with plaster-impregnated bandage. Use of the bandage offers, among other things, the opportunity of regulating the tightness of the cast by controlling the tension applied to the bandage while it is being wrapped.</p> <p>With the amputee seated appropriately, somewhat as in <b>Fig. 1</b>A there is applied to the stump a thin cast sock of such size and length as to fit snugly and to come up well over the knee. To the top of the sock on either side of the thigh are attached, by harness clamps, the ends of a piece of 1-in. webbing passing around the patient's waist and just long enough to support the cast sock under comfortable tension. As in the cast-taking technique commonly used to produce other forms of below-knee sockets, the prosthetist must now identify and outline the bony prominences and other landmarks, both those known to be unusually sensitive to pressure (and hence requiring buildup in the model in order to give relief in the socket) and those especially well adapted to weight-bearing (those requiring reduction of the model and hence buildup in the socket), in this case particularly the patella and the patellar ligament (<b>Fig. 1</b><i>B</i>). To do so, the fitter moistens the cast sock and outlines the areas concerned with indelible pencil so that, subsequently, the tracings will be transferred first to the negative mold and then to the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Preparations for taking the negative cast. <i>A, </i>Patient seated with stump relaxed and knee flexed easily (about 30 deg.), cast sock applied and retained well above knee, prosthetist identifying (by palpation) bony landmarks and other pertinent features to be outlined by indelible pencil; <i>B, </i>the areas generally marked out for later use in modification of the model-some expected to be weight-bearing, some more or less pressure-sensitive and hence in need of relief. See text. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In all cases, at least nine areas are identified. These include the patella itself (<b>Fig. 1</b><i>B, a</i>), the mid-point (<b>Fig. 1</b><i>B, b</i>) of the patellar ligament (approximately at the level of the medial tibial plateau), the tubercle of the tibia (<b>Fig. 1</b><i>B, c</i>), the head of the fibula (<b>Fig. 1</b><i>B, d</i>), the anterior crest of the tibia (<b>Fig. 1</b><i>B, e</i>), the distal end of the fibula (<b>Fig. 1</b><i>B, f</i>), the antero-distal end of the tibia (<b>Fig. 1</b><i>B, g</i>), the medial flare of the tibia (<b>Fig. 1</b><i>B, h</i>), and the medial border of the tibia (<b>Fig. 1</b><i>B, i</i>). Marked only if they are prominent or sensitive to pressure are the anterior prominences of the lateral and medial tibial condyles, the lateral border of the tibia, and any other sensitive areas that might suggest the presence of bone spurs, adherent scar tissue, neuromas, or similar conditions.</p> <p>When the necessary marking has been completed, the patient having maintained his stump as much as possible in the original position of knee flexion without external rotation of the femur, a few rolls of 4-in. plaster bandage are laid out conveniently beside a basin of clean, cool water. As needed, each strip of plaster bandage is immersed in the water for about four seconds, squeezed to remove excess water, and applied to the stump over the marked cast sock. The wrap is begun with one or two layers of bandage running lengthwise (<b>Fig. 2</b><i>A</i>), beginning in front and just above the top of the patella, passing down and around the end of the stump, and continuing up the back of the stump to the posterior crease of the knee. Thereafter a series of circumferential wraps (<b>Fig. 1</b><i>B</i>) is begun at the upper border of the patella and made to spiral down, then up, the stump so that half the width of the bandage (2 in.) overlaps each successive layer. Each layer is smoothed carefully as it is applied, and the wrapping is continued until the shell thus formed has a thickness of about 1/8 in. in the proximal third. Additional layers are applied over the distal portions until about six rounds have been completed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Taking the negative cast. <i>A, </i>Beginning of the wrap with plaster bandage, strips extending well above knee, front and rear; <i>B</i> completion of the spiral wrap (see Fig. 3). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While the amputee continues to maintain the original angle of knee flexion with relaxed musculature, the plaster is smoothed over the surface and worked in around the prominences and depressions by means of the hands until the plaster begins to harden. At this point, the fingers and thumbs of the operator are called upon to outline the patellar tendon and to compress the popliteal tissues, as shown in <b>Fig. 3</b>, and considerable experience and judgment are required to establish just how much pressure should be applied and in what direction. The thumbs are placed in such a position as to make a 45-deg. angle with the long axis of the tibia, and their ends are directed upward and inward midway between the lower edge of the patella and the tubercle of the tibia. Meanwhile, the fingers, wrapped around the knee, force the cast into the popliteal area, the forefingers being at the level of the posterior crease of the knee. Contact with the sides of the knee is maintained to prevent bulging, but distortion of the sides and pressure on the hamstring tendons are to be avoided. Pressure should be firm but not so great as to cause finger fatigue (a sign that too much pressure is being exerted). Both prosthetist and patient attempt to remain as motionless as possible while the plaster hardens beyond the possibility of permanent deformation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of the hands to shape cast while plaster is hardening. Thumbs compress bandage in and around patella, fingers force cast into popliteal area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Casting the Positive Model</b></p> <p>When the plaster has hardened completely, finger pressure is released, but the cast is allowed to remain in place for an extra minute or two, whereupon the harness clamps are released and the cast sock is reflected down over the cast, the amputee flexes his knee to 90 deg., and the prosthetist, with his hands in the same position as when forming the cast, removes the whole cast from the stump by an anteroposterior rocking motion induced while simultaneously pulling downward (<b>Fig. 4</b>). The cast sock, bearing the indelible markings, is allowed to remain in the cast, and the latter is then filled to the top with fluid plaster of Paris of the usual consistency. Into the center of the still-liquid plaster is inserted lengthwise (to a depth of not more than 6 in.) an 18-in. length of 1/2-in. iron pipe (approx. 1 in. O.D.) to serve as a mandrel in future bench operations. When the plaster has set for 20 to 30 minutes, the wrap cast is stripped off after it has been cut lengthwise down the posterior surface, and the model is ready for modification in accordance with the outlines originally marked on the cast sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Removal of the cast. Because of the depressions made in the cast purposely, a rocking motion is required to get cast off stump. Knee flexion helps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Modification (Rectification) of the Positive Model</b></p> <p>With the exception of those areas where the wrap cast was purposely distorted by the prosthetist's fingers and thumbs (around the patellar ligament, just under the lower edge of the patella, in the popliteal space, and so on), the positive plaster model now constitutes a faithful reproduction of the stump. It remains to revise the model in such a way that, when a socket is laminated over it, the shape of the socket will be that required to distribute the weight of the body over those areas best suited to weight-bearing while at the same time relieving sensitive areas from responsibility for bearing more weight than will be comfortable. This is accomplished by carefully carving away plaster where additional force transfer will be acceptable and by building up the model (with shaped patches of leather or other suitable material) in areas expected to be incapable of accommodating any appreciable part of the load. Guidance in this operation is to be had from the indelible outlines previously transferred first from cast sock to cast and then from cast to model.</p> <p>Although the original compression of the cast in the vicinity of the patellar ligament and around the tibial tubercle represents a preliminary step in shifting the anticipated load in the direction of the ligament midway between the lower border of the patella and the upper margin of the tibia, further modification of the model in this area is now required to intensify the effect. Accordingly, the model is cut away, as shown in <b>Fig. 5</b>, to form a channel at least 1/2 in. deep, on a radius of about 1 in., and extending horizontally across the front about 1 1/2 in., just short of the thumb prints on either side of the tibial crest. Smooth contours are obtained by sanding rough spots with a piece of wire screen.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Initial step in modification of the positive model - undercutting to enhance support on patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another stump area normally capable of bearing a portion of the body weight is the anteromedial flare at the proximal end of the tibia. As shown in <b>Fig. 6</b><i>A</i>, then, the model is shaved down in this area. At the deepest point of the resulting concavity, at least 1/8 in. should be removed (depending at least in part upon the amount of soft tissue overlying the stump in this area), and the edges should be smoothed out into continuous surfaces of gentle curvature. Since adequate vector forces cannot be exerted upon the anteromedial surface of the tibial condyles without corresponding vector forces on the lateral side, and since in any event the PTB socket is designed to provide, if possible, mediolateral stability without the necessity for sidebars, knee joints, corsets, and so forth, the lateral surface of the model is now also shaved down, as shown in <b>Fig. 6</b><i>B</i>. Depending upon the individual characteristics of the particular stump concerned, 1/8 in. to 3/8 in. of plaster is removed, beginning about 3/4 in. below the border of the head of the fibula and continuing to within 1/2 in. of the end of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Successive steps in modification of the positive model. <i>A, </i>Reduction for enhanced support on medial tibial condyle; <i>B, </i>the same to provide lateral support against fibula; C, the same to avoid pressure on anterior crest of tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Just as the PTB socket is expected to furnish adequate mediolateral stability, so it also must provide enough anteroposterior stability to come under full control of the knee of the wearer on the side of the amputation. Relatively comfortable and yet adequate fixation of the stump within the socket in the anteroposterior direction is effected by trimming down the anteromedial and anterolateral surfaces of the model almost throughout the length of the remaining tibia (<b>Fig. 6</b><i>C</i>). The result is a wedgelike support along both sides of the front of the tibia, which, then, must be backed up by corresponding but opposite forces to the rear of the socket in the popliteal area. As seen in <b>Fig. 7</b>, the popliteal area of the model is thus shaved down to the depth of the fingerprints, the upper portion of the model in this vicinity being rounded out to give a flare to the posterior brim of the socket. Finally, should it be the intention that the ultimate socket provide some amount of end-bearing, thin layers, up to about 1/4 in., of plaster may be shaved from the end surface of the model. If only the closed socket with no appreciable end-bearing is sought, the end of the model is simply smoothed with sandpaper, as is the whole model in any case to provide a finished job.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Further modification of the model. Popliteal area is shaved away to provide countersupport against forces from the front, thus improving anteroposterior stability of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model having been thus reduced to obtain the proper distribution of the loads to be anticipated in the socket, it is now equally necessary to build up those areas needing more or less relief from the pressure of weight-bearing. These ordinarily include the head and the end of the fibula, the prominent crests of the medial and lateral tibial condyles, the tibial crest throughout its length, and the antero-distal end of the tibia. In general they will already be outlined on the model from the indelible markings on the cast sock. Skived patches of leather carefully trimmed to fit (<b>Fig. 8</b>) are used to provide the modification needed. They are bonded to the plaster in the places needed, and the rectified model is then ready for use in fabrication of the plastic-laminate socket. The drawings of <b>Fig. 9</b> present for comparison the shapes of stump, original stump model, and stump model after rectification.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Build-up of positive model to furnish relief in pressure-sensitive locations. Skiving of the leather patches provides a smooth transition from plaster to build-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Contours at successive levels overlaid to show comparative shapes of stump, of stump model as made from the cast, and of stump model after suitable rectification (modification). The specific shapes vary from patient to patient, of course, depending upon individual differences. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>The Soft Insert</b></p> <p>To accommodate any inadvertent irregularities in the socket, or any minor incongruities between stump and socket, and because in general it has been found desirable to provide a comparatively soft and pliable liner in below-knee fittings, lamination of the socket itself is preceded by fabrication of an insert made of medium-weight horsehide (4 to 6 oz.) and 1/8-in. sponge rubber. Although the making of the liner and the lamination of the socket may be reviewed as two separate operations, they are, as will be seen, actually carried out as two successive steps in the layup, reinforcement, and lamination of the socket. Since the socket and its liner are both prepared <i>over </i>the rectified model, the innermost layers are the ones designed first, and hence the first step is to lay up the leather insert.</p> <p>The modified plaster model having been placed in the bench vise upside down and held there, in the vertical position, by means of the mandrel of iron pipe, there is cut from medium-weight horsehide a piece in the shape of an isosceles trapezoid such that the two parallel sides are 2 in. longer respectively than the proximal and distal circumferences of the model, the other dimension being about 2 in. longer than the model, and the direction of stretch of the leather being in the same direction as are the parallel sides (<b>Fig. 10</b><i>A</i>). With the smooth side in, the leather is fitted to the model, the intended seam line being so placed as to follow the posterior centerline. While the leather sheet is held in place by a suitable number of harness clamps (<b>Fig. 10</b><i>B</i>), the seam is marked with pencil. The sheet having then been removed from the model, it is sewed along the mark, the clamps being removed one at a time as the sewing proceeds. After the seam has been trimmed neatly throughout its length to within 1/8 in. of the stitching, the leather sleeve is replaced on the model, the work is removed from the vise, and the proximal extension of the leather is tucked and stapled to the top surface of the model (<b>Fig. 10</b><i>C</i>). An approximation of the final trim line of the socket is now drawn around the top of the leather-covered model (<b>Fig. 11</b>), and the whole is replaced in the vise, the mandrel again serving as the means of support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Preparation and layup of the leather insert, or socket liner. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Proximal trim line of the leather liner. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To form an end pad for the socket, there is now cut from a 1/8-in. sheet of sponge rubber (Kemblo) a disc large enough to fit neatly over the end of the model, the diameter of the disc being usually equal to the average diameter of the stump (<b>Fig. 12</b><i>A</i>). The distal end of the liner and one side of the rubber pad are now coated with cement (Stabond T-161), allowed to dry until the cement is tacky, and then placed together so that the pad will conform to the shape of the end of the model. Unless the curvature of the model is extreme, the pad will conform when pressed into place. Should it not conform well, a dart or two will suffice to correct any difficulty in arriving at a smooth transition between rubber and leather. In either event, the periphery of the Kemblo end pad is now skived with a sanding drum (<b>Fig. 12</b><i>B</i>) so that the outer edge will be flush with the horsehide.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Construction of the socket end pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Padding of the sidewalls of the model is now undertaken by the successive application, beginning on the anterior surface, of a circumferential series of fitted strips of Kemblo running the length of the model. To begin, there is first cut a strip of Kemblo 2 in. wide and long enough to overlap the end pad 1/2 in. and to extend beyond the model about an inch proximally. The anterior surface of the leather liner and of the end pad are coated with cement,<a style="text-decoration:none;">*</a> as is also one surface of the first strip of Kemblo. When the surfaces are tacky, the Kemblo strip is placed in the position representing the anterior crest of the tibia and allowed to extend over the end cap about half an inch (<b>Fig. 13</b><i>A</i>). Carefully pressed into place so as to conform to all of the irregular areas, the edge of the first strip constitutes the pattern for one edge of the second. So that when finally cemented in place the second strip will fit as snugly as possible against the edge of the first, one edge of the applied first strip is marked with chalk (<b>Fig. 13</b><i>B</i>), and the second strip is laid along the model parallel to the longitudinal axis and so that one edge just overlaps the chalked edge (<b>Fig. 13</b><i>C</i>). The chalkline thus transferred to the new strip marks the trim line for tailoring to the contours of the model (<b>Fig. 13</b><i>D</i>). When the new strip has been trimmed as marked, it is cemented in place, and the process is repeated until the entire surface of the liner has been overlaid with a smooth covering of Kemblo. Where the strip ends overlap the end of the model, they are skived on the sanding drum, and a second end pad, like the first, is cemented over the end of the padded model. Skiving of the second end pad to be flush with the longitudinal strips of Kemblo completes the layup and fabrication of the soft insert (<b>Fig. 13</b><i>E</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Layup of the soft liner of sponge rubber (Kemblo). One edge of the first strip (<i>A</i>) becomes the pattern (<i>B, C, D</i>) for the second, and so on, until the entire model is overlaid with a smooth and neatly fitted covering (<i>E</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>The Plastic Shell</b></p> <p>The next step is the lamination of the plastic shell over the soft liner but readily separable from it after construction of the shell is complete. As in the case of plastic-laminate sockets for other levels of amputation, use is here made of sleeves fabricated from sheeting of polyvinyl alcohol (PVA). Since in the construction of the below-knee socket it is desired to keep the liner separate from the plastic shell, two sleeves are used-the first to form a separator between liner and shell and the second, as usual, to enclose the whole layup-and-resin combination as a means of impregnating the reinforcing materials. Since neither sleeve need be more than an approximate fit for the model, two identical ones are fabricated to the dimensions shown in Figure 14. After the outer surface of the socket liner has been coated liberally with talc (to prevent sticking), the first PVA sleeve is stretched over the model and liner and trimmed around the distal end where it parts company with the surface of the liner (<b>Fig. 15</b><i>A</i>). A half-inch annular area of PVA adhesive is now painted around the cut edge (<b>Fig. 15</b><i>B</i>), and the open section is covered with another piece of PVA neatly bonded to form an end for the sleeve (<b>Fig. 15</b><i>C</i>). At the proximal end of the model the other end of the PVA sleeve is tied tightly about the mandrel, and any loose material is trimmed away to give a neat layup (<b>Fig. 15</b><i>D</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Application of PVA separator over socket liner and model </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model and overlying liner, thus covered with the PVA separator, are now ready for layup of the laminations and reinforcing materials to be incorporated into the plastic shell, or socket. Three pieces of 1/2-oz. Dacron felt, cut to the same pattern as used for the leather liner (<b>Fig. 10</b><i>A</i>), are sewed as shown in <b>Fig. 16</b><i>A </i>and pulled over the model one after the other, the seams lying on the posterior aspect of the model. Then, under the last layer of felt, in the vicinity of the postero-proximal margin, there are placed five rectangular pieces of Dacron felt (<b>Fig. 16</b><i>B</i>) measuring 2 in. by 4 in., the purpose being to thicken and reinforce the posterior edge of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of reinforcing materials for plastic socket. <i>A, </i>Layers of Dacron felt in place; B, extra material added in posteroproximal area; <i>C, </i>application of Fiberglas cloth and cast sock over Dacron. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A strip of Fiberglas cloth wide enough to cover the proximal half of the model is now wrapped around the Dacron so as to overlap itself by at least an inch, and a light cotton cast sock is slipped over the distal end of the model to hold the Fiberglas reinforcement in place (<b>Fig. 16</b>C). When the second PVA sleeve has been stretched over the whole and tied tightly about the mandrel, the layup is complete and ready for application of the resin-catalyst mixture.</p> <p>A quantity of the resin (200-400 grams, depending on socket size), prepared according to the recipe given in Appendix A, is poured into the open, distal end of the second PVA sleeve and thoroughly worked down into the fibers of the laminating materials. The open end of the sleeve is tied off, and working is continued to remove air and to complete impregnation by the familiar process of "stringing." To ensure that undercut areas and all other irregular contours of the model are reproduced in the final socket, the layup is now wrapped, as appropriate, with strips and pads of sponge rubber or with pressure-sensitive tape, whichever is more convenient (<b>Fig. 17</b><i>A</i>). Left thus undisturbed, the resin will cure at ambient room temperature in about 30 minutes, whereupon it is allowed to lose any heat of reaction and to return to room temperature.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Plastic lamination and initial finishing of the PTB socket. <i>A, </i>Layup encased in second PVA bag, impregnated well with resin, and undercut areas bound down by wraps of sponge rubber; <i>B, </i>removal of socket and liner from model after curing of resin is complete; C, specifications for trimming the top brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It remains now but to free the socket and liner from the plaster model. This is accomplished by trimming along the proximal edge of the layup (<b>Fig. 17</b><i>B</i>) at a 45-deg. angle until the underlying sponge rubber is just exposed. The shell is then readily slipped off the model, as the liner in turn may be slipped out of the socket. With liner removed temporarily, the proximal brim of the socket is now trimmed as shown in <b>Fig. 17</b>C.</p> <h3>Preparation of Socket for Alignment</h3> <p>The socket thus produced must next be properly aligned with respect both to the residual anatomy of its intended wearer and to the rest of the prosthesis, including the prosthetic foot and the shoe to be worn over it. Although the below-knee prosthesis may be so aligned, as it has been for a great many years, by the simple expedient of "aligning by eye" (that is, simply by trial and error and by observation of the static and dynamic behavior of the amputee-prosthesis combination), the whole procedure is made much easier (and the resulting relationships much more readily amenable to duplication if need be) by application of one of the more modern tools of prosthetics practice. Recommended for use in the present instance is the below-knee adjustable shank developed at the University of California. As may be seen in <b>Fig. 18</b>, the UC below-knee adjustable shank consists essentially of a steel plate perforated with a rather large number of countersunk screw holes and supported on a crossed-bar mechanism in which two identical and graduated bars cross each other back to back at a fixed angle of 90 deg. and in which each bar is capable of sliding across the other at the point of intersection, or of rotating about the longitudinal axis of the other, or of doing both simultaneously in an infinite variety of combinations of sliding and tilting. Each bar is held in position by a pair of opposing setscrews, such that loosening of any one screw permits both sliding of the bar to which that screw is attached and rotatory motion about the companion bar. The net result is a kind of universal joint in which, within the limits required, any combination of anteroposterior and mediolateral shifting horizontally may be had together with any combination of anteroposterior and mediolateral tilting. Included with the device is a pylon shank for temporary service during alignment, and a clamp on the shank portion provides for attachment of the foot and for adjustable foot rotation with respect to socket orientation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The University of California below-knee adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Attachment of Socket to Adjustable Shank</b></p> <p>Since the below-knee adjustable shank is intended for use in combination with the socket shell, and since the latter is asymmetrical in all directions on the outside as well as on the inside, there is now required some practical means of attaching the socket rigidly to the shank. Experience shows that such an attachment is best arrived at by first sinking the socket into a hollow block of wood of suitable size and shape. For purposes of reference, here and throughout the remaining stages of construction, the socket is first marked with vertical centerlines representing, respectively, the anteroposterior and mediolateral planes. As shown in Figure 19, the lines are established by connecting, in side and rear views, the estimated center points of the top and of the bottom of the socket, the proximal center point for the anteroposterior plane (<b>Fig. 19</b><i>A</i>) being taken at the level of the posterior brim of the socket while the corresponding center in the lateral view (<b>Fig. 19</b><i>B</i>) is taken slightly above the indentation provided for the patellar ligament.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Anteroposterior and mediolateral center-lines of the socket, intended for reference in alignment. In each of the two views, the approximate "center" of the brim and the estimated "center" of the bottom of the socket are connected by straight lines, except that in the lateral view the proximal center point is taken just above the level of the indentation provided for the patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A cylindrical socket block of willow, about 6 in. long and about 6 in. in diameter, is now drilled through along the longitudinal axis of the cylinder (parallel to the grain) with a 2-in. bit, and one end of the tubular aperture is carved out so as to receive the lower end of the socket to a depth of 3 or 4 in. and in such a way that the socket will rest easily in the block with 5 deg. of adduction (<b>Fig. 20</b><i>A</i>) and 5 deg. of initial flexion (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Positioning of the socket in the socket block to give 5 deg. of adduction and 5 deg. of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal surface of the socket shell, roughened to improve adhesion, is now bonded into the block in the predetermined position by use of a mixture of resin and sawdust (or other filler). When the bond has hardened thoroughly, the lower end of the socket block is sawed across squarely at such a level as to leave only about an inch of wood below the end of the socket shell.</p> <p>With the socket attachment plate and the slide-tilt unit of the below-knee adjustable shank (<b>Fig. 18</b>) centered and level, the socket block is now set upon the attachment plate in an orientation such that the mediolateral center plane of the socket (posterior reference line) lies in the same direction as the lower pair of setscrews of the slide-tilt unit (<b>Fig. 21</b>). Thereafter the socket block is moved upon the attachment plate in the anteroposterior direction until a plumb line dropped from the anteroposterior centerline of the socket at the level of the midpatellar tendon lies 1 1/2 in. in front of the centerline of the upper tube clamp (<b>Fig. 21</b><i>A</i>). Similarly, the block is then moved in the mediolateral direction until a plumb line dropped from the center of the posterior brim of the socket lies 1/2 in. lateral to the centerline of the upper tube clamp (<b>Fig. 21</b><i>B</i>). While the block is held in this position temporarily, a pencil line is drawn about the attachment plate onto the base of the block, the socket and block are removed from the adjustable shank, and excess wood is cut away from the block to produce the result shown in <b>Fig. 22</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Orientation of socket and socket block upon adjustable shank using socket centerlines for reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket and socket block after removal of excess wood from the latter. Circle on base marks position of socket-attachment plate for reattachment of adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the block thus partially trimmed, the adjustable shank is replaced against the bottom of the block in the same relative position as before, and the block is attached to the plate of the shank by means of not fewer than six 3/4-in. flat-head wood screws (No. 10), which, incidentally, will seat nicely into the countersunk holes in the attachment plate. The particular position chosen in the individual case is, of course, as already described and as shown in <b>Fig. 20</b> and <b>Fig. 21</b>, and the net spatial relationships of socket to adjustable shank shall be such that, to begin with, all of the adjustment setscrews are near the middle of their ranges of possible adjustment.</p> <p><b>Choice and Preparation of the Prosthetic Foot (With Shoe)</b></p> <p>Although in the construction of the patellar-tendon-bearing below-knee prosthesis use might be made of any one of a variety of foot-ankle units commercially available, the most satisfactory results are usually obtained with the nonarticulated SACH foot (Solid Ankle, Cushion Heel), in which a heel wedge of compressible but resilient material provides shock absorption and the equivalent of plantar flexion at heel contact while a solid wooden core (or keel) properly shaped at the ball of the foot furnishes needed support during roll-over and push-off in the stance phase of walking. <b>Fig. 23</b> presents schematically the familiar SACH foot as seen through a transparent shoe properly fitted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The SACH foot, in transparent shoe, schematic. <i>A, </i>Heel contact; <i>B, </i>plantar flexion immediately after heel contact, heel wedge compressed. Rocker shape of keel at the ball of the foot gives support during roll-over and furnishes needed assistance at toe-off. Flexible toe piece permits normal toe-break in the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Generally, choice of SACH foot in the individual case depends on three factors: shoe size, height of the patient, and relative stiffness of the heel wedge. At present, oversize SACH foot blanks, left and right, are available in three ranges of shoe size (6-8, 8-10, 10-12) and two degrees of stiffness of the heel insert ("firm" and "medium"). As for heel stiffness, "medium" is generally recommended for below-knee amputees weighing up to 140 lb., "firm" for those exceeding 140 lb. As for Table 1, which presents the recommended size of foot blank as related to shoe size and height of patient, it should be noted that, as in most aspects of lower-extremity prosthetics, no hard and fast rules exist and that in any case borderline sizes have to be worked out as compromise. Ultimate choice of foot-blank size and heel-cushion stiffness should always be based on evaluation of the needs of the individual patient.</p> <p>Once the foot blank has been selected, it remains to shape the foot (<b>Fig. 24</b>) until it fits properly into the intended shoe. Although in the oversize blank the general contours of the foot are provided for by the manufacturer, so that in general only slight modifications are required, certain precautions need to be exercised. For example, the portion of the foot above the top of the shoe should not be reduced until the final wooden shank has been installed. Similarly, no material should be removed from the lower third of the heel contour lest the distance from heel to toe-break be made too small for a tight fit. Conversely, certain size reductions are usually essential, especially on the lower surface of the arch of the foot, in the toe area, and in the heel cushion above the lower third of the heel, all as shown in <b>Fig. 24</b>. In particular, the lower surface of the arch of the foot must be so reduced that it can never come into compression contact with the arch of the shoe (<b>Fig. 23</b>). Required here is a minimum clearance of 1/8 in., for otherwise motion may be restricted or the shoe damaged. In like manner, the dorsal surface of the arch of the foot should be reduced until the lacing gap of the shoe matches that of the shoe on the remaining normal foot, but not to the extent that fitting in this area might be loose.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Shaping of the SACH foot blank to the requirements of the shoe. Failure to maintain tightness in the areas indicated, or to provide relief in the others, leads to abnormal gait regardless of the care taken in construction of the rest of the prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Just as the arch of the foot must be prevented from binding against the insole of the shoe, so the toe portion of the foot blank must be reduced so that expansion under compression will not restrict motion in the toe of the shoe. Finally, the upper two thirds of the heel insert must be shaped to give about 1/8 in. of clearance from the lateral, medial, and posterior brims of the counter of the shoe, a feature which permits the heel wedge to expand under compression without binding against the shoe (<b>Fig. 23</b>).</p> <p>A subtle feature in the shaping of the heel wedge is that the rearmost point of the heel should be fashioned to lie 1/4 in. lateral to the anteroposterior midline of the foot (<b>Fig. 25</b>) so that later, when the necessary toe-out is introduced, the point of the heel will automatically return to a position directly in the line of progression.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shaping of the heel of the SACH foot to accommodate proper toe-out in the finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>All of these shaping operations are of course best carried out by means of a cone or drum sander, the sanding being done as much as possible in a direction parallel to the direction of the laminations at all points. A spindle speed of at least 1750 r.p.m. is desirable; and in the course of fitting, a thin sock should be placed over the boot whenever the foot is inserted into the shoe for trial.</p> <p>There remain now but two final adjustments-the first having to do with heel elevation (distance between bottom of heel and the surface upon which the ball of the foot rests when the top surface of the foot is parallel to the supporting surface) and the second with heel-cushion stiffness. Currently, SACH foot blanks are manufactured with a heel elevation of 11/16 in. If, when the shaped foot and companion shoe are held on a surface with top of foot parallel to that surface, there should be undue compression of the heel wedge, the heel elevation may be increased (by not more than 3/16 in.) by sanding the lower surface of the foam crepe shoe-sole material in the heel area. Should compression of the heel wedge be inadequate under the same circumstances, shims of crepe shoe-sole material, leather, or any other firm but flexible material may be shaped and bonded to the bottom of the heel.</p> <p>If needed at all, the second adjustment (heel-cushion stiffness) awaits attachment of the foot (with shoe) to the rest of the assembly (<i>i.e.</i>, to the bottom of the adjustable shank). Accordingly, the foot-attachment plug of the adjustable unit is now bolted to the flat, top surface of the foot, and the distance between foot and adjustable unit is established with an appropriate length of aluminum-alloy tubing 1.625 in. O.D., 1.510 in. I.D. Attachment of the proximal end of the tube is by insertion into the clamp at the bottom of the adjustable unit. To clamp the distal end of the tubing about the foot-attachment plug, the lower end of the tubing is split, the tubing is slipped over the plug, and the assembly is fixed together with the tube clamp furnished with the adjustable shank. Preliminary toe-out of the foot is obtained simply by loosening the tube clamp, rotating the foot so that the line of progression is parallel to the anteroposterior (bottom) slide bar of the adjustable unit, and resetting the tube clamp. Should the unit be too short when tried on the patient, the foot is removed, annular spacers are added, the foot is replaced, and the clamp tightened again. If the unit is found to be too long, the foot is removed and a shorter length of aluminum-alloy tubing is substituted.</p> <p>With the socket-and-block combination, the adjustable unit, the tubular pylon, and the foot-and-shoe combination thus assembled, the amputee dons the socket and stands upon it, weight distributed equally between heel and ball of foot. If all has been done well, the orientation in the parasagittal plane will be such that, when the prosthesis stands unloaded, the longitudinal axis of the shank will be inclined some 2 to 3 deg. anteriorly (<b>Fig. 26</b>, solid outline) whereas when the amputee stands upon the prosthesis the longitudinal axis of the shank will rotate posteriorly until it lies in a vertical plane (<b>Fig. 26</b>, dotted outline). The change in relative position brought about by addition of the wearer's weight represents of course an initial compression of the heel wedge. Over and above initial compression is that needed and acceptable at heel contact during the stance phase of walking. In general, the heel should compress about 3/8 in. at heel contact (<b>Fig. 23</b><i>B</i>). Should, in any particular case, any of these values prove to be appreciably larger or smaller than the recommended compression values, the heel cushion must be replaced by a stiffer or a softer cushion, whichever applies. The procedure for so doing is set forth in Appendix B.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial below-knee leg showing proper anterior tilt of shank (2 to 3 deg.) in the unloaded condition (without weight of wearer). Dotted outline shows return of the long axis of the shank to the vertical when amputee stands upon the prosthesis (initial compression of heel wedge). Should these relationships not prevail upon examination, a change in heel stiffness is indicated (Appendix B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Making the Supracondylar Cuff</b></p> <p>All prior conditions having been met satisfactorily, the assembly shown in Figure 26 is now ready for preliminary alignment on the amputee. But before any alignment can be undertaken it is first necessary to fabricate the means of socket suspension-the supracondylar cuff fitting about the distal flares of the femur and resting in front upon the upper margin of the patella (<b>Fig. 27</b>). Though in some cases it may be necessary later to resort to jointed sidebars and thigh corset, with or without still additional paraphernalia, the simple cuff, with its side tabs attached to the socket posteriorly, commonly suffices in actual prosthetic use and, in any case, serves adequately the purposes of final fitting and alignment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To make the cuff, including the tabs, a suitable piece of pearled elk leather is first cut out along the pattern labeled <i>a </i>in <b>Fig. 28</b>. Since ultimately closure of the cuff is to be by buckle on the lateral side, and since it is desired to have the smooth side of the leather outside, the orientation of pattern and material must be chosen properly. One side of the pattern is of course for right amputees, the other side for left amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Patterns (one half actual size) for preparing supra condylar cuff. a, Pattern for the cuff itself; <i>b, </i>pattern for the buckle billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rubber cement is now applied to the rough side of the leather part just cut, and two pieces of Dacron webbing 1/2 in. wide and 4-1/2 in. long are bonded to the leather tabs (<b>Fig. 29</b>) as insurance against excessive stretching. A piece of horsehide large enough to cover cuff and tabs is then selected, the rough side is covered with rubber cement, and the horsehide is bonded in place as a liner. When this laminate has set, the elk leather, Dacron webbing, and horsehide are sewed together along the edges, and the horsehide and webbing are trimmed flush with the elk leather.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Application of Dacron webbing to cuff side tabs to prevent undue stretching of the leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the cuff itself has been completed, a buckle billet is cut from a scrap of horsehide according to the pattern labeled <i>b </i>in <b>Fig. 28</b>, the ends of the piece are skived on the rough side, a slot for the buckle is cut out, a 5/8-in. buckle is inserted in the slot, and the billet is lapped back on itself, rough side in, and bonded together with rubber cement. The billet containing the buckle is then glued and sewed to the pearled elk surface of the cuff, as shown in <b>Fig. 30</b>. Finally, six or seven 3/16-in. holes are punched in the tabs at 3/8-in. intervals, and buckle holes of suitable size are punched into the strap of the cuff on 1/2-in. centers (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of buckle and buckle billet on condylar cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Attaching Cuff to Socket</b></p> <p>As will be noted in <b>Fig. 27</b>, one intention of the condylar cuff is that it shall bring about tension in the side tabs as the knee is extended throughout the range and that it shall permit the side tabs to relax as the knee flexes in sitting or in the swing phase of walking. Thus the points of attachment of the side tabs are pivots, the axes of rotation being behind the anatomical knee axis. Since the cuff must pull in against the patella over a full 60 deg. of knee flexion in the swing phase, while for comfort in sitting the tabs must relax throughout an additional 30 deg. to give 90 deg. of knee flexion (<b>Fig. 31</b>), the optimum points of attachment of tabs to socket must be arrived at by trial of the socket and cuff on the patient for whom they are intended.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Positioning of cuff side-tab attachments such as to provide tab tension throughout 60 deg. of knee flexion in the swing phase of walking and tab relaxation throughout an additional 30 deg. to accommodate comfortable sitting with knee flexed a full 90 deg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee first dons the cuff so that the tabs are on either side of the knee and fastens it comfortably. He then dons the socket over a stump sock, being careful to obtain proper seating of the stump, and stands on the prosthesis with weight evenly distributed on two legs. While this condition is maintained, the tabs are pulled down on either side of the knee and approximated to their natural position on the sides of the socket. The hole nearest the level of the tibial plateau but behind the average anatomical knee axis is selected on each side and the points marked through the holes with a pencil (<b>Fig. 32</b>). By means of self-tapping screws, the necessary buttons are attached temporarily at the points indicated, pending final alignment and walking trials. When all adjustments are complete, the buttons are attached permanently by means of rivets.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Attachment of side-tab buttons at position determined in Figure 31. The usual position, arrived at by trial and error, is behind the average anatomical knee axis at the level of the tibial plateau. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Preliminary Alignment</h3> <p>From the alignment established at the time of assembly of socket, adjustable shank, and foot (pp. 36-42) it is now necessary to arrive at the optimum alignment for the given case, a requirement demanding ultimately the participation of the amputee himself. Since the positioning of the socket in the block, the orientation of the adjustable unit, and the characteristics of the foot are all mutually interdependent in defining the "net" optimum alignment, it is imperative that no attempt be made to correct a fault at a given point without considering the possibility of thus upsetting position relationships at another. The whole process of alignment is in fact a series of checks and rechecks, and it is the responsibility of the prosthetist to determine the site of faults, if any, and to make appropriate corrections as the process advances in stepwise fashion. As has been seen, use of the below-knee adjustable shank makes it possible to orient a below-knee socket to any necessary combination of fore-and-aft positioning, side-wise positioning, fore-and-aft tilting, or side-wise tilting. But because each setscrew fixes not only the lengthwise positioning of its own bar but also the rotatory positioning of the companion bar, it is essential, in the course of successive adjustments, to reset the <i>same </i>screw as was first loosened (not its opposing counterpart) and to recheck any preceding adjustment to make certain that it has not been disturbed.</p> <p>The amputee having first donned the socket-shank combination (together with the condylar cuff for suspension and with the intended shoe on the prosthetic foot), a preliminary approach to alignment on the individual is made in four steps, as shown in Figure 33. While anteroposterior tilting is avoided, mediolateral sliding is accomplished. While anteroposterior sliding is avoided, mediolateral tilting at the desired angle is established. While mediolateral tilting is avoided, anteroposterior sliding is carried out to the extent desired. While mediolateral sliding is avoided, anteroposterior tilting is accomplished. To avoid any unintentional disorientation, each operation is followed by a check of the previous setting. Additional minor adjustments are made as needed until the alignment of the prosthesis upon the wearer is such that the toe-out of the prosthesis matches that of the normal foot, that the amputee can stand erect, hips level, with weight equally distributed between the two feet and with heels not more than 4 in. apart, and that in standing in one position between parallel bars (or with the aid of crutches) he can shift his weight comfortably with adequate control of both mediolateral balance and of knee flexion-extension.</p> <p>Of the principal faults sometimes encountered at the time of preliminary alignment of the trial prosthesis on the patient, some have to do with spatial relationships in the frontal plane (<b>Fig. 34</b>), others with relative positioning of parts in the parasagittal plane (<b>Fig. 35</b>). If, for example, there should be a gap at the brim of the socket on the lateral side, accompanied by undue pressure at the medial brim, the pylon of the adjustable shank may be found to be either vertical (<b>Fig. 34</b><i>A</i>, foot necessarily flat on the floor) or tilted laterally (<b>Fig. 34</b><i>B</i>, foot resting incorrectly on lateral edge of sole). In the first case, the remedy consists in shifting the socket medially by means of the adjustable unit (<b>Fig. 34</b><i>A</i>). In the second, elimination of the trouble is to be found in tilting the socket laterally, again by means of the adjustable unit (<b>Fig. 34</b><i>B</i>). When, in <b>Fig. 34</b><i>B</i>, the pylon shall have assumed a vertical position in the medio-lateral plane, the socket will have settled into a satisfactory fit near its proximal end. Similar, but opposite, corrections are made should undue pressure be found to prevail on the lateral brim of the socket, it being kept in mind that the long axis of the shank pylon must always lie in a vertical plane (foot flat on floor).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Two faults in mediolateral alignment sometimes found during initial trials of prosthesis on amputee. <i>A, </i>Pylon vertical (foot flat on floor) but socket too far lateral; <i>B, </i>same situation but with pylon tilted laterally so that foot rests on outside edge of sole only. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Faults in anteroposterior alignment sometimes found during initial trials of prosthesis on amputee. <i>A, </i>Knee forced backward, shank pylon tilted posteriorly so that too much weight is borne on heel; <i>B, </i>knee forced backward but with shank pylon vertical (foot flat); <i>C, </i>heel off floor, all weight borne on ball of foot; <i>D, </i>knee forced forward by virtue of too much anterior tilt in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the parasagittal plane, a number of faults may be observed from time to time with individual patients (Fig. 35). For example, it may be found that application of the wearer's weight forces the knee backward, the shank pylon tilting posteriorly in one case (<b>Fig. 35</b><i>A</i>), standing vertical in another (Fig. 35<i>B</i>).</p> <p>Should a shift of the socket block forward on the adjustable shank prove not to correct the difficulty shown in <b>Fig. 35</b><i>A</i>, it may be that the heel cushion in the foot is too soft, in which case the heel wedge must be replaced by stiffer material according to the procedure outlined in Appendix B. When, on the contrary, the knee is forced backward while the pylon remains in a vertical plane (<b>Fig. 35</b><i>B</i>), then adequate correction should be obtained simply by tilting the socket-block combination anteriorly upon the adjustable unit. Occasionally, the weight of the amputee forces the socket forward while the pylon remains vertical (<b>Fig. 35</b><i>D</i>). When such a relationship prevails, it is usually corrected by tilting the socket posteriorly. And finally it may happen that, when the amputee stands erect in the prosthesis, the heel is not in contact with the base of support (<b>Fig. 35</b><i>C</i>), which of course means that all of the weight is borne on the ball of the foot instead of being distributed equally between heel and ball. Tilting the socket anteriorly usually corrects this undesirable arrangement.</p> <p><b>Fig. 35</b></p> <p>It should now perhaps be noted that, in the process of preliminary trials on the patient, none of the indicated adjustments should be more than a minor adjustment. The necessity for any gross adjustment at this point in the procedure reflects some inadvertence in the conduct of the preceding steps of construction, and in such a rare case it may be better for the prosthetist to start over, or at least to retrace his own performance from socket casting to assembly of the adjustable leg. In any event, it will be obvious that the orientation of the socket in the wooden block, the position of the block with respect to the adjustable shank, the orientation of the adjustable unit itself, and the design of the SACH foot are all interdependent and that each of these factors contributes to the final result, so that a change in any one feature affects the behavior of all the others. Accordingly, successful alignment of the PTB prosthesis is still partly a matter of art and thus calls for extraordinary skill and judgment on the part of the prosthetist. Throughout the preliminary tests it should be remembered that the wearer of the PTB prosthesis is expected to walk with the knee on the side of the amputation flexed some 5 to 8 deg. and with weight borne over the middle third of the prosthetic foot in midstance. If any major changes are made in the initial alignment, then over-all height should be checked, since an increase in anterior tilt reduces the effective length of the prosthesis while an increase in posterior tilt tends to increase it.</p> <h4>Dynamic Alignment</h4> <p>Despite the apparent implications of the nomenclature, dynamic alignment of the PTB prosthesis is less an actual alignment as such than it is a check to make certain that the alignment established in the static condition of standing is satisfactory when the amputee undertakes normal, level walking along a substantially straight line of progression. The features sought in dynamic alignment are essentially the same as those sought under static conditions, though the criteria are different. If, indeed, the requirements of static alignment have been met fully, and if the particular case involved presents no gross deviations from the characteristics of the average below-knee amputee, then the chances are that dynamic alignment will amount to no more than a confirmation, at most a minor revision, of the spatial relationships already existing.</p> <p>Since, however, no amputee-prosthesis combination, however carefully worked out, can be expected to perform in an optimum way without the active and cultivated participation of the wearer, no attempt at checking out the dynamic alignment of a PTB prosthesis is apt to be valid until the amputee has become familiar not only with what is to be expected from the prosthesis but also with what responsibility he, the wearer, has in the management of the limb. Accordingly, the patient is first encouraged to experiment (at first between parallel bars) with simple weight-bearing on the limb, with active knee flexion-extension, with standing and sitting, with short and simple steps including roll-over on the prosthesis, and finally, when he has gained some confidence, with straight and level walking without benefit of parallel bars or crutches. Meanwhile, the prosthetist and trainer continue to make such minor adjustments as seem indicated by observation of dynamic conditions. Thus, the indoctrination of the patient and the final details of alignment are carried out together, sometimes alternately, sometimes successively, until both patient and clinic team are satisfied that the best possible job has been done. Some of the problems that project themselves occasionally during dynamic alignment are depicted in <b>Fig. 36</b>, <b>Fig. 37</b>, and <b>Fig. 38</b>, and the final antero-posterior position of the socket with respect to the shoe is shown in <b>Fig. 39</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Check of foot and socket in mediolateral plane during walking. <i>A, </i>Proper alignment in front view; <i>B, </i>correction for undue pressure at medial brim of socket, rear view. Compare with Figure 34<i>A.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Check of anterior tilt of socket (and hence of initial knee flexion). Too much initial flexion, as here, may cause loss of knee stability at heel contact <i>(A) </i>or lack of support (drop-off) at the end of the stance phase (<i>B</i>), or both. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Check of posterior tilt of socket. Too little initial knee flexion (excessive posterior tilt of the socket) may cause early arrest of knee flexion after heel contact, or a prolonged period of unstable weight-bearing on the heel, or an excessive shift of the body weight to the ball of the foot accompanied by premature heel rise at midstance <i>(A). </i>Inadequate knee flexion may also give rise to scuffing of the toe during swing-through <i>(B).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Ultimate anteroposterior position of socket with respect to shoe. A plumb line dropped from the anteroposterior centerline of the socket at the level of the midpatellar tendon should pass just ahead of the breast of the heel of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because in the practical matter of walking comfortably, effortlessly, and with acceptable appearance the details of alignment in the anteroposterior direction are more critical than those having to do with the mediolateral, it is recommended that the latter always be attended first, the anteroposterior adjustments being left until the very last. As in all other steps of alignment, each successive change should be followed at once by a check on the preceding one so that no correction coming later can upset another made earlier, except with the full knowledge of the prosthetist (as is sometimes necessitated in compromise situations where one advantage is to be gained only at the expense of another). In all cases, the patient should be allowed to walk upon the adjustable shank long enough (days, if need be) to demonstrate that all adjustments are at an optimum for the particular physico-anatomical circumstances then prevailing. When the prosthetist is convinced that he has attained the best possible set of conditions, the alignment is duplicated in the finished prosthesis by means of the UC adjustable alignment-duplication jig.</p> <h3>Alignment Duplication</h3> <p>The so-called "alignment-duplication jig" of the University of California, intended originally for duplication of the alignment of above-knee prostheses, consists of two adjustable, viselike clamps so mounted side by side upon a firmly fixed, tubular base as to be capable of being moved along the length of the base as required or of being fixed in any selected positions along the base in any chosen linear relationship to each other. One clamp is intended to position and hold the thigh portion and artificial knee of an above-knee prosthesis, while the other holds and positions the shank-foot combination. To be interposed between the two clamps, mounted on the same base, and movable along the base between the clamps, is a bracket intended as a guide for a miter saw whenever the saw is needed. When the bracket is in place, it is so oriented that the saw will make a cut normal to the long axis of the tubular base.</p> <p>Once the clamps have been set so as to accommodate as precisely as possible a thigh socket, adjustable knee unit, shank, and foot in the relative positions established in alignment trials, the component parts of the final prosthesis may be substituted for the adjustable devices without upsetting the prevailing alignment. Similarly, the alignment of an existing prosthesis may be duplicated in a new prosthesis simply by setting up the alignment jig to match the first limb and then making the second limb to match the setting of the jig. When the desired orientation of socket and knee block with respect to shank and foot has been attained, the saw is used to cut the planes representing the intended juncture of the two segments.</p> <p>Application of this device to the below-knee case, including the case of the patellar-tendon-bearing prosthesis, is readily accomplished by introduction of a special fixture called the "ankle bracket." Mounted on the base in the same way as the clamps, it is used in place of one of them, that one being simply shoved out of the way temporarily (<b>Fig. 40</b>). Drilled through the top of the ankle bracket is a 3/8-in. hole whose axis is such that, when the bracket is in place, the axis is parallel to the base tubes of the jig. When, in the below-knee case, static and dynamic alignment with the adjustable leg satisfy both prosthetist and amputee, the SACH foot is removed from the adjustable shank, and the distal end of the shank is attached to the ankle bracket by means of an Allen-head screw (<b>Fig. 41</b>). Since toe-out of the foot must be re-established after the final shank piece has been properly substituted for the adjustable shank, the prevailing relationship of the foot to the socket is keyed before the foot is removed from the adjustable leg. Using a straightedge and one of the bonding lines of the foot for reference, the prosthetist first marks points on the front and back brims of the socket (<b>Fig. 42</b>). Thus later, when the final shank has been aligned and cemented into place, the foot may be replaced in the same relative position of toe-out as established in the alignment trials on the adjustable shank.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. University of California alignment-duplication jig for above-knee prostheses, as adapted for below-knee alignment duplication through substitution of the ankle bracket (cross-hatched) for one of the adjustable clamps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Attachment of adjustable shank (with socket and socket block) to ankle bracket of alignment-duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Recording toe-out of foot before removing foot from adjustable shank. Same toe-out must be reestablished later. See Figure 50. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since, when the ankle bracket is fixed to the base, the axis of the hole through the bracket is parallel to the long axis of the base, so also then is the long axis of the shank parallel to the base tubes when subsequently the shank has been bolted to the ankle bracket. The orientation of the socket being thus established, the socket clamp is brought up into position alongside the socket (<b>Fig. 43</b>), care being taken to see that the clamp is then not less than 10 in. from the end of the base tubes (so that later it can be backed out of the way). The socket clamp is there locked to the base tubes, and the clamping thumbscrews are run down carefully but firmly so as to clamp the socket without at the same time placing any distorting strains upon the shank. The relative positions of shank and socket are thereby established in the jig for later reproduction in the finished prosthesis. To establish the over-all length of the final prosthesis, the positions of the ankle bracket and of the socket clamp are then recorded from the scale running the length of the base tubes of the jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Setting of socket clamp to the orientation previously established by the ankle bracket. At least 10 in. should be allowed at socket end so that socket clamp and socket may later be moved out of the wav. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the socket thus fixed in the clamp and with the clamp and ankle bracket secured to the base of the jig, the adjustable shank is now removed, first from the ankle bracket and then from the wooden base of the socket (<b>Fig. 44</b>). The saw guide is mounted near the base of the socket (<b>Fig. 45</b>), and a cut (not more than 1/4 in. from the end of the base) is made (<b>Fig. 46</b>) so as to produce a surface normal to the axis of the jig. The clamp holding the socket is moved out of the way, a partly hollowed, wooden shank block is now attached to the ankle bracket by means of the same Allen-head screw as before (<b>Fig. 47</b>), and a cut is made to produce a surface which, like the bottom surface of the socket base, will be normal to the long axis of the jig (<b>Fig. 48</b>). When the sawing is completed, the saw guide is removed from the jig, and shank and socket block are brought together by sliding the socket clamp back to its original position on the tubular base.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of the adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Installation of saw guide on same base as other fixtures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Making saw cut on bottom of socket block. Remove not more than 1/4 in. at thinnest point about periphery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Attachment of shank block to ankle bracket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Making saw cut on top of shank block. Length of block after cutting shall be such that it may be substituted for the adjustable shank and pylon without significant change in over-all length of the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If all has been done properly, the top surface of the wooden shank and the bottom surface of the socket block will now meet comfortably all around the periphery. When that is the case, the mating surfaces are spotted with glue, brought together firmly, and held in place by locking the fixtures to the base tubes (<b>Fig. 49</b>). To avoid inadvertent dripping of glue onto the equipment, the base of the jig may be draped loosely with scraps of paper, rag, or waste. When the glue has set firmly, the whole unit is removed from the jig, and the foot is attached to the shank (<b>Fig. 50</b>) in the same position (with respect to the socket) as before (reference lines match). Thereafter the leg is ready for final shaping and finishing (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Shank and socket block glued together in relationship established by jig fixtures. Dripping glue is caught by waste thrown over jig base. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Attachment of foot to shank with same relative toe-out as existed in trial leg using adjustable shank. Compare with Figure 42. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Assembled prosthesis ready for external finishing. Orientation of parts is that established in trials of static and dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Finishing the Prosthesis</h3> <p>Since it is inconvenient, if not actually impossible, to determine in advance exactly how the shank block and the socket block are going to line up in the finished prosthesis, and since ultimately, in the interest of weight-saving, it is desirable to carve out the shank block to the thinnest possible shell compatible with strength requirements, it is necessary to break apart the temporary attachment of shank and socket, but not until essential landmarks have been recorded for the purpose of later reassembly in the same relative positions as established in the alignment jig. Similarly, finishing the foot and ankle (distal part of shank) requires another removal of the foot, but not until the necessary reference position has been recorded on the work itself. To begin, the toe-out of the foot is marked with pencil, as shown in <b>Fig. 52</b><i>A</i>, and the foot is removed by unscrewing the attachment bolt. Because in the shaping of the distal end of the shank, and in its preparation for the lamination to follow (page 56), some material usually has to be shaved off the outside of the shank in the ankle area, the pencil mark on the anterior aspect is carried onto the base with a sharp tool, such as an awl or a penknife (<b>Fig. 52</b><i>B</i>). In order that the later plastic-laminate covering may form a smooth transition from shank to foot, a line is now scribed around the periphery of the bottom of the shank about 1/16 in. from the edge (<b>Fig. 52</b><i>C</i>), and the shank is ground down smoothly to the line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Preliminary steps in the finishing of the PTB prosthesis. <i>A, </i>Marking the established toe-out of foot with respect to shank; <i>B, </i>foot removed, reference mark transcribed to bottom surface of shank to avoid obliteration in next step; C, 1/16-in. annular ring marked about bottom surface of shank block as guide line for shaving down ankle area; <i>D, </i>ankle area shaved down, reference lines marked to record orientation of shank and socket block (after whole limb has been shaped on outside to match contours of the remaining leg of patient); <i>E, </i>shank block removed from socket block and routed out to form shell uniformly 1/4<i> </i>in. thick all around. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rest of the external surface of shank and socket block are now ground down to approximate the contours of the natural counterpart (preferably to match the shape of the remaining leg of the particular individual for whom the prosthesis is intended), and reference marks are made front and rear to indicate the established relationship of socket and shank (<b>Fig. 52</b><i>D</i>). The temporary, glued attachment of socket block and shank is now carefully broken apart by a sharp knife, and the inside of the shank is routed out (by routing machine or by hand) until the walls are uniformly only 1/4 in. thick (<b>Fig. 52</b><i>E</i>). Thereafter socket block and shank are glued back together, this time with intent of permanency, the front and back reference lines being made to match up as in the original attachment.</p> <p>To provide additional strength and at the same time to give the prosthesis a pleasant, perhaps even realistic, finish, the whole socket-shank combination is now covered with a suitable plastic laminate of Fiberglas cloth, nylon stockinet, and polyester resin, the latter appropriately tinted to simulate the color of the human skin. The technique is essentially the same as in other plastic-laminating procedures now in widespread use in prosthetics, for example in the making of the PTB socket itself (page 73).</p> <p>The socket-shank unit, less the foot, being supported on a mandrel held in a vise (F<b>Fig. 53</b>), a disc of Kemblo is first bonded to the bottom of the shank to protect it from resin and to close the foot-bolt hole. Then a sheet of Fiberglas cloth wide enough to extend from the foot base to within 2 in. of the socket brim is wrapped around the unit and is in turn covered with two layers of nylon stockinet, the first being made to spiral in the interest of increased strength (<b>Fig. 54</b>). A PVA sleeve made in the usual manner is now pulled over the layup, and the fibrous layers are impregnated with polyester resin in the fashion described earlier (page 36). When the resin has cured, the excess (including the ends of the PVA sleeve) is trimmed off at top and bottom (at ankle and at socket brim), and the foot is replaced with the same degree of toe-out as before.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Application of disc of Kemblo to end of shank prior to layup and lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Layup for lamination of socket-shank combination. <i>A, </i>First of two layers of nylon stockinet twisted over layer of Fiberglas cloth; <i>B, </i>second layer of nylon stockinet applied and tied off at both ends. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As a final finishing touch, the superior plane of the foot (which will now be somewhat larger than the end of the shank) is scored around with a pencil (<b>Fig. 55</b>), and the foot is sanded down in the vicinity of the ankle to give a smooth transition to the shank. The result is a finished prosthesis ready for trial on the amputee to determine, among other things, the necessity, if any, for further support, or added stability, or improved suspension in the form of conventional sidebars and thigh corset. Should the supracondylar cuff already prepared prove adequate, the amputee should be able to perform with an optimum of comfort, function, and appearance both in standing and in normal walking on a level surface. In the event it should <i>not </i>for any reason, the prosthetist proceeds with the construction of additional equipment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Scribing foot at ankle line for sanding to provide smooth transition between foot and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The PTB Prosthesis in Special Cases</h3> <p>The design of the so-called "patellar-tendon-bearing" below-knee socket is such that, ordinarily, the socket itself provides adequate stability in both the anteroposterior and the mediolateral directions and is itself adequately suspended from the limb of the wearer by no more than the supracondylar cuff already described. With proper relief in the rear for the hamstring tendons, and with high enough side and front walls, there develops no insurmountable problem in knee flexion-extension, either in walking or in sitting, and the amputee is thus free of all impedimenta otherwise characteristic of the articulated below-knee prosthesis. In a comparatively small percentage of cases, however, special anatomical and/or physiological circumstances invalidate the simple cuff suspension and the equally simple means of support and stabilization typical of the true PTB prosthesis. In such cases there is no alternative but to resort to the thigh corset and metal sidebars, and sometimes even to the ischial seat and the waist belt, despite the known advantages of the PTB socket. Since improvement of weight-bearing characteristics and inherent stability as offered by the patellar-tendon-bearing socket in no way alters the problem of the moving center of rotation of the normal knee, and since single-axis mechanical knee joints are for various reasons still found to be the most satisfactory under all conditions of use, introduction of the thigh corset and sidebars to improve stability, or to assume some of the weight, or both, presents the same problems as have prevailed heretofore. To date the most useful approach to this problem, when corset and sidebars are unavoidable, has been the development of an improved and simplified method of arriving at the best compromise location of single-axis joints with respect to the moving axis of the normal knee.</p> <p><b>Use of Side Joints and Thigh Corset</b></p> <p><i>Theoretical Considerations</i></p> <p>Single-axis side joints must be aligned on the shank and corset of the below-knee prosthesis so that they effectively stabilize the prosthesis on the stump and allow the amputee to sit comfortably. This is a complicated problem, first because the anatomic joint is not a single-axis joint and, second, because the exact path of a series of "instant centers," degree by degree, during knee motion is impractical to determine in each specific case. Even an average anatomic center may be estimated only roughly in the posterior portion of the femoral condyles. Thus at any one position of the single-axis mechanical joints, the center of rotation of the joints and the center of rotation of the knee will inevitably be incongruent during part or all of knee flexion and will give rise to some relative movement between the stump and the components of the prosthesis as the knee and side joints move from full extension to flexion at 90 deg. The task is to place the joints in a compromise position that will offer the best function and eliminate discomfort resulting from this relative motion. This may be done either by reducing the motion or by having the motion relieve pressures which would otherwise cause discomfort.</p> <p>The effect of a particular position of the side joints with respect to the socket and corset can best be understood by investigating the effect of making a change from a position assumed to be the optimum one. Since movements result from a combination of several factors, total motion is a complex problem. In a hypothetical situation, it would be possible to have knee flexion occur either with the stump held tightly in the socket<a style="text-decoration:none;">*</a> and all motion occurring between thigh and corset or with the thigh fixed in the corset and motion occurring between stump and socket. Of these two extreme hypothetical situations, and the many possible variations in between, the one which will be considered is that in which the stump is fixed in the socket and in which relative motion occurs between the thigh and upper side arms of the joints. This condition most nearly approximates the real situation and forms the basis for the joint-location procedure described below.</p> <p><b>Fig. 56</b><i>A</i> shows a hypothetical situation in which the socket is held fixed and the stump is not allowed to move relative to the socket. In the fully extended position, the upper sidebar is parallel to the shaft of the femur, and the mechanical joint center is placed directly above the average position of the anatomic center. The anatomic center, although it actually varies in position from high in the thigh during hyperextension to near the center of the femoral condyles at 90 deg. of flexion, is assumed to maintain a single axis of rotation for comparison with the mechanical center during this analysis. Alternatively, one may consider the effect of a tiny range of motion and study the slight motion of the thigh corset on the thigh caused by a mechanical joint center higher than the instant center of rotation during this tiny knee motion. As the thigh flexes, the mechanical sidebar tends to move relatively anteriorly on the thigh (for 90 deg. of flexion, distance <i>A</i>) and to be drawn distally along the thigh (distance <i>B</i>). As a result, pressure is created between the thigh corset and the posterior aspect of the thigh because the stump is fixed in the socket. The stump might be forced against the anterior part of the brim (the patellar-tendon area of the stump), though by assumption the stump cannot move in the socket. Thus the conical thigh corset moves distally away from the conical thigh, thereby releasing pressure by allowing a greater perimeter of corset for a given level and perimeter of thigh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 56. Relative motion to be expected between thigh and thigh corset (stump fixed in socket) during 90 deg. of knee flexion when single-axis mechanical joints are placed in any of six positions relative to a hypothetical average anatomic joint center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 56</b><i>B </i>shows the effects of placing the mechanical joint below the average anatomic center (or instant center for a tiny motion). With flexion, the sidebar tends to move posteriorly on the thigh (for 90 deg., distance <i>C</i>) and to move proximally on the thigh (distance <i>D</i>). As a result, pressure is created anteriorly between corset and thigh, or else by reaction forces the socket is pressed upward against the stump. In this case, the conical corset is forced proximally, engaging the thigh more tightly and thus further increasing pressure on the thigh. Because such motion is sharply limited, the reaction on the sidebars in effect attempts to push the socket forward and thus increases pressure on the posterior popliteal area of the stump. Clearly this situation is unsatisfactory.</p> <p><b>Fig. 56</b><i>C</i> shows the effect of placing the mechanical joint in front of the average anatomic center. With flexion, the sidebar tends to be forced posteriorly (distance <i>E</i>) and distally (distance <i>F</i>) with respect to the thigh. As a result, pressure tends to be created anteriorly between corset and thigh, but the corset is withdrawn distally down the thigh so that its fit is loosened and hence the anterior pressure on the anterior portion is partially or wholly relieved.</p> <p><b>Fig. 56</b><i>D </i>shows the effect of placing the mechanical joint behind the average anatomic center. With flexion, the sidebar tends to be forced anteriorly (distance G) and proximally (distance <i>H</i>) with respect to the thigh. As a result, pressure is created posteriorly between corset and thigh, and the conical corset is forced proximally until it can go no farther, whereupon reaction forces the socket forward to cause pressure in the popliteal area.</p> <p><b>Fig. 56</b><i>E</i> shows an interesting special case in which the mechanical joint is located on a 45-deg. anterior diagonal through the anatomic center. In this case, the sidebar is drawn distally downward on the thigh (distance <i>I</i>), but there is no tendency for the sidebar to move either anteriorly or posteriorly with respect to the thigh. Thus there is no anterior or posterior pressure between corset and thigh. The distal motion would indicate that the corset might pull the stump anteriorly and cause pressure on the patellar tendon. In practice, the conical corset merely moves distally so as to relieve pressure on the thigh.</p> <p>A similar analysis of the situation shown in <b>Fig. 56</b><i>F</i> would indicate that in this situation (posterior diagonal) posterior pressure between corset and thigh would be created by the substantial movement / (anterior movement of the sidebar). There would be no tendency for the stump to be pushed anteriorly or posteriorly against the socket brim or for the corset to move on the thigh.</p> <p><i>Optimum Mechanical Relationship Between Joint Axis and Average Knee Axis</i></p> <p>Relative movement in the mechanical joint position as compared with that in the anatomic joint position must first be understood. The prosthetist can then establish the best position for the joint axis by deciding what motions to suppress and what motions to allow. However, when the conical corset is attached to the upper side arms of the joints, proximal motion of the side arms will be suppressed so that reaction forces on the arms will cause commensurate forward movement of the socket against the stump and lead to pressure in the popliteal area. This factor must be borne in mind when the motions of the upper side arms of the mechanical joints are considered in establishing the best position. The hypothesis above of fixation of the stump in the socket may now be modified.</p> <p>There are two situations in which the mo-Lions between the prosthesis and the stump are of particular significance: when the amputee sits (a major fraction of the waking hours of most amputees) and when the prosthesis is swinging through during walking.</p> <p><i>Sitting. </i></p> <p>When the amputee sits, some motion between prosthesis and amputee will occur because of the inevitable incongruity. This being so, it is better to permit joint movement to draw the stump slightly out of the socket, and perhaps to move it forward so that roll formation and pinching between the corset and the back of the socket are reduced; yet forward motion should not press the rigid bony areas against the socket wall. In order to lift the stump, the mechanical joints must pull the corset up against the back of the thigh as the amputee sits. This will occur when the upper joint arms move anteriorly with respect to the thigh (as in <b>Fig. 56</b><i>A</i>, <i>D</i>, and <i>F</i>). To move the slump forward or avoid forcing the socket forward as the amputee sits, the upper joint arms should move distally with respect to the thigh (as in <b>Fig. 56</b><i>A</i>, <i>C</i>, and <i>E</i>). Thus, theoretically, a satisfactory position for the mechanical joints will be directly above the average anatomic joint axis, as in <b>Fig. 56</b><i>A</i>, if it is assumed that the amount of forward motion and upward motion should be approximately the same.</p> <p><i>Swing Phase. </i>For swing-phase control, and freedom from chafing, there should be little or no motion between the stump and the socket. Thus, the mechanical joint axis should be as close as practical to the instantaneous anatomic joint axis during the 60 or 65 deg. of knee motion in the swing phase. Because the instant center seems to move substantially during full extension, and especially during hyperextension, the alignment in slight initial flexion and the training of the amputee to maintain slight flexion at heel contact are considered to be important steps in reducing incongruities between axes and thus in reducing chafing.</p> <p>If the prosthesis is to function satisfactorily both during sitting and during the swing phase, the mechanical axis should be above the average anatomic axis but not so far above as to introduce too much relative motion between stump and socket during walking.</p> <p>All the foregoing analyses are based on consideration of the knee as if it could be averaged over 65 deg. of swing or 90 deg. between sitting and standing to behave as a single-axis joint. But, as is shown in the preceding article by Murphy and Wilson (page 4), the knee joint is actually made up of two complex bony surfaces-the femoral condyles and the tibial condyles. The femoral condyles are two convex surfaces separated by an anteroposterior groove, while the tibial condyles are two concave surfaces which fit their femoral counterparts. Further, these bony surfaces are separated by cartilages and fluids and are connected in complex ways by ligaments, so that analysis by x-rays alone may be inadequate.</p> <p>The femoral condyles roll and slide on the tibial condyles as the knee joint moves. The amount of sliding and rolling determines the axis of rotation of the knee joint at any instant. A shift in the axis of rotation may sometimes help and sometimes oppose required function. If the path of the knee axis were exactly known, the best position for the single-axis knee joint could be positively stated, and joints fully satisfying the functional requirements could be designed. As noted above, such refinements for each individual case seem impractical. However, experience has shown that the mechanical joints can be located accurately enough when use is made of the procedures proposed below, based on consideration of the knee as a single-axis joint at an average location.</p> <p>A typical relationship between socket, joints, and thigh corset in the finished prosthesis is shown in <b>Fig. 57</b>. The back brim of the socket will be trimmed to the patellar-tendon level. With the joints flexed 90 deg., the posterodistal edge of the thigh corset will be 1 in. behind the posterior brim of the socket and at the same level as or slightly above the posterior brim of the socket. The joints are approximately on a mediolateral axis parallel to the back wall of the socket, midway between the patellar-tendon protuberance and the posterior wall, and the axis is approximately 2-1/4 in. above the level of the mid-patellar tendon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 57. Typical relationship between socket, joints, and thigh corset in a below-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Side-Joint Locating Chart</i></p> <p><b>Fig. 58</b> is a chart based on the theoretical analysis given above. The chart can be used for correct positioning of the side joints on a below-knee prosthesis. It indicates the motion to be expected between the upper sidebar (the corset will be attached later) and the femur (<b>Fig. 59</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 58. Chart for determining location of joint axis of sidebars in below-knee prostheses. The motion referred to is that of the upper straps of the sidebars with respect to the thigh as the amputee sits from the standing position (Figs. 59 and 60). Outline of distal end of femur is considered to be mean actual size. The open circle, represents the average anatomic knee center; the closed circle is the optimum position for the mechanical joints. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 59. Compromise location of upper sidebar straps in optimum position for comfortable walking as well as for comfortable sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Procedure:</i></p> <ol> <li>After the socket is aligned on the adjustable leg and foot, the lateral lower sidebar is attached to the socket temporarily in the position indicated in Figure 57 so that the center of the joint is 2-1/4 in. above the midpatellar-tendon level and midway between the patellar-tendon protuberance and the posterior wall of the socket. Only one attachment point is used, namely, at the bottom of the sidebar, the bar being secured above by wrapping masking tape around the socket. The single attachment point at the lower end of the sidebar allows the joints to be moved back and forth during trials and simplifies a change in position up or down. The upper bar is not shaped or attached to the corset at this time. </li><li>The amputee stands and extends the mechanical joint. The position of the front and top edges of the sidebar on the thigh is marked with a skin pencil. </li><li>The amputee sits on a hard chair with his knee flexed 90 deg., and a check is made to see that the posterior brim of the socket and its lining are properly trimmed and that the stump is well seated in the socket. </li><li>While the amputee is sitting in this position, the upper sidebar is moved until the front edge is parallel to the line on the thigh marked in Step 2. A second mark is made on the thigh along the front and top edges of the sidebar. </li><li>The relative motion as evidenced by the difference in position of the marks in Step 4 as compared with Step 2 is measured. </li><li>On the chart (<b>Fig. 58</b>) is entered, in accordance with the scales shown, the data obtained in Step 5. This information will indicate in true scale the approximate location of the mechanical joint center with respect to the femur, as shown in typical true size by the dotted outline. </li><li>The direction in which to move the joint to improve its position is now estimated. The optimum compromise position is located a short distance above and slightly behind the average anatomic center. On the basis of experience with adult amputees, the upper sidebars of the mechanical joint should move distally on the thigh approximately 1/4 in. with 90 deg. of knee flexion. A motion between 1/4 and 1/2 in. is allowable. Motion greater than 1/2 in. results in the stump being forced forward excessively or the corset moving distally excessively after the sidebars are attached to the corset. The upper sidebars should move toward the front of the corset approximately 1/2 in. with 90 deg. of knee flexion. This motion is equivalent to a stump withdrawal with knee flexion after the sidebars are attached to the corset.</li></ol> <p>If the movements are not within the suggested limits, the joint is moved as indicated by the chart to bring them within these limits, and a recheck is made by the same procedures.</p> <p>When the joint has been properly located, both sidebars are riveted to the socket so that a line connecting the centers of the medial and lateral joints would coincide with the axes of the joints themselves and would be parallel to the floor and to the posterior wall of the socket. The upper sidebars are shaped to fit the thigh with the joints coaxial. Particular attention should be paid to the shaping of the upper bars over the femoral condyles because a close fit here helps to suspend the prosthesis. At this point the corset is cut to shape and is temporarily attached to the upper sidebars of the joints with binding screws.</p> <p><i>Example (<b>Fig. 60</b>):</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 60. Example of use of chart shown in Figure 58, chart reduced from actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Step 5 indicates a relative motion of 1 in. posteriorly and 1 in. distally along the thigh. </li><li>Enter data on chart as shown to locate point <i>A. </i>Point <i>A </i>represents the probable position of the mechanical joint relative to the femur. </li><li>The femur outline is actual size in <b>Fig. 58</b>. Therefore the movement required to relocate the joint in the assumed optimum position <i>B </i>may be scaled directly from the drawing in Figure 58 (not in the reduced example, <b>Fig. 60</b>). In this example, the joint axis shown is moved posteriorly a distance of 1-1/8<i> </i>in. and proximally a distance of 3/8 in.</li></ol> <p><i>Fabrication of Thigh Corset and Joint Cover</i></p> <p>Just as an encasement for any other part of the body must be made to conform to the shape of the part and must have enough elasticity and pliability to meet the requirements of necessary body activity, so the thigh corset of the below-knee prosthesis must be custom-cut to the particular size and shape of the thigh for which it is intended and it must be strong enough and yet flexible enough to meet the changing demands placed upon it. Because of its special combination of properties, leather has for many years been the material of choice in the construction of thigh corsets, almost to the exclusion of all other possible materials. Though from time to time in the history of prosthetics there have been introduced a good many variations intended to provide this or that beneficial feature, the basic construction of the modern-day thigh corset remains unchanged. It amounts to the custom fabrication of a comparatively long leather cuff, laced in the front, and furnished with the usual tongue to protect the thigh from local compression and constriction by the lacing. A common error is to make the corset too short, the amount of purchase on the thigh then being inadequate to provide the degree of stability required.</p> <p>In the method of corset fabrication currently recommended for use when corset and sidebars are needed with the PTB prosthesis, the first step is to prepare, from appropriate measurements of the patient, a suitable paper pattern of the surface of the thigh in the area between the lesser trochanter and the condyles of the femur. While the optimum length of the corset varies somewhat with the height of the individual, in general it may be said that the pattern should extend upward some 8 in. from about 2 in. above the midpatellar level on the lower end. Accordingly, the circumference of the thigh is taken at these levels, and the corresponding measurements are carried forward to the pattern step by step.</p> <p>A square of paper of suitable weight and texture (ordinary kraft wrapping paper, for example) and measuring 2 ft. on a side is first folded in half (<b>Fig. 61</b><i>A</i>). Along the fold are marked with pencil the two points corresponding respectively to the top and bottom margins of the corset (distance between points corresponds to intended length of corset). From one mark there is extended, parallel to the edge of the paper, a line of length equal to half the selected circumference of the proximal portion of the thigh. From the other there is extended a similar line of length equal to half the selected circumference of the thigh in the distal area. With the ends of these two lines as reference, a third line is now drawn to join them, all as shown in <b>Fig. 61</b><i>A</i>, and a line (broken line in <b>Fig. 61</b><i>A</i>) is then drawn to connect the points of bisection of the proximal and distal circumference measurements, the latter line representing the ultimate location of the upper straps of the jointed sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 61. Preparation of corset pattern. <i>A, </i>Paper folded in half, top and bottom margins of corset marked, lines parallel to edge projected to the extent of half the circumference of thigh at upper margin and half the circumference of thigh at lower margin respectively, ends of lines connected by straightedge, top and bottom circumferences joined by straightedge at points of bisection (broken line); <i>B, </i>paper opened at centerfold, reference lines transcribed to opposite side, proximal margin modified to match sine curve with maximum deviation of 1/2<i> </i>in. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The paper pattern is now opened at the fold to reveal the isosceles trapezoid shown in <b>Fig. 61</b><i>B</i>, and the proximal margin is cut roughly in the shape of a sine curve of 1/2 in. maximum deviation. Similarly, the distal margin is cut to the dimensions shown in <b>Fig. 62</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 62. Distal margin of corset pattern outlined to match requirements of popliteal space, location of upper straps of single-axis sidebars marked for future reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the pattern has been completed, it is laid upon a selected piece of 7-oz. cowhide (or English bridle) in such a fashion that, when the leather has been cut out, it will fit upon the thigh (left or right as required) with the rough side in, with opening toward the front, and with the high side of the proximal margin lateral. By means of a straightedge, the locations of the upper straps of the sidebars are transferred to the leather for future reference in the construction of the corset, and the leather is cut out along the lines of the pattern.</p> <p>The piece of cowhide, shaped as already described, is now applied to the thigh of the amputee smooth side out and held in place by pressure-sensitive tape or some other suitable means. The upper straps of the two sidebars are bent and shaped in such a way as to follow as closely as possible the external contours of the thigh (to assist in stabilization during the stance phase and in limb suspension during the swing phase), and the proximal ends are trimmed off as necessary so that the straps will extend to about 3/4 in. below the top of the corset (thus providing maximum leverage while leaving room for finishing the top of the corset). Then, for purposes of later attachment of the upper straps of the sidebars to the corset, each upper strap is drilled with three holes 1/8 in. in diameter and so spaced along the length of each strap that the first is 1/2 in. from the proximal end, the second is about 2 in. above the center of the ballbearing race on the distal end, and the third is half way between the other two (<b>Fig. 63</b>). The two upper sidebar straps, thus drilled to accommodate screw-type fasteners, are now placed against the corset, one on each side and each along one of the two guide lines outside the centerline, and the positions of the two top holes are marked through to the leather. The straps are removed, 1/8-in. holes are punched through the leather at the points indicated, and the two upper straps are attached, each by means of its top hole only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 63. Preparation of upper sidebar straps for later attachment to leather thigh corset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To set temporarily, subject to later revision if necessary, the bottom (distal) attachment holes of the straps, the amputee stands, the prosthetist positions each strap directly over the corresponding guide lines, and the bottom hole of each strap is marked through to the leather with pencil (<b>Fig. 64</b><i>A</i>). The amputee then sits with knee flexed 90 deg., the straps are once again positioned over the guide lines (<b>Fig. 64</b><i>B</i>), and the bottom holes are again marked through to the leather (at the new position). The holes for the bottom attachments are now punched through the leather at the proper height but midway between the two points marked on each side (<b>Fig. 64</b><i>C</i>). The process amounts to bisecting the angle between the positions of the bars in standing and their positions during sitting with knee flexed 90 deg. When the lower attachments have been completed, subject to final adjustment, the prosthetist proceeds with the remaining details of corset construction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 64. Tentative attachment of upper sidebar straps to corset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While the amputee stands upon the socket-shank-foot unit, the leather corset is wrapped about the thigh in the intended position, edges in front, and the edges are marked for trimming so that, thereafter, they will be 1-1/4 in. apart (<b>Fig. 65</b>). The corset is removed from the patient, the edges trimmed as marked, and 1/4-in. holes for the lacing are punched along each edge on 1-in. centers along lines 3/8 in. from the edges (<b>Fig. 65</b>). Now the amputee dons the corset and laces it up with a suitable length of nylon parachute cord singed at each end to prevent fraying. While he stands thus, any necessary adjustments are made in the trim lines at top and bottom, the intent being to have the front lower edge fit closely about the patella and just above it while in the back there is enough relief to avoid bunching of the flesh when the patient sits. Should the alignment of the sidebar straps prove to be faulty for any reason, re-alignment should be carried out before proceeding further.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 65. Trimming of front edges of corset, placement of lacing holes in proper position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the fitting is thus far satisfactory, a tongue is provided out of the same kind of leather (cowhide) as was used for the corset itself, and the entire component is lined with cream horsehide of medium weight (4 to 6 oz.). To form the tongue, a piece of cowhide is cut long enough to extend from top to bottom of corset and wide enough to extend 1 in. beyond the rows of eyelets on either side (<b>Fig. 66</b>). One of the long edges is then skived so that, when that edge is later sewed to the body of the corset, there will be a smooth transition from corset to tongue such as not to cause any unnecessary irritation when the unit is worn. To line that portion of the corset between the fixed side of the tongue and the edge on that side (<b>Fig. 67</b>), a piece of medium-weight horsehide is cut 2 1/2 in. wide and long enough to extend from top to bottom of lacer. One of the long edges is skived, and the strip is then bonded (with rubber cement) to the inside surface of the corset, smooth side facing in and skived edge lying 2 1/4 in. in from the edge (which leaves about 1/4 in. of surplus horsehide for later trimming).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 66. Relative size and shape of corset tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 67. Lining of corset tongue area on fixed side of tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tongue of cowhide is now placed smooth side out (toward the front of the corset) over the horsehide lining of the edge of the lacer and with skived edge about 2 1/4 in. in from the edge of the corset. When a smooth transition has thus been attained by whatever local adjustment is necessary, both tongue and liner are sewed along the long side. The smooth side of the lacer and the corresponding smooth side of the tongue thus face each other to avoid any otherwise unnecessary bunching or wrinkling of tongue or corset.</p> <p>The next step is to line with medium-weight horsehide the entire remaining internal surface of corset and tongue. To do so, the corset (together with the tongue) is laid out flat on the bench, rough side down. Thereupon is placed, rough side up, a piece of medium-weight horsehide large enough to cover the entire piece of work. Thus horsehide liner and corset-tongue combination are placed smooth side to smooth side. When the liner has been cut out to correspond roughly to the shape of the corset, the two pieces are sewed together across the top, the seam line starting where the tongue joins the corset and ending about 1 in. short of the opposite side. Thereafter the whole piece is inverted (<b>Fig. 68</b>) so that the horsehide falls over the cowhide corset and tongue to form a smooth liner, smooth side of horsehide in, smooth side of cowhide out. The entire facing surfaces are then bonded together with rubber cement, the edges are sewed around carefully, and any excess is trimmed close to the seams. On the side opposite the base of the tongue, a final seam is sewed down the edge of the corset just inside the row of eyelet holes, and the latter are then cut through the horsehide liner. Into the punched holes are then installed the metal grommets for the lacing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 68. Lining of entire internal surface of corset and tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To protect the clothing from excessive wear, specially designed leather covers are commonly placed over the upper flanges of the sidebars and over the housings of the ball-bearing races. For this purpose use is made of cowhide one third the thickness of the leather used to make the basic part of the corset. By appropriate use of the pattern shown in <b>Fig. 69</b>, one cover is made for each side of the corset, one medial and one lateral. When the sidebars have been riveted in place permanently through all three holes on each side (with 1/8-in. copper rivets), the covers are set in place, the distal portions being doubled back upon themselves and glued together with rubber cement. After the upper portions of the covers have been sewed to the corset on both sides, any excess is trimmed off, and a rivet is installed at about the point shown in <b>Fig. 70</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 69. Pattern for side-joint covers, half actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 70. Installation of side-joint covers for protection of clothing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, as protection against the effects of moisture and bacteria, all of the leather parts are coated with nylon solution according to the usual techniques <a></a>.</p> <p><b>Auxiliary Belt Suspension</b></p> <p>In below-knee prosthetics, the conventional thigh corset (and sidebars) may serve any of three purposes to varying extents and in varying combinations. It may be needed to provide necessary additional stability not to be had from the below-knee socket alone. It may provide needed suspension over and above that furnished by the supracondylar cuff. It may be needed to furnish additional weight-bearing over and above that provided by the PTB socket. Or it may be required for any of these purposes in one combination or another. Occasionally, additional suspension is needed for the PTB prosthesis with or without the thigh corset, and in such cases use is made of the pelvic belt in any of several forms. In all cases the belt fits about the iliac fossa on the normal side and extends downward on the side of the amputation to connect to the prosthesis itself. When, in addition to thigh corset and side joints, the pelvic belt is needed, it is attached to the prosthesis above the mechanical axes of the artificial knee joints. When the belt suspension is required on a limb without thigh corset or sidebars, it is attached to the limb either just below the brim of the socket or else to the supracondylar cuff, whichever is applicable. In general, the pelvic belt serves to reinforce the suspension provided by the supracondylar cuff, not the other way round. The supracondylar cuff is always tried first. Whenever it suffices, no pelvic belt is required.</p> <p>To prepare the pelvic belt and associated suspensory attachments for the below-knee prosthesis, use is made of the patterns shown in <b>Fig. 70</b> and usually of one or the other of those shown in <b>Fig. 72</b>. First there is cut from 2-in. cotton webbing a length 3 in. shorter than the waist measurement. It forms the belt component labeled "waistband" in <b>Fig. 73</b><i>A</i>. Next a 7-in. length of 2-in. elastic webbing is cut to form the tensile element of the vertical support (<b>Fig. 74</b>). Then there are cut from 6-oz. cowhide or pearled elk one piece according to pattern <i>A</i> (<b>Fig. 71</b>), two pieces according to pattern <i>B </i>(<b>Fig. 71</b>), and two pieces according to pattern <i>C </i>(<b>Fig. 71</b>). These form respectively the boomerang-shaped portion of the waistband (section <i>A </i>in <b>Fig. 73</b><i>A</i>), the buckle billets (5/8-in. buckles) to be installed on the belt (<i>B </i>in <b>Fig. 73</b><i>B</i>) and at the proximal end of the elastic suspensor (<i>B </i>in <b>Fig. 74</b>), and the two elements labeled "sections <i>C</i>" in <b>Fig. 73</b><i>C</i>. When, in addition to the thigh corset and sidebars, the pelvic belt is required, suspension is by virtue of the inverted Y-strap shown in <b>Fig. 74</b>, the forked section being fashioned according to pattern <i>D </i>of <b>Fig. 72</b> and the ends of the fork being attached to the prosthesis above the mechanical axes of the artificial knee joints, as already pointed out (page 61). When pelvic suspension is required in the absence of thigh corset and sidebars, section <i>D </i>(<b>Fig. 72</b>) is replaced by section <i>E </i>(<b>Fig. 72</b>), or the elastic vertical suspensor (<b>Fig. 74</b> and <b>Fig. 75</b>) may be attached directly to the anterior aspect of the supracondylar cuff (<b>Fig. 75</b>) without the necessity for sections <i>D </i>or <i>E </i>(<b>Fig. 72</b>). Details of fabrication technique for these several variations in auxiliary suspension are readily to be had from Figures 71 through 75.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 72. Patterns (one half actual size) for suspension straps when <i>(D) </i>thigh corset and sidebars are used and <i>(E) </i>when thigh corset and sidebars are not used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 73. Details of assembly of the pelvic belt. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 74. Details of suspensor strap when pelvic belt is used in addition to thigh corset and sidebars. When thigh corset and sidebars are not required, section <i>D </i>(Fig. 72) is replaced by section <i>E </i>(Fig. 72). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 71. Patterns for construction of the pelvic belt shown in Figure 73, half actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 75. Arrangement of suspensor strap when auxiliary support from pelvic belt is used in conjunction with the supracondylar cuff but without thigh corset and sidebars. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for details of actual construction, section <i>A </i>(<b>Fig. 73</b>) is first bonded to the waistband with rubber cement with an overlap of 1 1/2 in. the bonded side being on the side of the amputation (<b>Fig. 73</b>C). The skived ends of the leather sections <i>B </i>(<b>Fig. 71</b>) are lapped back on each other, each piece is threaded with a 5/8-in. buckle, and the billets so formed are applied, one to section <i>A </i>(<b>Fig. 73</b>) and one to the proximal end of the elastic vertical sus-pensor (<b>Fig. 74</b>). The billets (<i>B</i>) having been fixed in place with rubber cement, the forked section <i>D </i>(or the U-shaped section <i>E) </i>is cemented to the distal end of the elastic webbing, as shown in <b>Fig. 74</b>, and the ends of the fork (or of the inverted U) are attached to the socket just below its brim on the medial and lateral sides. When belt suspension is intended simply to supplement the cuff-suspension system, less corset and sidebars, the vertical section shown in <b>Fig. 74</b> is attached directly to the anterior portion of the supracondylar cuff (<b>Fig. 75</b>). In every case all leather parts are backed with a lining of horsehide, and all segments are sewed around, excess horsehide being trimmed off close to the stitching.</p> <h3>Conclusion</h3> <p>In the construction or manufacture of any piece of apparatus or equipment, for whatever purpose, there may occur to the experienced craftsman any number of variations in technique to effect the same result-some in the interest of economy perhaps, some possibly with the intent of making the task easier, conceivably some with the idea of improving reliability in a stepwise procedure and hence of reducing the possibility for error, some perhaps for other reasons. Just so with the patellar-tendon-bearing, total-contact, below-knee socket. The particular method herein described for construction of the PTB socket, and of associated equipment for use in special cases, is not, therefore, the only possible method. It is simply the one which, in U. S. experience covering more than four years, has proved to be successful and the one most widely used. It is entirely possible that desirable changes in the recommended technique of construction, or with respect to the materials used, will be apparent at once to prosthetists and others. There is, indeed, nothing particularly sacred about the actual stepwise procedure described for fabrication, or about the actual materials suggested, so that it is reasonable to expect changes here and there as the application of the PTB prosthesis comes more and more into widespread use.</p> <p>Whatever changes in materials or fabrication technique may in the future be found to be useful, however, it is essential that the principles utilized in the PTB socket-in its design and in its application with respect to the wearer and to the rest of the prosthesis- be held inviolate if success is to be attained in the majority of cases. Features such as the ledge for weight-bearing on the patellar tendon, the high sidewalls for increased medio-lateral stability in standing and walking, the relief for the hamstring tendons during knee flexion in sitting and in the swing phase of walking, the firm but gentle contact of stump with socket throughout its length as well as at the terminal end, the soft liner and end pad for shock absorption, and the subtle aspects of alignment in slight adduction and slight initial knee flexion are all based on systematic analysis of physical and anatomical fact and are therefore indispensable to the usefulness of the true patellar-tendon-bearing below-knee prosthesis. If, in the otherwise average below-knee case, any one of these details is lacking, difficulty in one form or another will ensue, in which case other and undesirable expedients have to be devised and the inherent advantages of the PTB prosthesis-freedom from the restrictions imposed by additional equipment-are at best seriously discounted and may in fact be lost entirely.</p> <p>Although precision and meticulous workmanship are generally acknowledged to be essential requirements in the successful construction and fitting of any limb prosthesis, they are in the PTB limb especially in need of emphasis. Since the self-stabilizing, total-contact, patellar-tendon-bearing, below-knee socket is intended to be manageable by the wearer with little or no external assistance, all features of measurement, of fit, and of orientation are particularly critical, so that even a minor fault may result in gross deviation from proper performance. The eventual outcome of any PTB fitting is thus not only a matter of formal instructions but also of the exercise of sound judgment on the part of the clinic team in each and every individual case. General experience to date has indicated that the added investment in time and precaution almost always results in a satisfied and successful wearer. Failure to attend details almost always gives rise to failure and disappointment.</p> <h3>Appendix A</h3> <p><b>Formulation of Polyester Laminating Resin</b></p> <p>(for Each 100 Grams)</p> <p>Into 100 gms. of polyester resin mix thoroughly 2 gms. of ATC catalyst. Then mix in color paste according to manufacturer's recommendation. Add 10 drops of Naugatuck Promoter No. 3. Mix thoroughly.</p> <h3>Appendix B</h3> <p><b>Procedure for Changing Heel-Cushion Stiffness in SACH Foot</b></p> <p>In the event the amputee, standing on the socket-shank-foot-shoe combination, demonstrates proper heel elevation (11/16 in.) but too hard or too soft a heel cushion during walking, the heel wedge must be replaced with another, either softer or harder as the case may be. The amputee first steps out of the socket, the shoe is removed from the foot, and the remaining unit is placed on a level bench with a block of wood 11/16 in. deep under the heel (<b>Fig. 1</b><i>A</i>). By means of an ordinary carpenter's square, a vertical reference line is marked on one side of the socket block in the vicinity of the anteroposterior midline so that, after the wedge has been replaced, the prosthetist can be certain that the same orientation of the socket has been re-established.</p> <p>The edge of the sole around the heel is not marked in such a way as to locate the anterior point of the existing heel cushion (<b>Fig. 1</b><i>B</i>), the shank is clamped in a wood vise heel up, and the entire heel cushion is cut out with a sharp knife, the sole being peeled back first, the wedge itself later. Ant irregularities in the cut surfaces are smoothed with a fine file, and the new wedge is inserted, longest lamination next to the sole, and to such an extent that the point falls as nearly as possible into the position previously occupied by the point of the old wedge.</p> <p>Thereafter the whole unit is remobed from the vise and placed upon the bench with the 11/16-in. heel block under the heel as before. Movement of the new wedge forward or backward, as required, re-establishes the original alignment, as indicated again by the square (<b>Fig. 1</b><i>C</i>). When all is in order, the new wedge is cemented into place with Stabond T-161, and the heel is again shaped in the way previously recommended.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Pattern for preparation of the PVA sleeves. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Preliminary alignment of trial leg in four successive steps using the adjustment facilities of the UC below-knee adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy, <i>The construction and fitting of lower-extremity prostheses, </i>Chap. 6 in <i>Orthopaedic appliances atlas, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Appl. Microbiology, 3 (No. 4): 238 (1955).</li> <li>Leonard, Fred, T. B. Blevins, W. S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>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.</li> <li>University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>Manual of below-knee prosthetics, </i>November 1959.</li> <li>University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>The patellar-tendon-bearing below-knee prosthesis, </i>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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Appl. Microbiology, 3 (No. 4): 238 (1955).</td></tr><tr><td class="clsTextSmall"><b> 3.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W. S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Particularly if the socket wall were rigid and lacking a soft lining.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Application of cement within the 1/2-in. border around the estimated trim line is avoided at all times.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960.</td></tr><tr><td class="clsTextSmall"><b>4.</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.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, CPRD, NAS-NRC, 2101 Constitution Ave, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Bryson Fleer </b></td></tr><tr><td class="clsTextSmall">Staff Editor, CPRD, NAS-NRC, 2101 Constitution Ave, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-15.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-16.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-17.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-18.jpg Figure 18 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-19.jpg Figure 19 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-20.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 Construction of the Patellar-Tendon-Bearing Below-Knee Prosthesis Creator An entity primarily responsible for making the resource Bryson Fleer * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/de497b398ace75dc2d796c805105fa2b.pdf 27d26b0e9c1554ef1390a967e60ce082 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_001.pdf Year 1963 Volume 7 Issue 1 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/1963_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Transition</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> With this issue, <i>Artificial Limbs </i>embarks upon a new pattern of activity, changing from monographs covering major aspects to issues with articles on more diversified topics related to artificial limbs. A brief review of the philosophy and contents of prior publications may illuminate the logic of this transition. </p> <p> In nearly every issue, stress has been laid upon the management of the amputee through a clinic team. This noble idea, arising from the follow-up of the cases fitted immediately after the suction-socket schools in 1947, was destined to have a profound impact not only upon prosthetics but also, through this program and many parallel developments, upon the management of other disabilities as well. </p> <p> Early issues, many of them now out of print, were devoted to explanations of the total program of research, development, and evaluation in the fields of upper- and lower-extremity prosthetics. In a series of monographs, with copious references, <i>Artificial Limbs </i>has considered nearly every important level of amputation and has discussed the medical and psychological management of amputees, whether typical cases or those with special problems. Other related journals and reference books have become available to the clinician and to the research scholar. </p> <p> With the establishment of this solid base of reference literature, both in previous issues of this journal and elsewhere, it now seems appropriate to deviate from the classic monograph style so as to permit relatively more rapid publication and greater freedom in pursuing timely yet widely varied topics. In the past, one of the major causes for frustrating delay in the publication of this journal has been the necessity to wait upon the last manuscript needed to round out a comprehensive monograph. Those concerned with the policy of the journal, of course, have long recognized that more rapid publication of a reasonably useful document could be obtained with far less effort and suspense. A series of manuscripts, each individually worthy yet not necessarily directly related to the others, could simply be accumulated until the bundle "weighed enough to print." </p> <p> The articles in this transitional issue, however, are related to the background of past issues and to other publications of the Committee on Prosthetics Research and Development. In the traditional role of the editorial or lead article, this is an attempt to correlate the articles in this issue, to comment on them, and to stimulate each reader to apply them to his problems. </p> <p> Dr. Glattly's preliminary report on a survey of amputees, conducted with the cooperation of the prosthetics profession of this country, discloses a number of fascinating facts yet leads to interesting speculations. Obviously, the information in the article is related to the important considerations of methods of treatment for each level of amputation covered in past monographs and in the "case studies" issue of Spring 1957. Improved prostheses are available for every level of amputation; but perhaps more important are the principles of management valid for all levels which have evolved since World War II. The great preponderance of geriatric amputees in civilian practice points up the value of the report arising from a conference sponsored by CPRD in 1961-<i>The Geriatric Amputee. </i>At the other extreme, the number of child or juvenile amputees emphasizes the importance of the work of CPRD's Subcommittee on Child Prosthetics Problems and of the slowly growing number of special children's clinics engaged in a cooperative program. Fortunately, high-level and bilateral upper-extremity amputees are relatively limited in number, but they especially emphasize the need for auxiliary power, as discussed in the record of a conference held at Lake Arrowhead, California, in 1960 under the auspices of CPRD-<i>The Application of External Power in Prosthetics and Orthotics.</i> </p> <p> Indeed, the entire problem of amputation emphasizes the role of the Committee on Prosthetics Education and Information in widely disseminating information to the medical and paramedical professions through their professional schools, and local and national meetings, and by exhibits, publications, films, and slides. In fulfilling its important role, CPEI will join CPRD in sponsoring <i>Artificial Limbs, </i>beginning with the next issue. Dr. William J. Erdman, II, a member of CPEI, will join the Editorial Board. </p> <p> Mr. Colin A. McLaurin's article on independent-control harnessing for upper-extremity prostheses is clearly related to previous issues on the upper-extremity problem as a whole, harnessing for artificial arms, and discussions of problem cases. Elbow flexion independent of operation of the terminal device has long been sought, as shown by the patent literature in this country and by the German literature of World War I. Immediately after World War II, many of the amputees working with Northrop Aircraft in the relatively warm climate and casual atmosphere of Los Angeles preferred to sacrifice independent control in favor of simplicity of harnessing. However, the amputees fitted in the relatively cooler German climate by Professor Hepp after his return from his 1951 trip to the United States laboratories were more willing to accept his expert judgment that some form of "triple control" was important for function. Thus they were more willing to tolerate the more restrictive type of harness. As a result of experience with problem cases seen at the Rehabilitation Institute of Chicago and at the Michigan Area Child Amputee Center at Grand Rapids, Mr. McLaurin and Mr. Sammons have decided that independent control is important for selected amputees. Their suggestions, presented in one of the major articles of this issue, deserve careful consideration. </p> <p> The article on porous laminates in this issue, by Mr. Hill and Dr. Leonard of the Army Prosthetics Research Laboratory, is closely related to the discussion of perspiration and its consequences in a past issue on dermatological problems of amputation stumps. Readers of that classic will no doubt remember the cartoons of gremlins representing perspiration and bacteria attacking the stump within the typical air-tight socket. Porous sockets in the past have been only imperfectly approximated with porous, wicklike stump socks worn within wooden or metal shells, sometimes with numerous drilled holes, or in sockets molded of leather, which is slightly porous but undesirable from so many other hygienic aspects. The typical above-knee suction sockets of lacquered solid wood or of molded plastic laminate, both completely impermeable, have been worn without a stump sock. An early goal of the Sarah Mellon Scaife Foundation Fellowship on Orthopedic Appliances at Mellon Institute, in 1947 and following, was the development of a porous-plastic material. Though techniques of the time for attaining porosity were not satisfactory, the project made an important indirect step-the introduction to the orthotics and prosthetics field of epoxy laminate which later proved to be a key feature in the early development of porous laminates. After many years of effort, techniques only recently have been developed for the production of porous laminates of polyester resins as well as epoxy. </p> <p> The adjustable coupling for alignment of lower-extremity prostheses, developed by Messrs. Staros and Gardner of the Veterans Administration Prosthetics Center, is obviously related to the early issue of May 1954 in which tools to aid in achieving alignment based upon biomechanical principles were discussed by Professor Radcliffe. The adjustable coupling is particularly useful in aligning prostheses containing special knee joints intended for better control of the limb, though it is also applicable in alignment of the patellar-tendon-bearing below-knee prosthesis. The present coupling, useful though it is, seems only a step toward a light, expendable coupling which may be left in the prosthesis, thus obviating the need for transfer of alignment. </p> <p> Though amputees represent a relatively small fraction of the disabled of the country, the serious physical and psychological aspects of their problems demand special attention. Neglect of these severely disabled persons has sometimes, as at the end of World War II, been the cause of public criticism and emotional or even unjust reactions. It is gratifying that, since then, the systematic and steady work of many devoted individuals and organizations has led to the body of knowledge outlined in the literature now available and to many thousands of persons being trained through intensive short courses in the field, and thus to the present happier state when this highly specialized publication may move from a series of monographs to the greater freedom enjoyed by other journals. </p> <p> Eventually, it is hoped to cover such other problems as fluid mechanisms and children's prosthetics, to provide a review of clinical experience, and to enter the much broader and more complex field of bracing, or orthotics. Also, it will be a pleasure to consider for publication voluntary contributions, without placing continual pressure upon a few devoted contributors. In the meantime comments will be appreciated from our readers throughout the world. </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>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York 1, N Y.; member, Editorial Board, Artificial Limbs.</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 Transition Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/ef9c33fd77b148aa90de4a15eba38d63.pdf 6b120f4df1e3a107e3d3c68bef3540f9 https://staging.drfop.org/files/original/aecc71c9f63ca3de9635b49186ef0fe2.jpg ee0dd270acf130106c5b30ef3f556f83 https://staging.drfop.org/files/original/9c3a89cb7f7730cd4c6b56b7590d7391.jpg f4cec16ef9035d5921c41f90ca28bcd6 https://staging.drfop.org/files/original/b5fd66a485fcb7d48eb30a63f5504417.jpg 5b69122a27795a14bcb9a1cb7a594a03 https://staging.drfop.org/files/original/17d159b930dfb31d71d62c5ee691ba0d.jpg 2a72b8f6ae90f2e9e1524ac5f30529c3 https://staging.drfop.org/files/original/eb00ea2eaae4f210b268d565e63c7e0d.jpg 54fc0b54bbd8edad785ea19df297b698 https://staging.drfop.org/files/original/640dd4eb6ba2ed2b6c98f608c29c713b.jpg b9543354d744c53f2572778988313b32 https://staging.drfop.org/files/original/b2d38ec808677879975c23042b055df4.jpg aa1d9e01ee14c6de2fde688835090f3a https://staging.drfop.org/files/original/3bb75593aa89a50b825f8368f7f92b73.jpg 347a553c959fa12bd1f4978f9eecf597 https://staging.drfop.org/files/original/d9d8ecde312bfe6431d3e6d17c56d6cb.jpg aec588355a2ba508857a04c899f7bb26 https://staging.drfop.org/files/original/9464bc47067b808f2c144ad6714d4c83.jpg ba3630b2632efa359fc9d1889de8e90d https://staging.drfop.org/files/original/3fbbfc9c24383b1570eb5768ffc83c89.jpg 1798118642ea00b00689a5bfed53f585 https://staging.drfop.org/files/original/5270bfa0fa18365e770ebb78a42d2436.jpg 91718b4d11f9d8da1db4a041219b78b1 https://staging.drfop.org/files/original/4fe6516dbb0072232e7634731bd5069e.jpg 954bd4f2762fc59a0fd590821ab51073 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_005.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 5 - 10 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Preliminary Report on the Amputee Census</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>What is the magnitude of the amputee population of the United States? What is the composition of this group of physically handicapped individuals in terms of their sex, ages, and sites of amputation? What proportion of amputations is caused by disease? By trauma? By tumor? The answers to these questions are today more a matter of opinion than of documented fact since statistics relating to amputees that are based on large numbers of cases collected from all states of the Union have never heretofore been available.</p> <p>In the interest of developing certain basic descriptive data concerning the amputee population of the United States, the Amputee Census was initiated in October 1961 as a joint project of the Committee on Prosthetics Education and Information and the American Orthotics and Prosthetics Association. The rationale of utilizing the limb facilities of this country as the data source for the Census is based upon the assumption that a relatively high percentage of new amputees visit these shops for the purpose of being fitted with a prosthetic device. It is believed that this percentage is materially higher today than it was in 1946, at which time a federally sponsored prosthetics research program was initiated. Since that date there has been a very marked improvement in the function and comfort of prostheses, and amputees who formerly were unable to pay for a replacement device now find that there are several Government agencies to assist them. These include the federally supported State Bureaus of Vocational Rehabilitation, the Children's Bureau, the Veterans Administration, and the Workmen's Compensation programs. It has been variously estimated by both surgeons and prosthetists that between 80 and 90 per cent of all new amputees desire a prosthesis. It is hoped that some spot checks can be made in a few large medical centers to document this estimate.</p> <p>The project title, Amputee Census, is strictly speaking a misnomer (although it is a concise expression of the hoped-for result), since no national or regional head count of amputees is involved. In that only new amputee cases are included in this study, it will be possible to establish annual rates of amputation by age and cause. By applying life-expectancy tables to these rates, it is hoped to develop information that will bear upon the size of our amputee population. For example, it is obvious that there is a very wide disparity in the life expectancy of a 55-year-old man in good health who loses a limb by reason of an accident as compared with a man of the same age who suffers an amputation of his leg as the result of vascular disease. This quantitative study will not be undertaken until the census has been completed in the fall of 1964.</p> <p> Two simple data-collection forms were devised that can be executed in a matter of minutes by limbshop personnel ( <b>Fig. 1</b> and <b>Fig. 2</b> ). The participating limbshops were provided with bound books of these serially numbered forms. The books consist of original data slips that are retained by the facilities and carbon copies in the form of self-addressed and stamped postcards to be mailed to the National Academy of Sciences. It will be noted in <b>Fig. 1</b> and <b>Fig. 2</b> that the upper left-hand corners of the data cards are blocked out. It is in this space that the name of the amputee appears on the original forms retained by the facilities. Since the cards are serially numbered, it will be possible at some future time to identify certain types of amputees for further study. In the upper right-hand corner is a symbol consisting of three capital letters that identify each facility. The code to these symbols is known only to the staff of CPEI, and the limbshops have been assured that no information concerning their volume of cases will be disclosed to anyone. ( <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Amputee Census Card No. 1. Data form for single amputations and multiple amputations that result from a single cause at the same time.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Amputee Census Card No. 2. Data form for multiple amputations that occur serially at different times from the same or different causes.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The participating facilities were instructed to fill out a card on each new amputee case for whom an original prosthetic device of some type was provided. Amputees furnished with a replacement for a worn-out or otherwise unusable limb are not recorded in this study. The card shown in ( <b>Fig. 1</b> ) is used for single amputations and for multiple amputations that occur simultaneously from a single cause. The card shown in ( <b>Fig. 2</b> ) is prepared for those cases that have had more than one amputation at separate times from either the same or different causes. Examples of this type of case include: </p> <ol> <li>An individual who is a left, below-knee amputee due to an injury who, years later, becomes a right. above-knee amputee due to vascular disease.</li><li>An individual who is a left, below-knee amputee due to vascular disease and is converted into an above-knee case a year later.</li></ol> <p> Since this card amounted to only three per cent of the total data forms received, an analysis of these cases will not be accomplished until the end of the project. ( <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> , <b>Fig. 10</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The following data items are entered on the census forms:</p> <ul> <li>State of Residence.</li> <li>Age.</li> <li>Sex.</li> <li>Date of Amputation.</li> <li>Date Prosthesis Furnished.</li> <li>Site of Amputation:</li> <li>Upper Extremity:<ul> <li>(SD) Shoulder disarticulation (includes fore-quarter cases and very short above-elbow stumps that require fitting as an SD).</li> <li>(AE) Above elbow.</li> <li>(E) Elbow disarticulation.</li> <li>(BE) Below elbow.</li> <li>(W) Wrist disarticulation.</li> </ul></li> <li>Lower Extremity:<ul> <li>(HD) Hip disarticulation (includes hemipelvec-tomies and above-knee stumps so short that they must be fitted as an HD).</li> <li>(AK) Above knee.</li> <li>(KB) Knee-bearing (includes knee disarticulations, Gritti-Stokes, etc.).</li> <li>(BK) Below knee.</li> <li>(S) Syme's operation or ankle disarticulation. (Partial-hand and partial-foot amputations are not included in the census.)</li> </ul></li> <li>Cause of Amputation:<ul> <li>Trauma-amputations due to physical and thermal injuries.</li> <li>Disease-amputations due to vascular diseases and infections.</li> <li>Tumor-refers to all types of growths for which an amputation is performed.</li> <li>Congenital-only cases that are fitted with a prosthesis are included. The type of prosthesis is used to determine the level of "amputation." It is recognized that the data card is not appropriate for certain types of congenital amputees.</li> </ul></li> </ul> <p>The statistical material that is presented in this preliminary report on the Amputee Census is based upon the data forms received from the prosthetics facilities during the 16-month period from October 1, 1961, through January 31, 1963. During this time, 8,416 new cases were reported. This sampling of the amputee population of the U. S. is sufficiently large so that the distribution by sex, age, side of amputation, levels of amputation, and causes of these new amputations is already well established. This conclusion is based upon the fact that the percentages presented in this report are almost identical to those that were obtained from an analysis of the first 5,000 cases. It is thus possible in this initial census report to present in graphic and tabular form (Figs. 3-13) a simple description of the group of individuals upon whom amputations are presently being performed. The following comments and observations on this statistical material are noteworthy: ( <b>Fig. 11</b> , <b>Fig. 12</b> , <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The disparity in the amputation rates for males and females is due primarily to the facts that: <ol> <li> Amputations in males by reason of injury are nine times as frequent as in females. This is due to the vocational and avocational hazards to which males are more liable ( <b>Fig. 8</b> ). </li><li> Amputations in males by reason of disease are 2.6 times as frequent as in females ( <b>Fig. 8</b> ). </li></ol> </li><li> Amputations due to tumor are roughly comparable between the sexes ( <b>Fig. 8</b> ). </li><li> Congenital deformities of the extremities that are fitted with prostheses occur with almost equal frequency in males and females ( <b>Fig. 8</b> ) </li><li> There is no significant difference in the incidence of left- and right-sided amputations in either the upper or lower extremities ( <b>Fig. 7</b> ). </li><li> There is a surprisingly large number of lower-extremity amputees over 70 years of age who are being fitted with prostheses. In this series, they number 1,020, or 13.2 per cent, of the total number of reported cases. It will be noted that there are four who are over 90 years of age ( <b>Fig. 5</b> ). </li><li> The incidence of malignancy resulting in amputation is fairly constant for individuals between 21-60 years of age. The decade 11-20 years has an indicated rate of twice that of any other ten-year period ( <b>Fig. 12</b> , <b>Fig. 13</b> ). </li><li>In this series there were 162 cases of multiple amputations that occurred from the same cause at the same time. Twenty-two were bilateral upper-extremity cases, 132 were bilateral lower-extremity amputations, and eight involved one upper and one lower extremity.</li><li>During the 16-month report period there were 1,798 cases of below-knee amputations for disease. It is believed that the vast majority of this group falls into the vascular insufficiency category. During this same period there were 2,520 cases due to disease in which the initial amputation was above the knee. There is no reason to doubt but that similar numbers of below-knee and above-knee amputations for vascular disease have been performed in years past during comparable periods of time. Although theoretically the site of amputation in vascular disease is based on the level of vascular sufficiency in the extremity, it may be that too many surgeons are overly concerned with the possibility that amputations at the below-knee level will later require re-amputation above the knee. This possibility is suggested by the fact that in this series there were only 12 instances in which below-knee amputations due to disease were re-amputated at a later date. This is an extremely low incidence, considering the number of below-knee amputations that are performed annually for vascular conditions. A clinical study may be needed that is designed to define better the criteria that bear upon the decision as to the level of amputation in cases of lower-extremity vascular disease. The advantages of preserving the knee joint are obvious, especially in the older age group.</li><li>The reader must recognize that the foregoing statistical material relates only to new amputee cases. The statistics are not valid for the amputee population at large due to the wide variation in the life expectancy of various types of amputees.</li></ol> <h4>Acknowledgments</h4> <p>The Committee on Prosthetics Education and Information wish to express their appreciation to the owners and managers of the participating prosthetics facilities who made this study possible and to the officers, directors, and staff of the American Orthotics and Prosthetics Association for their full cooperation in this project.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetics Education and Information of the Division of Medical Sciences, NAS-NRC. This Committee is jointly supported by the Training Division, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, and the Prosthetic and Sensory Aids Service, Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-11.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-9.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-13.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-14.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Preliminary Report on the Amputee Census Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/2454e632e42420f5fbd9bce3b94c5d26.pdf 3fb2fc0e82bf0e81ff3b766417726825 https://staging.drfop.org/files/original/0fbb48cc7f8be2062a6ef1860380b1db.jpg 10f58f606d2826e85a8834bcf4ce1618 https://staging.drfop.org/files/original/390aa04ec4ca8747dd76e9b7bd7ee923.jpg a420b9510857f5050d953cc7c1dee1ba https://staging.drfop.org/files/original/d6c388c96a97ee0286d3f33bcc663dd9.jpg a71b2664ba6bc532c8b584aafd92456d https://staging.drfop.org/files/original/2cc3677702fc63277a84b78b31553d0f.jpg 6bf6d709cea5e41e4181f8eb491dc322 https://staging.drfop.org/files/original/05e2635a31f6705d8964743ef1ab1c97.jpg cc7ec1ecaa1920e120445f96e23716d0 https://staging.drfop.org/files/original/67b2a42098ed37709567c9cd073a9523.jpg bc01ac1ea334653d58fecdd6f5232991 https://staging.drfop.org/files/original/4c7372b87bbc2e39ea813a2106c92c3f.jpg e272ccb3f9305d4b903f02dcd80224a3 https://staging.drfop.org/files/original/8ff31674a51e9a5d98c2f2188c482daa.jpg 396fb37a1bb92c6bcb2510bb162e656d https://staging.drfop.org/files/original/5abdff87ef605569db6e6ab85ad9b943.jpg c0a32d7611423c170a7177848c2b005b https://staging.drfop.org/files/original/3ec5b5db0ac4ca86109c5997049d32cb.jpg 522c4216b81d5039e308af4c1224f86b https://staging.drfop.org/files/original/b1431bea1bd1d049787c1fa4eb76a711.jpg 0fb3c0624d8f212d8e80f17509fc503a https://staging.drfop.org/files/original/bfbeba79a2bad347ee410568ae691658.jpg 19e99f2f82038d2f139eb8f7e65cbab7 https://staging.drfop.org/files/original/31ae0055d196b577a378c7c29d9c0ca6.jpg f164e0fce76adab851b700520eec3f55 https://staging.drfop.org/files/original/ecf043f5da4a407762cbc21b2649ac2a.jpg db341d796ac5ee6990d6d22dd0553957 https://staging.drfop.org/files/original/157812260024af546d8310f288656a54.jpg 2305349ac4bfcc69d72d871d8b8ba666 https://staging.drfop.org/files/original/ba2062e98c97e0ad3402067cb4590bed.jpg b8fb3650cf8864acf85624db8ba24d54 https://staging.drfop.org/files/original/f85cd06ba61564a5b292b694411a6b82.jpg f9189a9e041000dbde0205ca6ef3c979 https://staging.drfop.org/files/original/300196424114c54c85384a83479a82f4.jpg 8964e11122634a6bea8dc3b70d105b17 https://staging.drfop.org/files/original/c00ea5fedee712bef421e1419159012f.jpg ad2e82f7a0a3b3ed35a29be5c8b4bee0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_001.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 1 - 42 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_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>Limb Prosthetics Today</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic "History," written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (Circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and. until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A, Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H.. Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Haddan and Thomas, a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end-results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made. Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past dozen years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 20 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The over-all program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Research Council.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association, this organization consists of some 415 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification of Prosthetists and Orthotists was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 2,100 physicians, 1,900 therapists, and 1,400 prosthetists have been enrolled in these courses during the period 1953 through 1962.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In addition to these Government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of Government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and power tools also account for many amputations.</p> <p>Diseases that may make amputation necessary fall into one of three main categories-vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the bod}'. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>Recently, "thalidomide babies" have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as twro-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>). The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place. Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained- an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, prostheses have been highly beneficial in knee-disarticulation cases. Development of adequate devices for obtaining control of the shank is currently under way, and such devices should be generally available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation. Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticu-lation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>As soon as the stump has healed sufficiently, exercise of the stump is started in order to keep the muscles healthy and reduce the possibility of muscle contractures. Contractures can be prevented easily, but it is most difficult and sometimes impossible to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 18</b>) and worn continu- ously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheel chairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present (<b>Fig. 20</b>). The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. One form of the "phantom" sensation. Here the two toes seem to reside in the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Time of Fitting</h4> <p>Surgeons increasingly have become aware that best results are obtained with artificial limbs when they are fitted as early as possible after surgery, that is, when pain and soreness have disappeared. This time will vary, depending upon type of amputation and condition of the patient. The earliest time is about six weeks after the operation. Below-knee stumps as a rule require a longer healing period than above-knee and upper-extremity stumps. An elderly patient whose legs have been amputated by reason of vascular insufficiency usually requires a longer healing period than an otherwise-healthy young person whose legs have been amputated as the result of an accident.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Wood construction is still the type most used in the United States for above-knee prostheses, but plastic laminates similar to those so popular in small-boat construction are the materials of choice for virtually all other types of prostheses. Plastic laminates are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature- can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 22</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syrae prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 23</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 25</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Two views of the Canadian-type Syme prosthesis as modified bj the Veterans Administration Prosthetics Center, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 26</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 27</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap. The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 28</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed uti- lizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as 2-1/2 in. have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 29</b>). Because of the length of the knee-disarticulation and supracondylar stump, it is not possible to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Better devices for control of the knee joint are being developed and should be available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>The prosthesis prescribed most commonly today for the above-knee amputee consists of a carved wooden socket, a single-axis knee unit with constant but adjustable friction, a wooden shank, and a SACH foot. The shank and socket are reinforced with an outer layer of plastic laminate to reduce the amount of wood required and thus keep weight to an optimum.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 30</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Morten-sen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The "Hydra-Cadence" above-knee leg (<b>Fig. 31</b>) was until recently the only unit available that provided hydraulic friction to control the shank during the swing phase of walking. In addition to this feature, incorporated in the Hydra-Cadence design is provision for coordinated motion between the ankle action and the knee action. After the knee has flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thus giving more clearance between the foot and the ground as the leg swings through. Other hydraulic units recently made available are the Regnell (a Swedish design) and the DuPaCo. Still others are in advanced stages of development.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 32</b>A) is generally the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 32</b>B), a light belt attached to the socket in such a way that there is very little restriction to motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 32</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 32</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket (<b>Fig. 32</b>A). As the name implies, the socket is in contact with the entire surface of the stump. The total-contact socket has helped to cure most of the problem cases and is now being used routinely in many areas.</p> <p>In fitting the above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 33</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Hip-Disarticulation and Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 34</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses</h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and fore-quarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p><i>Hand Substitutes-Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants. Two basic types of mechanism have been developed for terminal-device operation- voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 35</b> and <b>Fig. 36</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the over-all length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 37</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-eight, ring-type harness is most generally used Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire slump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of preflexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 38</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-dis-articulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 39</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 40</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 41</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticu-lation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 42</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee is to enable him to walk as gracefully as possible. Training of the leg amputee is begun as soon as the clinic team is satisfied with fit and alignment, and preferably while the artificial leg is in an unfinished state, or "in the rough." Thus, should there be need for changes in alignment as training progresses, they can be made readily. Often training can be started on an adjustable leg.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 44</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 45</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for bio-mechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training the Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is there- fore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 47</b>, <b>Fig. 48</b>, and <b>Fig. 49</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O). Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees</h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the De-partment of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each slate that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects -and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 35-36 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty</h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for mili- tary personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U. S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U. S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Recently some of these programs have been extended to render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, Inc., 828 Davis Street, Evanston, Ill.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., <i>Amputations and prostheses</i>, Chapter 12 in <i>Christopher's Textbook of surgery</i>, 5th ed., W. B. Saunders Co., Philadelphia, 1949.</li> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas</i>, vol. 2, Artificial Limbs, J. W. Edwards, Ann Arbor, Michigan, 1960.</li> <li>Batch, Joseph W., August W. Spittler and James G. McFaddin, <i>Advantages of the knee disarticulation over amputations through the thigh</i>, J. Bone and Joint Surg., Boston, 36A. :921-930, October 1954.</li> <li>Brunnstrom, Signe, <i>The lower extremity amputee</i>, in Bierman and Licht's <i>Physical medicine in general practice</i>, Hoeber-Harper, New York, 1952</li> <li>DeLorme, Thomas, Progressive resistive exercise, Appleton and Co., New York, 1951.</li> <li>Eisert, Otto and O. W. Tester, <i>Dynamic exercises for lower extremity amputees</i>, Arch. Phys. Med. and Rehab., 25:11, November 1954.</li> <li>Gillis, Leon, <i>Artificial limbs</i>, Pitman Medical Publishing Co., Ltd., London, 1957.</li> <li>Hitchcock, William E., <i>Notes on the diagnosis and treatment of above-knee fitting problems</i>, Prosthetics Education, Post-Graduate Medical School, New York University, New York, August 1957.</li> <li>Kerr, Donald and Signe Brunnstrom, <i>Training of the lower-extremity amputee</i>, ed. Charles C Thomas, Springfield, Ill., 1956.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al, <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>MacDonald, J., Jr., <i>History of artificial limbs</i>, Am. J. Surg., 19:76-80, 1905.</li> <li>Motis, G. M., <i>Final report on artificial arm and leg research and development</i>, Northrop Aircraft, Inc., Hawthorne, Calif., Final report to the Committee on Artificial Limbs, National Research Council, February 1951.</li> <li>Slocum, D. B., <i></i>An atlas of amputations, C. V. Mosby Co., St. Louis, 1949.</li> <li>University of California (Berkeley and San Fran- cisco), Biomechanics Laboratory, <i>Manual of below-knee prosthetics</i>, 1959.</li> <li>University of California (Los Angeles), Depart- ment of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi, ed., 1958.</li> <li>University of California (Los Angeles), School of Medicine, Prosthetics Education Program, <i>Manual of above-knee prosthetics</i>, Miles H. Anderson and Raymond E. Sollars, eds., January 1, 1957.</li> <li>University of California Press (Berkeley and Los Angeles), <i>The limb-deficient child</i>, Berton B lakes-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>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-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 Limb Prosthetics Today Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * 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/b21f639d8362d0faf7871fcd6b206981.pdf 00160730564941a88e1227cce0fc4cd6 https://staging.drfop.org/files/original/ae5fbb09b20594328d67143767a4b196.jpg 1f7187fd9cd02bd85bbacdc01a7d59b1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_050.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 50 - 52 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_050.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_050.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Limb-Deficient Child, a Review</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p><i>The Limb-Deficient Child</i> is important as the first comprehensive summary of modern techniques in the relatively new field of child prosthetics. For until recent years, the consensus was that prosthetic fitting could wait "until the child is older"-an opinion based on the generally unsatisfactory attempts to care for the child amputee as if he were simply a small adult. The presentation made in <i>The Limb-Deficient Child</i> is based on the experience of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The Project was started in 1955 and is supported by grants from the United States Department of Health, Education, and Welfare. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. <i>The Limb-Deficient Child</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dr. Milo B. Brooks, who is the Medical Director of the Project, various members of the Project staff, and other persons closely associated with the Project are the contributors to <i>The Limb-Deficient Child</i>. The nine chapters of the book cover the role of the medical director, orthopedic considerations, psychosocial problems, preprosthetic evaluations, preprosthetic therapy, child prosthesis design and fitting, training, training the upper-extremity amputee, and lower-extremity training. There are numerous illustrations, the appendix contains various evaluation charts developed at the Child Amputee Prosthetics Project, and there is an index.</p> <p>Chapter I, "The Role of the Medical Director," describes the type of information desired from the referring physician and parents, stressing social information concerning the family organization, the child's general physical condition, and the type of amputation presented. A number of charts depict the normal development of children, with heights and weights for given ages. There is some discussion of the growth and development of limb-deficient children, the problems of limb dominance, and psychological adjustment. The etiology of congenital limb deficiencies is briefly discussed, and statistics are presented on cases studied at the Project. The thalidomide syndrome is briefly mentioned.</p> <p>Chapter II, "Orthopedic Considerations," discusses the relative importance of orthopedic management, the utilization of plas-ter-of-Paris cast techniques for correction, the use of braces, indications for surgical interference, the problem of scars, and the functional range of joints. Although very brief, the discussion on long bones, osteotomies, the problem of terminal overgrowth of long bones, neuromata, and the judgment and timing of surgical conversion of deficient extremities to more conventional types of stumps will be of interest to the orthopedist.</p> <p>This reviewer, however, is not in agreement with the attempt made in the discussion of the development of limbs to assign dermatome relationships to the limb buds.</p> <p>In general, this reviewer agrees with the brief classification of limb deficiencies, although it is incomplete from an anatomical standpoint. Perhaps future modifications may be in order to produce a more universal nomenclature, understandable to all who are interested in the limb-deficient child. The classification is followed by the prosthetics management of the terminal transverse deficiencies from wrist disarticulation (acheiria) up to amelia or shoulder disarticulation.</p> <p>Chapter III, "The Psychosocial Problems," gives a realistic discussion of parental guilt feelings and parental cooperation and emotional stability. There is discussion of the role of the physician in attempting to produce an environment of cooperation by the parents, an environment that is essential for success in treating the child amputee. The problems confronting the prosthetics team during the child's preadolescent and adolescent years are discussed, and the role of the social worker is clearly defined. This is an important chapter in the book.</p> <p>Chapter IV, "Preprosthetic Evaluations," discusses in detail the roles of the occupational therapist and the physical therapist. Reference is made to <i>The First Five Years of Life</i>, by Arnold Gesell and others, and it is highly desirable that therapists be well acquainted with this work. Chapter IV briefly describes the progress of motor kinesthetic development from the infant to the toddler. Techniques for determining the range of motion and the functional needs of the child are analyzed carefully. The chapter discusses the self-care needs of the child and relates them to the type of prosthesis indicated.</p> <p>In Chapter V, "Preprosthetic Therapy," the principles of joint motion, the correction of contractures, techniques of bandaging for shrinkage, the proper use of crutches, and skin care are elucidated and beautifully illustrated by photography.</p> <p>Chapter VI, "Child Prosthesis Design and Fitting," presents the important consideration of the growth of the child as contrasted to the adult. Materials for prostheses, such as plaster and polyester and epoxy resins, are discussed. The choice of terminal devices appropriate to the age and size of the child is clearly stated and well illustrated. Techniques for harnessing are demonstrated by photography. In addition, there are shown nonstandard types of prostheses for fitting upper-extremity phocomelic children. Unusual methods for operating elbow locks, by the phocomelic limb, buried in the humeral section of the prosthesis, are given special attention. The problems of upper-extremity amelia, both unilateral and bilateral, are discussed and shown in photographs, including cable systems and the various methods of hook-ups for the transmission of power. The problem of fitting a multihandicapped child is covered, together with some of the frustrating problems of finding power for terminal-device operation that is adequate in terms of the amount of energy expended. Stages of fitting lower-extremity amelic children from a small stationary bucket up to two prostheses are shown.</p> <p>In Chapter VII, "The Training Period," the training of the limb-deficient child is stressed, and rightly so. The child must know what the prosthesis will do for him. The chapter also emphasizes that one cannot go beyond the child's capabilities or his kinesthetic development for his years. One must not expect too much too soon in the avenues of function. There is a practical and well-illustrated discussion of clothing needs and modifications for ease of application. Illustrations also show how to reduce friction from the system through proper alignment of the cable-control assembly. Techniques to be employed by the unilateral and the bilateral amputee in applying and removing the prosthesis are excellently illustrated. The lower extremities are dealt with briefly with respect to the fitting of the socket, proper application-especially the fitting of a suction socket-and the problems involved with a patellar-tendon-bearing prosthesis and bilateral lower-extremity prostheses.</p> <p>Chapter VIII, "Training the Upper-Extremity Amputee," is well illustrated and goes into considerable detail. The environmental situation is discussed, and the necessary equipment is illustrated. In this reviewer's mind, there is some question about the discussion of training infants, because it is debatable whether one actually trains an infant or simply exposes him to experience in motor fields. There is discussion of the desirability of the presence of parents during training periods. Techniques for activating the components in stages by the young child are clearly presented, and action photographs show the functional capabilities of youngsters of various ages, both unilateral and bilateral types. Activities (aids to daily living) are well documented and very practical. This chapter should be especially interesting to occupational therapists.</p> <p>Chapter IX, "Training the Lower-Extremity Amputee," is much shorter than the preceding chapter. It gives a brief description of the progress of a youngster from infancy to an erect standing posture. Three phases of training are discussed with respect to the lower-extremity amputee. Comfort, fit, and skin tolerance are important during the first phase, with frequent inspection of the skin and prosthesis alignment. Independent ambulation is achieved during the second phase. During the third phase, faster ambulation, stair climbing, and walking up and down ramps and over uneven ground are mastered. This training is clearly illustrated by excellent photographs.</p> <p>Judging by its title, one would expect <i>The Limb-Deficient Child</i> to be a textbook on all facets of the child amputee. It is not such a text. It is a well-written presentation of the experiences of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The problems of the limb-deficient child are much more far-reaching than this volume indicates.</p> <p>But the book is important as the first of its kind and should serve as a reference for physical and occupational therapists and for pros-thetists. It is a clear and very adequately illustrated narrative, with excellent photographs of children in action during their training periods, and photographs of prostheses. Harnessing patterns and cable operations are clearly depicted. There is much material here that should be of great assistance to therapists and prosthetists, particularly those who have broad experience with adult amputees. For with this text they can translate their past experience into the area of child amputees, especially those with congenitally malformed limbs.</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>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Co-Director, Area Child Amputee Program, Michigan Crippled Children Commission; Chairman, Subcommittee on Child Prosthetics Problems, CPRD, NAS-NRC, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_050/1963-Autumn-59.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Limb-Deficient Child, a Review Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/1d1ceef5e0e7ae1a01db4bf1a14f920a.pdf 15dde9b5748aae3e70554e693a2ccc35 https://staging.drfop.org/files/original/7341a1c789bf50c28c6f291e6ce1b8f1.jpg a3415062e2c78119f25ba9e99a91aab7 https://staging.drfop.org/files/original/58d7d562a2d2d25b6b29f764f5d0cfb4.jpg 9323149b8c303a17391f937f755ab79f https://staging.drfop.org/files/original/91b42dd18f1fc3412b1263cdc9856b74.jpg 977982cad4750c82718536539f96a0c1 https://staging.drfop.org/files/original/6a553c553328022c82face981f32bc08.jpg 7be62c5f05196a9b3fcee0f6702c980c https://staging.drfop.org/files/original/be77138d9c5e8b93c403e5150d85485f.jpg b0ac7e722904c5644175eb02eb4e1fda https://staging.drfop.org/files/original/f9cc0bf598af3d0a6e01e53df4364432.jpg 43756341fd355ef896d2d087e0f4aa7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_011.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 11 - 16 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_011.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>Independent Control Harnessing in Upper Extremity Prosthetics</h2> <h5>Colin A. McLaurin, B.A.Sc. <a style="text-decoration:none;">*</a><br />Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Functionally, the well-designed and well-constructed body harness for an upper-extremity prosthesis serves a twofold purpose: first, it helps to hold the prosthesis in place; second, it transmits body power for operation of the prosthesis. </p> <p> For shoulder-disarticulation amputees and for high above-elbow amputees, the provision of an adequate functional harness presents a challenging problem particularly with respect to power transmission and control. The problem is especially difficult in the case of shoulder-disarticulation amputees because of the lack of a control source from humeral motion, which is the major source of power and control in the case of above-elbow amputees. The typical prosthesis for shoulder-disarticulation amputees utilizes shoulder motions and chest expansion. </p> <p>In the present limited state of the art of prosthetics, there are three minimal operations to be controlled in an upper-extremity prosthesis: lifting of the forearm, operation of the terminal device, and management of the elbow lock. </p> <p> Here in the United States, the usual harnessing method for shoulder-disarticulation and above-elbow amputees utilizes the so-called "dual-control" system.<a></a> Lifting of the forearm of the prosthesis and operation of the terminal device are so linked mechanically that a single control motion (shoulder motion in the case of shoulder-disarticulation amputees arm flexion in the case of above-elbow amputee) produces either operation, dependending on weather the wlbow is locked or unlocked.</p> <p> In shoulder amputees, operation of the elbow lock must be managed by various special arrangements; for example, elevation of the shoulder, expansion of the chest, or use of the chin to nudge the elbow-lock control. In above-elbow amputees, operation of the elbow lock in a dual-control system depends upon extension of the humerus and depression of the shoulder. </p> <p> In a triple-control system, operation of the terminal device is separated from lifting of the forearm of the prosthesis. Triple control has been a recognized method of harnessing upper-extremity amputees for many years, and standard harness patterns providing triple control can be found quite readily in prosthetics literature.<a></a> However, triple-control harnessing in actual application is seldom seen in the United States, although it is used extensively in Germany and elsewhere. A possible reason for lack of use in the States is that in early trials it was difficult for the patients to operate the controls independently. </p> <p>Recent experiments at Xorthwestern University in fitting bilateral shoulder-disarticulation amputees have resulted in a harnessing system that provides acceptable function using standard components. Success with some five or six cases renewed interest in "independent-control" harnessing for above-elbow amputees. </p> <p> In describing this experimental harnessing for bilateral shoulder-disarticulation amputees and above-elbow amputees, the term "independent control," rather than "triple control," is used in order to avoid confusion with the standard harness patterns for triple control. </p> <h4> Bilateral Shoulder-Disarticulation Amputees </h4> <p> The limited availability of control sites constitutes a serious restriction on the effectiveness of a harnessing system for bilateral shoulder-disarticulation cases. Shoulder motions are available on both sides, and chest expansion can be utilized. However, there may be only sufficient control motions to obtain acceptable function from one prosthesis. In this event, activities which require the use of two hands, such as eating with a knife and fork, are necessarily precluded. </p> <p> Major consideration is given to operation of the terminal device and lifting the forearm of the prosthesis. In addition, the elbow lock must be operated and the functions of wrist and shoulder positioning should be supplied. </p> <p> Although there is but one prosthesis, two shoulder sockets are used. On the side of the amputee on which the prosthesis is suspended, the socket must, provide weight-bearing at the top. This socket may be fitted well down toward the lower edge of the rib cage in order to provide good stability. The other socket, or shoulder cap, is designed specifically to provide independent control of the terminal device, and it is made as small and as light as possible. (<b>Fig. 1</b> and <b>Fig. 2</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Shoulder disarticulation on the right and humeral neck amputation on the left. Amputation followed electrical burns. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Bilateral amelia with scoliosis and short left leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Shoulder Joint </h5> <p> A passively adjustable shoulder joint is essential for ease in putting on a coat, for positioning the prosthesis so that it does not interfere when sitting in an armchair, and for positioning the prosthesis for eating, writing, and similar tasks. Humeral abduction and flexion may be combined in a single axis joint. The friction plate shown in (<b>Fig. 2</b>) includes two wedge-shaped discs ("Wilson-Riblett wedges") which can be rotated during the preliminary fitting to provide the optimum plane of motion for the shoulder joint (<b>Fig. 3</b>). When this is obtained, thev are locked into position. The amount of friction can be regulated by a self-locking nut and washer which hold the assembly together. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic drawing showing principle of "Wilson-Riblett wedges." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Forearm Lift </h5> <p> Because the weight-bearing socket has been extended downward over the rib cage, the chest strap may be positioned around the center of the rib cage where maximum excursion can be obtained. The harness pattern shown in <b>Fig. 1</b> uses chest expansion in series with scapular abduction of the prosthesis-litted side to lift the forearm The forearm lift cable terminates in a swivel fitting at the lift tab. Since excursion is usually limited, the lift tab should be positioned close to the elbow joint. II this is not possible, a pulley may be titled to double the effect of the excursion. But. of course, such an arrangement doubles the input toree requirement In <b>Fig. 2</b>. the forearm lift cable is fitted internally in a special groove cut in the locking quadrant ol the elbow unit </p> <h5> Terminal Device </h5> <p> With the chest strap fastened about the middle ot his rib cage, the amputee is free to move the scapula of his nonprosthesis-bcaring shoulder. Thus, a small shoulder cap. carefully lilted to the scapula, can provide independent control of the terminal device. An anterior elastic strap is usually required to hold the shoulder cap in position. In <b>Fig. 2</b>, the available excursion was limited, and therefore a step-up pulley was necessarv in order to achieve full opening of the terminal device, </p> <h5> Elbow Lock </h5> <p> Since operation of the elbow lock requires a relatively small amount of excursion and force, there are several ways in which it can be accomplished. The patient shown in <b>Fig. 1</b> originally was fitted with a cable which ran from the elbow lock, around a pulley high on the shoulder, and thence down to a waist belt, so that shoulder elevation was used, alternately, to lock or to unlock the elbow. Later, this was replaced by the nudge control (<b>Fig. 1</b>), which the amputee preferred. </p> <p> For the patient shown in <b>Fig. 2</b>, the prominent acromioclavicular joint was utilized by cutting a hole in the anterior part of the socket and positioning a lever so that forward motion of the clavicle moved the lever forward and downward to develop tension in the elbow-lock cable. </p> <h5> Wrist Unit </h5> <p> A standard passive wrist-rotation unit, which permits pre-positioning by the amputee, was provided in both cases (<b>Fig. 1</b> and <b>Fig. 2</b>). </p> <p> For many tasks, such as toilet care, wrist flexion is important. Flexion can be provided by building it into the prosthetic forearm (<b>Fig. 2</b>), or by using a nudge control and Bowden cable to operate the lock on a standard wrist-flexion unit (<b>Fig. 1</b>). In the latter case the lock for the wrist-flexion unit is operated by relative motion between cable and housing. In this application the cable is stationary and the housing pushes to open the lock. To achieve this, the cable guides must be drilled out to allow the housing to slide freely. The inner cable passes through a hole drilled in the locking lever on the wrist-flexion unit and is anchored to a post screwed to the cover of the wrist unit (<b>Fig. 4</b>). When the wrist unit is unlocked by pressure on the nudge control, tension in the terminal-device cable will cause the wrist to flex. If the terminal-device cable is relaxed, gravity will cause the wrist to extend. Thus a measure of active wrist flexion is obtained. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of wrist-flexion unit for use with nudge control. Refer to Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Capabilities and Limitations </h4> <p> The harnessing arrangement just described provides reasonably acceptable prosthetic function without the use of perineal straps. Independent control of the terminal device apart from operation of the elbow allows maximum opening of the terminal device in all positions of elbow flexion and improves the performance rate, since it is not necessary to lock the elbow before using the terminal device. Also, there is no tendency for the terminal device to open when the elbow is being flexed. </p> <p> The amputee who is a skilled foot user may be able to put on or take off the prosthesis without assistance, particularly if Velcro straps are used (<b>Fig. 2</b>). If the amputee is not a skilled foot user, assistance is required in fastening the chest strap snugly. </p> <p> The prime objective in fitting this type of prosthesis to a severely disabled amputee is to provide at least a minimum of self-sufficiency in public. Problems of selfdressing are complex, and their solution can scarcely be achieved without the use of external power and devices which have not yet been developed. </p> <h4> Above-Elbow Amputees </h4> <p> The same three minimal operations (namely, operation of the terminal device, lifting of the forearm, and management of the elbow lock) must be controlled in the prosthesis for a unilateral above-elbow amputee. To avoid restriction of the sound arm, the axilla loop of the harness should provide stabilization only. Hence the shoulder motions available for prosthetic use are those that remain on the amputated side. These are scapular abduction, humeral flexion, and humeral abduction. It is conceivable that humeral extension and humeral abduction could be harnessed, but an entirely different harnessing configuration would be required. As in the case of the shoulder-disarticulation amputee, shoulder elevation can be used only in conjunction with a perineal strap or a firm waistband. Most above-elbow amputees can separate scapular and humeral motion, and the harnessing described here is specifically designed to utilize this independent control. </p> <p> In this harnessing system, lifting of the forearm of the prosthesis is activated by scapular abduction. The anchor point is a ring held in the center of the back by the axilla loop. The reaction point is attached high on the socket, so as to be independent of humeral flexion. If the reaction point is placed centrally near the top edge of the socket, rotation is minimized and humeral abduction can be used to increase the excursion. The cable is passed through the reaction point and terminates in a swivel at the forearm lift tab, the length and position of which should be carefully adjusted to make full use of the available excursion. (The cable housing at the reaction point serves only as a cable guide.) The suspension strap and elbow-lock strap are attached as shown in <b>Fig. 5</b>, the configuration being essentially the same as that used in the Northwestern University dual-control ring-type harness. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Congenital above-elbow amputee fitted with independent control. Scapular abduction is used for forearm lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Humeral flexion and abduction are harnessed to provide operation of the terminal device. Experiments indicate that the harness pattern shown in <b>Fig. 5</b> is preferable to that in which the control cable is attached solely to the harness ring. A Bowden cable is used, with the housing anchored on the humeral section and on the forearm in a manner similar to that of a standard below-elbow fitting, so that operation of the terminal device is independent of flexion of the elbow. </p> <p> Optimum results are obtained when the shoulder motions are used in combination. Maximum lift of the forearm is achieved when the humerus is abducted at the same time that the scapula is abducted. This means that the elbow is held close in to the body as the forearm is lifted-a motion that is not ideal for certain tasks, such as switchboard operation. Scapular abduction also tends to affect the terminal-device cable. Thus, when the elbow is held in full flexion, there may be some tension induced in the terminal-device cable, making it difficult to hold the hook closed without locking the elbow. Conversely, the hook is very easy to open fully in this position. </p> <p> Three amputees have been fitted with this type of harness and have been wearing it routinely for several months. In addition, one bilateral amputee has been fitted with dual control on one arm and independent control on the other. All the subjects had been users of prostheses. They learned the basic controls with about an hour's training and became proficient at the end of a week. </p> <p> This harnessing provides excellent terminal-device function throughout the full range of elbow flexion, without locking or even stabilizing the elbow. Since the terminal device is independent of the forearm lift, there is no tendency for the hook to open when the forearm is being raised. However, near the point of full flexion, the interaction of the harness straps does require considerable effort to avoid opening the hook. Moreover, the force available for lifting the forearm is adequate only for the lightest loads. </p> <p> After several months' wear, one of the amputees rejected the harness and was refitted with a different type of independent control (<b>Fig. 6</b>). The operation of the terminal device was left unchanged, but the forearm-lift and elbow-lock straps were interchanged so that shoulder depression was used to raise the forearm, and scapular abduction to operate the lock. This seemed to provide greater force for lifting the forearm, provided the humerus is not flexed more than about 20 deg. Operation of the terminal device appeared to be slightly improved. The amputee is still wearing the prosthesis routinely. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Same amputee as shown in Figure 5 fitted so the shoulder depression is used to lift the forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li><p>Pursley, Robert J., <i>Haness patterns for upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 26. </p> </li> <li><p>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Chap. 4 in <i>Orthopaedic appliances atlas</i>, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </p> </li> <li><p>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 4. </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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, 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>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall">Research Therapist, Northwestern University Prosthetics Research Center, 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>Colin A. McLaurin, B.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Project Director, Northwestern University Prosthetics Research Center; Research Associate, Department of Orthopedic Surgery, Northwestern University, Chicago, Ill</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-15.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-16.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-17.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-18.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-19.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-20.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 Independent Control Harnessing in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Colin A. McLaurin, B.A.Sc. * Fred Sammons, B.A. * https://staging.drfop.org/files/original/ffc8eca439bcae403581feacfc98144e.pdf 4193bb67ab6993250dcf123adae8278b DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_001.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 1 - 2 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Measurement and Evaluation</h2> <h5>Herbert R. Lissner, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>"I often say that when you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it in numbers your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge but you have scarcely in your thoughts advanced to the stage of science, whatever the matter may be."</p> <p>-<i>Lord Kelvin</i></p> <p>Most of us devote appreciable time in the course of daily activity to making evaluations and forming value judgments. Every time we make a purchase, watch television, eat a meal-the list is endless-we make evaluations. Factors considered may involve monetary costs, saving of labor and time, ethical principles, aesthetic enjoyment, and many other matters.</p> <p>In order to reach a final decision, it is usually necessary to combine, or even to counterbalance, evaluations made in many subsidiary categories. Those subgroups to which numbers can be applied, such as initial monetary cost and maximum attainable speed, are the easiest to consider, while those to which numbers cannot be easily assigned are more difficult to evaluate.</p> <p>The establishment of standards is a recognized aid in the making of evaluations. Standards may consist simply of a set of lower limits; any product which fails to meet them is automatically eliminated from consideration. Examples of this hurdle or barrier type are some of the standards of the Underwriters' Laboratories for electrical appliances. A variant of this kind of standard may involve an upper as well as a lower limit, such as the "go-no-go" type. Conversely, a standard may involve the expression of a ratio of the specific item to the ultimate attainable, so each evaluation is a rating indicating how closely the limit is approached. A standard of this type is involved in the grading of examinations. (Even then the relationship between the score and the practical application is not always clear; the "A" student is not always successful in later life.) An intermediate form of standard is a rank ordering of individual items, along some defined scale, thus allowing comparison of each item with the average and its fellows.</p> <p>All these types of standards are clearly of value, so the establishment of standards, at least tentatively, should generally precede the process of evaluation. In the production of materials and the fabrication of products of all kinds, industry and Government depend on established standards in making purchases, compliance testing, and the design of more complex products. For many years the American Society for Testing and Materials, the American Standards Association, numerous trade associations, and various Government agencies have sponsored development of standards and specifications.</p> <p>Now what has all this to do with artificial limbs and braces? Evaluation serves one primary purpose in this case-the improvement of the product, a special type of man-machine combination. If the artificial limb could duplicate exactly all the functions of the natural limb in spite of the limited resources of power, sensibility, and control remaining available to the amputee, presumably we would have an ideal prosthesis. Minimal standards can rule out gross malfunctions, frequent and hazardous physical breakdowns, and obvious discomfort. Reasonably accurate lower and upper boundaries of physical dimensions to match specific categories of amputees can be established from anthropometric data illuminated by the best experience of the industry. In another sense, the physical strengths and practical minimal wall thicknesses set lower limits to weights, while maximal tolerable weights and inertias can also be estimated. By specifying the functional capabilities of the human limb we can establish the maximum standards we would like to achieve with our replacement. (The frequent recent suggestions of servo systems or "man amplifiers," though, imply that merely human performance may not be an upper bound.)</p> <p>These standards of several types should be specified in many categories. Any problem, no matter how complex, can be approached by breaking it down into small segments which can be analyzed. It is only as we define the significant categories, establish and progressively refine standards, and make objective evaluations that further appreciable advances in artificial limbs and braces will be made.</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>Herbert R. Lissner, M.S. </b></td></tr><tr><td class="clsTextSmall"> Professor and Chairman of the Department of Engineering and Mechanics, and Coordinator, Biomechanics Research Center, Colleges of Engineering and Medicine, Wayne State University, Detroit, Mich. 48202; Chairman, Subcommittee on Evaluation, Committee on Prosthetics Research and Development.</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 Measurement and Evaluation Creator An entity primarily responsible for making the resource Herbert R. Lissner, M.S. * https://staging.drfop.org/files/original/e9f6b0ca0af8a979b6d3b20f2d9bf767.pdf 1bf7ecb945d70a0277568f72c0dd60e4 https://staging.drfop.org/files/original/e15daffdfb1ccd3c85ae31f758316228.jpg c7dc78f031800bd557e5e56886799610 https://staging.drfop.org/files/original/d7ecccb8dead833240dffb959177354c.jpg c31f94bc12db418af7fb09b67b391776 https://staging.drfop.org/files/original/443471c199b97e3910f5097fdeb8663e.jpg 4d1970fb7af2dcebb6d5aab2f7a0cf6c https://staging.drfop.org/files/original/8dbf7c64f23ae2955b3479bbb5fb302b.jpg 6b10e90231ab54505b1f29f0b21d1b18 https://staging.drfop.org/files/original/3a7c493869b8831afd00e9855e6c13ed.jpg f1fadc470bf7c0e5e704d5a587bda07f https://staging.drfop.org/files/original/eafcf91b4f973afa24add247a75817cf.jpg ea25252f54c00432d4ae8cdacd36ceb0 https://staging.drfop.org/files/original/eaea3592bc911874251c428e1ed0160b.jpg c21941b7ba4a91a5aa35d3e543daa7b1 https://staging.drfop.org/files/original/c585a3d3e836903584dba11878c0eac4.jpg 27ffd0226c847cdedb8ccf353f198219 https://staging.drfop.org/files/original/d7bd659b04aae888f075c506f9f1384c.jpg 53058ebbcd650e261bf37943275d6def https://staging.drfop.org/files/original/c54a555fdecec535e9a9d65b05a7edad.jpg bb55f6b1b0e326f1b85948db260a2740 https://staging.drfop.org/files/original/8cd98250a947dc0e83ffe62feb4ce885.jpg 88a53d4cfc08a94c502625bde4132277 https://staging.drfop.org/files/original/df58327f0134c1887a1fbe9da76db215.jpg a1bcc591f0218b53b85af82918d4d5a3 https://staging.drfop.org/files/original/abfc8d66ef593ba1303fdceca612b1f7.jpg 3ab086cb4672a061b9c84c4f105a6734 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_017.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 17 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_017.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Porous Plastic Laminates for Upper-Extremity Prostheses</h2> <h5>James T. Hill, C.E., B.S. <a style="text-decoration:none;">*</a><br />Fred Leonard, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The problem of perspiration and its removal from the amputee's arm and leg stumps encased in sockets has engaged the attention of the doctor and limb fitter for as long as limbs have been fitted. </p> <p> In the early days of leather prostheses, a few months of wear during the summer were sufficient to cause the leather to rot and degrade because of perspiration. Since it was not possible to wash leather prostheses easily, severe hygienic problems were created. Efforts to coat leather with plastic films to overcome this difficulty were only partially successful for, in many instances, the adhesion of the coating was poor and frequent re-coatings were necessary. With the development of the all-plastic arm, it became possible to wash the socket thoroughly and virtually eliminate the hygienic problem. However, because the plastic did not permit diffusion of water vapor, sweat gathered profusely in the socket and became a source of discomfort and irritation. Efforts to permit diffusion of sweat by drilling gross holes in the plastic socket were not very successful. Although this practice permitted greater removal of sweat than in undrilled prostheses, the strength characteristics were seriously affected when a sufficient number of holes were cut to permit adequate removal. In addition, there still remained between the holes impervious plastic which could block large numbers of sweat pores-approximately 155 per square centimeter on the forearm<a></a>-and permit puddling between the plastic and the stump. </p> <p> It appeared that for optimum socket ventilation a porous-plastic socket should be developed which contained a large number of interconnnected pores. Such a socket should permit rapid diffusion of sweat with minimal blocking of sweat pores. The porous laminate envisioned would consist of a layered fabric resin composite with unbridged voids between the filler strands. Such material should be easily cleaned by soaking in detergent, followed by flushing with water. The following design criteria were outlined for the desired socket material: </p> <ol> <li>The socket material should have a uniform distribution of minute pores which would result in high porosity without blockage of sweat pores. </li><li>It should be easily cleaned.</li><li>Porous socket fabrication should conform as closely as possible with well-known fabrication techniques current in the practice of upper-extremity prosthetics.</li></ol> <p> Procedures for preparing porous upper-extremity prostheses were developed, utilizing the design criteria as a guide. In general, the method comprised the use of a solvent or diluent with an epoxy resin. After initial cure had occurred, the solvent was permitted to evaporate by removal of the outer polyvinyl-alcohol (PVA) bag. </p> <p> A series of experiments determined the combination of diluent, curing rate, and other factors necessary to produce a laminate with the optimum ratio between porosity and strength.<a></a> Evaluation at New York University indicated that the procedure initiallv developed by the Army Prosthetics Research Laboratory produced a satisfactory material insofar as porosity and strength were concerned but that use of the conventional stockinet as filler produced rough surfaces that made cleaning difficult. Subsequent experiments at the Army Prosthetics Research Laboratory showed that this problem could be overcome by using a nylon stockinet of 200-denier Banlon knit (<b>Fig. 1</b>) for the outer and inner layers of the laminate and by the reapplication of a PVA bag at a critical time in the curing process. Further testing and development resulted in a practical technique which is described in detail in a manual prepared by the Army Prosthetics Research Laboratory.<a></a> Sockets fabricated in accordance with this manual have smooth surfaces and high porosities. Patients fitted with porous sockets have reported a definite increase in comfort as a result of improved ventilation.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Porous epoxy laminate made in accordance with the procedure developed at the Army Prosthetics Re search Laboratory. Magnification approximately 21X. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Laboratory tests have shown that porous epoxy laminates are not as strong in compression and tension as nonporous laminates, but that resistance to impact loads appears to increase with the porosity and reach a maximum at approximately 17 per cent of effective porosity.<a style="text-decoration:none;">*</a> In practice, the combination of physical properties possessed by the porous laminate which has been developed is satisfactory for use in arm prostheses. Experiments in the use of porous laminates for lower-extremity prostheses are under way. </p> <p> If actual prosthetist working time is considered, the man-hours required for fabrication of porous laminates are somewhat longer than those required for the conventional plastic laminates. Depending on the technique employed, the porous laminating process may take up to one-and-one-half times as long as the conventional technique. </p> <p> The components of the liquid resin system may elicit allergic reactions in certain sensitive individuals. Therefore, fabrication should take place in a well-ventilated area and protective gloves should be used in preparing the layup. </p> <p> No stump dermatitis or other adverse reactions have been reported from the use of the porous laminates to date. </p> <p> Because the socket is porous, it is necessary that it be cleaned thoroughly and often in order to preclude an accumulation of foreign matter in the pores of the wall. It is recommended that ordinary soap and water be used for this cleaning. </p> <p> Porous laminates may be considered for application to all upper-extremity amputation levels from below-elbow to shoulder-disarticu-lation. The technique is of particular value whenever perspiration presents a significant problem. </p> <h4> Epoxy-Resin Mixture </h4> <p>The following epoxy-resin system has been found to produce a satisfactory porous laminate:</p> <table> <tbody><tr> <td> </td> <td> </td> <td>parts by weight</td> </tr> <tr> <td>Epoxy resin    </td> <td>ERL 2795<a style="text-decoration:none;">*</a>or Epon 815<a style="text-decoration:none;">*</a>    </td> <td>65</td> </tr> <tr> <td>Curing agent</td> <td>Versamid 140<a style="text-decoration:none;">*</a></td> <td>35</td> </tr> <tr> <td>Solvent</td> <td>Trichloroethylene</td> <td>43</td> </tr> </tbody></table> <p> The "pot life" of the liquid resin mixture resulting from this formulation is never less than 30 minutes and usually considerably longer. </p> <p> The individual limb fitter can best determine the actual amount of resin mixture required for a particular lamination. Appendix A (page 29) contains a table which may serve as a guide in determining the correct amounts of materials for various applications. </p> <h4> Fabrication </h4> <p> Briefly described here is the fabrication of a double-wall, below-elbow, porous prosthesis, utilizing a plaster-of-Paris (or wax) buildup; this account is followed by a brief description of the fabrication of a single-wall, below-elbow, porous prosthesis, based on the Mylar<a style="text-decoration:none;">*</a> cone method.<a style="text-decoration:none;">*</a> </p> <h4> Double-Wall, Below-Elbow, Porous Prosthesis </h4> <p> For the fabrication of a double-wall, below-elbow, porous prosthesis, the stump model is prepared in accordance with common practice<a></a>. As shown in (<b>Fig. 2A</b>), the model is then placed in a vise, distal end up, and coated with a lacquer such as Hi-Glo.<a style="text-decoration:none;">*</a> When this coating has dried, a moistened sheet of PVA is stretched over the model and tied at the base (<b>Fig. 2B</b>). The next step in preparing the layup is to cut one length of tubular Banlon stockinet with a 200-denier weave<a style="text-decoration:none;">*</a> and three lengths of tubular orthopedic stockinet so that each is at least 6 inches longer than the stump model (<b>Fig. 2C</b>). The end of each piece of stockinet is sewed in a curve to match the distal end of the model, and the excess stockinet is trimmed at the sewed end. The Banlon stockinet is turned inside out and pulled down over the model (<b>Fig. 2D</b>). Two of the orthopedic stockinets are pulled down over this. Then the remaining piece of stockinet is turned inside out and pulled down over the layup. The stockinet is smoothed, pulled down tightly, and tied at the base. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Preparing the layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A PVA pressure sleeve is now prepared in the usual manner, pulled down snugly over the layup, and tied at the base rod (<b>Fig. 3A</b>). The layup is ready for impregnation, and it is time to mix the resin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Applying the resin mixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To measure the ingredients for the resin mixture, it is well to balance a disposable container, such as a paper cup, on a scale. The resin, curing agent, and solvent are then put in the cup in the proper amounts by weight. By referring to the table contained in Appendix A (page 29), it can be seen that the following quantities should be sufficient for a short below-elbow socket: </p> <table> <tbody><tr> <td>ERL 2795 (resin).................</td><td>45.5 grams</td> </tr> <tr> <td>Versamid 140 (curing agent)......</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene (solvent)......</td> <td>30.0 grams</td> </tr> </tbody></table> <p>To this resin mixture should be added an appropriate pigment; for example, 2.5 grams of Caucasian epoxy pigment or 3.5 grams of Negroid epoxy pigment (Appendix A, page 29). The pigment is stirred into the mixture until it is uniformly blended. </p> <p> The resin mixture is poured into the open end of the PVA sleeve and worked down into the stockinet. Twisting the end of the sleeve (<b>Fig. 3B</b>) develops considerable force and aids in the impregnation. </p> <p> When the stockinet is fully impregnated, the PVA sleeve is pulled down, and the excess resin is "strung" down to the proximal end of the layup (<b>Fig. 3C</b>). Next, the PVA sleeve is cut and removed from the layup. Care should be exercised not to spill the excess resin contained in the bottom of the sleeve. The sleeve and the excess resin are discarded. Spilled resin may be cleaned off with isopropyl alcohol or trichloroethylene. The layup is "strung" with a heavy string until no further excess resin appears (<b>Fig. 3D</b>). </p> <p> The layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), for what is known as the pre-cure. During this stage, the solvent evaporates from the layup, leaving it porous. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven, and the oven is set at 212 deg. F (100 deg. C) for the cure. At this step in the procedure, the solvent has evaporated and the resin has gelled slightly. If any areas of the laminate contain excess resin, the excess is "strung" to the proximal end. When the oven has reached a temperature of 212 deg. F (100 deg. C), the laminate is placed back in the oven for one hour. During this hour, the laminate will be cured sufficiently to permit the buildup for the outer socket. </p> <p> At the end of the hour, the laminate is removed from the oven, and the oven is set at 115 deg. F (47 deg. C). </p> <p> As soon as the laminate is cool enough to handle, a sheet of Saran-Wrap or rubber sheeting is placed over the laminate as a separating medium. This sheet will facilitate the release of the outer socket which is to be laminated over the inner shell. </p> <p> For the forearm buildup, plaster of Paris is considered preferable rather than wax, for the reason that wax may enter the pores of the prosthesis. The buildup is done in the usual manner (<b>Fig. 4A</b>). After the plaster has hardened, the paper cone is removed and the plaster of Paris is shaped to the desired contour. Any plaster on the knurled surface of the wrist unit is removed. The plaster is coated with Hi-Glo or some similar lacquer. A PVA sleeve is prepared, moistened, pulled down over the buildup, and trimmed at the wrist unit (<b>Fig. 4B</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The forearm buildup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, a piece of Banlon stockinet and a piece of orthopedic stockinet are cut, each about 3 to 5 inches longer than the layup. Another piece of orthopedic stockinet is cut, a little more than double the length of the layup. (Additional lengths of stockinet may be used if additional strength is desired.) </p> <p> The Banlon stockinet is turned inside out, pulled 1 to 2 inches over the distal end, and tied at the wrist unit (<b>Fig. 4C</b>). Excess stockinet that is proximal to the wrist unit is trimmed off. </p> <p> The short piece of orthopedic stockinet is pulled over the longer piece so that both pieces meet at one end. The other end of the short piece should extend just past the middle of the longer piece. </p> <p> These pieces of stockinet are extended and slipped, double end first, down over the wrist unit until the double thickness covers the entire layup (<b>Fig. 4D</b>). The double thickness of stockinet is tied at the wrist unit and pulled down and tied at the proximal end. The Banlon stockinet should be on the inside. Two PVA pressure sleeves are now prepared in the usual manner, with the shiny surface of the material on the inside. One sleeve is set aside to be used later. The other is pulled down snugly over the layup and tied to the base rod at the proximal end. </p> <p> Resin and pigment are mixed in the manner described previously. For a short or medium below-elbow forearm, the following quantities should be sufficient: </p> <table> <tbody><tr> <td>ERL 2795............</td> <td>68 grams</td> </tr> <tr> <td>Versamid 140........</td> <td>37 grams</td> </tr> <tr> <td>Trichloroethylene...</td> <td>45 grams</td> </tr> <tr> <td>Pigment..................</td> <td>As required to match previous mix</td> </tr> </tbody></table> <p> The resin is poured into the pressure sleeve (<b>Fig. 5</b>) and worked into the stockinet. When the stockinet is fully impregnated, the pressure sleeve is pulled down as far as possible, and the excess resin is "strung" down from the layup. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Impregnating the forearm layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the layup has been thoroughly "strung" down, the PYA sleeve is stripped off and discarded. The layup is "strung" once more to remove all excess resin. </p> <p> There may be considerable resin in the stockinet around the base rod. This excess resin should be absorbed in the scrap stockinet wrapped around the base, so that it will not be drawn back into the laminate during the cure. </p> <p> For the pre-cure, the layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), allowing the solvent to evaporate. </p> <p> While the pre-cure is taking place, the second PVA pressure sleeve previously prepared should be moistened by wrapping it in a damp towel for 10 to 15 minutes. The next step in the procedure gives the prosthesis a smooth surface, and it is essential that the PYA sleeve be thoroughly moistened. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven. The moistened PVA sleeve is pulled down until the entire layup is in contact with the sleeve. Light contact pressure is most desirable, for this will result in a smooth surface without reducing the porosity. It is important that the sleeve slide easily over the layup; otherwise, the force and pressure may cause pooling of the resin. At this point in the procedure, there should be no pools of resin on the stockinet. If there are, they should be "strung" out. </p> <p> The PVA sleeve is taped around the wrist unit (<b>Fig. 6</b>); any severely undercut areas should also be taped. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Molding the surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The layup is now placed for one hour in an oven pre-set at 212 deg. F (100 deg. C). During this period the PVA sleeve shrinks around the layup, giving the surface a smooth gloss and aiding in molding the undercuts. At the end of the hour, the laminate is removed from the oven and the PVA sleeve is stripped off. At this point the laminate should be firm and free from tackiness. </p> <p> The laminate is now ready for the final cure. It is replaced in the oven, set at 212 deg. F (100 deg. C), for 75 minutes to complete the final cure. </p> <p> While the plastic is still warm, the layup is cut to the desired length. The outer socket will separate easily from the inner socket. The plaster may be removed by striking the socket with a rubber mallet. If necessary, a chisel may be used to dig the plaster out of the distal end of the socket. Remaining PVA film can be stripped off by hand or dissolved with hot water. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked, after which the socket is removed and trimmed in the usual manner. After the socket and the forearm have been properly aligned, the edges are sanded and bonded together with liquid epoxy resin (ERL 2795, 65 parts; Versamid 140, 35 parts) (<b>Fig. 7</b>). The bond may be cured with a heat gun, or the prosthesis may be placed for one hour in an oven set at 212 deg. F (100 deg. C). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Bonding the socket and forearm </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The porosity of the finished prosthesis can be tested by holding it under a water tap and allowing the water to run through the prosthesis (<b>Fig. 8</b>). If the prosthesis has been prepared properly, the laminate should show a uniform porosity. The prosthesis is now ready to be harnessed in the usual manner. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Testing the porosity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Single-wall, Below-Elbow, Porous Prosthesis (Mylar Cone Method) </h4> <p> For the fabrication of a single-wall, below-elbow, porous prosthesis, the stump model is prepared in the usual manner,<a></a> placed in a vise, distal end up, and coated with lacquer. When the lacquer has dried, a moistened PVA sheet is pulled down over the stump model and tied at the base. </p> <p> The stockinet layup, consisting of one length of tubular Banlon stockinet and three lengths of tubular orthopedic stockinet, is prepared in the same manner as the stockinet layup for the socket of the double-wall prosthesis previously described. </p> <p> When the stockinet layup is completed (<b>Fig. 9</b>), a sheet of PVA is pulled down over the layup and tied at the base rod. This PVA cover will protect the layup during subsequent steps. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The stockinet layup on the model. A PVA sheet is pulled down and tied at the base rod. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, on an 8 in. X 12 in. sheet of Mylar (5-10 mils), a crayon mark is made halfway along one of the sides, about one-quarter in. from the edge. A second mark is made one-half in. inside the first mark. Then two final marks are made; one 3 in. above the first mark, the other 3 in. below the first mark. A curve is drawn from the edge of the Mylar sheet through the upper mark, through the inside mark, through the lower mark, and thence to the edge of the sheet. A cut is made along the curve. This cut side will permit the standard adult wrist unit to fit squarely to the Mylar sheet when it is fitted into a cone (<b>Fig. 10A</b>). The wrist unit should be fitted a minimum distance into the cone. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Mylar cone buildup and impregnation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The cone is placed over the stump model and adjusted so that the desired contour of the finished prosthesis will be obtained. Next, the prosthetist holds the cone and wrist unit in one hand, placing the unit flat on a table. With the other hand, he positions the stump model in the cone so that the distance between the elbow axis and the table surface corresponds to the required forearm length. The cone is adjusted at the proximal end, and the excess is trimmed off. The shortest cone that will give a desirable final shape to the forearm should be used, since it will provide the greatest bond area between the forearm and the socket. When the correct conical shape is obtained, the cone is closed with transparent tape, the proximal end of the cone is taped to the socket with transparent tape, the wrist unit is taped in place, all holes in the unit are closed with a sealer, and all seams are taped. </p> <p> Next, a piece of orthopedic stockinet is cut so that it is at least 10 in. longer than twice the length of the layup. The stockinet is pulled down over the entire layup in such a manner that half of the stockinet extends above the wrist unit. The stockinet is tied at the wrist unit, and the extended half of the stockinet is pulled back down over the layup. The stockinet is pulled smooth and tied at the base rod. </p> <p> The proximal edge of the Mylar is found by palpation, and a light line is drawn around the layup just distal to the edge of the cone. All the areas below this line are covered with masking tape (<b>Fig. 10B</b>). </p> <p> A batch of resin is mixed as follows: </p> <table> <tbody><tr> <td>ERL2795...................</td> <td>45.5 grams</td> </tr> <tr> <td>Versamid 140..............</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene.........</td> <td>30.0 grams</td> </tr> </tbody></table> <p> Sufficient pigment is added to give a slight color to the batch. </p> <p> The entire layup is inverted and brush-coated with this resin mixture. The excess resin is "strung" down toward the wrist unit (<b>Fig. 10C</b>). </p> <p> The layup is now placed for 30 min. in a pre-heated oven set at 115 deg. F (47 deg. C) for the pre-cure. After the cone has been pre-cured for 30 min., the oven temperature is increased to 212 deg. F (100 deg. C) and the cone is cured for 30 min. at this temperature. </p> <p> The layup is then removed from the oven, the masking tape is removed from the lavup, and the cone is separated from the inner socket. The Mylar sheeting is removed from inside the porous cone. The porous cone is sanded around the wrist unit until a smooth taper is obtained (<b>Fig. 11</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Sanding the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With the table contained in Appendix A (page 29) as a guide, a 250-gram batch of resin mixture is prepared, including in it a suitable amount of pigment. </p> <p> At this point the PVA sheet placed over the socket layup early in the procedure is removed, and a PVA sleeve is placed over the socket layup. </p> <p> The inner socket layup is impregnated with resin in the usual manner. Excess resin is removed from the layup by "stringing," the PVA sleeve is removed from the layup, and any excess resin is "strung" out. </p> <p> Now the porous cone is pulled down over the inner socket and aligned so that the wrist unit is in the proper position. The stockinet is tied at the base rod (<b>Fig. 12A</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Preparing the layup combining the socket and the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A piece of Banlon stockinet is cut so as to be 3 to 5 in. longer than the layup, and a piece of orthopedic stockinet is cut so as to be twice the length of the Banlon stockinet. One end of the Banlon stockinet is tied around the wrist unit. The orthopedic stockinet is pulled over the Banlon stockinet and tied at the middle around the wrist unit. (Additional layers of stockinet may be used if greater strength is required.) All layers of stockinet are pulled down over the layup and tied at the base rod (<b>Fig. 12B</b>). </p> <p> The layup is now thoroughly impregnated with the remaining resin mixture, with the use of a PVA sleeve and "stringing." It is very important that all the excess resin be "strung" down toward the proximal end, so that there will be no pooling of resin when a PVA bag is pulled down in a subsequent step. A few pieces of scrap stockinet should be wrapped around the base pipe to absorb excess resin. </p> <p> The layup is now placed for 30 min. in an oven pre-set at 115 deg. F (47 deg. C) for a pre-cure. While the layup is pre-curing, a PVA sleeve is prepared to fit the forearm. The PVA sleeve is wrapped in a moistened towel for 10 to 15 min. during the pre-cure. At the end of the pre-cure, the layup is removed from the oven and any excess resin is "strung" out. The oven temperature is increased to 212 deg. F (100 deg. C). Meanwhile, the moistened PVA sleeve is pulled down over the layup so that the entire laminate is in firm contact with the sleeve. If the sleeve is sufficiently moist, it will slide easily over the layup without causing any resin pools. However, if any resin pools do form, they should be "strung" out of the laminate. The PVA sleeve is taped around the wrist unit and any undercut areas to insure proper lamination. </p> <p> The laminate is now placed for 60 min. in the oven, previously set at 212 deg. F (100 deg. C). At the end of 60 min., the laminate is removed from the oven and the PVA sleeve is stripped off. At this point, the laminate should be free from tackiness. </p> <p> For the final cure, the laminate is replaced in the oven, still set at 212 deg. F (100 deg. C). </p> <p> After the final cure, the laminate is removed from the oven and cut to the desired length. The laminate should separate easily from the mold. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked. Then the socket is removed and trimmed in the usual manner. </p> <h4> Polyester-Resin Mixture </h4> <p> Shortly after the initial success of the porous epoxy laminates, attempts were made to produce similarly porous polyester laminates. At first these attempts were unsuccessful. Although highly porous laminates were produced, their physical strengths were inadequate for prosthetic application. </p> <p> However, because of significant improvements in the method of preparing porous epoxy laminates, particularly through the reapplication of a PVA bag at a critical time in the curing process, it was decided to reinvestigate the porous polyester system. The Army Prosthetics Research Laboratory has produced a series of cylindrical, porous polyester laminates which have shown when tested a strength sufficient for prosthesis<a></a>. Preliminary results of the evaluation are promising. The fabrication procedures presently recommended are the same as have been described for porous epoxy laminates in this article and set forth in full in <i>A Manual for the Preparation of Above and Below Elbow Prostheses, </i><a></a> published by the Army Prosthetics Research Laboratory. <b>Appendix A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Appendix A: Color appropriate for the individual should be added to the resin mixture and stirred in until it is uniformly blended. For a 100-gram mixture, 1 to 4 grams of color is sufficient. Epoxy pigment, Caucasian, tan, No. 22826 (60% pigment) and epoxy pigment, Negroid, brown, No. 22831 (53% pigment) (Plastics Color Company, 22 Commerce Street, Chatham, N. J.) have been used successfully at New York University (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The following polyester-resin formulation is tentatively suggested for a medium below-elbow porous prosthesis: </p> <table> <tbody><tr> <td>Laminae 4110<a style="text-decoration:none;">*</a></td> <td>80 grams</td> </tr> <tr> <td>Paraplex P-13<a style="text-decoration:none;">*</a></td> <td>20 grams</td> </tr> <tr> <td>Luperco ATC<a style="text-decoration:none;">*</a></td> <td>3 grams</td> </tr> <tr> <td>Trichloroethylene</td> <td>43 grams</td> </tr> <tr> <td>Naugatuck Promoter No.3<a style="text-decoration:none;">*</a>   </td> <td>6 drops</td> </tr> <tr> <td>Polyester pigment</td> <td> +/- 1 gram</td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li><p>Gray, Henry, <i>Anatomy of the human body</i>, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </p> </li> <li><p>Hill, James T., <i>A manual for the preparation of above and below elbow porous prostheses</i>, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </p> </li> <li><p>Hill, James T., and Egbert de Vries, <i>Evaluation of porous epoxy laminates for use in prosthetic arms</i>, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </p> </li> <li><p>Hill, James T., Egbert de Vries, and Fred Leonard, <i>Porous plastic laminates</i>, SPE Journal, Vol. 16, No. 9, September 1960. </p> </li> <li><p>Hill, James T., <i> Porous polyester laminates</i>, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </p> </li> <li><p>New York University, <i>Adult Prosthetic Studies</i>, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</p> </li> <li><p>New York University, Prosthetics and Orthotics, Post Graduate Medical School, <i>Guide for fabrication of double wall porous epoxy prosthesis for short B/E</i>, September 1961. </p> </li> <li><p>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B Lippincott Co., Philadelphia, Pa., 194S. </p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper-extremity prosthetics</i>, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </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">U. S. Rubber Co., Naugatuck Chemical Division, Naugatuck, Conn.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Wallace and Tiernan, Incorporated, Lucidol Division, 174 Military Road, Buffalo, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Rohm and Haas Company, Philadelphia 8, Pa.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">American Cyanamid Company, Plastics Division, 30 Rockefeller Plaza, New York 20, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hill, James T., Porous polyester laminates, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Wm. H. Horn and Bros., Philadelphia, Pa.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Western States Lacquer, Dallas, Tex. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Both accounts compiled for CPRD, NAS-NRC, from A Manual for the Preparation of Above and Below Elbow Porous Prostheses(2), published by the U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">DuPont Corporation Trademark.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">General Mills Chemical Division, Kankakee, 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">Shell Chemical Company, New York, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Bakelite Chemical Division, Union Carbide Chemical Company, New York, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Effective porosity is the ratio of the quantity of water that flows through the laminate to the amount that flows through the stockinet alone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Adult Prosthetic Studies, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Egbert de Vries, Evaluation of porous epoxy laminates for use in prosthetic arms, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </td></tr><tr><td class="clsTextSmall"><b> 4.</b> </td><td class="clsTextSmall">Hill, James T., Egbert de Vries, and Fred Leonard, Porous plastic laminates, SPE Journal, Vol. 16, No. 9, September 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>1.</b> </td><td class="clsTextSmall">Gray, Henry, Anatomy of the human body, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 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>Fred Leonard, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Scientific Director, APRL, WRAMC, Washington 12, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James T. Hill, C.E., B.S. </b></td></tr><tr><td class="clsTextSmall">Chief, Process Engineering Section, U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-21.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-24.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-25.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-26.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-27.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-28.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29b.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-31.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-32.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-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 Porous Plastic Laminates for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource James T. Hill, C.E., B.S. * Fred Leonard, Ph.D. * https://staging.drfop.org/files/original/3a52a8d4775fa3efd09318a22cf6e7b3.pdf 820ff6a0c1135f0effa1bae156a7f712 https://staging.drfop.org/files/original/a1127c14978be6ddba76a103d184fb20.jpg be7afb490777286577070fbfccb774fc https://staging.drfop.org/files/original/78848ce98a4983ca8bf83352f38fd5eb.jpg 254b27df04281f573e9df2cee9c33abc https://staging.drfop.org/files/original/6825c3c6eea1009afaf91c7abf8227ca.jpg 166a7fea19db92181e6cbf2a89d08b40 https://staging.drfop.org/files/original/aaf817a225ef897343a8c2a894b1cb69.jpg 537a989bf8ed7128316bdca570ab2915 https://staging.drfop.org/files/original/14f06bf8a55bb3dfed87489cacd1e28a.jpg fac89206bdc9aba86a21e615d9c70faf https://staging.drfop.org/files/original/f985278fc90ed029c1cc392206138e17.jpg 228d46ddc1545dc9fe5b34cf26bc0a72 https://staging.drfop.org/files/original/dab6c070737e365ed5aabce3fcf2bde1.jpg 6305700f03605ff97f24df6a08155562 https://staging.drfop.org/files/original/2d289146083105144b69c9c79a98b25a.jpg 5fd23e93a85b7ff731445a12a77fad61 https://staging.drfop.org/files/original/b63a1c7506812aa1f371254f1f53b919.jpg e3d7a7321d595d0fdfa23dd3c162429d https://staging.drfop.org/files/original/6cc643811deadfa2ead2f26357104ceb.jpg 5b94dac9a6d3f5727b81c3abfb6f7875 https://staging.drfop.org/files/original/2e7a46fb0b770171b5189860ba9f368d.jpg e82ff8d146f3473fbc167b759af9a148 https://staging.drfop.org/files/original/23562bc9cb410180cad1610a008e5cc1.jpg ff7b7f3b0ce7d6269d5364de3956538e https://staging.drfop.org/files/original/d92a31d65ae1a659d76f5e29b10d470d.jpg 25398ed94e7c48ac3b146aa62c192d24 https://staging.drfop.org/files/original/57a0d24e094a84654d83bd92944f70dc.jpg 3262f1eacd42160e24ca088febd063c8 https://staging.drfop.org/files/original/f40eee279da314366168879def856866.jpg 842e6fcd496ecdbae607d0554dea8d78 https://staging.drfop.org/files/original/3a999ee1d480ce73e8f934dd4e2117a2.jpg 2e3f15ea4f5f19befc8183e0723376d8 https://staging.drfop.org/files/original/e0315e1fb3761348b30e9c2a1a2d86d8.jpg 3cc0d759597ea5812be8ae99b3c204fb https://staging.drfop.org/files/original/8c2dc6b9dac90d6aa61cae8c1791afd5.jpg 56951aad21e6f648183614a200b26b17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_031.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 31 - 42 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Dynamic Alignment of Artificial Legs with the Adjustable Coupling</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p> Since World War II one of the most significant advances in limb prosthetics has been the introduction of rational principles for fitting and aligning artificial legs.<a></a> The University of California (Berkeley-San Francisco), sponsored by the Veterans Administration, has been primarily responsible for the steady improvement in methods and devices used by prosthetists in artificial-leg construction. </p> <p> To assist the prosthetist in carrying out these principles, a number of mechanical aids or tools were devised. The two adjustable legs-one for above-knee cases (<b>Fig. 1</b>), the other for cases below the knee (<b>Fig. 2</b>) and an alignment duplication jig (<b>Fig. 3</b>) were developed by the University of California, and are now recognized as important tools of the prosthetist.<a></a> And dynamic alignment of artificial legs is a standard part of the curriculum of prosthetics schools<a></a> and standard operating procedure in most limbshops. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An above-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 2. A below-knee adjustable leg used in current practice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alignment duplication jig. A, Adjustable leg mounted in jig. B, Adjustable leg has been removed and wooden set-up substituted. Prosthetist is sawing shank to proper length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But there have been problems. For one, the limbshop must have a minimum of two adjustable legs for adult cases, and two smaller ones for child cases. A shop of any size requires multiple quantities because frequently a given unit must remain attached to a socket for a particular amputee for an extended period of time. And to make best use of the adjustable legs an alignment transfer jig is needed. </p> <p> Other limitations in the above-knee adjustable leg appeared when knee units or knee-shank-foot units with fairly complex functions were introduced. Use of the UC adjustable AK leg, with its single-axis, constant friction joint for achieving alignment which is to be transferred to a permanent leg having a somewhat different type of function, is a questionable procedure; i.e., alignment suitable for a constant friction unit may not make proper use of the functions provided by more sophisticated devices. Some prosthetists have learned to accommodate for the required deviations by rules of thumb, but essential are some method and some tool for dynamic alignment to be made directly on the knee or knee-shank-foot mechanism to be used in the final prosthesis. </p> <p> Ideally, the device should be of simple design and useful for both above-knee and below-knee cases. For the above-knee case, such a device should be inserted between the socket and permanent prosthetic knee for "functional" alignment. </p> <p> If the unit were simple enough, it would be expected that more generalized use of alignment tools might result, and that facilities in other countries, where it is difficult to procure adjustable legs, could enjoy the advantages of dynamic alignment. Moreover, the alignment-transfer process needed scrutiny to see if simplifications in the equipment necessary might result. </p> <p> For these reasons, the VA Prosthetics Center developed the Adjustable Coupling, sometimes termed the "Staros-Gardner Coupling." </p> <h4> Description of the Adjustable Coupling </h4> <p> The adjustable coupling (<b>Fig. 4</b>) consists essentially of two plate assemblies held together by a central toggle pin. Mounted to a middle or intermediate plate but part of one plate assembly are four screw subassemblies, spaced 90 deg. apart, which contain independently adjustable, knurled screws used to "lock" the entire coupling as well as to provide adjustment for adduction-abduction and flexion-extension. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The adjustable coupling assembled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 5</b> are illustrated the major assemblies of the coupling. The single-flange part of the toggle and the top plate constitute the top assembly. The bottom assembly contains the "box" part of the toggle, the bottom plate, the intermediate plate, the four tilt-screw subassemblies, and the toggle pin. The bottom and intermediate plates both contain "A" and "P" marks to indicate the anterior and posterior sides, respectively. The two assemblies contain countersunk holes for screws used for attachment to the prosthesis. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Major assemblies and parts of the adjustable coupling. The toggle pin is permanently located in the semi circular channel just above the AA marks on the intermediate plate.<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The top assembly, primarily offering medio-lateral and tilt adjustability, contains a 1-1/4 in., 1/8 in. increment scale for gauging medio-lateral adjustments (with an index on the single-flange toggle which is free to slide with respect to the top plate). A tilt scale<a style="text-decoration:none;">*</a> is provided by markings on the threaded bushings of the four tilt-screw subassemblies. The indexes for tilt scaling are the lower surfaces of the knurled screws. Scale sensitivity for tilt adjustment is 2 deg. </p> <p> The bottom assembly provides rotation about the vertical axis and anteroposterior adjustability because the intermediate plate (and toggle "box") is free to move with respect to the bottom plate. On the anterior surface of the bottom plate is the 20-deg. (2-deg. increment) rotation scale. The index is located on the intermediate plate. The anteroposterior adjustment scale consists of a series of arcs, 1/8 in. apart for 1-3/4 in., etched on the top surface of the bottom plate. The index for this scale is simply the outer contour of the intermediate plate. </p> <p> The coupling, made primarily from an aluminum alloy (except for the toggle assembly which is steel), weighs 12 oz., is 3-3/4 in. in diameter, and is 1-1/8 in. thick when the plates are parallel. Ranges of adjustment are as follows: </p> <ol> <li><i>Mediolateral: </i>Total Range-1-1/4 in. <ul> <li>Increment of Scale Markings-1/8<i> </i>in. </li> </ul></li><li><i>Anteroposterior: </i>Total Range-1-3/4 in. <ul> <li>Increment of Scale Markings-1/8 in.</li> </ul></li><li><i>Tilt: </i>Total Range-10 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li><li><i>Rotation: </i>Total Range-20 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li></ol> <p> The coupling is disassembled by first lowering each of the four tilt screws two increments on the tilt scale. This operation loosens the entire assembly because it is held together as a result of the forces produced by tightening the force screws, and the toggle pin can thus be disengaged from the toggle box and flange. The top assembly and bottom assembly can then be separated. </p> <p> Installation of the coupling into a prosthesis is made with the coupling so separated. </p> <h4> Installation of the Coupling for Dynamic Alignment<a></a> </h4> <p> (<b>Fig. 6</b> and <b>Fig. 7</b>) show the coupling in position for dynamic-alignment trials. When installed, the coupling should be located as close as possible to the distal end of the stump. A piece of material may have to be added to accommodate the wood screws without affecting the socket sealing plate itself. By so locating the coupling, small tilt adjustments on the coupling will produce major changes in the geometrical relationship of stump to prosthetic components distal to the coupling. When the "bench" or static alignment is reasonably close, the 10 deg. range of tilt adjustment is more than adequate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The coupling installed in an above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The coupling installed in a below-knee prosthesis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the socket is constructed and the components approximately dimensioned<a style="text-decoration:none;">*</a> lengthwise, the top assembly of the coupling is attached to the bottom of the socket using as many wood screws as possible (<b>Fig. 8</b>). The bottom assembly then is attached to the top assembly by placing the single-flange part of the toggle within the "box" part and pushing the toggle pin through the holes in both toggle parts. One must make certain that the "A" marks (or "P" marks) are located properly with respect to the socket. The coupling is then set with all adjustments on "neutral" so that top plate and bottom plate are parallel and coaxial, care being taken to ensure that the intermediate plate is not rotated with respect to the bottom plate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Attaching the top assembly of the coupling to the bottom surface of the above-knee socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket with the coupling attached is then temporarily placed on the above-knee setup (knee-shank-foot) or on the below-knee setup (shank-foot). A height check<a style="text-decoration:none;">*</a> is made with the amputee standing on the prosthesis. </p> <p> Since the coupling has not been fully assembled into the prosthesis, the prosthetist must, of course, assist the amputee in maintaining stability. After the height check has been made, the section of the prosthesis below the coupling (on the knee block or shank) can be sanded to obtain the correct height. </p> <p> One must consider the desired static or bench alignment before fully attaching the bottom plate assembly to the prosthesis. A recently published chart<a></a> shows recommended guides for "bench" alignment when the SACH foot is used. In any case, care should be exercised in locating the bottom assembly to assure that the ranges of adjustment available in the neutrally set coupling will not be exhausted during dynamic alignment. </p> <p> When the bottom plate is being installed, the countersunk clearance holes are made accessible by shifting the intermediate plate with respect to the bottom plate (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Attaching the bottom assembly of the coup ling to the top surface of the knee block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Dynamic alignment can begin when the coupling is reassembled and "locked" in the neutral position. This procedure should ordinarily be carried out in the following fixed sequence, making the linear adjustments first and the lilt adjustments second: </p> <ol> <li>With the amputee seated, loosen only the two front tilt screws and make the anteroposterior adjustment. Tighten the two front screws.</li><li>With the amputee seated, loosen only the two front till screws and make the mediolateral adjustment. Tighten the two front screws.</li><li>With the amputee standing, provide tilt adjustment by turning down one of the two tilt screws on the side to be depressed (The screw should be turned down only as far as needed for the angular adjustment desired.) Then tighten the till screw diagonally opposite to establish the angular adjustment desired. Next loosen (the same amount) the second screw on the side to be depressed and tighten the screw diagonalh" opposite to complete the angular adjustment and "lock" the coupling.</li><li>rotation may be established or reestablished before the screws are completely tightened in any of the above three adjustments. The rotation scale reading may be recorded before making any adjustment so that the position of rotation may be readily restored.</li></ol> <h4> Alignment Transfer </h4> <p> No special jig is required for alignment transfer with the coupling. Actually, alignment is not "transferred" but rather "maintained" while the coupling is replaced with a permanent material. </p> <p> Around the periphery of the bottom plate of the coupling, there are ten radial holes located 36 deg. apart that serve as centers for a special compass which is used for scribing reference marks on the socket after dynamic alignment has been completed. The alignment compass is inserted in each of the holes in the periphery of the bottom plate, and small arcs are drawn or scribed on the socket base (<b>Fig. 10</b>). The <i>tops </i>of these arcs are then connected bv a circumferential line which will be exactly 2 in. above the bottom surface of the bottom plate and parallel to it. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 10. Use of the special compass for an alignment-transfer reference. The vertical reference lines will be used to reestablish anteroposterior, mediolateral. and rotation positions. The horizontal line tangent to the tops of the compass arcs will reestablish tilt. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At least four vertical reference lines (90 deg. apart) are made on the socket and continued onto the distal component (knee block or shank). </p> <p> The toggle pin of the coupling is removed and the top and bottom plate assemblies are detached from the socket and from the knee block (or shank). </p> <p> A saw cut is then made in the socket base<a style="text-decoration:none;">*</a> <i> just below </i>the horizontal circumferential line (<b>Fig. 11</b>) and the socket base is sanded to the line (<b>Fig. 12</b>). A 2-inch-thick wood or foam block (with parallel top and bottom surfaces) is then placed between the socket and the knee block (or shank). The wood or foam block is then firmly attached (with cement, resin, and/or other fastening media) to both socket and knee block (or shank), care being taken to restore the coincidence of the vertical reference lines on the assembled components (<b>Fig. 13</b>). Although not necessary, an apparatus for holding the parts together during cement or resin cure can be used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Using the band-saw to cut the socket immediately below the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Sanding of the socket to the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Replacement of the coupling with a 2-in. wood block. Coincidence of the vertical reference lines must be restored in the alignment-transfer process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> If one wishes, the standard alignment transfer jig may be used instead. Following standard procedures, the prosthesis with the coupling may be fixed in the jig and then the coupling removed. Saw cuts through the socket base and knee block (or shank) and substitution of an appropriately sized block of wood will be needed. In the above-knee limb transfer, one saw cut in the socket base will be sufficient if the prosthesis is mounted in the jig with the bottom plate of the coupling perfectly perpendicular to the long axis of the jig. </p> <h4> Experience with the Coupling </h4> <p> The coupling, although primarily designed as a simple device for alignment of "permanent" lower-extremity prostheses, can also be used for temporary, or interim, prostheses. </p> <p> The coupling has been in routine use in the Limb and Brace Section of the VA Prosthetics Center since March 1961. The numbers of permanent prostheses aligned with the coupling in the 22-month period ending December 31, 1962, were as follows: </p> <table> <tbody><tr> <td>Hip_disarticulation............</td> <td>13</td> </tr> <tr> <td>Above-knee....................</td> <td>130</td> </tr> <tr> <td>Knee-bearing...................</td> <td>16</td> </tr> <tr> <td>"Bent" Knee.....................</td> <td>3</td> </tr> <tr> <td>Below-knee....................</td> <td>192</td> </tr> </tbody></table> <p> In addition, 34 above-knee and 22 below-knee sockets were replaced on existing prostheses by use of the coupling. </p> <p> Experience indicates some economic benefits in use of the adjustable coupling. Starting at the same point in an above-knee prosthesis fabrication (with the socket roughly fitted), the adjustable leg-transfer jig procedure takes, on the average, slightly over 1/2 hr. more than the coupling-compass procedure. The end point for this time measure, in both procedures, is completion of alignment transfer with the prescribed prosthetic components assembled. </p> <p> A more significant advantage of the coupling accrues from its use in aligning above-knee prostheses when special knee or knee-ankle mechanisms have been prescribed. A prosthesis system with functional features providing more than just a mechanical-friction control at the knee may require some deviation from that alignment which might be used with only mechanical friction. Even an extension bias strap will affect the alignment to be used. Thus, for such devices as the Bock Safety Knee, the Hydra-Cadence (with a relatively free plantar-flexion control), the Mauch hydraulic devices, polycentric linkages, and others, it is well to align the prosthesis with the prescribed special-function system installed. The coupling is designed primarily for dynamic alignment of such systems. </p> <p> Added to the economic advantage of one device for both below-knee and above-knee use is the simple and inexpensive process for alignment transfer. For a new shop, this means that investment in an expensive jig is not mandatory. Also, because of the comparatively low cost of the coupling itself, many more alignment devices can be available in the shop. Thus, shifting alignment apparatus already installed in a setup awaiting an amputee trial may not need to be as frequent as formerly. </p> <p> The coupling also facilitates the alignment of replacement sockets. Fitting problems often require the fabrication of a completely new socket before the remaining parts of the prosthesis need replacement. The new socket and coupling can be installed on the "old" prosthesis for dynamic alignment and replacement-socket fitting. This process is more expeditious than one in which the adjustable leg is used and then transfer is made to the "old" components. Also, proper fairing of new socket to "old" components can be assured by the coupling method of realignment because fairing problems can be readily observed and immediately corrected. When the adjustable leg is used, fairing problems can be noted only at the time of transfer. Major corrective procedures may then be necessary. </p> <p> Many foreign practitioners have read and appreciated the various United States' documents which have emphasized the importance of dynamic alignment. But also, many have felt frustrated for, even though they have realized the value of dynamic-alignment apparatus, economic or technical handicaps prevented them from enjoying the use of the devices the practitioners in the United States had readily available. The coupling, therefore, because of its simplicity, can make a significant contribution to the benefit of the disabled all over the world, particularly in developing areas. </p> <p> The coupling was introduced into Yugoslavia in 1961.<a></a> At about the same time, Denmark became interested in its use. E. Lyquist of the Orthopaedic Hospital, Copenhagen, has published a report on the coupling<a style="text-decoration:none;">*</a> and on the apparatus he designed for clamping the prosthesis on a band-saw bed for alignment transfer<a></a>. See (<b>Fig. 14</b>). Dr. B. Zotovic of Belgrade has kindly offered the photograph (<b>Fig. 15</b>) of a prosthesis with the coupling now in use in Yugoslavia. In 1962, the coupling was introduced into Argentina. Still more applications to foreign use are anticipated. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Special band-saw jig used by Danes during alignment transfer. This jig holds components of the prosthesis in a fixed position to allow parallel band-saw cuts on both sides of the coupling. Subsequent clamping after cementing of wood block to replace coupling is also facilitated by this device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A Yugoslav above-knee prosthesis incorporating the adjustable coupling tor dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Many clinicians have realized the importance of temporary or interim prostheses<a></a> for preliminary trials by an amputee. When temporary limbs which have alignment adjustability are used, dynamic stump conditioning and, especially for geriatric cases, evaluation of an amputee's ability to cope with a prosthesis are possible before a final prosthesis is ordered. Of utmost importance in temporary limb use is that prosthesis <i>"function</i>not be seriously compromised".<a></a> A well-fitted, soundly designed socket must be used, and all parts should be continually maintained in proper alignment. Straps provide additional reinforcement of socket to coupling assembly- mostly for horizontally directed loads. For plaster sockets, they are especially helpful since they can be contained within an outer, reinforcing plaster wrap.</p> <p> There are now available several devices which might be used for temporary prostheses.<a></a> Among these is the coupling. (<b>Fig. 16</b>) illustrates a temporary or interim above-knee. prosthesis incorporating the coupling and making possible the use of the type of knee (and function) anticipated for a permanent prosthesis. Now, not only fit and alignment can be '"tuned" to each other, but both can be "tuned" to function. And, if necessary, function can possibly be altered by a rather rapid change from one knee-shank mechanism to another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. The adjustable couplingused with a plaster -of-Paris above-knee temporary sockel and an unfinished knee shank. The three straps are eaeh 1/8 in by 3/4 in. low-carbon steel. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 17</b>) shows the coupling used in a below-knee temporary, or interim, prosthesis. For this level of amputation, the practitioner has the choice of the coupling or the Northwestern Adjustable Below-Knee Pylon shown in (<b>Fig. 18</b>). This apparatus also has sufficient alignment adjustability available for most below-knee applications in both temporary and permanent prostheses. When attached to a "permanent" (plastic or wood) socket, its advantage is that it can remain in the prosthesis after the dynamic-alignment process is complete. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig, 17. The adjustable coupling used with a plaster-of-Pa.ris below-knee temporary socket and unfinished shank. The three straps have the same cross-section as those used with the above-knee socket. The position of the carbon steel straps in both the above-knee and below-knee sockets should be reinforced with an extra plaster-of-Paris bandage wrap, as illustrated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. A temporary or interim prosthesis with the Northwestern adjustable below-knee pylon, plaster-of-Paris patellar-tendon-bearing socket and SACH foot, The three straps are similar to those of the previous two illustrations. An adaptor plate must be provided to iittach the straps to the pylon. In addition to the alignment adjustability available in the pylon, the position of the socket can still be altered if necessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Further Development </h4> <p> The Northwestern Adjustable Below-Knee Pylon demonstrates a design principle long sought in alignment apparatus. With it, adjustments needed for dynamic alignment can be made as usual during the early stages of prosthesis fabrication, but the adjustable apparatus is now made a part of the limb obviating a transfer process but sometimes causing a slight increase in limb weight. At a later date, if the cosmetic-shank design allows it, readjustment of alignment can be made without a complete alteration of the prosthesis. Use of a relatively flexible cosmetic cover will probably be best for this purpose; if a plastic-covered foam shank is used, only destruction of the shank before realignment and a foam replacement and plastic finishing after realignment will be required. </p> <p> Most desirable would be one apparatus, perhaps coupling-like, which could be used in above-knee and below-knee prostheses alike. The present adjustable coupling is both too heavy and too expensive for this purpose. A. B. Wilson, Jr.<a style="text-decoration:none;">*</a> and Victor T. Riblett<a style="text-decoration:none;">*</a> have designed a simple and inexpensive plastic, tapered-disc device which might remain in the prosthesis after the primary alignment trials (<b>Fig. 19</b>). At present the device usually must be partly trimmed during the shaping of the limb for cosmetic finishing. Therefore, it could probably not be used at a later date for realignment purposes. But still this device will obviate transfer after initial alignment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Schematic drawing of the "Wilson-Riblett wedge," as applied to the VAPC coupling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In eliminating only the primary-transfer process, a so-called "leave-in" alignment device must be priced at a level which would offer some gain to the prosthetist-user. If, at least with the regular coupling, alignment transfer involves an investment of approximately $5.00 in labor and materials by the limbshop, then the <i>one-time, </i>"leave-in" alignment device should cost somewhat less. But even so, possible saving per prosthesis or additional profit is of a very low order of magnitude. </p> <p> Needed is a device (and prosthesis design) which would allow realignment at a later date without major reconstruction of the prosthesis. Economic benefits would accrue to prosthetist and amputee alike; at least some of the major cost-saving in the realignment process can be passed along to the customer. Perhaps many prostheses now condemned for alignment reasons would not need to be. </p> <p> But most of all, such a device would offer convenience, allowing almost immediate accommodation to an amputee's needs. Instead of major delays in receiving a new alignment in a new or grossly altered older prosthesis, rather prompt prosthetist attention can be focused on an alignment problem in the existing limb. The prosthetist, if uncertain of an amputee's over-all fitting problem, can start with realignment of the existing prosthesis in his progressive analysis of the situation. He might be able to overcome what may seem to be socket-fit difficulties without major changes there. But, in any case, he would have readily available the mechanism for study of the problem and the problem's dependency on alignment. </p> <p> Prosthesis design must of course be changed to accommodate the permanent installation of such a unit. A below-knee shank should preferably be a pylon-cosmetic-cover type, somewhat similar to the Northwestern device. Preferably, the lower part of the above-knee limb thigh (where this device would be placed) should have an easily removable cosmetic cover. Perhaps a simple plastic finish over foam forced into the spaces around a lightweight, inexpensive coupling would be adequate. The foam would need to be cut away (or possibly dissolved by appropriate chemical means) when realignment was necessary. But even with present plastic-laminate finishing methods, realignment would involve only destruction of the laminate and then refinishing. </p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy,<i> Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars)</i>, Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, <i>The locomotor mechanism of the amputee</i>, Chapter 16 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954. </li> <li>Lyquist, Erik, <i>Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01</i>, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artificial Limbs, January 1955, p. 35. </li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputees</i>, Artificial Limbs, Spring 1957, p. 41. </li> <li>Staros, Anthony, and Henry Gardner, <i>Report on orthotics-prosthetics research developments in Yugoslavia</i>, Department of Health, Education, and Welfare, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Suggestions for fitting and aligning the SACH foot</i>, a chart, May 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Temporary prostheses for lower-extremity amputees</i>, Technical Report 1, September 1, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Use of the alignment coupling</i>, a chart, July 1962. </li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program</i>, Artificial Limbs, May 1954, p. 8. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Supervisor, Mechanical Development Branch, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Forest Glen Section, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, CPRD, NAS-NRC, 2101 Constitution Ave., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Lyquist, Erik, Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Lyquist (in November 1962) reported that the coupling was being used in all patellar-tendon-bearing fittings at the Orthopaedic Hospital. Some above-knee use was also reported.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry Gardner, Report on orthotics-prosthetics research developments in Yugoslavia, Department of Health, Education, and Welfare, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Normally, if there is enough material here for the wood screws to attach the coupling, there will be enough material for this saw cut and the subsequent sanding without disturbing the socket itself.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Suggestions for fitting and aligning the SACH foot, a chart, May 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> With especially long above-knee stumps, the knee center must be dropped during alignment trials because of the thickness of the coupling. Later, during transfer, true or near-true knee-center height can be restored.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The over-all length of socket, knee unit, shank piece, and foot, plus 1-1/8 in. for the coupling, should be slightly larger than the amputees dimensional requirements. Later sanding after a height check will produce accurate longitudinal dimensioning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">All scales have neutral positions highlighted. The neutral positions on the tilt scales are most important in establishing the middle position of tilt, when top and bottom plates are parallel, or for disassembly, when it is important to unlock the coupling by having all four tilt screws down at least two increments below neutral.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars), Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomotor mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954, p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Chief, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-034.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-035.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-036.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-037.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-038.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039b.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-041.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-042.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-043.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-044.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-045.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-046.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-047.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048b.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-050.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-051.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Dynamic Alignment of Artificial Legs with the Adjustable Coupling Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * https://staging.drfop.org/files/original/48ab984f63ee9944e8e12c1bf86b8f60.pdf eb995e5594f719eb9d7d1ab8a1c490d7 https://staging.drfop.org/files/original/30569f396b331fcb2e12947a520b6ac1.jpg b543805b7c4b513f32d0060281f28c1e https://staging.drfop.org/files/original/0bc95d63b994e86882e4517d2359f830.jpg 0069caac4493054393b8321505a3418b https://staging.drfop.org/files/original/0ac31bbaa9a0a7f0fec072dd32eb01f6.jpg 19f787d2297a18ef0b242b756a3d565c https://staging.drfop.org/files/original/56454d222bdd3468d5eed2e8285140ef.jpg 04a3c0120545162192a92cc89fdd5ea9 https://staging.drfop.org/files/original/b3e026292277cb859e0e3f4e1784de44.jpg 04e4a36aff5d4f3465d4ab2fe4c2eb7e https://staging.drfop.org/files/original/a446473c17f3288b20207e31bf640f91.jpg 3dd944585433639209e6aba1f6d7e02b https://staging.drfop.org/files/original/b4220edb41cf61a457cbce3d8d3a85e0.jpg dad70000c6445e43ad5115934dfa2024 https://staging.drfop.org/files/original/1a34ee9269e75b1fa11438a645cd9358.jpg 2359c6121a81674e01e8e0aa1813a104 https://staging.drfop.org/files/original/3b83b9695f8d5a45b85fa5f3a3ce8226.jpg b08bd2cf52601d42a9580945fdf0d194 https://staging.drfop.org/files/original/5f2a0eb01af4723d6ad1e673e29af358.jpg d7d0dd21ba3d40e30d463c485cd9df31 https://staging.drfop.org/files/original/a17dff824e882e699ea4241bfdbf1846.jpg 509a6217d3f638c8106e4550bf96d6fc https://staging.drfop.org/files/original/c30118b21e4ccd90a540f956aff44c6b.jpg 5f8d71453173a61fea69ddf09fcf2826 https://staging.drfop.org/files/original/5777bdcd4ca4e1a7990e70d71a0df8e7.jpg 312c5c5027c454f6003665d2d9181936 https://staging.drfop.org/files/original/b80f2cd616a14438719aca13ed27bc35.jpg 6b1cc88760e3fbc9d7438c15ca4ca148 https://staging.drfop.org/files/original/343ea7b1198667406303ad4a8eac51f4.jpg 17767ee459c4d8018faba396f8f5c19e https://staging.drfop.org/files/original/963b2539a143b91e55ee0cf19833183e.jpg 76527cfc69d9e0f23e1f447c0cbf9c91 https://staging.drfop.org/files/original/2a72f1972ae1c761efec324edc5046c8.jpg a02cf0378a7b652331dfffc2f591a00e https://staging.drfop.org/files/original/9f3416f8d473f377d1f6f6ac162f7396.jpg 0cae68f411ca1165884fc7275b632e7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_003.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 3 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_003.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_003.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>A Hemipelvectomy Prosthesis</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>A Hemipelvectomy amputation involves removal of the entire lower extremity and half of the pelvis, separation generally being effected at the sacroiliac and symphysis pubis joints. Whenever possible the gluteus maximus and oblique abdominal muscles are preserved and usually are sutured together along the lower anterior aspect of the abdominal cavity. Because of disease or trauma, it is often necessary to remove the gluteus maximus, in which case the "stump" consists simply of a skin-covered abdominal cavity. The operative procedure is described and pictured in detail in <i>An Atlas of Amputations </i>by Dr. Donald B. Slocum.<a></a></p> <p>Because there is no longer a skeletal structure on the affected side to assume the forces required during ambulation with a prosthesis, many workers have attempted to design sockets that will transfer weight-bearing loads directly to existing bony structure. Some have tried to use the ischial tuberosity on the unaffected side to support body weight, but with limited success. Others have felt it necessary to extend the socket so that the rib cage can absorb most of the weight-bearing forces, but this arrangement greatly restricts body motion and heat dissipation.</p> <p>However, it has been found that it is entirely feasible for the "stump" to carry the loads if the socket is designed so that the semisolid abdominal mass of the stump is upward and medially toward the somewhat firmer area of the lower rib cage. Sometimes it is possible to utilize the sacrum for some support but relief for the coccyx must be provided because pressure on this sensitive bone almost always results in pain. Some additional support can often be achieved by utilizing the area of the gluteus maximus on the unaffected side.</p> <p>Such support may be achieved by means of a piece of 1-in. Dacron webbing anchored to the inner distal area of the socket so that the anchor point is anterior to the ischial tuberosity on the sound side. The Dacron tape is led from its anchor point in the socket, under the gluteus maximus on the sound side, passing just distal to the trochanter and then diagonally across the anterior of the socket to a buckle (<b>Fig. 1</b>). Because the strap passes across the sound side at the level of the trochanter, it acts as a counterforce to the shearing action of the stump slipping in the socket under weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sketch shows webbing used as additional support to help to stabilize the amputee in the socket during stance phase. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article describes a method for fitting the hemipelvectomy patient in such a manner that the major loads are carried through the stump. The hemipelvectomy prosthesis incorporates many of the features of the Canadian hip-disarticulation socket, which was fully discussed in the Autumn 1957 issue of <i>Artificial Limbs. </i>However, the opening used for donning the prosthesis has been moved from the anterior portion to the lateral side of the socket. Greater stability is achieved by this arrangement since both the anterior and the posterior sections of the socket can contribute more support.</p> <p>The hip-disarticulation socket utilizes the ischial tuberosity on the amputated side to support the patient in the socket, and the crest of the ilium for suspension of the prosthesis. In the hemipelvectomy case, the skeletal structure is absent and support of the patient in the prosthesis depends upon oblique upward pressure on the stump with an equivalent opposing pressure on the sound side, obtained by the shape of the socket <a></a> (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Hemipelvectomy socket. Arrows indicate pressure applied by the socket to the "stump," upward and medially. Shaded areas indicate bulges produced by the use of hip sticks. The bulges aid in suspension of the prosthesis, in preventing rotation, and serve as guides for correct alignment while donning the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During casting, hip sticks (<b>Fig. 3</b>) are used to obtain the desired contours of tissues necessary for good suspension of the prosthesis.<a></a> Casting a patient while suspended in a sling is one method of compressing tissues in an upward oblique direction, resulting in a cast of the desired shape.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Hip sticks. <i>A, </i>two sticks, approximately 14 in. in length, 1 in. in diameter, joined by a piece of 2-in. webbing, adjustable by means of a buckle. <i>B, </i>hip sticks as applied to the "stump" during casting to create relief for the crest of the ilium on the sound side and desired shape of tissues on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The hemipelvectomy prosthesis utilizes the principles of alignment of the Canadian-type hip-disarticulation prosthesis. Moreover, the mechanics of the hemipelvectomy prosthesis are essentially the same as those of the hip-disarticulation prosthesis.<a></a></p> <p>New features incorporated in the hemi-pelvectomy prosthesis are: First, silicone foam is used in the socket construction to fill the cavity at the location of the hip joint; silicone foam is nontoxic, easily used, and provides a surface that is not as slippery as the polyester laminates. Second, the attachment for the hip joint is an integral part of the socket. Third, there is an articulated thigh fairing which is lightweight, easily fabricated, allows reduction in the size of the thigh block, and greatly enhances cosmesis in both the sitting and standing positions. Fourth, there is a support strap under the ilium and around the trochanter.</p> <p>The prosthesis includes the use of a single-axis knee and a SACH foot with a very soft heel wedge. This soft heel wedge increases the stability of the prosthesis at heel strike.</p> <h3>Examination of the Amputee</h3> <p>When an amputee with a hemipelvectomy stump is first seen, a visual examination will reveal scar tissue or other surface conditions that may affect the design of the socket. The location of sensitive areas should be noted so that they may receive special treatment if necessary. All hemipelvectomy amputations are not sectioned at the same level; some surgeons leave behind a small amount of the ilium or a small amount of the pubic bone. Palpation of the stump will usually permit determination of any remaining bony structure, but for definitive evaluation an x-ray of the pelvic area is desirable.</p> <p>When all the conditions relative to the amputation are known and recorded on the Prosthetic Information Form (<b>Fig. 4</b>), the prosthetist is ready to proceed with the first step of prosthesis fabrication; namely, production of a model of the stump and adjacent areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Prosthetic Information Form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting the Stump</h3> <p>It has been found that a minimum of modifications to the positive model is required if the cast is taken under weight-bearing conditions. To achieve these conditions, a simple adjustable overhead sling is used. The arrangement shown in <b>Fig. 5</b> utilizes existing structure in the laboratory and a tent-rope tension bar to achieve height adjustability, but a number of equally satisfactory designs can be devised.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Adjusting the sling to obtain proper height. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The seat area of the sling may be made with a piece of 6-in. or 8-in. stockinette tied to the rope at both ends. The stockinette should be long enough to clear the outline of the superior brim of the socket.</p> <p>In taking the cast, hip sticks are used to assist in locating and providing relief for the anterosuperior spine of the ilium on the sound side, and to produce a similar impression on the amputated side. This impression assists in suspension of the prosthesis and helps to prevent rotation of the socket on the stump. Materials required for taking the cast are:</p> <table> <tbody> <tr> <td> <p>4-in. or 6-in. plaster bandages</p> </td> <td> <p>Indelible pencil</p> </td></tr> <tr> <td> <p>3-ft. length of 8-in. or 10-in. stockinette    </p> </td> <td> <p>Plumb bob</p> </td></tr> <tr> <td> <p>Two 3-ft. lengths of 1-in webbing</p> </td> <td> <p>Yardstick</p> </td></tr> <tr> <td> <p>Four harness clamps</p> </td> <td> <p>Paper</p> </td></tr> <tr> <td> <p>Container with water</p> </td> <td> <p></p> </td></tr></tbody></table> <h3>Preparation of the Patient</h3> <p>A 3-ft. length of stockinette (8-in. or 10-in. width as required) is pulled up on the amputee until it is quite snug on the sound thigh. Proximally, it should cover half the thorax. The stockinette is secured with 1-in. webbing over the shoulders and should be pulled tight enough to give some support to the stump mass (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Tentative outline of socket drawn on stockinette. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal portion of the rib cage and any areas that need relief are outlined with an indelible pencil. The remaining anterosuperior spine of the ilium is located and outlined. The trochanter on the sound side is located and marked.</p> <p>An approximate outline of the socket is drawn (<b>Fig. 6</b>). The anterior distal portion of the outline starts at the pubic ramus and arcs upward along the inguinal crease onthe sound side with clearance for the sartorius muscle, then passes down to a point just superior to the trochanter. The posterior distal portion of the outline passes from the midline of the body to a point just lateral to the ischial tuberosity, then arcs upward to join the anterior line superior to the trochanter. The proximal outline circumscribes the body at the level of the tenth rib.</p> <h4>Sling Orientation</h4> <p>The amputee is seated in the sling after it has been positioned approximately for height. Pressure on the stump should be diagonally upward and toward the opposite shoulder. Therefore, the sling should pass diagonally across the body to the sound side. A piece of 1-in. webbing under the axilla on the sound side will hold the rope away from the neck and face of the amputee.</p> <p>A slot is cut in the sling posteriorly and just superior to the seat area. Another slot is cut opposite this in the anterior section. A piece of 1-in. webbing is pulled through these slots, around the thigh, and clamped together to prevent the seat from sliding on the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Orientation of amputee in sling. Retention strap adjusted just distal to trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is instructed to place more weight on the sling than on the sound leg, and the sling is adjusted for height. It is ascertained that the seat area is contacting the remaining ramus.</p> <p>The setting of the hip sticks is checked. The length of the webbing should be adjusted to fit the patient so that the groove for relief of the remaining ilium and a corresponding groove on the amputated side will be in the proper position. The fulcrum of the hip sticks should be slightly posterior to the crest of the ilium to obtain leverage necessary to bring adequate pressure against the proximal posterior portion of the plaster wrap.</p> <h4>Wrapping The Stump</h4> <p>The procedure of wrapping the stump usually requires two people. Except for obese cases, the patient is removed from the sling for application of the plaster wrap. This is done to contain the tissues and so prevent lateral distortion of the stump when weight is reapplied in the sling. An obese amputee, however, should not be removed from the sling. The wrap cast should be made to incorporate the stockinette initially, because it is too difficult to wrap the stump and properly orient the patient back into the sling before the plaster starts to set.</p> <p>The wrap is started at the lateral proximal brim on the sound side and is brought diagonally upwards across the anterior (<b>Fig. 8</b>). Moderate pressure is placed on the wrap, but ridges should be avoided. The stump should be completely wrapped just past the outline previously drawn on the stockinette. Care must be taken to include the trochanter on the sound side. While the wrap is still wet, the amputee is positioned back in the sling, and the ropes are adjusted until he is standing erect, with at least equal weight being borne on the amputated side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Beginning diagonal wrap of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The webbing of the hip sticks is placed across the back of the patient and under the stockinette sling, if it is bridging. The sticks should slant diagonally down just medial to the anterosuperior spine of the ilium on the sound side and a corresponding position on the amputated side. The crest of the ilium on the sound side is palpated by hand to ensure that the hip sticks are not impinging on the anterosuperior spine of the ilium. When the hip sticks are in the correct position, they are held with sufficient pressure to ensure adequate relief. At the same time, an oblique upward pressure is exerted to the lateral distal area of the stump and a counterforce is applied on the opposite ilium. This condition is maintained until the plaster is set. The hip sticks are removed, and the cast is reinforced with additional bandages over the sling. The wrap should touch the remaining ramus, and a portion of the gluteus on the sound side should be included.</p> <p>The trochanter is marked (<b>Fig. 9</b>), and the amputee is removed from the sling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Locating trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is then placed on a table with the stump toward the near side of the table. The gap between the plaster cast and the patient's abdomen is checked to determine if alteration to the wrap is required to contain the viscera and ensure an intimate fit to the socket (<b>Fig. 10</b>). The plaster wrap is cut from the proximal to the distal rim just medial to the socket section. The gap, if there is one, is eliminated by pushing the cast down to meet the abdomen, care being taken not to squeeze the cast mediolaterally and so disturb the placement of the bulge caused by the hip sticks on the sound side (<b>Fig. 11</b>). One side of the cut is covered with vaseline to a depth of approximately 4 in. to facilitate removal of the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Checking the gap between the cast and the patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Closing the gap by downward pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A panel of plaster-of-Paris bandages approximately 8 in. wide is formed and laid across the front of the cast, the cast being held in the desired position. Lines to relocate the position of the panel and the cast are drawn, and the cast is secured on the patient by means of a web belt. This will prevent the cast from spreading when the amputee stands and will result in more accurate datum lines.</p> <p>With the amputee standing, the cast is checked for lit and comfort.</p> <h4>Reference Lines</h4> <p>To provide datum lines for alignment of the prosthesis, vertical reference lines are marked on the cast at this time.</p> <p>The amputee should stand erect using an adjustable support under the cast. The spine should be straight and the shoulders level and at right angles to the line of progression.</p> <p>A plumb bob is suspended from the sternum (<b>Fig. 12</b>), and a vertical line is drawn on the cast. A plumb bob is suspended from the spine, and a vertical line is marked on the cast. A plumb bob is suspended from tinder the axilla to bisect the trochanter on the sound side, and the line is drawn on the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Use of plumb bob to obtain reference lines on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is removed from the amputee and, after being cut down to the outline previously drawn on the stockinette, is used as a check socket. It should be checked for support and comfort under weight-bearing while the amputee is standing, for pressure on the rib cage, and for clearance of the sound leg while the amputee is sitting. The area of the coccyx should be checked, also the area providing relief for the anterosuperior spine of the ilium on the sound side.</p> <p><b>Pouring the Plaster Positive Model</b></p> <p>The common method of forming the plaster positive model is to pour the negative cast full of a plaster slurry. A mixture of plaster and vermiculite in equal proportions results in a lighter model and one that is quite easy to work. A slush, or hollow model, may be used, but care should be taken to make the model thick enough for it to withstand the pressures involved when lamination is carried out.</p> <p>The leg opening is closed, and the cast is reinforced with plaster bandages. A separator such as vaseline or silicone spray is applied to the inside of the cast.</p> <p>The reference lines are reestablished if they were covered by the reinforcement.</p> <p>A sheet of paper large enough to extend beyond the cast is laid out and divided into four equal parts by means of two perpendicular lines. The cast is placed on the paper so that the vertical reference lines on the cast coincide with and are vertical to the lines on the paper. The cast is secured in this position by blocking it up with plaster.</p> <p>After the plaster has been poured into the cast to form the positive model, a pipe is inserted not only to provide for ease of handling but also to act as a pathway for the air to be drawn out of the laminate by a vacuum pump. A paper cup is installed on the pipe, as shown in <b>Fig. 13</b>, to keep plaster from clogging holes that have been drilled in the pipe to allow the passage of air. The pipe is inserted so that it is aligned with the vertical reference lines; thus it can be used as a reference line when the negative mold has been removed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Setting pipe vertically using vertical lines on cast as reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of the Hip Joint</h3> <p>Before any modifications to the positive model are undertaken, a buildup is made so that the finished socket will contain a flat area suitable for installation of the hip joint. Instructions given here are for the so-called Northwestern hip joint,<a style="text-decoration:none;">*</a> a unit which provides for alignment adjustment.</p> <p>The hip joint should be placed laterally to provide adequate clearance in the crotch area, placed well forward to ensure adequate stability during the stance phase of walking, and high enough so that the extension stop does not interfere with sitting.</p> <p>If the hip joint is placed too far to the rear, the amputee will be insecure, the joint will interfere with sitting, and more energy will be expended in walking. If it is placed too far forward, the prosthetic knee will extend past the normal knee when the patient is seated. This condition can be partially alleviated by shortening the thigh and lengthening the shank. However, a compromise in the location of the joint is essential.</p> <p>Location of the hip joint in approximately the optimum position may be achieved by the following method:</p> <blockquote><p>Before the positive model is removed from the cast, a reference trochanter, the point on the cast directly opposite the trochanter on the sound side, is established. By means of a height gauge, the trochanter mark on the cast is transposed to a point vertical to the layout line on the opposite side. A point on the surface of the cast 1 1/2 in. vertically below this point is marked. Through this last mark, a line is drawn on the cast at an angle of 45 deg. A useful aid for this is a piece of wood approximately 1 in. thick, cut on an angle of 45 deg. (<b>Fig. 14</b>). In scribing the line, the pencil must be held flat on the 45-deg. surface. All reference lines from the cast are cut through to the positive model by use of an awl. When the cast is removed, the lines are marked on the model with an indelible pencil.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Scribing 45-deg. line on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>An outline of the socket is drawn on the model. Heretofore, it has been the common practice to cut the anterior portion of the socket to allow entry and exit of the torso. Experiments at the Northwestern University Prosthetics Research Center have shown that more stability between patient and socket can be achieved if the opening is made on the lateral wall.</p> <h3>Modification of the Positive Model</h3> <p>To provide additional relief for the antero-superior spine of the ilium on the sound side, a skived piece of leather or a plaster buildup 1/4 in. thick on the positive model should be adequate.</p> <p>The anterior section of the model usually has a ridge caused by overlapping during the casting procedure. This ridge should be eliminated by removal of plaster. If there is a large bulge posteriorly in the gluteal area, the bulge should be reduced by removal of plaster. Sometimes the angle of the lateral wall will continue to the ramus. If this is apparent, the distal seat area may be modified and flattened slightly by removal of plaster in order to minimize slipping. Any other ridges should be removed, and the entire model should be smoothed with files, wire screen, or sandpaper. A good finish may be obtained by wet sanding with a piece of Wetordry Fabricut.</p> <p>Moisture must be contained in a new model to prevent the PVA bag used as a separator from becoming wrinkled. Application of a sealer, such as Ambroid or parting lacquer, will serve to retain moisture.</p> <p>Leather tongues used at the closure of the socket will deteriorate from sweat. A molded flexible polyester tongue is more durable and sanitary. It should be formed to the model before the flare is added to ensure a smooth transition from the tongue to the socket surface. The tongue is made by laminating four staggered pieces of nylon stockinette across the proposed opening with a flexible mixture of polyester resin (60 per cent Laminac 4134 to 40 per cent Laminac 4110 is an adequate mix). After the tongue has set, it should be trimmed to the desired shape and taped to the model.</p> <p>The outline of the socket on the model is built up to provide a flare with a radius of approximately 3/4 in. The buildup is accomplished by folding a piece of 4-in. plaster bandage lengthwise approximately seven times, wetting it, and laying it on the outline as a beading. The plaster bandage is formed over the tongue to provide a lateral opening at least 1 in. wide. The beading is formed to the desired flare and smoothed with plaster (<b>Fig. 15</b>). The flare should be coated with Ambroid or parting lacquer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Construction of flaring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model is now inverted and mounted in a vise with the sagittal plane vertical. The mounting pipe should be set at an angle of 45 deg. to the horizontal, with the anterior surface of the model upward (<b>Fig. 16</b>). The 45-deg. line on the model should now be vertical, and it should be extended past the flare, both proximally and distally.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Positioning joint on positive model using 45-deg. line as reference. (Model is held in vise at 45-deg. angle, so 45-deg. line, previously scribed, is now vertical.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The configuration of many hemipelvectomy sockets will not allow sufficient clearance for the joint in the crotch area. To allow the joint to be placed more laterally and to provide a flat area for mounting the joint, it is necessary to build up the positive model with rigid poly-urethane foam.</p> <p>The principal considerations in planning the joint location are: First, the flat area must be large enough to receive the mounting plate (about 2 3/4 in. in diameter). Second, the flat area will be horizontal when the model is mounted at the 45-deg. angle. Third, usually the axial center of the joint is somewhat anterior to the 45-deg. line. (It should be kept as close as possible to the line, but the joint must not be permitted to interfere with the sitting position.) Fourth, in most hemipelvectomy sockets, the joint will project beyond the lateral edge of the socket, but it should not project further from the midline of the body than the corresponding joint of the sound leg.</p> <p>Cardboard is formed on the positive model to form the buildup for the joint location and to allow for contours that will blend well with the socket. Polyurethane foam (Pelron 4-lb. density No. 9664<a style="text-decoration:none;">*</a>) is mixed and poured into the cardboard form (<b>Fig. 17</b>). As the foam is being shaped, care should be taken to shape the area immediately medial to the joint to permit full adjustment of the joint. <b>Fig. 18</b> shows the completed buildup on the positive model for the location of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Pouring polyurethane foam into cardboard form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anterior view of positive model showing flat area necessary to receive hip joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Fabrication</h3> <p>Although it is not necessary to use any specific laminating procedure, the vacuum technique described in this article is presented as one that has produced consistently good results in the Northwestern University Prosthetics Research Center.<a></a> </p> <p>Radial suction grooves are cut with a sharp knife from the crest of the flare on the positive model to the cup, or approximately eight 1/8-in. holes are drilled through the model into the cup, the holes being so situated as to ensure the evacuation of air from undercuts.</p> <p>A thin smear of vaseline or motor oil is applied over the sealed surfaces of the model and the polyurethane foam buildup. (Caution: Ambroid should not be applied to the polyurethane foam; the thinner in the Ambroid will soften the foam.) A light plaster slurry is used to blend the edges of the foam into the contours of the socket. A light plaster wash is then applied to the foam and allowed to dry. Ambroid, then vaseline or oil, may be applied to facilitate pulling the PVA separator over the model.</p> <p>A tailored PVA bag is pulled down over the positive model. One end is gathered and tied over the area of the sound leg. The other end is taped tightly around the pipe. Three or four holes are punched in the bag near the cup.</p> <p>Fabric is applied as follows:</p> <ul> <li>1 layer 1/2-oz. Dacron felt.</li> <li>1 layer nylon stockinette.</li> <li>7 layers of glass cloth over the joint and seat areas. The pieces of cloth should be of varying size to produce a gradual transition in rigidity.</li> <li>1 layer Dacron felt over all.</li> <li>5 layers of nylon stockinette pulled on tight and tied to the pipe. A PVA bag is pulled down over the layup and taped tightly to the pipe.</li> </ul> <p>Resin, in an appropriate amount, should be prepared in the proportion of 80 per cent rigid Laminac 4110 to 20 per cent flexible Laminac 4134. ATC catalyst-2 per cent of the weight of the resin mixture is added and spatulated thoroughly. Appropriate pigment, amounting to about 2 per cent of the weight of the resin mixture, should be added: 12 drops of Nauga-tuck # 3 promoter results in approximately 20 min. working time. This will vary according to temperature and humidity.</p> <p>One method of impregnating the fabric with the resin is to pour the resin into the top of the outer PVA bag and "string" the resin downward, working it into the layup, especially into the reinforced seat area, to obtain complete saturation. After the resin has been "strung" into the layup, the vacuum is applied and a head of resin is maintained at the top to prevent air from being sucked into the laminate. Insofar as possible, air is excluded from the top of the PVA bag, and the bag is tied off tightly at the top.</p> <p>Another method is to apply vacuum prior to "stringing" the resin into the layup. In this procedure, the resin is poured into the top of the PVA bag, which is then tied off and vacuum is applied. The resin is then "strung" down into the layup.</p> <p>In both procedures, the hands must be used to force the resin from undercuts, considerable "stringing" downward must be done to remove bubbles, and "stringing" upward to remove excess resin.</p> <p>Low negative pressure should be maintained until the plastic has set (<b>Fig. 19</b>). Excessive vacuum will pull the resin from the laminate, causing "starving."<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. View of laminate of socket using vacuum technique. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Removal of Socket from Positive Model and Replacement of Polyurethane Foam Buildup with Silicone Foam</h3> <p>With the flare as a guide, a Stryker cast cutter is used to cut through the laminate along the outline of the socket. If a molded tongue has been attached to the positive model, care should be taken when making the cut on the lateral side. It is prudent to leave a little extra laminate for subsequent trimming.</p> <p>The polyurethane buildup for the location of the hip joint is removed from the positive model. The positive model is smoothed in this area, and a thin smear of vaseline is applied. A piece of lightweight stockinette is stretched over this part of the model and stapled in place.</p> <p>Using the back plate as a template, three 1/4-in. holes are drilled. The center hole is drilled with a 1/2-in. drill. The back plate is mounted in the socket with two bolts and nuts. The bolts should not be cut.</p> <p>The socket is replaced on the stump model and secured tightly with a web belt or friction tape (<b>Fig. 20</b>). It is in position for the injection of silicone rubber through the 1/2-in. center hole in order to provide support for the amputee over the area of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Socket replaced on stockinette-covered cast preparatory to injection of foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In choosing the silicone rubber to be used, it should be remembered that Silastic 386 Foam Elastomer is relatively soft and may not be capable of supporting the weight of the amputee, while Silastic 385 Elastomer forms a solid rubber which will, if used by itself, add considerable weight to the prosthesis. Accordingly, a mixture of 70 per cent by weight of 386 with 30 per cent by weight of 385 is recommended. This is poured into a caulking gun. The 386 catalyst-6 per cent by weight of the mixture-is added, and the mixture is spatu-lated for 25 seconds. Because of the small amount of catalyst, the viscosity of the Silastic, and the shape of the chamber of the caulking gun, it is very difficult to get a homogeneous mix if spatulated by hand. A mixing rod should be formed that can be used in conjunction with a 1/4-in. electric drill. A rotary up and down movement should be used, mixing for 25 seconds. It is then injected through the center hole of the spherical plate to fill the socket cavity (<b>Fig. 21</b>). The mixture will expand approximately four times its volume during foaming. If necessary, more of the same mixture is added until the cavity is filled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Injection of silicone foam through center hole of spherical plate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is removed from the cast. The silicone pad is removed and the nuts are removed from the two bolts. The spherical plate is attached to the socket with three 1/4-in. flat head bolts. The bolts should be locked tight with a locking compound. The bolts are threaded into the spherical plate with a screwdriver, but they should be tightened with vise grip pliers applied to the protruding threaded portion of the bolt. If this spherical plate is not tightened sufficiently, movement and noise will result. The bolts should then be cut and ground to maintain the spherical contour (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket with spherical plate attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The edges of the socket are sanded and buffed to provide a smooth radius.</p> <p>For fitting purposes, the foam pad is secured in the socket by means of friction tape. It can be glued to the socket when the prosthesis is being completed. The edges of cloth reinforcement on the foam should be trimmed, and the surface coated with a skin of Medical Silastic S-5391 Elastomer (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. View of silicone foam pad with stockinette reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Layout of Thigh Block</h3> <p>One method of determining the configuration of the thigh block is as follows:</p> <ol> <li>On a large piece of paper, line A is drawn to represent the length of the foot (<b>Fig. 24</b>). The distance from the end of the heel to the center of the ankle bolt is measured and marked on line A.</li><li>Line B is drawn perpendicular lo line A from the point representing the foot attachment bolt. The length of this line is the distance from the ischial tuberosity to the floor.</li><li>On line B a point is located equal to the height of the medial tibial plateau (MTP) plus 1 1/4 in. for adults. The location of the hip joint often causes the prosthetic knee lo protrude beyond the sound knee when the patient is in the sitting position unless the thigh is shortened and the shin is lengthened. Therefore, 1 1/4 in. is added to the dimension between the floor and the MTP.</li><li>Two inches above this point a 6-in. line is drawn to represent the attachment plate of an adjustable leg. This line is drawn 3 1/2 in. anterior of and 2 1/2<i> </i>in. posterior of line B.</li><li>A line is drawn at right angles to line B at its topmost point. This line, D, represents the height of the level of the seat of the ischium from the floor.</li><li>From a point 1 in. behind the heel, line E is drawn to intersect the prosthetic knee center (PKC) and the horizontal line D.</li><li>The socket is superimposed on the layout, with the joint attached and in a neutral position. The inner edge of the socket must fall on line D and the hip joint center must pass through line E.</li><li>The hip joint is adjusted so that the angle of the straps with line D is 73 deg. in order to maintain the 45 deg. originally planned for the placement of the hip joint.</li><li>The position of the side straps is marked and outlined, line F, and also the offset for the shoulder of the straps, line G.</li><li>There should be 1/4 in. of wood anterior to the hip joint. Therefore, from a point 1/4 in. anterior to the shoulder of the side strap outline, a line should be drawn connecting with the anterior end of the socket attachment plate line. (Angle <i>a </i>in <b>Fig. 24</b> is the flexion angle.)</li><li>From a point 1/4 in. posterior to the shoulder of the side strap outline, a line is drawn to form the posterior outline of the thigh block. Often, this is not a direct connection with the posterior end of the socket attachment plate line, as this would not provide sufficient thickness of wood for screws at the attachment plate of the adjustable leg.</li><li>An anterior view is drawn of the thigh section in which the proximal center point is offset the equivalent of the distance from the center of the artificial hip joint to the vertical support line on the prosthesis, less 1 in. (distance H in lower part of <b>Fig. 24</b>). This establishes the approximate angle of adduction needed in the thigh block. The objective is to place the artificial foot in the approximate amount of adduction.</li><li>The thigh block, of correct length, is positioned with the lateral side up and angle <i>a, </i>obtained from step 10 above, is inscribed upon it.</li><li>The thigh block is positioned with the posterior side up. A goniometer is placed with one arm parallel to the lateral side of the posterior wall; the other arm, set in the angle required, should lie across the posterior wall and connect with the flexion angle previously established. If the adduction required is excessive, it is sometimes necessary to bend the side straps. A bend of approximately 8 deg. is usually sufficient. Care must be taken not to produce nicks and notches in the side straps which may cause premature fracture.</li><li>The table of the saw is set at the adduction angle and a cut is made along the flexion line.</li><li>The hip joint is centered on the thigh block, and the width of the straps is marked. The outline of the straps should be left showing after the excess wood has been cut away. Enough wood must be left for the socket attachment plate. Care must be taken that the distance between joints is accurately reproduced on the thigh block, otherwise binding will result when the joint is assembled and shimming will become necessary.</li><li>The joint is clamped to the thigh block. After the two indicated 1/4-in. holes have been drilled, the joint is bolted to the thigh block.</li></ol> <h3>Bench Alignment of Prosthesis</h3> <p>Two general rules to be followed in the bench alignment of the prosthesis are: First, the socket should be the correct height above the floor, with the transposed point of the ischium directly over the center of the foot. Second, the knee should be set in slight hyper-extension so that a straight line drawn through the hip joint intersects the floor about 1 to 1 1/2 in. behind the heel.</p> <p>It is recommended that a SACH foot with a soft heel wedge be used. A knee extension aid is important; it is provided by a piece of 1-in. elastic which also functions as a stride length control. This is adapted for temporary use on the adjustable leg by mounting a piece of leather on the socket approximately 2 in. behind the hip joint in such a way that the elastic strap can pass through the attachment. For a woman, the extension aid is built into the knee mechanism and the socket bias strap is secured to the distal thigh block. One end of the elastic is screwed to the shin 2 in. down from the PKC, and the other end of the elastic is secured by a buckle mounted in the corresponding position on the other side of the shin. A keeper of 1/2-in. Dacron webbing, with a buckle, is positioned about 1 1/2 in. proximal to the knee bolt. This keeper should be adjusted so that it holds the bias strap anterior to the knee bolt center when the patient is standing and walking but allows it to pass posterior to the knee bolt center when the patient is sitting.</p> <p>Velcro offers a convenient method of closure for the lateral opening of the socket (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Arrangement of closure straps using Velcro. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the prosthesis is assembled, the axes of the hip joint and of the knee joint should be essentially parallel to the floor and at right angles to the line of progression.</p> <h3>Static and Dynamic Alignment</h3> <p>Satisfactory suspension of the prosthesis often depends upon the proper application of the socket (<b>Fig. 26</b>). The stump should be forced as far laterally as possible and the closure straps should be tightened alternately until the amputee is well supported. The ischial support strap should be secured last. The relief provided by the socket for the an-terosuperior spine of the ilium on the sound side is a useful guide in orienting the socket to the patient. The socket should then be checked for fit and comfort under weight bearing in the areas of the ramus, the coccyx, and the rib cage. Lateral stability of the socket should be evaluated by supporting the prosthesis against a chair and asking the patient to raise his good leg without leaning over the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Socket mounted on adjustable leg preparatory to dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment line from hip center through PKC to a point behind the heel should be verified for stability. It should be ascertained that the height of the prosthesis is correct; that the extension bias strap is forward of the PKC; that there is no friction in the knee joint; and that the bumper and stop are in contact. The patient should not be in a forced position of lordosis, and the socket should not exert pressure proximally in the back. If either of these conditions exists, the bumper is contacting the stop too soon and the socket should be tilted backward by means of the adjustable hip joint. If the bumper is not in contact with the stop, correction should be made by adjustment of the hip joint.</p> <p>The amputee should then sit upright in a hard chair, and the anterior distal portion of the socket should be inspected for clearance of the thigh. If the amputee tends to lean to the amputated side, the exterior gluteal area of the socket should be built up with foam for support and to improve cosmesis. It should be ascertained that there is no pressure between the proximal edge of the socket and the rib cage; that the thigh block clears the chair; that the shank is vertical; that the prosthetic knee axis does not protrude excessively beyond the normal knee center; that toe-out is approximately correct; and that the extension bias strap is holding the shank in flexion.</p> <p>In training the amputee to walk, he should be impressed with the importance of standing upright by holding his hands parallel to or slightly posterior to the long axis of his body. If he leans forward to watch his feet, the hip bumper will not contact the stop, making it impossible to propel the leg forward. He should alternately bear his weight on the prosthesis and then lift it clear of the floor. To initiate flexion of the knee, the amputee should be instructed to "scoop" his stump and pelvis forward and flex his spine. This should be jepeated a few times and the bias strap ad-rusted to obtain the proper stride length.</p> <p>The amputee should be instructed to take a few steps. If the knee appears unstable just after heel contact, the durometer of the heel wedge should be checked, and it should be determined whether the shank is reaching full extension; whether the knee is in some hyper-extension; whether the hip joint is contacting the stop before the foot is flat on the floor; and whether the alignment line runs correctly from the center of the hip joint through the center of the knee joint to 1 1/2 in. behind the heel of the shoe. To eliminate medial or lateral whip, rotational adjustments are necessary at the knee or hip axis.</p> <p>Many amputees wear a stump sock, which decreases the friction between the patient and the socket during the stance phase and loses some of the socket's support. To increase the friction, it is sometimes advantageous to line the lateral aspect of the socket with a rubber material or with horsehide.</p> <p>If toe clearance is still a problem, the length of the prosthesis should be reduced. The hemipelvectomy amputee will tend to vault on the sound foot to increase the clearance of the prosthesis. This tendency should be minimized as much as possible, but it must be remembered that the patient cannot "hike" his pelvis on the amputated side since there is no remaining skeletal structure. Where obesity is a problem, it is sometimes necessary to use a shoulder strap to aid suspension.</p> <p>If the patient experiences rotational instability in the socket, a "teardrop" cutout on the lateral aspect of the socket will help to alleviate the problem and to aid suspension. The cutout should be approximately 2 in. wide at the lateral proximal edge of the socket and extend three-quarters of the length of the socket (<b>Fig. 27</b>). The foam insert in the socket should be removed before the panel is cut out. The edges of the panel should be sanded smooth to prevent cracking. A strap and buckle or Velcro should be attached proxi-mally for closure of the cutout. When the prosthesis is donned, this strap should be loose and should be tightened last.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Teardrop opening in socket on amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Duplicating and Finishing</h3> <p>For duplicating and finishing, the socket is removed and the duplicating jig is used; excess wood is removed from the thigh block and the block is faired into the knee; the knee, thigh, and shin sections are laminated; the keeper for the extension bias strap and all straps and buckles are riveted; and the prosthesis is reassembled (<b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Finished thigh block in reassembled prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Thigh Fairing</h3> <p>The chief purpose of the thigh fairing is to compensate for the differences in circumference between the thigh block and the sound leg, both in standing and in sitting. This must be done without impairing the function of the prosthesis.</p> <p>A light, articulated fairing has been developed at the Northwestern University Prosthetics Research Center. It utilizes a piece of 1/32-in. light aluminum alloy, 1/8-in. Kemblo rubber, and lightweight horsehide, with Velcro for closing. It is pivoted distally by two screws just superior to the knee bolt and fastened proximally by a snap fastener to the anterior wall of the socket.</p> <p>A piece of cardboard is used to make a pattern for the aluminum (<b>Fig. 29</b>). Distally, it should be wide enough to receive the pivot screws approximately l 1/2 in. superior to and vertical to the knee bolt center. Anteriorly, it forms an upward arc. To allow the pivot action, the posterior section is open and the anterior proximal section is cut away so that the socket can be fully flexed without touching the cardboard. The posterior medial and lateral edges govern the amount of anterior displacement of the fairing in the sitting position and the fullness of the thigh in the standing position. In the sitting position, both edges should be in full contact with the seat of the chair (<b>Fig. 30</b>). The cardboard pattern should fit close to the anterior thigh block in the standing position and should be cut and formed to allow the medial and lateral contours of the Kemblo rubber fairing to blend in with the contours of the socket (<b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cardboard used as template for metal portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Template shown on prosthesis in sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Contouring rubber portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the aluminum has been cut out, it is formed to the desired shape and attached with a screw to the knee. A sheet of 1/8-in. Kemblo rubber is wrapped around the metal to obtain the desired fullness (<b>Fig. 32</b>). The Kemblo should be long enough to start at the distal end of the aluminum and fair in proximally to the contours of the socket. The distal edge is skived to blend in with the metal form. The anterior proximal edge of the Kemblo should come up to meet the socket in the sitting position. The posterior proximal edge should meet the socket during the stance phase. The Kemblo is glued to the aluminum form.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Open view of completed thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Kemblo rubber is covered with lightweight horsehide, and the leather is rolled over the edges of the rubber.</p> <p>The fairing is attached to the socket anteriorly by means of a snap fastener. The leather continues from the medial and lateral sides to produce a triangle anteriorly with enough slack to allow displacement of the fairing in the sitting position. In the standing position, the attachment should return the fairing and eliminate any slack in the attachment area.</p> <h4>Acknowledgments</h4> <p>For valuable assistance in the development of this prosthesis (<b>Fig. 33</b>) and for help in the preparation of this article, I am most grateful to Colin A. McLaurin, B.A.Sc, Robert G. Thompson, M.D., H. Blair Hanger, C.P., Edwin A. Bonk, Mary Farnan, Walter Horiuchi, and Paula Hamilton.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. View of finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Schematic drawing (not to scale) for layout of thigh block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Lyquist, Eric, <i>Canadian-type plastic socket for a hemipelvectomy, </i>Artificial Limbs, Autumn 1958, pp. 130-132.</li> <li>McLaurin, Colin A., and Fred Hampton, .4 <i>method of taking hip disarticulation casts using hip sticks, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 71-77.</li> <li>McLaurin, Colin A., and Fred Hampton, <i>Fabricating hip disarticulation sockets using the vacuum method, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 66-70.</li> <li>Radcliffe, Charles W., <i>The biomechanics of the Canadian-type hip-disarticulation prosthesis, </i>Artificial Limbs, Autumn 1957, pp. 29-38.</li> <li>Slocum, Donald B., <i>An atlas of amputations, </i>C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</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">At sea level, the atmosphere will support a column of mercury 30 in. high. Most vacuum gauges, therefore, are calibrated in inches of mercury (in. Hg.), reading from 0 to 30. 10 in. Hg. negative pressure means 10 in. of mercury below atmospheric pressure.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">McLaurin, Colin A., and Fred Hampton, Fabricating hip disarticulation sockets using the vacuum method, Orthop. &amp;Pros. Appl. J., June 1960, pp. 66-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Pelron Corp., Lyons, 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">NHJ-100, Hosmer Corp., Santa Clara, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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., The biomechanics of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 29-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Hampton, .4 method of taking hip disarticulation casts using hip sticks, Orthop. &amp;Pros. Appl. J., June 1960, pp. 71-77.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Lyquist, Eric, Canadian-type plastic socket for a hemipelvectomy, Artificial Limbs, Autumn 1958, pp. 130-132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Slocum, Donald B., An atlas of amputations, C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-10.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-11.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-12.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-13.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-19.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 A Hemipelvectomy Prosthesis Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/527872ee9190fb7a616b0cc70410fbe0.pdf f629c37fa67f701c4b6aea78de76a2a8 https://staging.drfop.org/files/original/a6f09a9bde0aec6c464fbc7043e3fe3b.jpg 8ddc8354987eee1ddb5c98b5d7c77ca5 https://staging.drfop.org/files/original/626f567e943aaa264fa84b5f0333edda.jpg 63014457b9280ffcc858cd9079ba37fd https://staging.drfop.org/files/original/01833bc5541285c909871999020cb9b4.jpg 5fa7af520e891c8f39caf1685065aa51 https://staging.drfop.org/files/original/c3e424fe1ec3be458e58896700d78c4d.jpg 989474fa8119838ea695f94be3cd81cc https://staging.drfop.org/files/original/7a548b290f3da58ff06158588e81e48b.jpg bbbff8ef694a7d53e8ff5f8cf4f70251 https://staging.drfop.org/files/original/4c93630c0224b3c1f43af6f6fbfba87d.jpg 70057c8df762d2494a1232ee7ec2e860 https://staging.drfop.org/files/original/9eabbcd76d348b28f55b9cd7bd0c370a.jpg 03f397225e0cf2ba7432c561fb26e3c9 https://staging.drfop.org/files/original/d3a357f008aed8a49e631b01e0fc41f2.jpg ab424dfa71fd3027cd0b18f150597dc7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_028.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 28 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_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>Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>The need for a functional and cosmetically acceptable artificial hand for juvenile amputees has existed for many years. A voluntary-opening hook which has been available for a number of years in a variety of sizes was until recently invariably prescribed for children. In response to the demand on the part of both children and parents for a functional device with a more natural appearance, the Army Prosthetics Research Laboratory (now known as the Army Medical Biomechanical Research Laboratory) undertook in 1958 to develop a child's voluntary-opening hand. Earlier studies<a></a> had shown that a spectrum of five sizes should satisfy the needs of the entire arm-amputee population from childhood to maturity. Size No. 1 was the designation given to the smallest. Because it was hoped that a mechanism developed for the Size No. 1 hand might be suitable for use also in Size No. 2 and perhaps in Size No. 3, the smallest size was given the first priority. The Sierra Engineering Company<a style="text-decoration:none;">*</a> contracted to manufacture this hand and two other companies (Kingsley Manufacturing Company<a style="text-decoration:none;">*</a> and Prosthetic Services of San Francisco<a style="text-decoration:none;">*</a>) were enlisted to manufacture suitable cosmetic gloves.</p> <p>Following preliminary testing of a prototype model, modifications to eliminate certain shortcomings were incorporated in 50 production models. A field test was initiated in April 1960 with evaluation of the cosmetic gloves included as an integral part of the study. Preliminary findings based upon experiences in fitting 20 children indicated that the hand was acceptable cosmetically and provided satisfactory function in the activities typically performed by children.<a></a> The general workmanship and cosmesis of the gloves provided by both manufacturers had also achieved a satisfactory level after certain initial fabrication difficulties. However, several problems had been identified, the most serious of which was a lack of glove durability. Ridges and sharp edges on the exterior of the hand apparently contributed to rapid glove damage.</p> <p>Accordingly, the original production-model hands were modified and then refitted to the subjects of the field study. Modifications included eliminating the glove-cutting edges, strengthening the floating-finger attachments and the spring mechanism of the thumb, and raising the cable exit. In November 1960 "old" hands revised in this manner began arriving at New York University Child Prosthetic Studies, and in April 1961 the manufacturer produced a series of new hands which incorporated all the modifications.</p> <p>An Interim Report<a></a>, summarizing the results of the field study to mid-May 1961, was prepared for the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, and the results reinforced earlier findings concerning the acceptability of the hand and gloves. The APRL-Sierra Child-Size No. 1 Right Hand was accepted as satisfactory for general use by child amputees on the basis of this report, and the study was terminated in the latter part of 1961.</p> <p>Following the generally successful outcome of the evaluation of the Size No. 1 Right Hand, manufacture of the Size No. 1 Left Hand was initiated. In May 1961 NYU Child Prosthetic Studies reported the results of a preliminary examination of two units manufactured by the Sierra Engineering Company<a></a>. The hands appeared to be of excellent quality and workmanship with minor exceptions, and in June 1961 the manufacture of 55 additional left hands was authorized for field-test purposes.</p> <p>During September and October 1961, NYU Child Prosthetic Studies received two shipments totaling 40 hands from the manufacturer. These were found to be unacceptable because of engineering deficiencies, and all were returned for modification. In February 1962, 37 hands were finally accepted for use in the field study. Another 14 hands submitted later were also found to be acceptable, making a total of 51.</p> <p>Another Interim Report<a></a> on the status of the field study was submitted at the October 1962 meeting of the Subcommittee on Child Prosthetics Problems. It was reported that the APRL-Sierra Child-Size No. 1 Left Hand was considered to be essentially satisfactory both mechanically and functionally, although more rigid quality control in manufacture and assembly was desirable. The recommendation of this report that the hand and cosmetic glove be approved for commercial distribution was accepted by the Subcommittee and the study was terminated in January 1963.</p> <h3>Purposes of the Studies</h3> <p>The APRL-Sierra Child-Size Mo. 1 Hand (both right and left) was developed to provide the juvenile amputee with a cosmetically acceptable terminal device which would closely resemble the normal hand in size, shape, and coloring. Maximum function-commensurate with cosmesis, simplicity of operation, adequate strength, and reasonable cost-was a concomitant objective.</p> <p>Since the field study of the left hand was essentially an extension of the study of the right hand, the general goals of both evaluations were identical:</p> <ol> <li>To introduce the hand into clinical use.</li><li>To corroborate findings of laboratory studies.</li><li>To determine the acceptability, utility, application, and durability of the production-model hand and glove.</li><li>To investigate indications and contraindications for prescription.</li></ol> <p>In the light of the experience gained in the study of the right hand, three considerations were given closer attention in the study of the left hand:</p> Performance differences between the experimental hand and the hooks previously worn were investigated in greater detail than was the case in the study of the right hand. The short wear-life of the cosmetic gloves used in the study of the right hand presented a definite and challenging problem. In the course of the study, the exterior of the experimental hand was extensively modified to eliminate sharp edges which might contribute to glove damage. The effectiveness of these changes was of particular interest in the study of the left hand. The effect of wearing the hand on the child's school behavior was a planned aspect of the study of the right hand. Data secured on this significant subject were limited, however, since the study overlapped two school years. With the earlier commencement of the study of the left hand (February 1962), these data were obtained for some children fitted during March and April 1962. <h3>Description of the Hand</h3> <p> The APRL-Sierra Child-Size No. 1 Hand (both right and left) consists of a monocoque hand shell of cast aluminum, articulated index and middle fingers, a "two-position" thumb, and nonarticulated but flexible ring and little fingers. A voluntary-opening type of mechanism is housed within the hand shell and the entire unit is covered with a thin plastic glove that can be replaced as warranted ( <b>Fig. 2</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. APRL-Sierra Child Size Model No. 1 Hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The index and middle fingers each consist oi three aluminum castings which, along with a portion of the hand shell, form a four-bar linkage to provide coordinated articulation at points corresponding to the metacarpophalangeal and the proximal interphalangeal joints ( <b>Fig. 3</b> ). This arrangement results in a minimum amount of glove distortion through the range of motion required. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Cutaway views of the APRL-Sierra Model No. 1 Hand (3). When no tension is applied to the control cable B, spring D forces the index and middle fingers toward the thumb to provide prehension of the three-jaw-chuck type. Tension in the control cable B causes the quadrant C to rotate about point A, a point displaced from the true center of quadrant C. The cam action thus provided by the outer edge of the slot in quadrant C against roller G forces lever E to rotate counterclockwise about point F, in turn causing the index and middle fingers to open. A small brass plate is mounted within lever E in such a fashion that, when little or no tension is applied to the control cable, the plate wedges against the periphery of the quadrant C. The wedging action, known as "Bac-Loc," resists opening of the fingers when force is introduced through the finger linkage but has no effect on the system when force is applied through the control cable.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The thumb is an aluminum casting mounted to the hand shell through a locking mechanism that permits it to be held in either of two positions-one for maximum opening between fingers and thumb, the other for a smaller opening for conservation of excursion.</p> <p>The ring and little fingers, the two consisting of a one-piece casting of foam rubber, are simply fastened to the hand shell and left to move with the cosmetic glove.</p> <p>A threaded stud (1/2 x 20) attached to the wrist section of the hand is provided for use with currently available wrist units.</p> <p>Maximum allowable weight is 6 3/4 oz. (without the glove). Less than 9 lb. of tension in the control cable (measured at the point of entry into the hand) is needed to open the fingers and a minimum of 2 lb. of prehension force is provided.</p> <p>Cosmetic gloves for the hand are available in a minimum of seven Caucasian and six Negroid shades from each manufacturer.</p> <p> <b>Sample</b> </p> <p> The sample, which included a variety of upper-extremity types, consisted of 77 subjects, one of whom was fitted with hands bilaterally. All the children in the study, except two, had previously worn Dorrance-type hooks ( <b>Fig. 4</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Boy wearing Dorrance hook.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A total of 39 children, of whom 36 were unilateral arm amputees, were fitted with the right hand ( <b>Table 1</b> ). Of the three remaining subjects one (with bilateral shoulder-disarticulation amputations) was fitted with a right hand only and continued to wear a hook on the left side; one (with right above-elbow and left short below-elbow amputations) was also fitted with a right hand and retained a hook on the left; and a triple amputee (with bilateral long below-elbow and left knee-disarticulation amputations) was given hands on both sides. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This last subject was included in both the right- and left-hand samples.</p> <p> Thirty-nine children, of whom 36 were also unilateral arm amputees, were fitted with the left hand ( <b>Table 2</b> ). Of the three remaining subjects one amputee (with bilateral shoulder-disarticulation amputations) was given a left hand only; a triple amputee (with bilateral long below-elbow and right below-knee amputations) received a left hand and kept a hook on the right; and the third subject was the aforementioned triple amputee who was included in both samples. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <b>Procedures</b> </p> <p> The fittings in both the Right- and Left-Hand Studies were conducted through the clinics participating in the Child Amputee Research Program. <a style="text-decoration:none;">*</a> In order that wearers of the hand might secure the longest possible wear period before growth of the child caused an objectionable size discrepancy, it was recommended that the clinics select candidates whose nonamputated hand size was such that they should be able to wear the experimental hand for at least a year. </p> <p>The experiences of the clinics were evaluated on the basis of: first, the reactions of the children, their parents, and others to the experimental hand and to other previously worn terminal devices; second, observations of classroom behavior during the treatment period; third, ratings of the children's performance of standard prehensile tasks using the experimental and old terminal devices; and fourth, maintenance.</p> <p>In the course of the studies the children were required to make four visits to the clinic servicing them during a minimum period of five months.</p> <p> <b>First Clinic Visit: Screening</b> </p> <p>A screening session was conducted during the first visit. The children and their parents were oriented to the purpose of the survey, the number of visits required, and the need to follow through with experimental procedures.</p> <p>Parents and children expressing a willingness to participate selected glove shades from shade guides provided by both manufacturers. Neither the experimental hand nor a complete cosmetic glove was shown to the patients or their parents during the first visit. A selection form, recommending the child as a participant in the study and furnishing information concerning him, was completed and sent to the NYU Child Prosthetic Studies.</p> <p>The candidates were evaluated on the basis of information provided on the selection form and sampling requirements. Upon approving a candidate NYU sent the clinic a hand and glove for the child and a questionnaire to be completed by the child's classroom teacher prior to fitting the experimental hand.</p> <p>The questionnaire pertained primarily to the child's psychosocial adjustment to the school environment. The teacher was asked to fill out the questionnaire before the experimental hand was fitted and to fill out a similar form at the conclusion of the study. The purpose of this procedure was to determine whether the child's behavior or performance with a prosthesis in school was affected as a result of wearing the experimental hand. In order to provide comparability of data, it was important that the same teacher provide both pre- and post-fitting observations.</p> <p> <b>Second Clinic Visit: Fitting</b> </p> <p>At the second clinic visit a prosthetic performance test utilizing the old terminal device was administered and the reactions of children and parents to the old device were ascertained. The child was fitted with an experimental hand and initial reactions to the new component were secured from child and parents. The child and parents were then given instructions that the experimental hand was to be worn exclusively until the next clinic visit two months later.</p> <p> <b>Third Clinic Visit: Two-Months Post-Fitting Evaluation</b> </p> <p>Two months after the fitting the reactions of child and parents to the new component were again recorded at the clinic. Comparisons between old and new terminal devices with respect to weight, ease of operation, and usefulness were noted, and a prosthetic performance test, in which first the new hand and then the old terminal device were evaluated, was also conducted. The parents were then told to permit the wearing of either the old or the new terminal device as the child desired and were scheduled for a further clinic visit two months later.</p> <p> <b>Fourth Clinic Visit: Final Evaluation</b> </p> <p>The final evaluation was conducted four months after the initial fitting. The reactions of child and parent to the new hand were again obtained, and the old and new devices were compared in the same manner as earlier. The clinic summarized its data on a form provided for the purpose, and the child's classroom teacher was asked to complete another questionnaire.</p> <h3>Results-Subjective Reactions</h3> <p> <b>Parent and Child Preferences</b> </p> <p>At the conclusion of the test period, the 77 children participating in the study and their parents decided almost unanimously in favor of retaining the experimental hand with only seven rejecting it completely. In contrast to these seven rejections, 21 children expressed a desire to wear the hand exclusively. The remaining 49 children took intermediate positions ranging from a predominantly-hand to a predominantly-hook preference. All in all 42 children and their parents clearly preferred the hand; 15 were ambivalent or offered contradictory opinions; 20 preferred the hook.</p> <p> <b>Hand Used Exclusively</b> </p> <p>Of the 21 children (13 girls and 8 boys) who chose to wear the hand exclusively, 20 were prior hook wearers, one had previously worn a Becker Plylite hand, and one had never worn a prosthesis before because his parents had refused to accept a hook. Cosmesis was extremely important to this group and was often the only factor mentioned by the child.</p> <p>JM, a long below-elbow amputee who was 6 years and 11 months old at the initiation of the study, is typical of the children in this category. When asked what he liked about the hand after four months' wear, he replied, "I like it-the way it looks." He disliked the appearance of the hook and could think of nothing favorable to say about it or anything unfavorable to say about the hand. The hand functioned better, he said, and was important to him for use at school. Schoolmates stared at first, but liked it. JM's mother thought he had better function with the hook, but only because he had not had the new hand very long. She also remarked that he should wear the hand all the time because "it gave him more confidence." The hook's only contribution was that it prepared the child for the hand, she said.</p> <p>Sandra, a short below-elbow amputee, was 5 years and 9 months old at the beginning of the study. She cited better function as the reason for preferring the hand: "...can move things better-holds lots of things better." She disliked nothing about the hand, liked nothing about the hook, and said she wanted to wear the former all the time. Her mother preferred the hand for reasons both of appearance and grasp; schoolmates found it easier to hold on to when playing games, and it didn't slip when the child tied her shoes. Sandra should not wear a hook at her age, her mother declared.</p> <p> <b>Hand Used Predominantly</b> </p> <p>The hand was the terminal device of choice for an additional 21 children (15 girls and 6 boys). The hook was preferred for rough outdoor activities in which hook function was superior.</p> <p>Typical of the group was Curtis, age 5, a very short below-elbow amputee, who liked "everything" about the hand: it resembled his other hand, held paper when he wrote, and grasped a baseball bat better. However, he felt that the hook was lighter, was easier to open, and superior for playing with certain toys. His mother was pleased with the appearance of the hand, Curtis's attitude toward it, and the fact that other children were willing to hold it in games. However, she thought he should wear the hook at home for activities that might damage the glove. During the last two months of experimental wear, when parents and children could choose which device would be worn, Curtis used the hand exclusively, except when repairs were required.</p> <p>Diana, age 5, a short below-elbow amputee, expressed a desire to wear the hand most of the time and the hook only for swimming (sic!). The reason for her preference was that "it looks like my other hand." Earlier she had found the hand somewhat harder to operate and had experienced difficulty releasing it from bicycle handles. Her mother was concerned about tears on the glove fingers, but Diana said, "It doesn't matter what the glove looks like." Her mother agreed that the hand should be worn in most circumstances, but thought the hook could be used for swimming and as a replacement in case the hand broke.</p> <p> <b>Hand and Glove Used About Equally</b> </p> <p>Seven children (5 girls and 2 boys) and their parents desired to retain both hook and hand and to use them on an approximately 50-50 basis. For example, Carol, an 8-year-old short below-elbow amputee who lived on a farm, preferred the appearance of the hand: "It gives me another hand and people don't stare"; and the function of the hook: "I don't drop things with the hook or worry that someone might bump into me and knock them out of my grasp." She also was concerned about tearing the glove. Carol chose to wear the hand both to regular and Sunday school and the hook for farm chores and play. Her father agreed with the child's viewpoint. He thought the glove not rugged enough, but the hook handy and sturdy.</p> <p> <b>Parent and Child Disagreement</b> </p> <p>There were eight children (6 boys and 2 girls) whose primary choice of terminal device differed from that of their parents. In five instances, the child chose the hand and the parent the hook; in the other three cases, the positions were reversed. The basis for disagreement was usually a relative emphasis upon appearance and function.</p> <p>Michael, age 6, whose partial hand amputation was fitted as a wrist disarticulation, was pleased that the hand "looked like my other one," but acknowledged that the hook was lighter and easier to use. If he could retain only one device, he would choose the hook, since he could do much more with it; however, his mother and friends preferred the hand.</p> <p>The latter were sometimes afraid of the hook. Michael's father preferred the hand for cosmetic reasons and cited other advantages: "... more chance to play cowboy and wrestling . . . children not afraid . . . danger of bumping into others when playing with the hook."</p> <p> <b>Hook Used Predominantly</b> </p> <p>Six boys and seven girls preferred the hook for daily use and the hand for dress occasions. Five of the children were under 5 years of age (one, age 3 and four, age 4), and four of these had not yet attended primary school, kindergarten, or play school. Eleven of these children rated the hook function better and ten specifically said the hand was heavy or hard to operate; one older boy complained that the hand did not afford a tight grasp and a younger girl said the hook held things in a better position. Parents of twelve of these children declared hook function was better; the other parent expressed no preference.</p> <p>Danny, with an elbow disarticulation and split-ray hand, was the youngest child in the study-barely 4 years of age when fitted with the hand. To open it, he had to hold his elbow completely extended with maximum tension on the cable. Even in this position, full opening required more effort than he typically cared to exert, although he was pleased that the hand looked like his natural one. Danny stated that the artificial hand was heavier and harder to operate than the hook and did not pick up objects as well. The hook was better for grasping a swing chain and for holding his bread to push food. The child's mother hoped that his skill with the hand would improve, but after four months she reported that he wore it only for "going visiting." She thought the hand would be of greater use when he was older.</p> <p> <b>Hand Rejections</b> </p> <p>In view of the fact that complete rejection of the experimental hand was rare, it is interesting to note the instances when it occurred. Seven children rejected the hand completely; four of these were 4- or 5-year-old boys, one was a 7-year-old girl with bilateral shoulder disarticulations, and the other two were a boy and a girl, both 9 years old, who were excellent users of their hooks and apparently were not concerned with the appearance of this device. Various factors contributed to these rejections. Several of the younger boys and the 9-year-old boy and girl obtained better function with the hook and seemed relatively unmindful of appearance. The bilateral shoulder-disarticulation amputee was a marginal user of any prosthesis and found the increase in operating forces and the difficulty of positioning the hand without a wrist-flexion unit intolerable. Three children experienced excessive hand malfunctions and two others, because of frequency of glove damage or difficulty in getting replacements, wore unsightly gloves for prolonged periods.</p> <p> <b>Age and Sex in Relation to Acceptance Level</b> </p> <p>The data contained in the last two categories of acceptance level (Hook Used Predominantly and Hand Rejections) suggest that age is a strong consideration governing hand or hook preference. Such a relationship would not be surprising, since younger children may be expected to: first, experience difficulty with hand weight and operating forces because of limited physical development, and second, be more careless in their use of a device, less concerned with the niceties of appearance, and would not be subject to the social pressures of the school environment.</p> <p> Age, however, cannot be regarded as an absolute criterion, since several of the children in the study who selected the hand as their primary choice were 4-year-olds. In fact, when the age and sex of the children are tabulated against indicated levels of preference ( <b>Fig. 3</b> ), sex appears to be more significantly related to choice of device than does age. Thus, girls of all ages for whom the hand is of appropriate size appear to be potentially the best candidates for the No. 1 Hand, while younger boys would seem to be less likely to accept the device. </p> <p> <b>Effects on School Adjustment</b> </p> <p>The questionnaire to be completed by the classroom teacher was designed to secure pertinent information concerning the behavior of the child in school while wearing the old terminal device and the experimental hand respectively. It was hypothesized that the child's classmates and teacher might react more positively to a hand than they had to a hook and as a result adjustment of the child to the school situation would show discernible changes. This type of improved behavior had been noted previously when a child who had been a nonprosthesis wearer was fitted for the first time.<a></a></p> <p>Historically, two significant problems frequently encountered by juvenile amputees wearing hooks to school have been the indignity of being called "Captain Hook" and similar names by classmates and refusal by other children to hold their hooks in hand-holding games. Elimination or reduction of these difficulties was anticipated when the child was fitted with a functional terminal device that closely resembled a normal hand.</p> <p>The teacher's opinion was obtained concerning various aspects of the child's school behavior: attendance, homework, conduct, friendships, social participation and leadership, and extent of use of the prosthesis. As provided in the study plan, the teacher's questionnaires were to be completed twice: once while the child was still wearing a hook, and again after four months of hand wear when the child would presumably have acquired sufficient skill in the use of the hand, and changes in school behavior would have had an opportunity to develop.</p> <p>When it became apparent that a majority of the children in the Left-Hand Study would not have worn the hand for four months before the end of the 1961-1962 school year, the original plan was modified to provide for completion of the second questionnaire just prior to the end of the academic year regardless of length of time the hand had been worn.</p> <p>Unfortunately, comparable hook-and-hand questionnaires (that is, both completed by the same teacher) are available for only 16 of the 77 children in the sample. The majority of the remaining 61 children were of pre-school age or were fitted with the hand toward the end of the school year or during the summer, so that they did not have the same teacher at the beginning and the end of the study. The data from the teachers' questionnaires were, therefore, supplemented by information concerning school and personal adjustment from other sources wherever available.</p> <p> <b>Reactions and Representative Comments</b> </p> <p>Of the 29 boys and 21 girls in the sample who were 6 years of age or over, 26 boys and 21 girls were either wearing the hand in school at the termination of the experiment or stated that they intended to do so when the fall term began. Included in this group were four of the children whose preferred device was the hook. Nevertheless, they wore the hand to school. One boy, age 8, summarized the opinion of these four children when he said, "I wear it because the kids like it better."</p> <p>As mentioned previously, a number of children reported that prior to using the hand they had been called "Captain Hook" by other children and that this had disturbed them. There is considerable evidence that the effects of this name-calling can be quite destructive to social relations among children. One girl, in fact, refused to wear the prosthesis to school after such an incident. When the hand was worn these difficulties tended to disappear. The essence of the reaction to and acceptance of the hand may be gathered from the large number of favorable comments made by playmates, schoolmates, teachers, and others.</p> <p> Representative statements <i>reported by the children</i> included the following: </p> <p> "My schoolmates were excited about the hand because I have five fingers on the left hand now." <br /> "It smells nice, looks nice, and works nicer than the hook." <br /> "I like the feel of the hand; it looks real." "One little girl thought my hand had grown back." "They said it was prettv. The girls aren't scared of it." <br /> "I wanted to look at it. I always wanted to know when I was going to get it. It drives me out of my mind." "My school friends stared at first; they liked it." "At school they all liked the looks, especially how real it looked, including the fingernails." <br /> "Kids like to see the way I can bend the fingers (floaters) all the way back. They like to feel it. One boy bit it to see what it would do." </p> <p> Representative reactions <i>reported by the parents</i> included these remarks: </p> <p> "They were surprised when they found out he could move the fingers and thumb." <br /> "Children in school were not aware of his prosthesis until he wore a short-sleeved shirt. They displayed curiosity and then seemed to be very casual." <br /> "In many cases the fact that it is not a natural hand has had to be brought to their attention, even when it was worn without long sleeves." <br /> "Danny will start school this fall and the principal was amazed to see the hand. He said he had to look twice to make sure it was the same child. Danny's playmates were sure he had gotten a 'real' hand." <br /> "His friends are afraid of the hook. But with the hand, they will take hold of it and play games." <br /> "The child said she used to like the hook and wore it all the time, but now some of her friends don't like it and are afraid of it." <br /> "Her schoolmates noticed the change and they completely accepted it. Her sisters were quite proud and anxious for their friends to see she had a new hand." <br /> "When he played games with other children, most of them were afraid to hold his hook. Since he's worn the hand they aren't afraid." <br /> "Cindy is happy about the better attitude of the children around her, especially in school." <br /> "She said that one of her best friends 'almost fainted,' she was so delighted to see her with two hands." <br /> "The appearance has done wonders for her at school." <br /> "The children at school crowded around him and asked to see how it worked." <br /> "Her friends had called her 'Captain Hook' (when she wore the hook). Little ones cried and would run away from her, afraid. We actually had to bribe her to wear the hook to school. Now we have no difficulty getting her to wear her arm with the hand all the time." <br /> "Children don't call him names ('Captain Hook')." <br /> "School children are delighted and fascinated with the hand." <br /> ". . . interested because it is different; want to see how it works. Betsy will show it." <br /> "It is easier to hold on to when playing games." <br /> "The change from the hook to the hand caused a lot of questions to be asked at first. But it was soon accepted." <br /> "Danny wore the hand every day for two weeks and some of his classmates were not aware that it was not his own hand." </p> <p> Only a few <i>children</i> volunteered negative remarks: </p> <p> "His brother got scared of the hand, but later liked it." <br /> "Sister afraid of it at first." <br /> "Pammy (sister) thought it was a 'weirdy.' " </p> <p> <b>Attendance, Preparation, and Conduct in Class</b> </p> <p>The teachers' reports concerning the children's attendance, preparation, and conduct in class yielded very little information of significance. Only one child (a triple amputee) was considered below average in attendance as a result of absences related to his prosthesis. The factors of preparation for class and conduct showed slight changes in ratings from the first to the second questionnaire, but there were no differences specifically attributable to hand wear.</p> <p> <b>Friendships, Participation, and Leadership</b> </p> <p>Ten of the 16 children for whom teachers' questionnaires were available appeared to have achieved excellent to adequate adjustment and participation in class with both the hook and the experimental hand. Despite these satisfactory relationships, these children still found the appearance of the hand advantageous in the school setting as a means of decreasing social prejudice. Several of these 10 children remarked that their classmates were now more willing to hold hands in games and seemed friendlier. This pattern of increased acceptance tended to enhance the self-concept of the children in the study.</p> <p>Five children were reported as improved in class participation or friendships after being fitted with the artificial hand, although the prosthetic performance of two of this group was considered to have deteriorated. However, the improvement in appearance was obviously more important than the decrease in function. For this small group of children regardless of their skill in or amount of hand usage there was a discernible change in the type and extent of their social interactions. This took the form either of an increased number of social contacts with various children or of an improved relationship with one or two selected classmates.</p> <p>An example of the personal importance attached to the hand is apparent in the report of one child's physical therapist which describes his behavior after being fitted:</p> <p>"On the way back on the train, Randy patted his hand against his face and scratched the tip of his nose several times before settling down to sleep. Until then, he couldn't keep his eyes off it, and when he lay down he put the hand on his chest 'for all the world to see.' As we neared Bloomington, he wondered if we shouldn't go by the school because 'perhaps Mrs. Sheveland (the teacher) will still be there.'</p> <p>"After dinner he put his prosthesis on and toured the neighborhood to show everyone his hand. His mother reportedly was greatly pleased; so much so that she could not hold back the tears on more than one occasion during the evening, so that when Randy said his prayers, she had to leave the room. He wanted to wear his hand to bed but when his mother explained that it had to be put into the plastic bag, he accepted the explanation.</p> <p>"This morning he arrived at school in 'clam-digger' pants and a long-sleeved shirt. He had told his father yesterday that if he wore long-sleeved shirts no one would ever know his hand was not real."</p> <p>Other examples of the significance of the hand follow:</p> <p>"The teacher said the boy is actually using the hand more than he had ever used the hook. (This was in spite of the fact that all reports indicated that his functional capabilities with the hook were greatly superior.) His mother said, 'We were very pleased that he had the hand for his first Holy Communion.'</p> <p>"The nun said Randy did not need to hold hands in prayers or going to and from the altar, since she thought this might be a difficult thing to do, but he did as the other children were doing and was very proud."</p> <p>Another child, Sheila, had reconciled herself to the reluctance of other children to hold the hook:</p> <p>"Some children don't like to touch it (the hook), but I know a girl who has long fingernails and I don't like to touch her hands, either. When I first got it, I thought the kids in school will be surprised. They will think I don't belong in a crippled children's school!"</p> <p>Another child, Philip, used his artificial hand to shake hands.</p> <p>The last of the 16 children for whom data were available, a girl of 6, did not have a good relationship with her teacher or with the other children. There was no discernible improvement in the situation after she was fitted with a hand. Still, by the time of the second questionnaire report, she was somewhat more willing to display her prosthesis in public and make use of it.</p> <p> <b>Conclusion</b> </p> <p>Although there was no clear-cut evidence of widespread, dramatic changes in behavior attributable to the use of the APRL-Sierra Hand, the data all point in the direction of improved self-perceptions as well as better social attitudes and relationships. With the exception of the 10 per cent of the sample who rejected the hand for a variety of reasons, the remaining amputee children and their parents, teachers, and classmates reported a variety of positive social consequences related to hand wear. For the most part these reports referred to improved feelings, opinions, and attitudes of the subjects, although a small number of positive behavioral changes could also be documented. In general, the children themselves as well as their classmates and parents were socially more comfortable as a result of the introduction of the hand.</p> <p>The functional limitations of the hand in comparison to a hook will be documented in a subsequent article in Artificial Limbs. In contrast, the evidence concerning the cosmetic benefits of the device, particularly its concomitant psychosocial implications, is most impressive.</p> <h3>Results-Prescription Considerations</h3> <p> <b>Size of Sound Hand and Age</b> </p> <p>For the purposes of the Right-Hand Study, the No. 1 Hand was hypothesized as being appropriate for child amputees between the ages of 4 and 10. Consequently, experimental wearers were selected on the basis of this age range rather than of size. In the course of the study, however, it became apparent that the hand was undersized for many of the children selected.</p> <p>The clinics were then requested to report the following dimensions in all cases of noticeable discrepancy: circumference at the metacarpophalangeal knuckles, excluding the thumb, with hand in closed position (5% in, on the No. 1 Hand); and the length from the styloid process of the radius to the tip of the thumb (3 5/8 in. on the No. 1 Hand). Several clinics also reported hand dimensions of children for whom the No. 1 Hand was considered of appropriate size.</p> <p> <b>Table 4</b> presents the measurements of sound hands of children in the Right-Hand Study for whom the No. 1 Hand was too small; small, but acceptable; and well matched, according to the opinion of clinic personnel. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It would appear difficult to derive a precise range of sound-hand sizes or ages for which the No. 1 Hand provides an acceptable match. In one case, where the sound hand was 6 5/8 in. in circumference and 4 1/2 in. in length, the clinic rated the hand as unacceptably small, but in another instance it was considered suitable for a child whose hand was 7 1/4 in. in circumference and 4 1/2 in. in length. It should also be noted that while the majority of the "oversized" children were 8 years of age or older several younger children fell into this category. Furthermore, even hands regarded as unacceptably small by the clinics were retained by the children and worn, at least for dress, for several months longer.</p> <p>In the selection of candidates for the Left-Hand Study dimensions of the children's sound hands were taken into consideration. In general, an effort was made to accept as wearers only those children with a sound-hand circumference of not over 6 1/4 in. and a length up to 3 7/8 in. It was also anticipated that the majority of such children would fall into the age range of 4 to 8 years. As a consequence, there were few complaints about size in the Left-Hand Study.</p> <p>Christine, age 10, had sound-hand dimensions of 6 3/8 in. circumference and 3 7/8 in. length at the time of selection. These became 6 1/2 in. and 4 1/2 in. by the time of the four months' check and the clinic was then of the opinion that the hand was too small. Christine and her parents agreed, but strongly preferred even a poorly matched hand to the alternative of a hook. There were six other children in the sample with sound hands of excessive circumference or length, i.e., larger than 6 1/4 in. in circumference and 3 7/8 in. in length. There was indication that all the children in this group were not completely satisfied with the size of the No. 1 Hand, but their lack of enthusiasm was generally expressed in the comment, "a little small, but still all right."</p> <p>Thus, as a general guide in considering the prescription of a No. 1 Hand, it is possible to state:</p> <blockquote><p>For children whose remaining hand dimensions do not exceed 6 1/4 in. in circumference and 3 7/8 in. in length, the No. 1 Hand can probably be fitted without objectionable size disparity. Naturally the closer the children are to this level when fitted the faster they will outgrow the No. 1 Hand. 2. Children with these hand dimensions will typically fall into the age range from large 3-year-olds to small 8-year-olds, with a predominance of 4- to 6-year-olds. However, considerations of hand weight and operating forces may exclude some children at the lower end of this age range.</p> </blockquote> <p> <b>Clinic Opinions</b> </p> <p>Clinic opinions concerning various aspects of the No. 1 Hand were obtained in both phases of the study. Clinic personnel were also asked to express themselves on the question: "Are there any contraindications to prescribing this hand (age, sex, performance, etc.)?" Responses, however, were confined primarily to the experiences of the particular child under observation as each questionnaire was completed. Hence the comments made were essentially confirmatory of information gathered from other sources.</p> <p>Expressions of a general attitude toward prescription and use of the No. 1 Hand were relatively rare. Thus, it is possible that the typical reaction of the clinics participating in the study was one of reservation concerning the experimental item-of not wishing to take a strongly positive or negative position until more experience had been acquired and "all the returns were in."</p> <p>This situation reflects the fact that the majority of the clinics participating in the program appeared to be "functionally oriented," some of them strongly so. Hence, a device which historically and in fact provides lesser function was likely to be viewed with skepticism. Some clinics were also concerned about the initial cost of the hand and glove and the expense of repairs and replacements particularly of the glove.</p> <p>If this interpretation of the prevailing frame of reference is correct, such comments as were made concerning "contraindications to prescription" take on added significance by their infrequent occurrence. To cite the Left-Hand Study data again: For only nine of the 36 children discussed was dissatisfaction with some aspect of the hand strong enough to be mentioned as a possible contraindication to use. These instances were:</p> <table> <tbody><tr> <td> <p><b>No. of Children</b></p> </td> <td> <p><b>Contraindications</b></p> </td> </tr> <tr> <td>2</td> <td> <p>Discrepancy in size</p> </td> </tr> <tr> <td>2</td> <td> <p>Frequent breakage or malfunction</p> </td> </tr> <tr> <td>2</td> <td> <p>Force requirements excessive for particular child</p> </td> </tr> <tr> <td>1</td> <td> <p>Functional limitation as compared with hook</p> </td> </tr> <tr> <td>1</td> <td> <p>Rapid wear of glove a possible contraindication for a wry active child</p> </td> </tr> <tr> <td> 1 <a></a> </td> <td> <p>Emotional difficulty</p> </td> </tr> </tbody></table> <p>Excerpts from a letter written by one of the clinic chiefs might be appropriate as a summary statement of prescription considerations. His comments not only reaffirm reactions to the hand which appear to have been fairly typical, but also express an approach to prescription which seems to be conservative yet reasonable:</p> <p>"The mother's comment with regard to cosmesis is that the hand is 'beautiful.' She is perfectly willing to go to all extremes in cosmetic appreciation. The mother feels that the child's reaction to the appearance of the hand was one of 'being proud of it.' This was exemplified by the child's desire to always wear the hand at school. It was interesting to me that, after approximately six months of wear, Debra was anxious to wear the hand all the time and not to wear the hook any more. However, in the recent episode, when the hand became no longer functional, she was perfectly agreeable to return to the use of the hook. This is particularly interesting to me, because the mother feels that Debra actually lost no function in the transition from the hook to the hand.</p> <p>"At age 6, Debra learned to operate the thumb adjustment and, as a consequence, was able to continue with the prosthetic hand as the assisting side at school in such functions as holding a book while reading so that she could turn the pages with her normal hand; holding papers while writing; and holding papers while cutting. At home, she was able to hold fork and knife with the prosthetic hand but, at age 7, is still able to cut only soft meat, such as a hamburger. She uses the hand in all bi-manual activity.</p> <p> "Our own opinion here is that we will prescribe this hand for children who are already using a hook. In the unilateral case where there is reasonable dexterity, I feel that with the prosthetic side being the assisting side we can sacrifice the minimal loss of function which one <a style="text-decoration:none;">*</a> probably gets in the transition from hook to hand. The only criticism is the amount of force necessary to operate the hand." </p> <h3>Acknowledgments</h3> <p>The late Dr. Carleton Dean, former Director of the Michigan Crippled Children Commission, played a prominent role in the early stages of the child's hand program, particularly in the procurement of the experimental units. Colonel Maurice J. Fletcher, Dr. Fred Leonard, Colonel John Butchkosky, and Victor T. Riblett, of the Army Prosthetics Research Laboratory, were responsible for the development of the hand and assisted in the resolution of problems encountered in the study. To all these gentlemen, we express our appreciation.</p> <p>We also acknowledge the valuable cooperation and assistance of the children and personnel associated with the clinics participating in the Child Amputee Research Program.</p> <p>Roberta Bernstein, Alfred Brooks, Herbert Bursky, Bertram Litt, Deborah Osborne, and Dr. Edward Peizer, staff members of New York University Child Prosthetic Studies, have also made significant contributions at various stages during the development and testing of the APRL-Sierra Child Size No. 1 Hand and in the preparation of the report upon which this article and a subsequent article to appear in the Autumn 1964 issue of Artificial Limbs are based.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Child holding swing with artificial hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector VV. Kay,<i>Acceptability of a functional-cosmetic artificial hand for young children</i>,Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> <li>Fletcher, M. J., and Fred Leonard,<i>The principles of artificial-hand design</i>, Artificial Limbs, May 1955, p. 78.</li> <li>National Academy of Sciences-National Research Council, Final <i>summary report, APRL-Sierra Child-Size Hand, Size 1, Model A,</i> March 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right)</i>, October 1960.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right)</i>, May 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, APRL-Sierra No. 1 Hand {left)</i>, October 1962.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left)</i>, May 1961.</li> <li>S. Peizer, Edward,<i>The clinical treatment of juvenile amputees, 1953-1956</i>, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">One clinic felt strongly that prescription would be a dubious practice where cosmesis was highly important for child and parent if the next larger hand size was unavailable later.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich. Amputee Clinic, Childrens Division, Institute of Physical Medicine and Rehabilitation, New York, N. Y., Amputee Clinic, Newington Hospital for Crippled Children, Newington, Conn., University of Illinois Amputee Clinic, Chicago, Ill., Birmingham Child Amputee Clinic, Birmingham, Ala., Duke Orthopedic Amputee Clinic, Duke Medical Center, Durham, N. C, Georgia Juvenile Amputee Clinic, Crippled Childrens Service, Emory University Branch, Atlanta, Ga., Amputee Clinic, Childrens Rehabilitation Center, Buffalo, N. Y., Child Amputee Prosthetics Project, University of California Medical Center, Los Angeles, Calif., Amputation Clinic, Kernan Hospital, Baltimore, Md., Child Amputee Prosthetic and Congenital Deficiency Clinic, Childrens Orthopedic Hospital, Seattle, Wash., Juvenile Amputee Clinic, Florida Crippled Childrens Commission, Orlando, Fla., Amputee Clinic, Home for Crippled Children, Pittsburgh, Pa., Child Amputee Clinic, State Hospital for Crippled Children, Elizabeth-town, Pa., Juvenile Amputee Clinic, Crippled Childrens Hospital, New Orleans, La.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, APRL-Sierra No. 1 Hand {left), October 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left), May 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>5.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right), May 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>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right), October 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>Footnote</b></td></tr><tr><td class="clsTextSmall">San Francisco, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Costa Mesa, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Sierra Madre, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fletcher, M. J., and Fred Leonard,The principles of artificial-hand design, Artificial Limbs, May 1955, p. 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-02.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-03.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-04.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-05.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-06.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-01.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-07.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 Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/2110d586443d4b19b7fc9536683bc8db.pdf b96a92130c9eedff024e88641dc2063c https://staging.drfop.org/files/original/fb9ebe60dff913d9135a2935bdf2deda.jpg d13d55f144121d2cfb8b9d4b730617e3 https://staging.drfop.org/files/original/ed52127592e5a7556ac833dfac1e096e.jpg 09b1f0c571cdcf62a95b58b49c7de006 https://staging.drfop.org/files/original/7b8faeb9f25f51fe5128b4495503c950.jpg 99db08c49eea3368263b0db1627f47c4 https://staging.drfop.org/files/original/30dace90d04426eb54982c1e6db41b48.jpg 1ed343a6460af0febbb1795bc6c12e7e https://staging.drfop.org/files/original/f9b5fe8693775eed4668606286075472.jpg a15b89b39232a09a39e2b982223cb10c https://staging.drfop.org/files/original/3b8587872e5cd2828bb2963b8d88dbc6.jpg 0de0585464dffd0d381b1074931ae52c https://staging.drfop.org/files/original/ed4b52ce5ac75f7406ab601d3bcedf30.jpg 587647562e5551eb1a9ab4f918a8d05b https://staging.drfop.org/files/original/9d684744fe2af745dd567f69072abe94.jpg 6a8c37f94d45cf2102a83e1ba04ba532 https://staging.drfop.org/files/original/f47f13f4f517be2c68e4885132255a73.jpg 7a973ac6c580a0cd23a1aad0da06345e https://staging.drfop.org/files/original/ee934e7d6260f4fe6b2d0b475480c0c7.jpg 6a87da86f9c77268e89c2920e54290a7 https://staging.drfop.org/files/original/9eb67fe346807f23eb9721e730181cf6.jpg 3d6338336fa57f8e45e0c104c8e44f29 https://staging.drfop.org/files/original/d03ce299f5faed1b04bd1cb5d511348a.jpg 30c15358ad729c1d1b4c7c63b57d6e8f https://staging.drfop.org/files/original/f40a73ddf7abbe1bc363584464f188a0.jpg 8d3a34e6604c20c0b27728cfb136b495 https://staging.drfop.org/files/original/5c007bf3a01c041d44b41f637e3b98dd.jpg a3fad156c8637c58e8b2c697edb9aa86 https://staging.drfop.org/files/original/bbd4c7da3293e56cd493f889704a4ed4.jpg 40069e7ae5876d1e96e3a89a733cbb52 https://staging.drfop.org/files/original/36c833299af80c7d07ced66aa833331a.jpg 34987d61eca54e9e03b1ed422ae2ff44 https://staging.drfop.org/files/original/a1b4f107929b70c2c1e7b1bd1d4e4dcf.jpg 2f4d617a5b5753ac4821f7d6b284cd9b https://staging.drfop.org/files/original/840c46b44786ace3aff7daeaa6ff78f5.jpg 7e7806eb8e3e875d3fd8986e218f9c24 https://staging.drfop.org/files/original/6cda4b12ad5be268580aae44a30a5534.jpg b09bb8952a15ec26af4db027bbfc3382 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_044.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 44 - 66 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Body Segment Parameters: A Survey of Measurement Techniques</h2> <h5>Rudolfs Drillis, Ph. D. <a style="text-decoration:none;">*</a><br />Renato Contini, B.S. <a style="text-decoration:none;">*</a><br />Maurice Bluestein, M.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Human motor activity is determined by the response of the subject to constantly changing external and internal stimuli. The motor response has a definite pattern which can be analyzed on the basis of temporal, kinematic and kinetic factors.</p> <p>Temporal factors are those related to time: cadence (tempo) or the number of movements per unit time (minute or second), the variability of successive durations of motion, and temporal pattern. The temporal pattern of each movement consists of two or more phases. The relative duration of these phases and their interrelationships are indicative characteristics of the movement under consideration. For example, in walking, two basic time phases may be noted, the stance phase when the leg is in contact with the ground and the swing phase. The ratio of swing-phase time to stance-phase time is one of the basic characteristics of gait.</p> <p>The kinematic analysis of movement can be accomplished by studying the linear and angular displacements of the entire body, the joints (neck, shoulder, elbow, wrist, hip, knee, ankle) and the segments (head, upper arm, forearm, hand, thigh, shank, foot). For the purpose of investigation, the most important kinematic characteristics are: the paths of motion, linear and angular displacement curves, amplitudes or ranges of motion, the instantaneous and average velocities and their directions, and finally the linear and angular accelerations of the body segments under investigation. Information on these criteria can be obtained readily from objective (optical or electrical) recordings of the movements of a subject.</p> <p>The kinetic analysis is concerned with the influence of different forces and moments acting on the body or a body segment during the performance of a given activity. To determine these forces and moments, accurate data on the mass (weight), location of mass centers (centers of gravity), and the mass moments of inertia of the subject's body segments are required.</p> <p>At present there are limited data on body segment parameters, especially those for American subjects. Such data available are based on studies made on a limited number of dissected male cadavers. This cannot be regarded as a representative sample for our normal population with its wide range of age and difference of body build. There are no data available on female subjects in the United States.</p> <p>A precise knowledge of these body segment parameters has many applications, such as in the design of work activities or the improvement of athletic performances. It has particular value in understanding orthopedic and prosthetic problems. It would result in a better design of braces and prosthetic devices and more reliable methods for their adjustment. From these data it would also be possible to develop more precise and effective procedures for the evaluation of braces and artificial limbs. These procedures would replace the use of subjective ratings on performance by an amputee or a disabled person.</p> <p>The information on body segment parameters obtained by simple clinical methods can be very useful in general medical practice. It would provide a tool for the determination of:</p> <ol> <li>body segment growth and decay in normal and abnormal conditions</li><li>body segment density changes in normal and pathological cases;</li><li>body mass distribution asymmetry;</li><li>more precise body composition (fat, bones, muscles).</li></ol> <p>The aim of this article is to give a brief review of the methods used by different investigators for the determination of body segment parameters. Since some of the first treatises and papers are no longer available, we include some tables and figures which summarize the data obtained by some of the earlier researchers.</p> <p>Early Efforts</p> <p>Since ancient times there has existed an intense curiosity about the mass distribution of the human body and the relative proportions of its various segments. Those professions which had to select or classify subjects of varying body build were particularly interested in the problem. In spite of individual differences between particular subjects there are many characteristics which are common to all normal human beings. Thus the lower extremities are longer and heavier than the upper extremities, the upper arm is larger than the forearm, the thigh is larger than the shank, and other similar relationships.</p> <p>Historically this interest was first directed to the length relationships between the body segments. To characterize these relationships certain rules and canons were promulgated. Each canon has its own standard unit of measure or module. Sometimes the dimension of a body segment or component parts of a body segment were used as modules and occasionally the module was based on some abstract deduction.</p> <p>The oldest known module is the distance measured between the floor (sole) and the ankle joint. This module was used in Egypt some time around the period 3000 b.c. On this basis, the height of the human figure was set equal to 21.25 units. Several centuries later in Egypt a new module, the length of the middle finger, was introduced. In this instance body height was set equal to 19 units. This standard was in use up until the time of Cleopatra.(<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Egyptian middle finger canon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the fifth century B.C., Polyclitus, a Greek sculptor, introduced as a module the width of the palm at the base of the fingers. He established the height of the body from the sole of the foot to the top of the head as 20 units, and on this basis the face was 1/10 of the total body height, the head 1/8, and the head and neck together 1/6 of the total body height. In the first century B.C., Vitruvius, a Roman architect, in his research on body proportions found that body height was equal to the arm spread-the distance between the tips of the middle fingers with arms outstretched. The horizontal lines tangent to the apex of the head and the sole of the foot and the two vertical lines at the finger tips formed the "square of the ancients." This square was adopted by Leonardo da Vinci. He later modified the square by changing the position of the extremities and scribing a circle around the human figure.</p> <p>Diirer (1470-1528) and Zeising (1810-1876) based their canons on mathematical abstracts which were not in accordance with any actual relationships.</p> <p>At the beginning of the twentieth century, Kollmann tried to introduce a decimal standard by dividing the body height into ten equal parts. Each of these in turn could be subdivided into ten subunits. According to this standard, the head height is equal to 13 of these smaller units: seated height, 52-53; leg length, 47; and the whole arm, 44 units.(<b>Fig. 2</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Kollmann's decimal canon </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Previous Studies in Body Parameters</p> <p>Starting with the early investigators, the idea has prevailed that volumetric methods are best for determining relationships between body segments. There were basically two methods which were used for the determination of the volume of the body segments: (1) body segment immersion, and (2) segment zone measurement or component method. In these methods it is assumed that the density or specific gravity of any one body segment is homogeneous along its length. Hence the mass of the segment can be found by multiplying its volume by its density.</p> <p>Immersion Method</p> <p>Harless in Germany first used the immersion method. In 1858 he published a text book on <i>Plastic Anatomy, </i>and in 1860 a treatise, <i>The Static Moments of the Human Body Limbs. </i>In his investigations, Harless dissected five male cadavers and three female cadavers. For his final report, however, he used only the data gathered on two of the subjects.</p> <p>The immersion method involves determining how much water is displaced by the submerged segment. Previous researchers, including Harless, have relied on the measurement of the overflow of a water tank to find the volume of water displaced.</p> <p>Harless started his studies with the determination of the absolute and relative lengths of the body and its segments. The absolute lengths were measured in centimeters. For determining the relative lengths, Harless used the hand as a standard unit. The standard hand measurement was equal to the distance from the wrist joint to the tip of the middle finger of the right hand. Later Harless also used the total height of the body as a relative unit of length. In the more recent studies on body parameters, this unit is accepted as the basis for the proportions of the various segment lengths. The results of Harless' studies are shown in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For obtaining the absolute weights of the body segments, Harless used the gram as the standard. As a unit for relative weights, he first decided to use the weight of the right hand, but later established as his unit the one thousandth part of the total body weight. His results are given in <b>Table 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a very careful way Harless determined the volume and density (specific gravity) of the body segments. The results of these measurements are presented in <b>Table 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To determine the location of mass centers (centers of gravity), Harless used a well-balanced board on which the segment was moved until it was in balance. The line coincident with the fulcrum axis of the board was marked on the segment and its distance from proximal and distal joints determined. The location of the mass center was then expressed as a ratio assuming the segment length to be equal to one. Harless also tried to determine the location of segment mass center from the apex of the head by assuming that the body height is equal to 1,000. The data for one subject are shown in <b>Table 4</b>. From the table, the asymmetry of the subject becomes evident.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To visualize the mass distribution of the human body, Harless constructed the model shown in <b>Fig. 3</b>. The linear dimensions of the links of the model are proportional to the segment lengths; the volumes of the spheres are proportional to segment masses. The centers of the spheres indicate the location of mass centers (centers of gravity) of the segments.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Body mass distribution (After E. Harless). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Modified models of the mass distribution of the human body and mass center location of the segments have been made by several other investigators. It is unfortunate that up to now a unified and universally accepted subdivision of the human body into segments does not exist.</p> <p>In 1884, C. Meeh investigated the body segment volumes of ten living subjects (8 males and 2 females), ranging in age from 12 to 56 years. In order to approximate the mass of the segments, he determined the specific gravity of the whole body. This was measured during quiet respiration and was found to vary between 0.946 and 1.071 and showed no definite variation with age. The segment subdivision used by Meeh is shown in <b>Fig. 4</b> and the results of the segment volume measurements are presented in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Body Segments (After C. Meeh). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>C. Spivak, in 1915, in the United States, measured the volumes of various segments and the whole body for 15 males. He found that the value of specific gravity of the whole body ranged from 0.916 to 1.049.</p> <p>D. Zook, in 1930, made a thorough study of how body segment volume changes with age. In making this study, he used the immersion method for determining segment volumes. These were expressed in per cent of whole body volume. His sample consisted of youngsters between the ages of 5 and 19 years. His immersion technique was unique, but his claim that it permitted the direct determination of the specific gravity of any particular body segment does not seem to have been established. Some of his results are shown in <b>Fig. 5</b> and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean head volume change with age (After D. Zook). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean leg volume change with age (After D. Zook and others). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the period from 1952 to 1954, W. Dempster at the University of Michigan made a very thorough study of human body segment measurements. His investigations were based on values obtained on eight cadavers. Besides volumes, he obtained values for mass, density, location of mass center, and mass moments of inertia. The immersion method was used to determine volume. However, these data have limited application since all of Dempster's subjects were over 50 years of age (52-83) and their average weight was only 131.4 lb. The immersion method was used in Russia by Ivanitzkiy (1956) and Salzgeber (1949).</p> <p>The immersion technique can be applied for the determination of the total segment volume or any portion thereof in a step-by-step sequence. It can be applied as well on living subjects as on cadavers. In this respect it is a useful technique.</p> <p>There is some evidence that for most practical purposes the density may be considered constant along the full length of a segment. According to O. Salzgeber (1949), this problem was studied by N. Bernstein in the 1930's before he started his extensive investigations on body segment parameters. By dividing the extremities of a frozen cadaver into zones of 2 cm. height, it was established that the volume centers and mass centers of the extremities were practically coincident. It would seem therefore that the density along the segment was fairly constant for the case studied. Accepting this, it follows that the extremity mass, center of mass, and mass moment of inertia may be determined from the volume data obtained by immersion. However, it should be noted that for the whole body, according to an investigation by Ivanitzkiy (1956), the mass center does not coincide with the volume center, due to the smaller density of the trunk.</p> <h4>Computational Methods</h4> <p>Harless was the first to introduce computational methods as alternatives to the immersion method for determining body volume and mass. He suggested that this would be better for specific trunk segments since no definite marks or anatomical limits need be applied.</p> <p>He considered the upper part of the trunk down to the iliac crest as the frustum of a right circular cone. The volume (<i>V1) </i>is then determined by the formula:<b>Eq. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He assumed that the volume of the lower (abdomino-pelvic) part of the trunk (<i>V2</i>) can be approximated as a body between two parallel, nonsimilar elliptical bases with a distance <i>h </i>between them. The volume <i>V2 </i>is determined by the formula:<b>Eq. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On the basis of dimensions taken on one subject, using these formulas he arrived at a value for <i>V1 </i>of 21,000 cm cubed and 5,769 cm subed for <i>V2. </i>Using a value of 1.066 gr/cm cubed as the appropriate specific gravity of these parts, the total trunk weight was computed to be 28.515 kg. The actual weight of the trunk was determined (by weighing) to be 29.608 kg. The computed weight thus differed from the actual weight by 1.093 kg, or 3.69 per cent.</p> <p>Several subsequent investigators used this method subdividing the body into segments of equal height. For increased accuracy these zones should be as small as practically possible -a height of 2 cm is the practical lower limit. The zone markings are measured starting usually from the proximal joint of the body segment. The circumference of the zone is measured and it is assumed that the cross-section is circular. The volume may be computed and on the basis of accepted specific gravity values the mass may be found. From these values one may compute the center of mass and mass moment of inertia.</p> <p>Amar (1914) in order to compute the mass moment of inertia of various body segments made a number of assumptions. He assumed the trunk to be a cylinder, and that the extremities have the form of a frustum of a cone. The mass moment of inertia for the trunk about a lateral axis through the neck is determined from the formula:<b>Eq. 3</b><br /> and for the extremities by the formula:<b>Eq. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Weinbach (1938) proposed a modified zone method based on two assumptions: (1) that any cross-section of a human body segment is elliptical, and (2) that the specific gravity of the human body is uniform in all its segments and equal to 1.000 gr/cm cubed. The area <i>(A) </i>at any cross section is expressed by the equation:<b>Eq. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Plotting a graph showing how the equidistant cross-sectional areas change relative to their location from the proximal joint, it is possible to determine the total volume of the segment and hence its mass and location of center of mass. The mass moment of inertia (/) may be obtained by summing the products of the distances from the proximal joint to the zone center squared <i>(r squred) </i>and the corresponding zone mass:<b>Eq. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately both of Weinbach's assumptions are questionable since the cross sections of human body segments are not elliptical and the specific gravities of the different segments are not equal to 1.000 gr/cm cubed nor is density truly uniform in all segments.</p> <p>Bashkirew (1958) determined the specific gravity of the human body for the Russian population to be 1.044 gr/cm cubed with a standard deviation of ±0.0131 gr/cm cubed and the limits from 0.978 minimum to 1.109 maximum. Boyd (1933) determined further that specific gravity generally increases with age. Dempster (1955) showed that Weinbach's method was good for determining the volume of the head, neck, and trunk but not good for other body parts.</p> <p>It is evident that the determination of body segment parameters, based on the assumption that the segments can be represented by geometric solids, should not be used when great accuracy is desired. This method is useful only when an approximate value is adequate.</p> <p>Fischer introduced another approximate method of determining human body parameters by computation known as the "coefficient method." According to this procedure, it is assumed that fixed relations exist between body weight, segment length, and the segment parameters which we intend to find. There are three such relationships or ratios expressed as coefficients. For the body segment mass, the coefficient is identified as <i>C1</i> and represents the ratio of the segment mass to the total body mass. The second coefficient <i>C2 </i>is the ratio of the distance of the mass center from the proximal joint to the total length of the segment. The third coefficient <i>C3</i> is the ratio of the radius of gyration of the segment about the medio-lateral centroidal axis to the total segment length. Thus to determine the mass of a given segment for a new subject, it would be sufficient to multiply his total body mass by coefficient <i>C1 </i>corresponding segment mass. Similarly the location of mass center and radius of gyration can be determined by multiplying the segment length by the coefficients <i>C2 </i>and <i>C3</i> respectively.</p> <p><b>Table 6</b> compares the values of coefficient <i>C1</i>obtained by different investigators.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 6</b> shows that the differences between the coefficients obtained by different investigators for particular segment masses are great. The difference is highest for the trunk and head mass where the coefficients vary from 49.68 to 56.50 per cent of body mass. Next highest difference is in the thigh coefficients from 19.30 to 24.43 per cent of body mass. Since the number of subjects used in the studies, with the exception of that of Bernstein, is small and no anthropological information on body build is given, it is difficult to draw any definite conclusions about the scientific and practical value of these coefficients for body segment mass determination.</p> <p>As already mentioned, the data obtained by Harless are based on two decapitated male cadavers, and since the blood had been removed some errors are possible. The data of Meeh are based on volume measurements of eight living subjects. The large coefficient for the trunk is influenced by the assumption that all body segments have the same average density, where actually it is less for the trunk.</p> <p>Braune and Fischer (1889) made a very careful study of several cadavers. Their coefficients are based on data taken on three male cadavers whose weight and height were close to the data for the average German soldier. The relative masses (coefficients) of the segments were expressed in thousandths of the whole body mass. The positions of the mass center and radius of gyration (for determination of the segment mass moments of inertia) were expressed as proportional parts of the segment's total length. Fischer's coefficients have been accepted and used in most subsequent investigations to date.</p> <p>N. Bernstein and his co-workers (1936) at the Russian All-Union Institute of Experimental Medicine in Moscow carried out an extensive investigation on body segment parameters of living subjects. The study took care of anthropological typology of body build. The results of this investigation were published in a monograph, <i>Determination of Location of the Centers of Gravity and Mass (weight) of the Limbs of the Living Human Body </i>(in Russian). At present the monograph is not available in the United States. Excerpts of this investigation, which cover 76 male and 76 female subjects, 12 to 75 years old, were published by N. Bernstein in 1935 in his chapters on movement in the book, <i>Physiology of Work </i>(in Russian), by G. P. Konradi, A. D. Slonim, and V. C. Farfel.</p> <p><b>Table 7</b> shows data for the comparison of segment masses of living male and female subjects as established by Bernstein's investigation. The data are self-explanatory.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Determination of Mass Center Location</h4> <p>In the biomechanical analysis of movements it is necessary to know the location of the segment mass center which represents the point of application of the resultant force of gravity acting on the segment. The mass center location of a segment system such as an arm or a leg or the whole body determines the characteristics of the motion.</p> <p><b>Table 8</b> shows the relative location of the mass center for different segments. It is evident that the assumption that mass center of all segments is located 45 per cent from the proximal and 55 per cent from the distal end of the segment is not valid. Since the mass distribution of the body is related to body build it seems that the mass center location also depends on it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bernstein claims that he was able to locate the mass centers with an accuracy of ±1 mm. Hence the data of <b>Table 9</b> represent the result of very careful measurements. An analysis of these data shows that there is no definite trend of the coefficients differing with age or sex. The variance of the coefficients is very high and reaches nine per cent as maximum. Thus the use of the same coefficients for subjects with a wide range of body build is highly questionable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 7</b> and <b>Fig. 8</b> represent, in modification, Fischer's schemes for the indication of the mass center location of the extremities. The letters of the alphabet indicate the location levels of the mass centers on the human figure. The corresponding cross sections through the segments are shown separately. The letters designate the following:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Location of mass centers of the upper extremity (Redrawn from O. Fischer). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Location of mass centers of the lower extremity (Redrawn from O. Fischer). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>A</i>-mass center of upper arm</p> <p><i>B</i>-mass center of whole arm</p> <p>C-mass center of forearm</p> <p><i>D</i>-mass center of forearm and hand</p> <p><i>E</i>-mass center of hand</p> <p><i>F</i>-mass center of thigh</p> <p><i>G</i>-mass center of whole leg</p> <p><i>H</i>-mass center of shank</p> <p><i>I</i>-mass center of shank and foot <i>J</i>-mass center of foot</p> <p>The location of mass centers with respect to the proximal and distal joints as determined by W. Dempster (1955) is shown in <b>Fig. 9</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Location of mass centers of body segments (After W. Dempster). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is easy to find the equations for the determination of the coordinates of the mass center when the coordinates of the segment's proximal and distal joints are given.</p> <p>By using Fischer's coefficients for mass center of a particular segment the following formulas were developed:</p> <p>Coordinates of mass center of the:</p> <p>a. forearm:</p> <p><i>x = </i>0.42<i>xd</i> + 0.58<i>xp</i></p> <p><i>y = 0.42yd + </i>0.58<i>yp</i></p> <p>where <i>xd</i>, <i>yd </i>are coordinates of the distal (wrist) joint and <i>xp</i>, <i>yp </i>are coordinates of the proximal (elbow) joint.</p> <p>b. upper arm:</p> <p><i>x = </i>0.47<i>xd</i> + 0.53<i>xp</i> y <i>= </i>0.47<i>yd</i> + 0.53<i>xp</i></p> <p>where <i>xd, yd </i>are coordinates of the elbow joint and <i>xp, yp </i>are coordinates of the shoulder joint.</p> <p>c. shank:</p> <p><i>x = </i>0.42<i>dx</i> + 0.58<i>xpy = </i>0.42<i>yd</i> + 0.58<i>yp</i>where <i>xd, yd </i>are coordinates of the ankle</p> <p>joint and <i>xp, yp </i>are coordinates of</p> <p>the knee joint.</p> <p>d. thigh:</p> <p><i>x = </i>0.44<i>xd</i> + 0.56<i>xp</i> <i>y = </i>0.44<i>yd</i> + 0.56<i>yp</i></p> <p>where <i>xd, yd </i>are coordinates of the knee joint and <i>xp</i>, <i>yp </i>are coordinates of the hip joint.</p> <p>For the case of three-dimensional recordings of motion, similar equations for <i>z </i>are used. The coordinates of the mass center of trunk <i>(t) </i>are:</p> <p><i>xt = </i>0.235 <i>(xfr + xfl) + </i>0.265 <i>(xbr + xbl), </i>with similar equations for the <i>yt </i>and <i>zt</i> coordinates.</p> <p>Here <i>xfr </i>is the coordinate of the right hip and <i>xfl </i>is the coordinate of the left hip, and <i>xbr </i>is the coordinate of the right shoulder and <i>xbl </i>is the coordinate of the left shoulder.</p> <p>In the same manner the equations for segment systems are developed:</p> <p>a. entire arm:</p> <p>mass center <i>x </i>coordinate given by: <i>xac </i>= 0.130 <i>xgm + </i>0.148 <i>xm </i>+ 0.448 <i>xa + </i>0.27 <i>xb</i>, where</p> <p><i>xac</i>-entire arm mass center <i>x </i>coordinate <i>xgm</i>-mass center of the hand <i>xm</i>-wrist joint <i>xa</i>-elbow joint <i>xb</i>-shoulder joint</p> <p>Similar equations for <i>y </i>and <i>z </i>coordinates are used:</p> <p>b. entire leg:</p> <p>mass center <i>x </i>coordinate given by: <i>xlc = </i>0.096 <i>xgp</i>+ 0.119 <i>xp + </i>0.437 <i>xs + </i>0.348 <i>xf , </i>where</p> <p><i>xlc</i>-entire leg mass center <i>x </i>coordinate <i>xgp</i>-mass center of foot <i>xp</i>-ankle joint <i>xs</i>-knee joint <i>xf</i>-hip joint</p> <p>Similar equations are developed by the <i>y </i>and <i>z</i> coordinates.</p> <p>By analogy the formulas for coordinates determining the location of the mass center of the entire body in two or three dimensions can be developed.</p> <p>As regards the coefficient <i>C3, </i>it is known that the mass moment of inertia (<i>I</i>) is proportional to the segment's mass and to the square of the segment's radius of gyration <i>(p). </i>Fischer found that the radius of gyration for rotation about the axis through the mass center and perpendicular to the longitudinal axis of the segment can be established by multiplying the segment's length <i>(l) </i>by the coefficient <i>C3</i> = 0.3. Hence the mass moment of inertia with respect to the mass center is <i>Ig</i> = <i>mpp </i>= <i>m(0.3l)(0.31) </i>= <i>0.09ml squred.</i></p> <p>For the rotation of the segment about its longitudinal axis, Fischer found the coefficient <i>C4</i> = 0.35, so that the radius of gyration <i>p = </i>0.35 <i>d, </i>where <i>d </i>is the diameter of the segment.</p> <p>Since for living subjects the segment rotates about the proximal or distal joint and not the mass center, the mass moment of inertia that we are interested in is greater than <i>Ig </i>by the term <i>mee, </i>where <i>e </i>is the distance of mass center from the joint. It follows that the mass moment of inertia for segment rotation about the joint is equal to <i>Ij = mpp + mee = m(pp </i>+ <i>ee).</i></p> <h4>New York University Studies</h4> <p>At present the Biomechanics group of the Research Division of the School of Engineering and Science, New York University, is engaged in the determination of volume, mass, center of mass, and mass moment of inertia of living body segments. The methods employed will now be discussed. Some of these techniques are extensions of the methods used by previous researchers; others are procedures introduced by New York University.</p> <h4>Determination of Volume</h4> <p>The two methods being investigated by New York University to determine segment volumes are (1) immersion and (2) mono- and stereo-photogrammetry.</p> <p><i>Imersion Method</i></p> <p>The Biomechanics group at New York University uses water displacement as the basis for segment volume determination. However, the procedure differs from that used by previous researchers in that the subject does not submerge his segment into a full tank of water and have the overflow measured. Instead his segment is placed initially in an empty tank which is subsequently filled with water. In this way, the subject is more comfortable during the test, and the segment remains stationary to ensure the proper results.</p> <p>A variety of tanks for the various segments- hand, arm, foot, and leg-has been fabricated. It is desirable that the tank into which the segment is to be immersed be adequate for the extreme limits which may be encountered and yet not so large as to impair the accuracy of the experiments. A typical setup is shown in <b>Fig. 10</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Determination of the arm volume. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The arm is suspended into the lower tank and set in a fixed position for the duration of the test. The tank is then filled to successive predetermined levels at two-centimeter increments from the supply tank of water above. At each level, readings are taken of the height of the water in each tank, using the meter sticks shown. The volume occupied by water between any two levels is found by taking the difference between heights of water levels and applying suitable area factors. Thus to find the volume of the forearm the displacement volume is found for the wrist to elbow levels in the lower tank and between the corresponding levels in the upper tank. The difference between these two volumes is the desired forearm volume.</p> <p>To find the center of volume obtain volumes in the same manner of consecutive two-centimeter sections of the limb. Assuming the volume center of each section as one centimeter from each face, sum the products of section volume and section moment arm about the desired axis of rotation. The net volume center for the body segment is then this sum divided by the total volume of the segment. In a similar fashion, using the appropriate combination of tanks, we find the volumes of other segments, hand, foot, and leg. The use of an immersion tank to find hand volume is shown in <b>Fig. 11</b>. The data on volume and volume centers can also be used along with density as a check against methods of obtaining mass and center of mass.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Determination of the hand volume. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Photogrammetry Method</i></p> <p>In order to find the volume of an irregularly shaped body part such as the head or face a photographic method may be employed. Such a procedure, called photogrammetry, allows not only the volume to be found, but a visual picture of the surface irregularity to be recorded as well. The two types of this technique are mono- and stereophotogrammetry. The principles are the same for each, except that in the latter procedure two cameras are used side by side to give the illusion of depth when the two photographs are juxtaposed. The segment of interest is photographed and the resulting picture is treated as an aerial photograph of terrain upon which contour levels are applied. The portions of the body part between successive contour levels form segments whose volumes can be found by use of a polar planim-eter on the photograph as described by Wild (1954). By summing the segmental volumes, the total body segment volume can be found. A controlled experiment by Pierson (1959) using a basketball verified the accuracy of such a procedure. Hertzberg, Dupertuis, and Emanuel (1957) applied the technique to the measurement of the living with great success. The reliability of the photographic technique was proven by Tanner and Weiner (1949). For a more detailed discussion of the photogram-metric method, refer to the paper by Contini, Drillis, and Bluestein (1963).</p> <p><i>Method of Reaction Change</i></p> <p>In searching for a method which will determine the segment mass of a living subject with sufficient accuracy, the principle of moments or of the lever has been utilized. The use of this method was suggested by Hebestreit in a letter to Steinhausen (1926). This procedure was later used by Drillis (1959) of New York University. Essentially it consists of the determination of reaction forces of a board while the subject lies at rest on it. The board is supported by a fixed base at one end <i>(A</i>) and a very sensitive weighing scale at the other end <i>(B). </i>The location of the segment center of mass can be found by the methods described elsewhere in this paper. The segment mass is <i>m, </i>the mass of the rest of the body is <i>M. </i>The reaction force (measured on the scale) due to the board only should be subtracted from the reaction force due to the subject and board. First the reaction force <i>(S0) </i>is determined when the segment (say the arm) is in the horizontal position and rests alongside the body; second, the reaction force <i>(S) </i>is determined when the segment is flexed vertically to 90 deg. with the horizontal. The distance between the board support points <i>A </i>and <i>B </i>is constant and equal to <i>D. </i>The distance <i>(d) </i>of the segment mass center from the proximal joint is known and the distance <i>b </i>from the proximal joint to support axis <i>A </i>can be measured. From the data it is possible to write the corresponding moment equations about <i>A. </i>The solution of these equations gives the magnitude of the segment's mass as: <b>Eq. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To check the test results, the segment is placed in a middle position, approximately at an angle that is 45 deg. to the horizontal, in which it is held by a special adjustable supporting frame shown at the right in <b>Fig. 13</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Reaction board with supporting frame. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The magnitude of the segment mass in this case will be determined by the formula:<b>Eq. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By replacing the sensitive scale with an electrical pressure cell or using one force plate, it is also possible to record the changing reaction forces. If the subsequent positions of the whole arm or forearm in flexion are optically fixed as in Stick Diagrams, the corresponding changing reaction forces can be recorded by electrical oscillograph.<b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Determination of the arm mass (reaction board method). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is assumed that in flexion the elbow ioint has only one degree of freedom, <i>i.e., </i>it is uniaxial; hence the mass determination of forearm and hand is comparatively simple. The shoulder joint has several degrees of freedom and for each arm position the center of rotation changes its location so that the successive loci describe a path of the instantaneous centers. If the displacement <i>(e) </i>of the instantaneous center in the horizontal direction is known from the Slick Diagram, the magnitude of the segment mass will be: <b>Eq. 9</b>(<b>Fig. 14</b> and <b>Fig. 15</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Stick diagram of forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Stick diagram of arm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Quick Release Method</i></p> <p>This technique for the determination of segment moments of inertia is based on Newton's Law for rotation. This law states that the torque acting on a body is proportional to its angular acceleration, the proportionality constant being the mass moment of inertia. Thus if the body segment, say the arm, can be made to move at a known acceleration by a torque which can be evaluated by applying a known force at a given distance, its moment of inertia could be determined. Such a procedure is the basis for the so-called "quick release" method. To determine the mass moment of inertia of a body segment, the limb is placed so that its proximal joint does not move. At a known distance from the proximal joint at the distal end of the limb, a band with an attached cord or cable is fixed. The subject pulls the cord against a restraint of known force, such as a spring whose force can be found by measuring <i>its deflection. </i>The activating torque about the proximal joint is thus proportional to the force and the distance between the joint and the band (moment arm). The acceleration of the limb is produced by sharply cutting the cord or cable. This instantaneous acceleration may be measured by optical or electrical means and the mass moment of inertia about the proximal joint determined.</p> <p>This technique is illustrated in <b>Fig. 16</b>. The subject rotates his forearm about the elbow, thereby pulling against the spring shown at the right through a cord wrapped around a pulley. The mechanism on the platform to the right contains the cutter mechanism with an engagement switch which activates the circuit of the two accelerometers mounted on the subject's forearm. The potentiometer at the base of the spring records the force by measuring the spring's deflection. The accelerometers in tandem give the angular acceleration of the forearm and hand at the instant of cutting. A scale is used to determine the moment arm of the force. This method is further discussed by Drillis (1959).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Quick release method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Compound Pendulum Method</i></p> <p>This technique for finding both mass moment of inertia of the segment and center of mass may be used in one of two ways: (1) considering the segment as a compound pendulum and oscillating it about the proximal joint, and (2) making a casting of plaster of Paris or dental stone and swinging this casting about a fixed point.</p> <p>Using the first method, it is necessary to find the moment of inertia, the effective point of suspension of the segment, and the mass center; thus, there are three unknown quantities.</p> <p>A study by Nubar (1960) showed that these unknowns may be obtained if it is assumed that the restraining moment generated by the individual is negligible. In order to simplify the calculations, any damping moment (resulting from the skin and the ligaments at the joint) is also neglected. The segment is then allowed to oscillate, and its period, or time for a complete cycle, is measured for three cases: (1) body segment alone, (2) segment with a known weight fixed to it at a known point, (3) segment with another known weight fixed at that point. Knowing these three periods and the masses, one can find the effective point of suspension, the center of mass, and the mass moment of inertia from the three equations of motion. If the damping moment at the joint is not negligible, it may be included in the problem as a viscous moment. The above procedure is then extended by the measurement of the decrement in the succeeding oscillations.</p> <p>In the second procedure, the casting is oscillated about the fixed suspension point. The moment of inertia of the casting is found from the measurement of the period. The mass center can also be determined by oscillating the segment casting consecutively about two suspension points. This method is described in detail by Drillis <i>el al. </i>(1963). Since the weight of both the actual segment and cast replica can be found, the measured period can be corrected on the basis of the relative weights to represent the desired parameter (mass center or mass moment of inertia) of the actual segment. The setup for the determination of the period of oscillation is shown in <b>Fig. 17</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Compound pendulum method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The photograph in <b>Fig. 17</b> has been double-exposed to illustrate the plane of oscillation.</p> <p><i>Torsional Pendulum Method</i></p> <p>The torsional pendulum may be used to obtain moments of inertia of body segments and of the entire body. The pendulum is merely a platform upon which the subject is placed. Together they oscillate about a vertical axis. The platform is restrained by a torsion bar fastened to the platform at one end and to the ground at the other. Knowing the physical constants of the pendulum, <i>i.e., </i>of the supporting platform and of the spring or torsion bar, the measurement of the period gives the mass moment of inertia of the whole body. The principle of the torsional pendulum is illustrated schematically in <b>Fig. 18</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Torsional pendulum method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> and <b>Fig. 20</b> describe the setup in use. There are two platforms available: a larger one for studying the supine subject and a smaller one for obtaining data on the erect or crouching subject. In this way, the moments of inertia for both mutually perpendicular axes of the body can be found.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Body dimensions on torsion table. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Mass moment of inertia determination (squatting position). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> shows a schematic top view of the subject lying supine on the large table. Recording the period of oscillation gives the mass moment of inertia of the body about the sagittal axis for the body position indicated. Figure 20 is a side view of the small table used for the standing and crouching positions. This view shows the torsion bar in the lower center of the picture encased in the supporting structure.</p> <p>This method can also be used to find mass moments of inertia of body segments. Nubar (1962) describes the necessary procedure and equations. Basically it entails holding the rest of the body in the same position while oscillating the system for two different positions of the segment in question. Knowing the location of the segment in each of these positions, together with the periods of oscillation of the pendulum, the segment moment of inertia with respect to the mediolateral centroidal axis may be found. This technique is illustrated by the schematic Figure 19 for the case of the arm. The extended position is shown; the period would then be obtained for the case where the arm is placed down at the subject's side.</p> <p>Both the mass and center of mass of the arm can be determined using the large torsion table. The table and supine subject are rotated for three arm positions-arms at sides, arms outstretched, and arms overhead-and respective total moments of inertia are found from the three periods of oscillation. Assuming that the position of the longitudinal axis of the arm can be defined, <i>i.e., </i>the axis upon which the mass center lies can be clearly positioned, the following equations may be applied:<b>Eq. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>where <i>I1, I2, I3 </i>are the total moments of inertia of table, supports, and subject, found from the periods of oscillation, for the subject with arms at sides, outstretched, and overhead, respectively.</p> <p><i>h </i>is the distance from middle fingertip when arms are at the sides to the tip when arms are overhead.</p> <p><i>l</i> is the total arm length (fingertip to shoulder joint).</p> <p><i>g </i>is the distance from middle fingertip to the lateral center line of the table when the arms are at the sides.</p> <p><i>p </i>is the distance from middle fingertip to the lateral center line when the arms are outstretched.</p> <p><i>s</i> is the distance between the longitudinal center line of the table and the longitudinal axis of the arm when the arms are at the sides.</p> <p><i>d </i>is the distance between the mass center of the arm and the shoulder joint.</p> <p>In this case, the subject is placed so that his total body mass center coincides with the table's fixed point of rotation and there are no initial imbalances. The explanation of the above symbols may be clarified by reference to <b>Fig. 19</b>.</p> <p><i>Difficulties in Obtaining Proper Data</i></p> <p>In the commonplace technical area, where it has been necessary to evaluate the volume, mass, center of mass, etc., of an inanimate object, this object is usually one of fixed dimensions; that is, there is no involuntary movement of parts. The living human organism, on the other hand, is totally different in that none of its properties is constant for any significant period of time. There are differences in standing erect and in lying down, in inhaling and in exhaling, in closing and in opening the hand. It is necessary, therefore, to develop a procedure of measurement which can contend with these changes, and to evaluate data with particular reference to a specified orientation of the body.</p> <p>One ever-present problem in dealing with the body is the location of joints. When a segment changes its attitude with respect to adjacent segments (such as the flexion of the elbow), the joint center or center of rotation shifts its position as well. Thus, in obtaining measurements on body segments, it is necessary to specify exactly what the boundaries are. As yet there is no generally accepted method of dividing the body into segments.</p> <p>When an attempt is made to delineate the boundary between segments for purposes of experimental measurement, one cannot avoid the method of placing a mark on the subject at the joint. This mark will have to serve as the segment boundary throughout the experiment. Unfortunately an error is introduced here when the elasticity of the skin causes the mark to shift as the subject moves. This shift does not correspond to a shift in the actual joint.</p> <p>In an analysis of a particular body segment involving movement of the segment, such as the quick release, reaction, and torsional pendulum methods which have been described, one must take care to ensure that only the segment moves. Usually this involves both physical and mental preparations on the part of the subject.</p> <p>Finally, the greatest error in obtaining results on body parameters is due to variations in body build. As can be seen from the previous data brought forth, different researchers using identical techniques have gotten quite dissimilar data on the same body segment due to the use of subjects with greatly varying body types.</p> <p>In an effort to resolve this conflict, the Biomechanics group at New York University is endeavoring to relate their data on body segment parameters to a standard system of body typology.</p> <p><i>Anthropometric Studies</i></p> <p>In order to develop a means of classifying the subjects according to body build, the method of somatotyping is utilized. Here the body build is designated according to relative amounts of "endomorphy, ectomorphy, and mesomorphy" as described by W. H. Sheldon <i>et al. </i>(1940, 1954) in the classic works in the field. In order to determine the subject's somatotype, photographs are taken of three views: front, side, and back. These are illustrated in <b>Fig. 21</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Photographs for somatotyping. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Biomechanics group of New York University has obtained the services of an authority in the field, Dr. C. W. Dupertuis, to establish the somatotype of the subjects. The photographs also will be used to obtain certain body measurements.</p> <p>The aim of the study is to develop relationships between body parameters and body build or important anthropometric dimensions so that a pattern will be established enabling body parameters to be accurately found for all body types.</p> <p>If sufficient subjects are measured it should be possible to obtain a set of parameter coefficients which take into consideration the effect of the particular body type. When these coefficients are applied to some set of easily measurable body dimensions on any new subject, the appropriate body parameters could easily be determined.</p> <p>It is planned to prepare tables of these body parameter coefficients (when their validity has been established) for some future edition of <i>Artificial Limbs.</i></p> <p><b>References:</b></p> <ol> <li>Amar, J., <i>Le moteur humain, </i>Paris, 1914.</li> <li>Bashkirew, P. N., <i>Human specific gravity in the light of its practical importance to anthropology and medicine </i>(in Russian). Soviet Anthropology, 2 (2): 95-102, Moscow, 1958.</li> <li>Bernstein, N. A., O. A. Salzgeber, P. P. Pavlenko,and N. A. Gurvich, <i>Determination of location of the centers of gravity and mass of the limbs of the living human body </i>(in Russian), All-Union Institute of Experimental Medicine, Moscow, 1936.</li> <li>Boyd, E., <i>The specific gravity of the human body,</i> Human Biology, 5: 646-672, 1933</li> <li>Braune, W., and O. Fischer, <i>The center of gravity of the human body as related to the equipment of the German infantryman </i>(in German), Treat. of the Math.-Phys. Class of the Royal Acad. of Sc. of Saxony, 26: 1889.</li> <li>Contini, R., R. Drillis, and M. Bluestein, <i>Determination of body segment parameters, </i>Human Factors, 5 (5): 1963.</li> <li>Dempster, W. T., <i>Space requirements of the seated operator, </i>USAF, WADC, Tech. Rep. 55-159, Wright-Patterson Air Force Base, Ohio, 1955.</li> <li>Drillis, R., <i>The use of gliding cyclograms in the biomechanical analysis of movement, </i>Human Factors, 1 (2): 1959.</li> <li>Du Bois, J., and W. R. Santschi, <i>The determination of the moment of inertia of the living human organism, </i>paper read at the International Congress on Human Factors in Electronics, Institute of Radio Engineers, Long Beach, Calif., May 1962.</li> <li>Fischer, O., <i>Theoretical fundamentals of the mechanics of living bodies </i>(in German), Berlin, 1906.</li> <li>Harless, E., <i>Textbook of plastic anatomy, Part III </i>(in German), Stuttgart, 1858.</li> <li>Harless, E., <i>The static moments of human limbs </i>(in German), Treatises of the Math.-Phys. Class of the Royal Acad. of Sc. of Bavaria, 8: 69-96 and 257-294, 1860.</li> <li>Hertzberg, H. T., C. W. Dupertuis, and I. Emanuel, <i>Stereophotogrammetry as an anthropometric tool,</i> Photogrammetric Engineering, 24: 942-947, 1957.</li> <li>Ivanitzkiy, M. F., <i>Human anatomy </i>(in Russian); Part I, 3rd ed., Moscow, 1956.</li> <li>Meeh, C, <i>Volummessungen des menschlichen Korpers und seiner einzelner Teile in der verg-chiedenen Altersstufen, </i>Ztschr. fur Biologie, 13: 125-147, 1895.</li> <li>Nubar, Y., <i>Determination of characteristics of the compound pendulum by observing oscillations, </i>unpublished report, Research Division, College of Engineering, New York University, 1960.</li> <li>Nubar, Y., <i>Rotating platform method of determining moments of inertia of body segments, </i>unpublished report, Research Division, College of Engineering, New York University, 1962.</li> <li>Pierson, W. F., <i>The validity of stereophotogram-metry in volume determination, </i>Photogrammetric Engineering, 25: 83-85, 1959.</li> <li>Salzgeber, O. A., <i>Method of determination masses and location of mass centers of stumps </i>(in Russian), Transact. Scient. Researc Inst. of Prosthetics in Moscow, 3: Moscow, 1949.</li> <li>Sheldon, W. H., S. S. Stevens, and W. B. Tucker,<i>The varieties of human physique, </i>New York, 1940.</li> <li>Sheldon, W. H., C. W. Dupertuis, and C. McDermott, <i>Atlas of men, </i>New York, 1954.</li> <li>Steinhausen, W., <i>Mechanik d. menschlichen Korpers,</i>in Handbuch d. Normalen n. pathologischen Physiologie, 14: 1926-1927.</li> <li>Tanner, J. M., and J. S. Weiner, <i>The reliability of the photogrammetric method of anthropometry, with a description of a miniature camera technique, </i>Am. J. Phys. Anthrop., 7: 145-186, 1949.</li> <li>Weinbach, A. P., <i>Contour maps, center of gravity,moment of inertia, and surface area of the human body, </i>Human Biology, 10 (3): 356-371, 1938.</li> <li>Wild, T., <i>Simplified volume measurement with the polar planimeter, </i>Surveying and Mapping, 14: 218-222, 1954.</li> <li>Zook, D. E., <i>The physical growth of boys, </i>Am. J. Dis. Children, 1930.</li> <li>Zook, D. E., <i>A new method of studying physical growth, </i>Junior-Senior High-School Clearing House, 5: 1932.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice Bluestein, M.M.E. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini, B.S. </b></td></tr><tr><td class="clsTextSmall">Senior Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rudolfs Drillis, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Senior Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-9.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Body Segment Parameters: A Survey of Measurement Techniques Creator An entity primarily responsible for making the resource Rudolfs Drillis, Ph. D. * Renato Contini, B.S. * Maurice Bluestein, M.M.E. * https://staging.drfop.org/files/original/673830cf47fc4145408e60fb59c2e58e.pdf daa60cba2d873060d065a59d7d151976 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_001.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_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>Collaboration for Rehabilitation</h2> <h5>Mary E. Switzer <a style="text-decoration:none;">*</a><br /></h5> <p>I welcome the opportunity to express my appreciation for the wonderful cooperation and assistance that the Vocational Rehabilitation Administration has enjoyed in our many close relationships with the National Academy of Sciences-National Research Council. Our associations with the Committee on Prosthetics Research and Development and the Committee on Prosthetic-Orthotic Education have been long and fruitful, and the contributions of these committees have been substantial in the development and coordination of the research and informational programs for the fields of prosthetics and orthotics. VRA is glad to be associated with the National Institutes of Health-which is another agency of the Department of Health, Education, and Welfare-and with the Veterans Administration in supporting the CPRD program; and, naturally, we look with special pride on the CPOE program since we are its primary support.</p> <p>In our search for the judgment of the most knowledgeable people in each field which we support, the members of our National Advisory Council on Vocational Rehabilitation and the consultants on our Medical Advisory Committee have come to respect the professional competencies of the engineers, physicians, therapists, prosthetists, and orthotists who serve on CPRD. The professional advice and recommendations available to the Academy-Research Council on this basis assure impartial excellence in judgment and accessibility to professional skills that are not readily available from any other source in this country.</p> <p>I have been particularly impressed with the extensive informational program that CPOE has developed, especially the brochures, films, and slides for use in schools of medicine, physical therapy, and occupational therapy and for the work that has been initiated in the development of new amputee clinics in several of our State programs.</p> <p>There are special reasons why the functions of the Committees continue to hold special significance to our total rehabilitation program: State-Federal, research and demonstrations, and training activities.</p> <p>A recent study was made of the 120,000 persons who were rehabilitated in the State-Federal program during 1964, and it was found that the classifications of amputations, absence of extremities or other orthopedic deformities, accounted for a total of 42,352 persons rehabilitated. Approximately 35% of the total group, therefore, were orthopedic rehabilitants. Thus, it is obvious that, even with the changing emphases in disability groups needing service, the thread of orthopedic disabilities runs through the entire program of rehabilitation, and orthopedic cases are almost four times as large as the next largest category of disability.</p> <p>The VRA program of research and demonstrations, which began with a trickle ten years ago, has broadened into a flow of new ideas, methods, and patterns of service to facilitate and improve the restoration of the disabled to worthwhile lives. There have been approximately 850 VRA research projects approved during the period 1955-1964, and about seven per cent of these projects have been for studies primarily concerned with problems caused by or related to orthopedic disability. Thirty-one universities, hospitals, or rehabilitation centers have sponsored 55 research projects relevant to this field of work. During fiscal year 1964, VRA awarded research grants to 13 new projects relating to the orthotic-prosthetic field and an additional 14 ongoing projects received continuation grants.</p> <p>Some of the most imaginative and creative work in our total program is going on in this field of research, and we are constantly aware of the dramatic advancements that are taking place. The collaboration of medical rehabilitation and engineering with some of the discoveries in the space program should bring a whole new dimension to the war on disability. So naturally we are pleased that CPRD has followed our recommendation to hold a conference on the Control of External Power in Upper-Extremity Rehabilitation so that leading engineers, physicians, and scientists can come together to formulate and coordinate their programs and assist us in developing future plans for support of their efforts.</p> <p>Our training program, which continues to pour a steady stream of new professional rehabilitation workers into the ranks, has expanded so that professional training in all of the fields that contribute to rehabilitation has been influenced by VRA training grants: medicine, nursing, physical therapy, occupational therapy, rehabilitation counseling, social work, speech pathology and audiology, rehabilitation of the blind and deaf, the mentally ill and the mentally retarded, and recreation for the ill and disabled.</p> <p>Since 1953, over 600 short-term courses in prosthetics and orthotics with a total enrollment of about 9,500 trainees have been attended by physicians, surgeons, therapists, counselors, prosthetists, orthotists, and related rehabilitation personnel. Last year alone, over 1,500 persons were enrolled in 90 courses which were a part of the extensive offerings in upper- and lower-extremity prosthetics and orthotics, management of the juvenile amputee, and general orientation courses for these fields. The work of the University Council on Orthotic-Prosthetic Education has done much to achieve a more uniform approach in curriculum offerings, teaching materials and methods, and evaluation procedures for the courses.</p> <p>The semester courses at UCLA and Northwestern, the Associate in Arts courses proposed at Cerritos College and Chicago City Junior College, and the undergraduate curriculum at New York University-all these attest to the professionalism that is developing in prosthetics and orthotics.</p> <p>CPRD's and CPOE's paramount asset to us is a technical proficiency while ours is a resource of public funds and a wealth of experience which we try to combine through the State-Federal partnership and our research and training projects into a comprehensive program for helping the disabled to reach their physical, economic, social, and personal goals. Our task, as public servants, is to administer these Federal funds as wisely as we can, always bearing in mind the true function of the law and purpose of our program: to convert dependency into competence and independence. As we work together along the paths of rehabilitation, exchanging our knowledge and our resources, perhaps we can all share in the conviction expressed on the seal of the Department of Health, Education, and Welfare which reminds us constantly that Hope is the Anchor of Life.</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>Mary E. Switzer </b></td></tr><tr><td class="clsTextSmall">Commissioner, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, Washington, D. C. 20201.</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 Collaboration for Rehabilitation Creator An entity primarily responsible for making the resource Mary E. Switzer * https://staging.drfop.org/files/original/feebebaa37399c3b95576ae8e7aa803a.pdf e216245824105b9041905d276496dc47 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_001.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Whither Prosthetics and Orthotics?</h2> <h5>George T. Aitken, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The publicity concerning scientific and technical advances keeps us constantly aware of man's increasing competence to master his environment. The technologies available make possible a wide variety of mechanisms that expand man's sphere of activity and make possible comfortable living in environments previously considered undesirable. Some of the modern techniques, when applied in the biological fields, have eliminated some diseases, controlled others, and have made possible medical and surgical procedures that extend the life expectancy of persons of all ages. Continuing research undoubtedly is going to demonstrate eventually the etiological factors in other disease entities and thus permit the development of a nonsymptomatic approach to therapy.</p> <p> Many of the current scientific advances have been the result of interdisciplinary effort, where two or more separate disciplines have worked together, hopefully synergistically. This interdisciplinary effort in prosthetics and orthotics has produced what is often described as a bioengineering effort. In the past twenty years increasing emphasis has been placed on the engineering aspects of this specific problem. These years have witnessed a rapid advance in the development of new industrial materials and hardware that have been readily applicable to artificial limbs and braces. Many improvements in previous fabrication techniques and components were facilitated by using these newly available industrial developments, and thus some advances were made in upgrading the quality of prosthetic and orthotic devices.</p> <p> There have been varying degrees of concurrent fundamental research in the biological aspects of this interdisciplinary approach.</p> <p> It seems at times, though, that the glamour of technology has overshadowed the purely biological problems. Research activities involving these glamour areas have been more attractive to many, and funds for such research have been more available in these sometimes esoteric areas.</p> <p> At times it would seem that many involved in prosthetics and orthotics research and development have failed to see the entire problem. Basically, it is the problem of achieving the optimum man-machine interface. The ultimate resolution of the problem is the production of designs that result in comfort, maximum function, and reasonable cosmetic restoration.</p> <p>There is little question that much has been accomplished. Certainly we have available currently biological and engineering techniques that are capable, in a high percentage of cases, of producing improved function and cosmesis. Continuing intelligent modification of techniques and components produces more and more improvement in all of these areas. It is fair to assume that amputees and others with orthopaedic impairments are now better served than ever before.</p> <p>Unfortunately, many in the field of prosthetics and orthotics research and development seem to have a tendency to relegate the patient to a secondary position. They appear to be bent on the perfection of the machine without due consideration to the education or alteration, or both, of the man to perfect the interface.</p> <p>It seems timely to give consideration to some of the areas in which continuing, accelerated investigation is desirable.</p> <p>Research in amputation surgery to provide more functional stumps and consequently more comfort to the patient has been significantly lacking. There is a multiplicity of amputation techniques. Myoplastic and osteoplastic techniques either alone or in combination have been recommended to promote comfort and improved function. In this country there has been no well-organized clinical evaluation of these claims made primarily from abroad. It seems logical that such procedures be investigated and evaluated thoroughly. There are good theoretical reasons to justify consideration of these procedures so that they not be simply rejected because of dissimilar training and experience.</p> <p>Cineplastic procedures were critically investigated, and well-established criteria have been developed for their use. A similar review should be made of some of the other surgical problems.</p> <p>The immediate postsurgical fitting of sockets with or without early weightbearing currently is being investigated. Undoubtedly, the results of this wellorganized investigation will develop proper indications and techniques for this procedure. Hopefully, such techniques will be of positive value in influencing the man aspect of the man-machine interface.</p> <p>There are in addition many areas of basic biological research that need further investigation. The problem of biological signal sources for control of external power comes to mind immediately. Other, perhaps less exotic, problems, such as analysis of joint motions to permit more satisfactory alignment and construction of braces, or the metabolic problems incident to amputation and use of prostheses as well as analogous problems in the orthotics field, need further investigation. These are but a few of the many fundamental problems that need clarification.</p> <p>In the truly engineering area, there is a large volume of continuing research and development of systems, components, and techniques to produce better artificial limbs and better braces. Much of this work is in the newer areas of technology and has increasing emphasis on the problems related to the use of external power in prostheses and orthotic devices.</p> <p>There may be a need to review some of our accepted designs in the light of our recent progress and perhaps an effort should be made to determine whether previously acceptable items are really the best that can be developed in relation to some of our improvements in materials and techniques. It may be the time to review terminal-device design. It is possible that we now need (particularly in the light of external power) to redefine the functional requirements of a terminal device and arrive at some design criteria that will permit more efficient utilization of our technical improvements in power sources and transmission.</p> <p>With an increasing emphasis on prosthetic restoration in congenitally limbdeficient children, it may develop that there must be a redefinition of goals, in the case of the upper-extremity patient, as related to age, rather than as related to the needs of an adult. Possibly a careful analysis of the functional needs of pre-school and primary and secondary school children would permit us to develop components for a system that would be more effective than simply using scaled-down adult components and systems.</p> <p>An overall review of research and development in prosthetics and orthotics over the past twenty years cannot help but emphasize that people requiring prostheses and orthotic devices are being increasingly better served. There seems little question but that the efforts of our schools of prosthetics and orthotics education have produced a marked upgrading of the skills in prescribing and fitting these devices as well as greater competency in the training of the patient in the use of such devices.</p> <p>As a clinician, I am very pleased with the improvement of patient care in these areas. As an interested participant in research and development endeavors, I am increasingly aware that there is much more that remains to be done. There exist the technical facilities to do both better research and better development. What is needed is the wisdom to direct our efforts in such a way that we adequately explore all areas of this man-machine problem and so correlate our activities that the result—the functioning man-machine combine— is a continually improving biomechanical unit.</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>George T. Aitken, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Committee on Prosthetics Research and Development, July 1, 1962-June 30, 1965. Upon completion of his term as Chairman of CPRD, Dr. Aitken will continue to serve as a member of CPRD.</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 Whither Prosthetics and Orthotics? Creator An entity primarily responsible for making the resource George T. Aitken, M.D. * https://staging.drfop.org/files/original/ff93388a2b326482cd23ab1fe7b0530f.pdf 56f90f8e21d338b8b528570d124e7f89 https://staging.drfop.org/files/original/dcdfac18ac5ac3022676315508cf5d48.jpg dbee38bac224a96a2c011cb17d7d6a9f https://staging.drfop.org/files/original/e19ee311b0e20a0019bbf64b23a2defd.jpg 709d5e732087fd5a57d43b48a0652c1c https://staging.drfop.org/files/original/ff5fb16a3b6eb4327a31bb1992c94add.jpg 634c592b76ea73a55e13cf93c72ae7ca https://staging.drfop.org/files/original/dd03140d20e3ea247047a03394d6be8f.jpg 9801ffc457b82c0e5e04953cb4376b90 https://staging.drfop.org/files/original/1c887547c6cbac99872483f954e8b43a.jpg 056339fc83108b1608ab7864990f343f https://staging.drfop.org/files/original/8c92a0c6606452d4426b8a44d4f4bff6.jpg 3f5ae3451b2192b7ea3f4231b3f169e8 https://staging.drfop.org/files/original/32fdad7b172199d9b720f189835bc3c9.jpg 9710e54f4022a14c41497f00812a7a4c https://staging.drfop.org/files/original/aa48e315ac77e0e2136d3931d68f5e2e.jpg f8768c064188a404312b028d7fff4829 https://staging.drfop.org/files/original/b5bef2c3795da5096649620616ab5554.jpg 7bf997809b8206a66916590c0d7b404b https://staging.drfop.org/files/original/b19587d2238d7d8b888d85da0d64eef4.jpg aeafbf39f3d3f61b596eddca5ba9ffaf https://staging.drfop.org/files/original/c1ce590718115f39e52684aee441de8f.jpg d5ae4663e0a01f258e869afed35cbd4a https://staging.drfop.org/files/original/c7a6dde19f351a434ecf52aabd0334d3.jpg 65cdb5dd9ad39d3da6951490f7ee16f8 https://staging.drfop.org/files/original/cf1809077913f566b86fa7e5199c3c20.jpg 4530478b27ca832a157266ebe524bb10 https://staging.drfop.org/files/original/37824783f3fe6a952766ec00f7dd01d9.jpg b11bbffa4e419db31441af1f803b4640 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_004.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 4 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_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>The Münster-Type Below-Elbow Socket, an Evaluation.</h2> <h5>Sidney Fishman, Ph. D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> Short stumps have always presented fitting problems in both upper- and lower-extremity amputation sites for the obvious reasons of small attachment area and a lack of useful range of motion. In an attempt to alleviate these problems for upper-extremity amputees, Drs. O. Hepp and G. G. Kuhn<a></a> of Münster, Germany, developed fitting techniques for the below-elbow and the above-elbow amputee, respectively, that provide a more intimate encapsulation of short stumps. </p> <p> For the below-elbow amputee, the general characteristics of this technique (<b>Fig. 1</b>) are: </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Münster-Type fitting for below-elbow ampute. A, Lateral view ondicating the preflexion angle; B, anterior view indicating high trim line; C, posterior view indicating olecraron fit and the small tricep pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The elbow is set in a preflexed position (average 35 deg.). Because of the reduced range of useful motion, the socket is flexed so as to position the terminal device in the most generally useful area.</li><li>A channel is provided at the antecubital space for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket is fitted high around the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket.</li></ol> <p>For the above-elbow amputee, the characteristics of the technique are: </p> <ol> <li>The socket is fitted high on the acromian, utilizing this bony structure to retain the socket in position and provide stability. </li><li>The axillary section of the socket conforms closely around the tendons of the pectoralis major and latis-simus dorsi muscles to enable the patient to exert the force of these major muscles in moving his prosthesis.</li></ol> <p> In an earlier study<a></a>, amputee clinics reported a favorable experience in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children with short and very short below-elbow stumps. Since the Hepp-Kuhn technique seemed to represent an improvement in fittings of the preflexed type, New York University initiated a preliminary investigation of the procedure for adult amputees of this type. This study took place in the early part of 1961 and was limited to two short-below-elbow subjects. This exploratory study yielded generally positive outcomes in terms of function and comfort. One short-above-elbow amputee was also fitted with encouraging results. </p> <p> The present evaluation is an extension of the initial study with major emphasis given to below-elbow fittings. Concurrently, further exploration of the above-elbow fitting technique was undertaken and is continuing, although not reported in this article. </p> <p> For lack of a better term, the fitting procedures employed in this study are referred to as the "Münster-type" techniques. It should be emphasized that no claim is made that the techniques are identical to those followed by Drs. Hepp and Kuhn. New York University personnel witnessed a demonstration of the techniques given by Dr. Kuhn in 1960 and had available the cited reference. However, none of the New York University fittings were either directly or indirectly supervised or checked by the developers. </p> <p> Both logic and prior experience suggest that the greatest benefit from the Münster-type below-elbow fitting technique may accrue to subjects with short and very short below-elbow amputations in that the step-up hinges and split sockets characteristic of typical United States fittings for these categories could be eliminated. Historically, step-up hinges have lacked durability. Moreover, a price is paid for the step-up characteristic by a corresponding decrease in lifting power. Contrariwise, it is apparent that the range of elbow flexion is reduced by the Münster-type fitting. This reduction may or may not be significant in terms of amputee function (<b>Fig. 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparison of split socket and Münster-type fitting of very short below-elbow case. A, Very short below-elbow stump-3-1/4 in.; B, split socket with step-up hinge provides 140 deg. of elbow flexion; C, Münster-type fitting permits less elbow flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Sample</h3> <p> The sample in this study consisted of eight adult below-elbow amputee subjects (including one bilateral amputee) whose stumps were relatively short-from 3-1/4 in. to 5-1/2<i> </i>in. measured from the medial epicondyle to the end of the stump. The physical characteristics of the sample and a description of their previously worn prostheses are given in <b>Table 1</b> and <b>Table 2</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Methodology</h3> <p> The Münster-type techniques for fitting below-elbow prostheses, as understood by New York University personnel, were followed in fabricating experimental arms for the eight subjects in the sample. In one case (WP), however, the anterior trim line (channel for biceps tendon) was reduced in order to provide this bilateral amputee with a greater range of elbow flexion. All prostheses incorporated triceps pads, leather hinges, and figure-eight harnesses. Six of the eight subjects (OB, PL, TM, WP, ES, and PW) were fitted with polyester porous sockets fabricated in accordance with the technique developed at the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory)<a></a>. The other two subjects (DC and QS) were fitted with nonporous plastic sockets. </p> <p> The evaluation consisted essentially of a "before" and "after" comparison of status. The prosthetic status of all subjects in this study was assessed prior to their fitting with the Münster-type prosthesis in order to obtain a basis for later comparison. At one month and at six months after delivery of the experimental prosthesis, the prosthetic status of the subjects was reevaluated and comparisons between the conventional and experimental prostheses were drawn. </p> <p> The stumps of all subjects were examined prior to the experimental fitting in order to identify their condition (scars, irritations, discolorations, etc.). This examination was repeated at the specified intervals to see what effect, if any, the experimental socket had had on the physical condition of the stump. </p> <p> Two self-administering rating scales completed by all subjects elicited their opinions regarding prosthetic comfort, function, and cosmesis. A questionnaire was administered prior to the experimental fitting to assess the amputees' opinions regarding their conventional prostheses. A comparative questionnaire was administered in the post-fitting evaluations to compare the experimental and the conventional prosthesis in the factors previously rated. </p> <p> A prosthetic-usefulness schedule<a></a> was applied to the six subjects who had previously worn a functional prosthesis to investigate their opinions concerning the relative value and comparative ease of performance of the conventional and experimental prostheses in the areas of work, home tasks, social life, dressing, and eating. </p> <p> Three evaluation procedures were administered to the six subjects who had previously worn functional prostheses, as follows: </p> <ol> <li>The angles of preflexion and maximum flexion were measured on both conventional and experimental prostheses, as well as the amount of vertical downward force the amputees could resist with their elbows flexed at 90 deg. (live lift) and fully extended (axial load). </li><li>The accuracy of positioning control exhibited by the amputees was measured with both conventional and experimental prostheses. Scoring of performance on the positioning control test<a></a> was in terms of accuracy and speed</li><li>The amputees' ability to perform a series of 12 bimanual practical activities was rated on a seven-point scale. For each activity, six factors were rated independently but simultaneously by two experienced examiners. This evaluation was administered initially to the amputees with their conventional prostheses and then repeated with the experimental prostheses at the one-month and at the six-month post-fitting evaluations.</li></ol> <h3>Results</h3> <h4>Stump Examinations</h4> <p>In all cases a period of two to three weeks was required for the subjects to become adjusted to the more intimate fit of the Münster-type socket. During this initial wear period, the usual complaint was of an irritation in the medial epicondylar area, which was corroborated by visual examination. However, after this adjustment period, the experimental socket had no observed or reported effects on the amputation stump, although amputees were generally aware of increased pressure on the olecranon when the forearm was flexed. </p> <h4>Amputee Reactions</h4> <p> Comparative reactions to the conventional and experimental prostheses were obtained from the eight subjects in the sample. The factors investigated and the amputees' ratings are presented in (<b>Table 3</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> It is clear from (<b>Table 3</b>) that, with few exceptions, the amputees reacted very favorably to the Münster-type prosthesis. Sixty per cent of the responses were favorable toward the experimental item while only five per cent were unfavorable. The two factors which brought forth negative reactions were comfort (two subjects) and adjustments (two subjects). These negative reactions reflect difficulties experienced by these two amputees in adjusting to the intimate fit of the Münster-type socket. However, all seven subjects in the sample who had previously worn rigid hinges of one type or another cited the elimination of these hinges as a definite contribution to comfort. </p> <p>No differences in reactions which could be attributed to socket porosity, or lack of it, were noted. The fact that the wear period for most of the subjects was confined to the winter months may explain this lack of difference. </p> <p>The data on effort and control are of particular interest. All subjects in the sample reported improvement in these factors as a result of wearing the experimental prosthesis. Further questioning revealed that the amputees' opinions regarding improved prosthetic control with less expenditure of effort appeared directly attributable to the more intimate fit of the Münster-type socket. This reaction was commonly expressed by such statements as: "The prosthesis feels a part of me" and "I feel right-handed again." Several subjects reported that the Münster-type sockets did not tend to slip off their stumps under load, as was the case with their conventional sockets. One subject cited the more secure fitting of the Münster-type socket to be particularly advantageous in performing overhead activities because his stump did not slip out of the socket when he performed a pulling motion with the prosthesis. </p> <p>The reactions of the two subjects (ES and PL) who had previously worn nonfunctional prostheses (for 15 and 20 years, respectively) are noteworthy. Neither became especially skillful prosthesis users in the course of the study, but both did come to use their terminal devices for grasp, which they had not previously done. Their highly positive responses to the experimental item and the fact that it changed their prosthetic status from that of nonusers to users after so long a period were considered quite unusual. Since both patients were fitted with porous laminate sockets, the role of the Münster-type fitting is not completely "pure" but, at least, must be regarded as contributory. </p> <p>Of the six subjects who had previously worn functional devices, five were able to perform the same number of activities with the experimental prostheses as with the conventional, while one subject reported increased prosthetic function with the Münster-type prosthesis (for example, he was able to carry a coat on his flexed forearm and was able to use his prosthesis in steering a car). However, all six amputees indicated that activities were easier to perform with the experimental prosthesis because the close-fitting socket afforded better control and the elimination of the rigid hinges provided greater freedom. </p> <p>In no case was there any evidence that the decreased range of motion with the experimental prostheses caused an appreciable decrease in prosthetic function. Since unilateral amputees routinely use their prostheses as assistive devices, there are few activities that are performed prosthetically at the extreme ends of the flexion-extension range. Bilateral subjects, however, are dependent on their prostheses for all upper-extremity functions and therefore require a greater range of motion. To provide the bilateral subject in our sample with an increased range of elbow flexion on his dominant side (40 deg. to 120 deg.), the anterior trim line was lowered. In addition, a wrist-flexion unit was provided to facilitate the performance of tasks close to his body. </p> <h4>Functional Evaluation</h4> <h5><i>Biomechanical Data</i></h5> <p> The Münster technique provides an intimate encapsulation of the amputated stump which results in a decreased range of motion. Forearm rotation is virtually eliminated, and the elbow flexion-extension range is significantly reduced. However, this type of fitting frequently increases the amputees' ability to resist moments about the elbow and to sustain axial loads. </p> <p> A comparison of the flexion ranges of the conventional and experimental prostheses is presented in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The preflexion angle of the Münster-type socket ranged from 20 deg. to 45 deg., with an average of 35 deg. The exact preflexion angle was planned for each subject contingent on such factors as stump length, natural elbow motion, and amputee preference. Maximum flexion of the experimental sockets ranged from 85 deg. to 120 deg. with an average of 105 deg. </p> <p> <b>Table 5</b> compares the maximum holding forces that amputees (the six who had previously worn functional prostheses) were able to maintain with both prostheses. "Live lift" refers to the amount of vertical downward force (applied at the terminal device) that an amputee can resist while maintaining his elbow at 90 deg. (<b>Fig. 3</b>). To allow for different forearm lengths, the data are expressed in foot-pounds. "Axial load" refers to the amount of vertical downward force applied at the terminal device that an amputee was able to resist with his elbow in an extended position. A complaint of pain or one-inch slippage of the socket on the stump was taken as the maximum tolerable load (<b>Fig. 4</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. live-lift test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. axial-load test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In all cases the amputees were able to resist a greater force in the live-lift test with their Münster-tvpe prostheses than with their conventional prostheses. For three subjects (DC, WP, and PW) the differences were very significant. In subject DCs case, this difference can be readily understood since he had previously worn a split socket and step-up hinge with an inherent mechanical disadvantage. For subjects WP and PW (prior single-pivot and flexible-hinge wearers, respectively), it is speculated that their improved lifting power was directly related to the more intimate fit of the experimental sockets. However, it is not clear why the same ratio of improvement did not obtain for the other subjects. </p> <p> Four of the six subjects were able to resist a greater axial load with the Mtinster-type prostheses than with their conventional prostheses. The maximum axial load on the experimental prosthesis for the other two subjects was limited by stump pain, particularly in the epicondylar area. </p> <h5> <i>Positioning Control Test</i> </h5> <p> The positioning control test investigated the amputees' ability to control their prostheses; that is, to bring the terminal device to a desired location in space with measured speed and accuracy. Specifically, it tested the skill of the amputees in striking designated targets in the vertical (on the wall) and horizontal (on a table) planes. Three different sequences were applied in the vertical plane and two in the horizontal. Accuracy was measured by the distance of a mark (made by a pencil held in the terminal device) from the target. Superior prosthetic performance therefore is indicated by the lower scores and performance times. <b>Table 6</b> and <b>Table 7</b> present the data for the three vertical and two horizontal sequences of the positioning control tests, respectivelv. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Analysis of the data of the positioning control test reveals minimal differences between the conventional and the experimental prostheses. In the vertical sequences, these differences favored the experimental prostheses slightly, with regard to accuracy, but the reverse is true regarding speed. In the horizontal sequences the experimental prostheses were slightly favored in both accuracy and speed. However, none of the differences proved statistically significant. </p> <h5> <i>Practical Activities Test</i> </h5> <p> Comparative performance data were obtained on five subjects in the sample. Two of the remaining three subjects were not tested because they had no prior experience with a functional prosthesis. The third subject (WP) had previously worn English-made components (terminal devices, wrist units) which it was not possible to duplicate in his experimental prosthesis. Since these different terminal devices would have introduced an extraneous variable into the experimental situation, the data from this subject are not included here. </p> <p> Performance data were obtained on a 12-item practical activities test. The activities were: using a pencil sharpener, tying a necktie, tying a shoelace, carrying several packages, filing a fingernail, hammering a nail, opening a jar, putting on a glove, using a can opener, using a paper clip, using a telephone and taking a message, and removing bills from a wallet. Six factors, each rated on a seven-point scale, were considered for each test activity. The factors were: position of the prosthesis for use, grasp of the object (secure or insecure), position of object for use (efficient or inefficient), maintenance of position of object during use (efficient or inefficient), appearance of performance (natural or unnatural), adequacy of general performance (efficient or inefficient). The average scores for each subject in these six factors are presented in (<b>Table 8</b>), with the higher scores reflecting better performance. The average performance times for each subject are shown in (<b>Table 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The data from (<b>Table 8</b>) indicate that there were apparently no significant differences in performance between the Münster-type and conventional prostheses, and the time comparisons in (<b>Table 9</b>) present no clearcut patterns. Two implications of these findings are of interest. First, the obvious and measurable decrease in range of forearm flexion imposed by the Münster-type fitting has no discernible effect on the bimanual performance of unilateral amputees. Second, the highly favorable reactions of subjects to the function and control aspects of the experimental arm were not corroborated by the performance-test data. This apparent lack of agreement may derive from two factors, either singly or in combination: some subtle but important differences in performance did exist but were not detectable by the observational testing procedures applied, or the more intimate and perhaps better fit of the experimental prosthesis (as compared to the conventional) created a "halo" effect which positively affected opinions concerning other aspects of the prosthesis. That is to say, since the prosthesis felt better, it must necessarily perform better. </p> <h3>Applicability of the Technique</h3> <p> Since it was hypothesized that the experimental item might have prime applicability to amputees whose stumps fell into the very short or short categories, attention was focused in the study on the fitting of such subjects. However, it was also of interest to investigate the range of stump lengths (or types) for which the Münster-type fitting might be suitable. </p> <p> In the New York University sample the shortest stump fitted was 3-1/4 in. To investigate the possibility of fitting stumps <i>shorter </i>than this, a cast and check socket were made for a bilateral amputee with a 2-1/2 in. below-elbow stump on one side (currently wearing a stump-actuated elbow lock) and an above-elbow stump on the other side. Since the below-elbow stump virtually disappeared at 90 deg. of flexion, it was thought that this was the absolute maximum flexion angle that might be obtained. This limitation was not considered acceptable for the dominant prosthesis of a bilateral amputee. It was also considered that this stump length was very near the lower limit for acceptable fitting, even for a unilateral amputee. </p> <p> With respect to maximum stump length, two limiting factors are observed: </p> <ol> <li>Stumps of mid-length and longer usually have some amount of pronation-supination which can be harnessed in a conventional below-elbow socket (with flexible hinges), but not in the Münster-type socket. </li><li>The configuration of the Münster-type socket (proximal opening at a sharp angle to the shaft) presents progressively increasing difficulty to donning and doffing as stump length increases (<b>Fig. 5</b>).</li></ol> <p> In the New York University series, in which the longest stumps fitted were <i>5-1/2 </i>in. (two subjects), neither of the above considerations was significant in either case. It is estimated, however, that the slumps of these two subjects were approaching the upper length limit to which the Münster-type socket could be applied without sacrifice of residual pronation-supination, or modification of the proximal socket to facilitate donning and doffing. </p> <p> Subject to further study, therefore, it appears that the Münster-type socket can be applied to the range of below-elbow-stump types for which rigid hinges (step-up, multiple action, and single-pivot) are typically prescribed at present. Some consideration probably should be given to the development of a prosthesis that will permit stump-actuated pronation and supination of the terminal device, yet retain the stability afforded by the Münster-type socket. </p> <h3> Summary and Conclusions</h3> <p> The applicability of Münster-type fittings was investigated by New York University. The sample for this study consisted of eight subjects with below-elbow amputations ranging from 3-1/4 in. to 5-1/2 in. (34 to 52 per cent). The results of the evaluative procedures, which included interview techniques and performance testing, indicated the following: </p> <ol> <li>A brief "breaking-in" period was required by all subjects to adjust to the more intimate fit of the Münster-type socket. After this initial period of adjustment, the experimental sockets had no observable or reported effects on the amputation stumps except a slight increase in pressure on the olecranon during lifting activities. The use of soft (Silastic) inserts over the epicondyles and olecranon to ameliorate these factors is under investigation at New York University.</li><li>The subjective opinions of all subjects were heavily in favor of the Münster-type prostheses.</li><li>The decrease in flexion range had no appreciable effect on prosthetic function for the unilateral amputees. For bilateral subjects, modification of the anterior trim line and provision of a wrist-flexion device may be necessary for performance of tasks close to the body. </li><li>The lifting and holding forces demonstrated by the amputees were generally better with the Münster-type prostheses.</li><li>The data from the positioning control and practical activities testing were inconclusive.</li></ol> <p> The evidence suggests, therefore, that the Münster-type prostheses are functionally advantageous with considerable cosmetic and comfort appeal for amputees with very short to medium below-elbow stumps. </p> <h3>Recommendations</h3> <p> Based on the results of this study, it is recommended that: </p> <ol> <li>The Münster fabrication technique be accepted as a satisfactory means of fitting below-elbow amputees. Prime applications would be for patients with unilateral losses whose stump lengths were classified in the short and very short categories.</li><li>Upon completion of the detailed fabrication manual now being prepared by New York University, the Münster below-elbow fabrication technique be introduced into the curricula of the Prosthetics Education Programs.</li></ol> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. View of Münster-type socket showing sharp angle of the proximal opening in relation to shaft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Hepp, O., and G. G. Kuhn, <i>Upper extremity prostheses</i>, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plastic laminates for upper-extremity prostheses</i>, Artificial Limbs, Spring 1963, pp. 17-30.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, <i>Preflexed arm study</i>, November 1960. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plastic laminates for upper-extremity prostheses, Artificial Limbs, Spring 1963, pp. 17-30.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, Preflexed arm study, November 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>1.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper extremity prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-01.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-02.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-03.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-05.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-3.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-4.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-06.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-07.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-08.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Münster-Type Below-Elbow Socket, an Evaluation. Creator An entity primarily responsible for making the resource Sidney Fishman, Ph. D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/2ba44c5f9ec8c60d3a6423ce01cae5b9.pdf a43fa5236221ccee26a9e5f795227879 https://staging.drfop.org/files/original/9847a895cbb0e47c889cc46b60067737.jpg 174af1515ac8068d3ba651a0676237c2 https://staging.drfop.org/files/original/54cec80f0cecce2e15a82d15081386fa.jpg 268a5deb1dfa2e91ec39e0cda5df9553 https://staging.drfop.org/files/original/cfb040cf84ed9ddf06a4f4bd0d669e8e.jpg 03e8d28df85de2b168de9603bde28d7a https://staging.drfop.org/files/original/318951cdb08cfadc6743ddec4e2731bd.jpg b3cd9eccd9455a345c9ad40f33434a7b https://staging.drfop.org/files/original/62b69d04e8bccad2110030b6b195b6da.jpg c8cdc886c8007ff14e3b4a6fb297c18b https://staging.drfop.org/files/original/6e618a8e4eb7f870507fc74e9dee010f.jpg cccc1fb60da16baf073ba3b9ab9c9710 https://staging.drfop.org/files/original/cd1a4279ea6056e85574a9669843fcd4.jpg 2498b1a659d3ba96b364efe3b8d49b3e https://staging.drfop.org/files/original/bf816b1898815a58c6d64beee92479d4.jpg 8b9e0b5f10a159cb742c129c41ede96f https://staging.drfop.org/files/original/a897c85ba11ff91431544e7f1b757f99.jpg f74eb3b7381ab64121ff3a6577980d2e https://staging.drfop.org/files/original/798f29058b5c15bebdfda8ba6af5110d.jpg 3d0d619d882104d2335f773d7cd1d622 https://staging.drfop.org/files/original/46d27e76db81864a24330ff3846bd3c9.jpg 2b88d140aa0566a6759afdc3509eecac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_015.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 15 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_015.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>Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> In the study of the APRL Sierra No. 1 right hand, which preceded that of the left, the results of comparative performance testing indicated that there was little difference between the hand and the hook on the various test activities. Statements of children participating in the study and of their parents indicated a relatively high level of performance with the experimental hand, but advantages and disadvantages were not clearly defined. </p> <p> These results appeared to be at variance with past clinical impressions, which indicated that a significantly less functional terminal device than a hook. Hence, in the Left Hand Study the performance tests were repeated to check the results of the earlier study. An attempt wa hand wasas also made to delineate more completely the relative usefulness of the two devices by obtaining data concerning their effectiveness in a wide variety of activities. </p> <h3> Performance Tests</h3> <p> As indicated in Part I of this two part series of articles, the child amputees participating in these studies were required to make four visits to the clinics servicing them, during a period of five months. The first visit was a screening session to select suiTable candidates; on the second visit the child was fitted with the experimental hand; the third visit, two months after the fitting, was for the purpose of making evaluative comparisons between the old and the new terminal devices; and the purpose of the fourth visit, four months after the fitting, was to make a final evaluation. </p> <p> A prosthetic performance test, utilizing the old terminal device, was given the child on the second visit. On the third visit the same performance test was administered, utilizing first the APRL Sierra hand and then the old terminal device. The prosthetic performance test required the child to perform six activities, upon each of which he was timed and rated. The activities were: </p> <ol> <li>Unscrewing and reassembling five small plastic barrels ("Kitty in the Kegs") (<b>Fig. 1</b>)</li><li>Drying a wet cup, saucer, and dinner plate, using a dish towel (<b>Fig. 2</b>). </li><li>Putting on a shirt or dress as appropriate and shoes and socks (<b>Fig. 3</b>). </li><li>Assembling a jointed doll ("Loony Links") (<b>Fig. 4</b>). </li><li>Cutting out a printed figure and pasting it to a piece of paper (<b>Fig. 5</b>). </li><li>Eating ice cream from a paper cup, using a metal spoon (<b>Fig. 6</b>). </li></ol> <p> Typically, the test was administered by an occupational therapist. The rating scale employed ranged downward from a score of 5 for performance approximating that of a nonamputee to 1 for performance in which the terminal device was not used, in accordance with the following subjective criteria: </p> <table> <tbody><tr><th><p>Rating</p> </th><th><p>Criteria</p> </th> </tr><tr><td> <p> </p><p>5</p> <p></p> </td> <td> <p> </p><p>A nearly normal bilateral performance in which the terminal device seems essential; that is, it is used to perform active functions in addition to and more advanced than holding, such as grasp and transportation and manipulation of the object. </p> <p></p> </td> </tr> <tr><td> <p> </p><p>4</p> <p></p> </td> <td> <p> </p><p>A bilateral pattern in which the terminal device is a significant aid in grasping or hooking.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>3</p> <p></p> </td> <td> <p> </p><p>The terminal device is used for occasional grasping only, alternating with passive use.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>2</p> <p></p> </td> <td> <p> </p><p>The terminal device is used passively for pushing, weighting, or support, but not for grasp.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>1</p> <p></p> </td> <td> <p> </p><p>The terminal device is not used, although the elbow and forearm may be used as an aid. Ratings of 1.5, 2.5, 3.5, and 4.5 were interpolated to indicate performance whose quality was between two categories.</p> <p></p> </td> </tr> </tbody></table> <p> Each child's performances with hook and hand were compared on the basis of best scores obtained while utilizing each device. In the Left Hand Study performance times with each device were also obtained. The comparative data are presented in Tables <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There are obvious limitations to these data, in that the tests may have differed with individual children (the type of clothing donned, for example), and there were undoubtedly differences in the frames of reference employed by different therapists in rating a given performance. Since the data themselves are of doubtful precision, the application of tests of statistical precision is not indicated. Within these limitations, however, there is evidence that: </p> <ol> <li>Mean performance ratings in all activities were higher for the hook (<b>Table 1</b>), which clearly appeared to be the better device functionally. Its superiority was most evident in the test activities of "Put on Clothes" and "Cut and Paste." The smallest differences in mean ratings were found in the "Kitty in the Kegs" and "Loony Links" tests. Both of these latter activities involve the grasping of objects for which the active fingers and thumb of the hand are relatively well adapted.</li><li>In a total of 408 hook and hand performance comparisons shown in (<b>Table 2</b>) (68 children performing 6 activities with each device), hook performance was rated as superior in almost half the instances (189 times). Interestingly enough, however, hook and hand performances were rated as equal almost as frequently (184 times), although hand performance was considered better in only a relatively insignificant number of cases ²⁹. In this tabulation of the data also, the superiority of the hook appears less marked in the same two test items "Kitty in the Kegs" and "Loony Links." </li><li>The comparative time data (<b>Table 3</b>) indicate that in the majority of instances hook performance was faster as well as more effective than hand performance, although again the results are by no means unanimous.</li></ol> <p> It is interesting to note (<b>Table 1</b> and <b>Table 2</b>) that in the Left Hand Study the performance ratings more clearly reflected the functional superiority of the hook than was the case in the tests with the right hand. For example, only seven children of 32 were rated as performing the "Kitty in the Kegs" test better with the hook in the Right Hand Study. In contrast, 17 of 36 children had better ratings utilizing the hook in this activity in the Left Hand Study. A similar marked difference in comparative ratings is evident in the "Loony Links" task. In the other test activities, the differences diminished until in the "Eat Ice Cream" item the right and left hand data are almost identical. </p> <p> The reasons for these differences are not clear. The subjectivity of the rating scale may, of course, have been a consideration. However, since the trend of the data is consistent, that is, favoring higher comparative hook ratings in the Left Hand Study, it would appear that other than chance factors are operative. </p> <p> Handedness might possibly be a factor, but unfortunately data on this variable were not obtained in the study. It is also possible that in the earlier Right Hand Study the raters were affected by a "halo" factor which had diminished by the time of the later Left Hand Study. </p> <h3> Functional Preferences</h3> <p> In studying child and parent opinions concerning the function provided by the No. 1 hand in comparison to that available in standard hooks, the task is complicated by the strong emotional factors involved. In many instances the excellent acceptance of hand appearance clearly tended to influence the answers to questions concerning its function. In interpreting the responses of children and their parents, therefore, it must be borne in mind that the hand was almost three times as heavy as the hook previously worn by the children; and although operating forces to initiate opening were only somewhat higher than for the hook, the forces required to obtain full opening were significantly higher two factors which should make use of the hand more difficult.<a style="text-decoration:none;">*</a> Pertinent comparative data are presented in (<b>Table 4</b>). Thus, when children report, as some do, that the hand is lighter and easier to operate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The presentation which follows is based primarily on data from the Left Hand Study, but these are supplemented where appropriate by evidence from the preceding Right Hand Study. </p> <p> All 39 children and parents in the Left Hand Study were asked, "With which terminal device is the child able to perform more activities?" The answers were: </p> <table> <tbody><tr><td> <p> </p> </td> <td> <p>  | Hook |</p> </td> <td> <p>| Hand |</p> </td> <td> <p> | No Preference |</p> </td> </tr> <tr><td> <p>Children</p> </td> <td> <p>    18</p> </td> <td> <p>  14</p> </td> <td> <p>   7 </p> </td> </tr> <tr><td> <p>Parents</p> </td> <td> <p>    16</p> </td> <td> <p>  9</p> </td> <td> <p>  14</p> </td> </tr> </tbody></table> <p> However, two children and two parents in the no preference category added statements which suggested that the hook provided more function and that their no preference choice was motivated by a balance between hook function and the cosmetic appeal of the hand either to the child or to the parent. Furthermore, some children who rated the function of the hand as better than that of the hook made comments indicating the reverse. Joseph: "The hand is heavier and harder." Robin: "The hand can do a couple of things but not too many things." Linda: "The hand is heavier and harder but I like the way it works." The therapist said that this girl's answer was motivated by a strong desire to keep the hand. </p> <p> However, several children who preferred the function of the hand were able to back up their choice by specific examples. Susan, a young above elbow amputee, said the hand was easier to don, better for washing dishes, for holding paper, and to pick things up. Rodney, also an above elbow amputee with an unfitted paraxial hemimelia (ulnar) on the contralateral (right) side, said the hand was heavier but easier to operate. His therapist said the hand did not afford Rodney greater function but he was much more eager to use it. This greater enthusiasm was also noted in Susan, the above elbow amputee previously mentioned. The greater motivation to use the hand on the part of both these youngsters may have actually resulted in a higher level of functioning! </p> <p> Fourteen of the 39 children fitted with the No. 1 left hand reported it to be as heavy as or heavier than their hook, and 17 found it hard to open or otherwise more difficult to operate than their hook had been. There seemed to be a significant relationship here with age, as indicated by the fact that of 17 children, ages 3 to 5, eight found the hand heavy, while of 22 children, ages 6 to 10, only six reported that the hand was heavy. Of those who stated that the hand was difficult to operate, ten were in the 4 to 5 age bracket and only five were in the 6 to 10 age group. </p> <p> A relationship to amputation level was also apparent. The one shoulder disarticulation amputee found the weight accepTable but the hand too hard to operate. He retained the hand, nevertheless, for cosmetic reasons. Of the five above elbow amputees, four found the hand heavy and difficult to operate, and the remaining child rejected it after less than two months' wear. In contrast to these negative reports, two above elbow amputees, only 5 years old, were among those who were most highly motivated to use the prostheses with the hand device. </p> <p> The combination of youth and a higher level of amputation made the use of the hand much too difficult for the youngest child in the study, an elbow disarticulation case who was barely 4 years old when fitted. Consequently, at the conclusion of the study he was wearing the hand only for special occasions. Of the four wrist disarticulation amputees, the two 4 year olds found the hand a little heavy and difficult to operate, while two 8 year olds advised that both weight and operating forces were satisfactory. </p> <h3> Specific Types of Grasp </h3> <p> In the Right Hand Study a general comparison of the functional qualities of hand and hook, based on child and parent opinions, had yielded indecisive results. Therefore, in the Left Hand Study children and parents were requested to rate the suitability of both the old terminal device (hook) and the No. 1 hand, not only for grasping objects in general but also for eleven specific types of grasp or activity areas. Explanatory comments concerning terminal device use for each specific function were also solicited. The eleven activity areas were: </p> <ol> <li>Carrying objects, such as school bags, purses, lunch pails, etc.</li><li>Grasping or picking up very small elongated objects, such as pins, paper clips, etc,</li><li>Grasping or picking up small elongated objects, such as pencils, scissors, etc.</li><li>Grasping paper.</li><li>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</li><li>Grasping or holding a drinking glass.</li><li>Using silverware while eating.</li><li>Grasping large bulky objects, such as paste jars, books, balls, etc.</li><li>Grasping objects such as bicycle handles, swing chains or ropes, etc.</li><li>Putting on clothes, such as shirts, blouses, etc.</li><li>Putting on shoes and socks.</li></ol> <p> Many of these areas involve the performance of a number of discrete activities. Hence, the data obtained not only provide bases for comparison of hand and hook functions but also supply considerable general information concerning the activities of children with upper extremity prostheses. Since this information may be of significance to clinic personnel, especially to therapists and to persons concerned with the development of devices for children with arm amputations, the data relating to each of the activity areas are presented in some detail (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Carrying a school bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Carrying objects, such as school bags, purses, lunch pails, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   0</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   4</p> </td> <td> <p>   8</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   0</p> </td> <td> <p>   3</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p>Approximately four fifths of the children reported the hook as satisfactory for carrying objects with handles, while only half found the hand satisfactory. Parents, on the other hand, believed the hook and hand functioned about equally well for holding these objects. Where difficulty was experienced with the hand, it was usually because the objects carried were too heavy for the amount of "Bac Loc" provided. Illustrative comments follow. Betsy: "The hand doesn't let me hold heavy things." Linda's mother: "Buckets, lunch pails, and anything of metal or plastic that is heavy slip from her grasp." Gabriel's mother: "The hand is satisfactory provided the handle is not too thick and the object not too heavy." </p> <h5><i>Grasping or picking up very small elongated objects, such as pins, paper clips, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   23</p> </td> <td> <p>   4</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   13</p> </td> <td> <p>   6</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   10</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> More than half the subjects and parents rated the hook as satisfactory for picking up very small objects. The hand was considered adequate for this function by only about a third of the children and parents. Some children pointed out that the hand was satisfactory for holding very small objects but not for picking them up (<b>Fig. 8</b>). One parent suggested that the child's vision was blocked by the rest of the hand, another that the floating fingers were in the way. Some of the illustrative remarks are quoted. John: "Nails but not pins." Susanne: "I have to hold the object in the other hand to pick it up." Danny's mother: "Too much effort and concentration."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Holding a safety pin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or picking up small objects, such as pencils, scissors, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   26</p> </td> <td> <p>   7</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children and parents considered the hook satisfactory for this function, while a slightly smaller proportion also found the hand satisfactory. The objects given particular attention within this category of use were scissors, pencils, crayons, hammers, and put together toys. </p> <p> It was apparently impossible to cut with ordinary scissors held in either a hook or an artificial hand. Thus, unilateral amputees held scissors in their good hand, while bilaterally involved children could not use them at all unless the scissors were especially modified. </p> <p> Concerning pencils, the reports were mixed, with some children rating the hook better for picking up and holding pencils, but with more subjects preferring the hand (<b>Fig. 9</b>). Some illustrative comments follow. Jeff: "I can hold a pencil better with the hook." Danny: "The hand holds a pencil better for sharpening." Randy: "I can pick up pencils easier with the hand." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Holding a pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Only one or two of the children with unilateral amputations made reference to writing with the prosthesis, although this was, of course, necessary for bilateral amputees. In general, the hook was favored for writing. Gail: "I can write better with a hook." Randy's teacher: "He is more secure doing written work when he wears hooks." (Randy is a bilateral upper extremity amputee.) </p> <p> There were only two references to hammers, one favoring each terminal device. Concerning put together toys there were two statements, both favoring the hook. </p> <p> In summary, scissors appeared to be difficult, if not impossible, to grasp with either hook or hand, pencils somewhat easier to handle with the hand, and put together toys easier with the hook, and possibly writing also. </p> <h5><i>Grasping paper</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   37</p> </td> <td> <p>   0</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   2</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Nearly all children rated both the hook and hand as satisfactory, with only four rating the hand as unsatisfactory (<b>Fig. 10</b>). Almost all the parents considered both devices satisfactory. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Grasping paper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The comments indicated that grasping paper was not one function but several, each calling for a different application of the terminal device. Involved were such tasks as holding paper for cutting with scissors, holding paper on a desk for writing, picking up paper, selecting one sheet from many, holding playing cards for card games, etc. </p> <p> Two children cited holding paper to cut with scissors to explain their rating of the hook as satisfactory, but in both cases they considered the hand also suiTable for this purpose. The therapist of a third child (Susan) felt that the hand was less helpful: "When cutting paper, Susan usually places the paper in the hook. With the hand she seldom places the paper in the hand; it seems to crush the paper and hold it in an awkward position." Susan herself regarded both devices as satisfactory for grasping paper. </p> <p> The hand was considered better for holding paper on a Table or desk while writing (<b>Fig. 11</b>). Sean's mother: "With the hook the paper tends to slip resulting in ragged print." Danny: "The hand holds down paper better for writing." Gail's mother: "School paperwork seems to be neater with the hand because the paper doesn't slip." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Holding paper while writing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Several remarks seemed to indicate that the hand was better for picking up paper, but one bilateral amputee mentioned difficulty in selecting one sheet from many. </p> <p> Concerning holding playing cards for various games, Susan's therapist made the following comment: "Playing card games is an activity which is performed better with the hand. It is in a better holding position and the cards come out easier when she is taking them from the hand." </p> <h5><i>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   9</p> </td> <td> <p>   9</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   13</p> </td> <td> <p>   10</p> </td> <td> <p>   12</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   21</p> </td> <td> <p>   10</p> </td> <td> <p>   5</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   9</p> </td> <td> <p>   5</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Half the children rated the hook as satisfactory, but the number dropped to a third for the hand. Half the parents considered the hook as suiTable and a slightly greater number rated the hand as adequate. More children than parents reported that neither device was used for grasping soft objects. </p> <p>Picking up and holding a tube of toothpaste apparently presented no problem, but difficulties arose with sandwiches, cookies, candy bars, marshmallows, grapes, or raw eggs, all of which were usually held in the sound hand. The majority of the children experienced difficulty in holding soft objects with either device. Debra: "The hand squashes it and I can't eat it the hand squashes the sandwich." Joseph: "The hook might squash them; the hand can pick it up but I'll smash it." There were some children who made comments favoring the hand. Danny: "With the hand I can gel a sandwich better without squeezing it" (<b>Fig. 12</b>). Mother of Randy (triple amputee): "Eating sandwiches is a treat which he was unable to do with hooks." However, a larger number preferred the hook for this purpose. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Grasping a sandwich. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or holding a drinking glass</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   8</p> </td> <td> <p>   8</p> </td> <td> <p>   18</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   7</p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   8</p> </td> <td> <p>   13</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   11</p> </td> <td> <p>   15</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Less than a fourth of the subjects rated either hook or hand as satisfactory for holding a drinking glass. The parents were slightly more positive, a third of them rating both hook and hand as suitable. Several of the children who gave a rating of satisfactory explained that they would use a terminal device only to hold a glass by the rim when filling it with water or to carry it while setting the table. </p> <p> Comparisons between hook and hand were few. Some children stated that the hand did not open wide enough for available glasses or that the glass slipped. Two others, however, stated that the hand had a better grip and did not slip. Small opening and slippage were problems also reported with hooks. The general impression is that even children who rated a terminal device as satisfactory for holding a drinking glass were merely claiming they could hold a glass as a special feat, not as a commonly used skill (<b>Fig. 13</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Grasping a paper cup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Using silverware while eating</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   2</p> </td> <td> <p>   22</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   2</p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   14</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   2</p> </td> <td> <p>   16</p> </td> <td> <p>   0</p> </td> </tr> </tbody></table> <p> Approximately a third of the children and half of the parents rated both hook and hand as satisfactory for holding silverware, while half of the children and a third of the parents indicated that neither device was used for the purpose. The slight differences favored the hand. With the exception of three bilateral arm amputees, the children who answered this question were left arm amputees. It appears likely that they used the terminal device only for holding a fork while cutting meat (<b>Fig. 14</b>), although one or two held a spoon in the terminal device also. Many children, even some who regarded a terminal device as satisfactory, reported that the parents usually cut their meat for them. Particular mention was made of problems of slippage, of difficulty of positioning, the better appearance of the hand performance, and the need for practice.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Holding a fork. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping large bulky objects, such as paste jars, books, balls, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   18</p> </td> <td> <p>   12</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children rated the hook as satisfactory, but only half found the hand so. The same proportion of parents rated both hand and hook as satisfactory. </p> <p> The intention of the question was to determine whether the smaller opening provided by the hand was a disadvantage in actual use. The specifications of the No. 1 hand require that a minimum full opening of 2 in. be attainable with the thumb in the wide opening position, but most hands exceeded the specification to a maximum of approximately 2 3/8 in. However, there were indications that several children utilized the small, 1 1/2 in. opening only and did not bother to change the thumb position. A Dorrance 10X hook, by comparison, provided a 3 in. opening and the Dorrance 99X hook a 3 1/2 in. opening. </p> <p> A number of children and parents specifically mentioned holding baseball bats, balls, paste jars, books, boxes, dolls, and a see saw. Curtis: "With the hand, I can hold the bat better when I play ball." Glenda's mother: "Bats the ball using both hands now." Comments indicated that the hook was superior for throwing balls, but the hand was satisfactory for catching them in two handed fashion. In general, though, the children found it difficult to grasp balls with either the hook or the hand (<b>Fig. 15</b>). The hook was somewhat better for holding paste jars. Books, boxes, paper cups, and dolls (<b>Fig. 16</b>) were better held with the hook, but one boy said riding a see saw was easier with the hand. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Holding a large ball. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Holding a doll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping objects such as bicycle handles, swing chains or ropes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   36</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   33</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Most children and parents rated the hook as suitable, but some children stated that the hand was unsatisfactory or not used for these activities. Confusion may have existed because of the separate uses; several of the children played on swings but did not ride a bicycle or tricycle. The hook was more often preferred for holding a swing chain, but preference was evenly divided for riding a bicycle (<b>Fig. 17</b>). Several parents felt that the hand grasp appeared more natural. There was concern about the danger of tearing the glove or breaking the thumb of the hand on a swing chain. Other activities mentioned under this heading were climbing monkey bars and holding a jump rope, a broom and a hoe, or a bow for archery. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Holding a bicycle handle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Putting on clothes, such as shirt, blouse, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   27</p> </td> <td> <p>   1</p> </td> <td> <p>   8</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   2</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Two-thirds of the children and parents rated the hook as satisfactory, but only half the children considered the hand as satisfactory for this purpose. Several children who considered both devices as satisfactory commented that they were usually dressed, or were assisted in dressing, by their mothers. There were more comments favoring the hook than the hand; the glove tended to stick to cloth and there was glove discoloration attributed to contact with clothing, particularly from red dyes.</p> <h5><i>Putting on shoes and socks</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Two thirds of the children and the parents rated the hook as satisfactory, but less than half of the former considered the hand satisfactory (<b>Fig. 18</b>). A fourth of the children stated that they did not use either device to put on shoes and socks, and the number who did not tie shoelaces with prostheses was undoubtedly much higher. Timothy, for example, said that he did not know how to tie shoelaces and that his mother dressed him, but he and his mother rated both devices as suiTable for putting on shoes. Another reason given for parental assistance was that the child consumed too much time in dressing himself. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Putting on shoes and socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusions</h3> <p> In spite of the wide differences in the opinions expressed by the children and parents participating in the study, it was apparent that: </p> <ol> <li>The APRL Sierra No 1 hand was heavier and in most instances more difficult to operate than the previously worn hook, but for the majority of subjects in the sample these were not serious drawbacks. Those with shoulder disarticulation amputations and to a lesser extent some of the younger children and above elbow amputees were most likely to have difficulty with weight and operating forces. It is obvious, of course, that if the hand were lighter and had a more efficient operating ratio, it would be more accepTable to all.</li><li>The hand provided somewhat less pinch force than most of the hooks and a less precise grasp. The majority of children reported that they could perform more activities better with the hook; however, many could also specify a number of activities that were performed better with the hand. The latter was preferred somewhat more often for tasks such as picking up a pencil, grasping paper, and holding silverware for eating. The majority of the children and their parents considered the hand as "adequate" to "very satisfactory" for a wide range of activities.</li></ol> <h3>Acknowledgments</h3> <p> In Part I of this series of articles, grateful acknowledgments were made to the clinics participating in the Child Amputee Research Program and to a number of persons for valuable cooperation and assistance in the conduct of these studies and in the preparation of the report. We again express our sincere appreciation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Kitty in the Kegs," a set of small plastic barrels, one inside the other. A picture of a kitten is in the innermost barre. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Drying Dishes </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Putting on clothes. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Loony Links." The child is asked to assemble a jointed doll and stand it on its feel, using a preassembled doll as a model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and pasting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Eating ice cream. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, </i>Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Actual pinch forces in the hooks worn by children in the study were not obtained. However, recommended forces for the age group are: below elbow, 3 1/2lb, above elbow, 3 lb. than the previously worn hook, the data must be questioned. Nevertheless, conservative interpretation of the available information does provide insight not only into hand usage but also into terminal device function in general.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St , New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-08.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-10.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-11.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-12.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. *