15 20 371 https://staging.drfop.org/files/original/7b641cc2c5efff0b13ea00554ff0524c.pdf 7625f33cbc3d4cfb83ec80cc57916490 https://staging.drfop.org/files/original/2b460a57bd7e3cefefc865722303cf8f.jpg f61aec4f5e8a68c88c0f3a7934ceba87 https://staging.drfop.org/files/original/158699aa9b82e6f73a8a2b652cb7d6fd.jpg fbdb3216dca3e4ba5c6f63d3222e452b https://staging.drfop.org/files/original/a68325f5b73646b5b593a8acb1bbd837.jpg f36901c352aad3d7bb8795ed8f2a6646 https://staging.drfop.org/files/original/cc30670084ad14b7609684a6454ac848.jpg 56d45a2b3659d1499e21a5da9829a307 https://staging.drfop.org/files/original/233ef95f73081b8f7c73a4ef388b3eae.jpg deffb0023ad714487dbd06e45b858dc0 https://staging.drfop.org/files/original/4696142a132cee2456d1fdc6faeb4ca9.jpg 89c9bf5a3b883b4293bb308ede78dbd4 https://staging.drfop.org/files/original/5bffdfe2ad0da8b9f5cc1981f71cf7c3.jpg fddc2597a8f63495c8c21845fe13d0a5 https://staging.drfop.org/files/original/d4520c3e41c8750ce3b30ffd8da8e2e5.jpg 71f93afbfae1921384420fd2c1e67617 https://staging.drfop.org/files/original/4fe5adb111706602874b94494623dc2d.jpg b885f7d3eededf4598d34efa04ba7d66 https://staging.drfop.org/files/original/8efb8897726cd8dd75a4539c0b6b2463.jpg e7714a18bbc9e8eacf2f3a4f34b3a9eb https://staging.drfop.org/files/original/0c9233c7ec883b727ccba3e73ba7b4db.jpg f5bcc44ab3a4478f32af9bf11055980c https://staging.drfop.org/files/original/03d2e12c78b332580cb171eb3d225e8f.jpg 83b50125b9d6bb8baff6767c478c78dc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_022.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 22 - 28 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Evolution of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Colin A. McLaurin, BASc. <a style="text-decoration:none;">*</a><br /></h5> <p>Not many people are amputees. Still fewer people are prosthetists. Not many amputees are hip-disarticulation cases. Hence, not many prosthetists are interested in hip-disarticulation prostheses except when occasion demands. That just about sums up the history of hip-disarticulation prosthetics.</p> <p>A more intensive look at the picture reveals two more or less standard approaches to the problem, but usually there are as many variations as there are limbshops. The accompanying illustrations (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>) indicate the practice, if not the principle, of conventional fitting, together with some of the variants. A study of the principles of conventional fitting is even more revealing. The guiding one seems to be this: Take one standard above-kn ee leg and build on to it until it can be strapped to the amputee. The practice certainly bears this out. Even the term "tilting-table prosthesis" suggests working from the leg up to the stump, instead of beginning with the amputee, who properly should be the focal point in any attempt at rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Saucer-type prosthesis for hip disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Tilting-table prosthesis for hip disarticulation, basic design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Variations in tilting-table prostheses: strap-and-roller medial support. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Variations in tilting-table prostheses: latch-type medial support, cross-sectional view. Above, standing; below, sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Variations in tilting-table prostheses: hip joint below socket. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Variations in tilting-table prostheses: track-and-roller joint. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This back-handed approach to problems is not something unique among limbfitters. The plumber is more interested in joining pipes than he is in the water requirements of a household. The airplane pilot is more concerned with the trim of the aircraft than with the comfort of the passengers' seats. The prosthetist's main interest lies in making a leg he can fit on the customer, and in so doing he has shown a considerable amount of ingenuity. Perhaps had the variations not been local in nature, more progress could have been made. Many fitters have come surprisingly close to the Canadian-type prosthesis, and no doubt others actually envisioned the basic principles without achieving the mechanical design.</p> <p>Generally speaking, the hip-disarticulation case has been considered very unfortunate when compared with other above-knee cases. Perhaps some of this attitude is owing to the fact that a great many cases are not of traumatic origin and that therefore the life expectancy is short. In any event, the result is that the amputee is not encouraged to expect much from his prosthesis. The usual complaints are mechanical in nature-rattling in the joints and the need for frequent repair. Accordingly, most innovations in the prostheses have been directed toward solving these mechanical problems, and more by chance than by design functional advantages evolved.</p> <p>Conventional hip-disarticulation prostheses are usually classified into two main categories, the saucer type and the more common tilting-table type.</p> <h4>The Saucer-Type Prosthesis</h4> <p>The saucer type of prosthesis, shown in <b>Fig. 1</b>, is essentially a standard above-knee leg with a saucer-shaped socket on top of the thigh. Suspension is by means of a single-axis joint and pelvic band and may include fore and <!--Page 23--> aft straps that pass over the shoulder. This type is most suitable for short-femur amputations because adequate stability is difficult to achieve without the additional bone structure. In accord with common practice with above-knee legs, the hip joint is placed well forward, thus providing some measure of stability. A lock may or may not be used at the hip joint. If a lock is used, it is of the semiautomatic type. A lever is pressed to release the lock for sitting, and the lock engages automatically on full extension. The lock provides stability (at some loss of function), but it offers mechanical difficulties because all the loads are fun-neled through the relatively small joint.</p> <h4>The Tilting-Table Prosthesis </h4> <p>Although not so simple or as light as the saucer type, the tilting-table prosthesis is more generally used because of the additional support. <b>Fig. 2</b> shows a typical prosthesis. A socket, usually of leather, is made to fit the stump and attached by a belt around the pelvis and often with a strap over the shoulder. The socket is articulated on the thigh section with a metal joint lateral to the acetabulum. Again the joint may or may not have a semiautomatic lock. Without a lock, the wearer has little control over the limb, most of the stability during the stance phase being afforded by friction between the socket and the thigh section.</p> <p>Because it is extremely difficult to make a hip joint strong enough to bear the entire load, contact between the socket and the medial edge of the thigh section is essential in weight-bearing, and this expedient is of course equally important when a lock is used. <b>Fig. 3</b> and <b>Fig. 4</b> illustrate two methods <!--Page 24--> that have been tried. In <b>Fig. 3</b>, a strap is fastened to the socket and passed under rollers attached near the medial brim of the thigh. These rollers also take the downward thrust of the socket, and a metal track may be attached to the socket for the rollers to bear upon. <b>Fig. 4</b> illustrates a dead-center latch mechanism. When the hip joint is fully extended, the latch flips by dead center and secures the socket to the thigh. A hip lock is necessary with this arrangement.</p> <p><b>Fig. 5</b> illustrates a fairly common departure in design. The walking function is identical, but the hip joint has been lowered to a position beneath the socket where a full-width bearing may be made much lighter. Because of the position of the joint directly below the center of gravity, however, a lock must be used. Along with the usual inconveniences and mechanical difficulties, this type also has distinct disadvantages in sitting. The thigh section is much shorter than normal, and the bulk of the joint raises the socket about an inch above chair height.</p> <!--Page 25--> <p><b>Fig. 6</b> shows a rather interesting deviation. This design uses a track-and-roller mechanism in which the center of rotation is a few inches lower and anterior to the acetabulum. The actual model seen by the writer was heavy and crude in construction so that binding of the rollers on the tracks prevented free motion, but it is worth noting since in principle it is almost identical to the present Canadian type, and it seems to be designed with a view toward improving function.</p> <h4>The U.S. Navy Hydraulic Prosthesis</h4> <p>At the close of World War II, the U. S. Navy designed and fitted an hydraulic prosthesis with the primary purpose of improving function. <b>Fig. 7</b> illustrates the main features of the device. The very large ball-bearing hip joint was made strong enough to bear all the weight, thus obtaining a free joint. An extension controlled the motion about the knee joint. The cylinder in turn was controlled by a valve which was either automatically or manually actuated. Normal motion about the hip joint allowed the piston to move slowly, as in an automobile shock absorber, and the knee joint was thus permitted to flex and extend with some damping. But fast rotation about the hip joint (as in stumbling) caused the valve to close and thus stabilized the knee. The manual control also closed the valve and locked the knee in any position. There were two disadvantages of this device- cost and weight. In addition, the application of hydraulics to prosthetics usually introduces problems of noise, leakage, and occasional erratic behavior.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Navy hydraulic prosthesis for hip disarticulation, schematic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Influence of Materials</h4> <p>A review of prosthetics practice in the hip-disarticulation case would be incomplete without reference to materials. The shank and thigh members are usually of wood covered with rawhide as in standard above-knee legs, but because of the saving in weight aluminum-alloy members are preferable when available. Steel is the almost exclusive medium for hip joints and locks, but in the Navy hydraulic prosthesis aluminum alloy was used to save weight. Sockets are usually made of two layers of leather, with Celastic core for stiffness. Aluminum alloy and monel (an alloy of copper and nickel) have been quite successful. They are usually lighter, more sanitary, and easier to attach to the joints. Plastic laminates are light, strong, sanitary, and easily molded to complex shapes, and it is not surprising to find them successfully used in hip-disarticulation sockets. It was the ease of <!--Page 26--> fabrication that made possible the plastic socket with the wrap-around pelvic band (page 33).</p> <p>Generally speaking, the materials and the mechanical designs were chosen with a view toward solving the mechanical problems, and it was with this thought in mind that design study was begun at Sunnybrook Hospital in Toronto. The highlights of this study are worth noting as an illustration of how an indirect approach to a problem can achieve results.</p> <h4>Evolution of the Canadian Design</h4> <p>The primary objective at Sunnybrook was to construct a hip-disarticulation prosthesis that would avoid the stress concentrations in conventional locks and to provide a simple method for releasing the locks. The first experimental prosthesis employed a four-link mechanism, as shown in <b>Fig. 8</b>. The links were about 4 in. wide to provide adequate lateral strength. The socket was plastic and the thigh section aluminum alloy. It was intended that a posterior strap be used to lock the leg in full extension, but initial trials indicated adequate stability without a lock owing to the fact that at or near full extension the effective hip center was well forward of the center of gravity and because the posterior brim of the thigh prevented hyperextension. In order to achieve simplicity in assembly and to increase mechanical rigidity, the forward link was lengthened and made strong enough to support all the main loads (<b>Fig. 9</b>). The rear link thus acted only as a guide and could be made light and adjustable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: modified four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One difficulty remained-there was a chopping action between the top of the thigh and the socket such that serious pinching could result. Owing to the geometry of the linkage system, the gap between the thigh and the socket was present whenever the thigh was neither fully flexed nor fully extended.</p> <p>The next step in the evolution was to extend the front link to include the knee joint and to replace the rear link with a simple rubber stop to prevent hyperextension. This final configuration, shown in <b>Fig. 10</b>, permitted the use of a single broad joint without locks. At first it was felt that the position of the stop would be critical, and accordingly the first unit included a stop that could easily be adjusted by the amputee. It was soon found that this feature was not critical and that <!--Page 27--> initial adjustment by shimming or grinding was adequate. The most apparent difficulty was the tendency for too long and too slow a stride, and thus the elastic webbing was added to restrain hip flexion. Cosmetic appearance was improved by a floating thigh cover (<b>Fig. 11</b>) made of horsehide and attached to the socket only. A foam-rubber liner was glued to the horsehide to give it stiffness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: final design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: floating thigh cover for cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Apart from the mechanical simplicity of the new prosthesis, functional advantages soon became apparent. Little effort was required in the swing phase, and a full stride was easily obtained. Previously, with a locked hip joint, hip flexion was simulated either by pelvic rotation or by motion of the socket on the stump. The resultant gait was usually jerky and tiring, although some amputees had learned to walk surprisingly well. Since the amputee is actually "sitting" in the socket, complaints of discomfort were not common, but obtaining adequate security in the socket was a different matter.</p> <p>Too seldom have the bony prominences of the ilium been used for secure fitting. Usually a broad, leather pelvic belt, as in <b>Fig. 2</b>, was used for lateral support and a shoulder strap was added to prevent the socket from dropping down during the swing phase. The excessive weight of many prostheses necessitated the shoulder strap. The ischial seat is nearly always available for direct weight-bearing, and the areas for taking pressure elsewhere are large. If the socket is extended in the form of a band across the back of the pelvis and around to the opposite iliac crest, then three points of the innominate bones are firmly gripped, as shown in <b>Fig. 12</b>. Since these <!--Page 28--> three points are well spaced, excellent lateral stability is obtained. It is undesirable to have the socket extend above the iliac crests since doing so causes restriction and discomfort. Adequate vertical support can be obtained by ensuring a close fit in the area between the crests and the anterior-superior spine of each ilium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Anterior view of socket-waistband showing three points where the skeletal structure is firmly gripped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>The Canadian-type prosthesis has been fitted to many amputees at various centers and over a period of several years. Stability with the free hip and knee joints is adequate if correct alignment is attained and if some gait training is provided. In a fall, the prosthesis is usually safer, since the joints collapse and prevent vaulting. One amputee has sustained several falls without injury to himself or the prosthesis. There are, however, several improvements possible in walking characteristics of the prosthesis. The elastic check-strap prevents excessive hip flexion, but some means should be provided for cadence control. Without restraining forces at the knee and hip, the leg tends to walk at its own pace as determined by its pendulum properties. Correctly applied friction or hydraulic devices could enhance the swing characteristics so that various speeds and strides could easily be attained. Furthermore, stability at the knee joint depends upon hyperextension. This means that knee flexion requires effort. A knee which would provide adequate stability at heel contact and yet flex easily when required would offer a big advantage. No doubt several years hence the present device will seem crude and clumsy; in the meantime it provides a light, strong, and relatively efficient prosthesis.</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>Colin A. McLaurin, BASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Director, Prosthetics Research Center, Northwestern University, 401 E. Ohio St., Chicago; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-012.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 Evolution of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Colin A. McLaurin, BASc. * https://staging.drfop.org/files/original/1af135b4046fb2db501ded967f727ab2.pdf a4ca54acbda5984b15304cd6f7f016f5 https://staging.drfop.org/files/original/228e86e9452aa08be3bd9351e6c31dd0.jpg 5ccce9aaa2c5fa279985a74d639717be https://staging.drfop.org/files/original/c3df5a9743aed351dd319f2fb7e5112b.jpg a6f33c8ff187dab14eaff25dfafeecc3 https://staging.drfop.org/files/original/d5917e7f85a5a4c742cd2881c5d8c622.jpg 7b428b86fa69aeaa6a00da502d9b8c5b https://staging.drfop.org/files/original/d7d878173bbf5ec95e330af715e05b3a.jpg 3fc75ef8e1cadc253917ec7678b04d21 https://staging.drfop.org/files/original/da2a87a3ffef9f0eaf6e00bce461aede.jpg b746ec00689aa36b9d45c21f1587efca https://staging.drfop.org/files/original/54cbbe5693ea9e29ee0aab4eeb74d355.jpg f68af07a7951cc4830b6396717efbbcb https://staging.drfop.org/files/original/c865c0387c4ee04978be8c5707188774.jpg b2accc827111018a5ac53834cf59ac5a https://staging.drfop.org/files/original/ec3a3830c510a3a5beeeceb61f8ec202.jpg 9ef1d7fba1b6d89801277060612ca699 https://staging.drfop.org/files/original/85aee9dd4f8c9ffb71f4f4f600f45426.jpg 3ba2d1b34f53dbd76ad7069fbc2847d3 https://staging.drfop.org/files/original/e9760a32a1177547755bd80d61b859d0.jpg 0e658181df75e5a68bafb70e7e89cb7a https://staging.drfop.org/files/original/e83bead762c305b477ce5472b0c2c660.jpg cfe681da6e99338852c5c85b9aa8a8cf https://staging.drfop.org/files/original/efcb14dbaa8a3571f79a5c522cbfc587.jpg b7a17d0b20c308b84db4cb71383ed647 https://staging.drfop.org/files/original/063f9cc82fc0b22d33d5afc3b26ab2f8.jpg c0c7f6254ff24cb2489895ad919e66c5 https://staging.drfop.org/files/original/d9aef5c99b9e68a90850d61c434ee8fb.jpg 302927b6d2390d85826ddc3c38ea28fc https://staging.drfop.org/files/original/d1a8faaf3cedc688656a9fdf13e1d6b1.jpg e86b096968e144fb105e347fca51cc98 https://staging.drfop.org/files/original/bae29461b9316b470b68481ef53c0e67.jpg 3a177550c19df8561c721d998a50b471 https://staging.drfop.org/files/original/cf3f68b62ba311b841de515c0ad9727c.jpg 378c97c7ad10e652d2a03009da51411b https://staging.drfop.org/files/original/1739de25d66a546b4f81d95b07a9cd81.jpg 74e052d9003c72e4bb39645dfb2f587f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_001.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 1 - 13 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities</h2> <h5>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. <a style="text-decoration:none;">*</a><br />E. E. Rogers, M.A.O.T. <a style="text-decoration:none;">*</a><br />M. S. Clark, M.A.O.T. <a style="text-decoration:none;">*</a><br />W. G. Stamp, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Children with severe multiple congenital limb deformities associated with thalidomide are numerically few. <a></a> Because of the severity of this disability, the associated deformities, and the psychological trauma to both parents and child, the thalidomide tragedy has served as a catalyst to study the congenital amputee in depth. There is still controversy concerning the appropriate prosthetic and rehabilitation program for these children, but the attention this tragedy has focused on other less-involved children perhaps will reap benefits far beyond our expectations. <a></a></p> <p>The possible factors associated with acceptance or rejection of appliances may be inherent in the appliance, or they may arise from the child's own frustration, the parental reaction, <a></a> or other environmental factors. Retrospective studies of children who attend the Nuffield Orthopaedic Centre for prosthetic management and a review of the relevant literature have been carried out in an effort to establish a pattern of management and to delineate topics for future research.</p> <h3>Scope of the Study</h3> <p>During the past four years, 50 children with congenital amputations and limb deformities have attended the Disabled Living Research Unit at the Nuffield Orthopaedic Centre. Approximately half were deemed not to need prostheses or appliances at this time.</p> <p>This article reviews 21 children with multiple congenital limb deformities who have been under continuous care for prosthetic management and general rehabilitation for four years. All the deformities were presumed to be due to thalidomide, and the lesions were characteristically bilateral (<b>Table 1</b>). Thirteen of the children have been fitted with upper-limb prostheses only, four with lower-limb appliances only, and four with both upper-and lower-limb appliances (<b>Table 2</b>). Henkel's classification <a></a> was used; other classifications are used in various parts of the world. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each child has been fitted with appliances on more than one occasion. In considering acceptance or rejection of prostheses, attention has been focused on the type of prosthesis provided rather than actual numbers. A satisfactory design may well be repeated in different sizes or, after rejection of one type, a different pattern may be tried. On average, each child has passed through three stages of prosthetic management, but the number of prostheses made and supplied is in considerable excess of this (<b>Table 2</b>). The classification of type of prosthesis fitted is given in <b>Table 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some children had only conventional prostheses, and others only powered upper-limb appliances. The majority, however, started with conventional appliances and then "graduated" to the powered ones.</p> <h3>Criteria for Prosthetic Management</h3> <h4>Upper-Limb Appliances</h4> <p>The fitting of upper-limb prostheses at the Disabled Living Research Unit was governed by various factors. In the early stages, the demands of the parents and the availability of materials and appliances were the most dominant factors. As this was a disability incurred by a man-made drug, the parents felt that they had the right to have the best treatment available. For the first year or so the Unit was dependent upon the availability of material and parts from within the United Kingdom, those imported from Germany, or what could be made locally.</p> <p>When the children's rudimentary arms were long enough to grasp objects bilaterally, to reach the mouth, and to be within the child's vision, then an appliance was not considered appropriate. <a></a> But when both arms were absent, or the rudimentary arms were so short that they could not achieve the basic function of feeding, artificial arms were fitted. However, these children were also deliberately encouraged to use their feet to enable them to acquire sensory perception of texture, temperature, etc., as well as dexterity in movement and achievement of toilet management. <a></a></p> <p>The fitting of the upper-limb appliances attempted to follow the normal behavioral patterns. A cosmetic appliance fitted during the first few months of life helped them to get used to wearing such appliances and learn sitting balance.</p> <p>In order to give the child some form of bilateral grasp, "pat-a-cake" appliances were fitted when the child was approximately one year old. These were the first type of appliances to be powered by compressed carbon dioxide, and were actuated bv body movement (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The first powered upper-limb appliances known as "pat-a-cakes" were fitted at the age of about one year. These are no longer issued. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The next stage was the introduction of wrist rotation and externally powered hooks or hands, fitted as the materials became available and the needs of the child demanded (<b>Fig. 2</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Child with bilateral amelia who was issued an appliance giving powered prehension and wrist rotation with passive elbow and shoulder movements. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Limb Appliances</h4> <p>A child's development is directly dependent on the vertical positioning of spine. Sitting, standing, and walking at the normal age are important for the child's normal development. Therefore, it is important that babies with amelia or short dysmelia of the lower extremity sit up at the normal age of sitting; that is, at the age of six months in a "flowerpot" (<b>Fig. 3</b>), and at about one year they should be given some form of legs for mobility (<b>Fig. 4</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Child with lower-extremity amelias placed in a "flower-pot" at the normal age of sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Some form of mobility should be provided during the child's second year. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The type and height of the lower-limb appliances issued to the children depended on the degree of competence and confidence in balance (<b>Fig. 5</b>). The children were supplied appliances with "shoes" as soon as was practicable; in any case, before they commenced formal schooling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The type and height of a lower-limb appliance depend upon the child's competence and balance. Whenever possible, the height should be kept within the lower limits of normal growth. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Coping with appliances for all four limbs imposes a considerable physical and intellectual strain on small children. The physical maneuvers necessary to walk with bilateral lower-limb appliances are often considerably restricted by the presence of upper-limb appliances. The children's activities and needs should be balanced and the training program phased to allow the children to obtain practice with both sets of appliances separately and together. For some children, upper-limb appliances are an aid to balance, whereas for others these appliances are an impediment.</p> <h3>Method</h3> <p>The children and parents were interviewed, schools were visited, and all available records and reports were reviewed. These records include functional activities of daily living, simple objective tests of skill, and school reports. The extent of the activities covered included those featured in other simple follow-up studies. <a></a> All children were seen by a clinical psychologist.</p> <p>In the analysis, notation was made of:</p> <ol> <li>The children's preferences.</li><li>The parents' preferences.</li><li>The amount of cooperation from the child.</li><li>The amount of cooperation from the parent.</li><li>The amount of cooperation from the school and teachers.</li></ol> <p>Concerning mechanical aspects, comments were recorded concerning:</p> <ol> <li>The weight of the appliance.</li><li>Delay in supply of the appliance.</li><li>Delay in supply of spare parts.</li><li>Speed of response of the appliance.</li><li>Limitation of reach.</li><li>Limitation of other movements.</li></ol> <p>Physical reactions noted included heavy perspiration (associated with the weight of the appliance), skin rashes, soreness from the harness, and restriction of the child's body movement.</p> <h3>Definitions</h3> <h4>Appliances</h4> <p>The appliances have been grouped into: conventional upper limbs; powered upper limbs; lower limbs; and then classified according to their functional features (<b>Table 2</b> and <b>Table 3</b>).</p> <h4>Acceptance And Rejection</h4> <p>"Acceptance" of prostheses by children is often more passive than active. "Acceptance" of an appliance in this study means that the child uses the appliance for most of the day for various activities; for example, feeding, writing, or playing. "Acceptance" in this context does not necessarily indicate that the child prefers the appliance to his own limbs. Almost invariably, the children prefer to use their own body and residual limbs for most manipulative activities.</p> <p>"Total rejection" implies complete refusal to wear the appliance. Some children have to be persuaded to wear the appliances even for short periods each day, but will do so with encouragement; this usually means periods of half an hour. This condition is termed "partial rejection"; it could equally well be termed "partial acceptance."</p> <h3>Results</h3> <h4>Acceptance And Rejection Of Conventional Upper-limb Appliances</h4> <p>Undoubtedly, conventional appliances for this group of children have a poor record of acceptance. Of those fitted before the age of two years, 14 children fitted with 14 bilateral appliances rejected the appliances on nine occasions (64 per cent), whereas acceptance was recorded in five cases (36 per cent) (<b>Table 4</b>). But it is difficult to assess correctly whether a child of this age has accepted or rejected an appliance, as the observer's judgment is likely to be very subjective.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was noted, however, that after the age of two years conventional appliances were totally rejected.</p> <h4>Acceptance And Rejection Of Powered Upper Limbs</h4> <p>Thirty-nine powered upper-limb appliances were fitted on 13 children, and were rejected on 27 occasions.</p> <p>The acceptance of the powered upper-limb appliances in this series is 25 per cent in children under four years of age and 38 per cent in those over four years (<b>Table 5</b>). Acceptance increased considerably when the powered hand was introduced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>However, partial rejection (or partial acceptance) occurs for 50 per cent of appliances, and total rejection of powered appliances has not occurred in children over four years of age.</p> <h4>Acceptance And Rejection Of Lower-limb Appliances</h4> <p>Seventeen lower-limb prosthetic appliances have been fitted on eight children; 13 of these were accepted, one partially rejected, and only three totally rejected. Ultimately, <i>all </i>lower-extremity prostheses were accepted.</p> <p>One child rejected appliances during her second year, because any type of appliance restricted her mobility and she was able to progress well by crawling. One child rejected, when, at the age of five years, he was fitted with appliances and he found them cumbersome and restrictive. This child has now accepted caliper appliances. Another child preferred the ski-type of appliance rather than those with shoes, because the latter kept on breaking and she had little confidence in them.</p> <p>The swivel walkers were made according to the design principles described by Motloch and Elliott <a></a> (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Swivel walkers are a distinct improvement over previous lower-limb appliances. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>None of the swivel walkers fitted has been rejected. They are a distinct improvement over any previous appliance. The full details are given in <b>Table 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Acceptance And Rejection Of Appliances According To Age</h4> <p>Acceptance and partial acceptance are clearly related to increasing age (<b>Table 7</b> and <b>Table 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Major Reasons For Rejection Of Upper-limb Appliances</h4> <p>There were many recorded reasons for rejection or partial rejection, and for each child there were usually several contributory reasons.</p> <p>When these were grouped together and all the different appliances were considered, it was found that the commonest cause for rejection was the mechanical inefficiency of the prostheses (76 per cent); the next most common cause of rejection was the child's preference for using his or her own residual limbs. In a relatively few cases, the lack of cooperation of parents or child was a major reason for rejection (<b>Table 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Change From Rejection To Acceptance</h4> <p>It is even more interesting to analyze the major factors that lead from a rejection to an acceptance (<b>Table 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Family Environment</h4> <p>The problem of parental cooperation is partly reflected in the families' general environmental background. Although the numbers are small, the review indicates that the better-educated, middle-class families are more likely to help their children accept appliances (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Clinical Psychologists' Assessment</h4> <p>All the children in this series were of at least average intelligence, with three being distinctly above average. Two children of average intelligence developed aggressive tendencies and for a period would use their artificial arms almost entirely as weapons. Their aggression finally diminished after starting at normal primary schools.</p> <p>Psychological testing was unable to delineate specific features helpful in predicting acceptance or rejection of appliances. Perhaps if the testing had been more comprehensive and more frequent, trends might have been exposed. However, the simple clinical psychological appraisal reflected the acknowledged situation rather than helping to elucidate the underlying motivation toward acceptance or rejection of prostheses. <a></a></p> <h4>School</h4> <p>In this series, 13 children attended normal state schools, five attended day schools for the physically handicapped, and two were at residential schools for the physically disabled. One child was undergoing orthopaedic treatment during the period covered by this survey. From this small series, acceptance for upper-limb appliances was higher for children attending normal state schools than for children at special schools for the physically handicapped (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>The birth of a child with a congenital limb deformity is a domestic crisis and the parents need urgent help and advice on the total management of the child. The crisis intervention <a></a> is a critical function of the management team, but the personal approach and careful handling are also essential. <a></a></p> <p>That there should be complex factors interacting to produce acceptance or rejection of the appliances is understandable. Goldner and Titus <a></a> noted that they have been uniformly unsuccessful in the upper-extremity amelia and phocomelia, particularly when the condition occurred bilaterally. It was only when external power was added that they were able to make significant progress. This experience has been true of other authors. <a></a></p> <p>The outstanding findings in this study are that therapists, parents, and children partake in a mutual learning process, and very close cooperation between all concerned is essential for good rehabilitation. <a></a> Brooks <a></a> emphasizes the importance of recognizing situations which are known to produce adverse reaction and aptly refers to this as "crisis intervention." Each stage of the child's development must be watched, <a></a> and the value of the appliances should be frequently reassessed.</p> <p>Many children have deformities which at first do not seem to need surgical or prosthetic intervention. However, as the child develops, function and environmental features change, and there is a need for continuity of supervision and repeated clinical and functional reappraisal. The need for aids to daily living, special aids, or, indeed, surgical management may become relevant at any stage of the child's development. <a></a> Although surgery of the upper limbs should be approached with caution during infancy, arteriograms indicate that the blood supply, even in single-digit phocomelia, is likely to be adequate for major reconstructive surgery to be contemplated in later life. <a></a></p> <p>Objective records of activity, writing, and performing other prearranged tasks which can be timed, or for which some degree of accuracy can be charted, are of more value than a "clinical impression" or answers to a questionnaire. <a></a> This study has employed simple tests which can be timed, and from which "learning curves" can be constructed. <a></a></p> <p>The assessment of a child's function is more than simple assessment of activities of daily living in a therapeutic environment. Assessment must be in "real life" terms, and the children, the teachers, and the parents need to be integrated into the assessment and therapeutic team. This is well illustrated by the comprehensive evaluation of a functional cosmetic hand carried out by New York University. <a></a></p> <p>The teacher does not need to be particularly orientated toward the physically handicapped. The children in this study often appear to do better at normal schools than at special schools for the physically handicapped, unless they have all four limbs severely involved; and very often a normal school near home would seem to be more appropriate than a school for the physically handicapped that is located further away. Estimation of intelligence should be an accepted method of evaluation of all children prior to entrance into school, and psychological evaluation may be of significant help. <a></a></p> <p>However, it may be necessary to adapt the child's physical environment, so that he is not penalized by unsuitable classroom furniture or unduly physically fatigued. This can usually be overcome by relatively simple devices.</p> <p>Gouin-Decarie <a></a> compared thalidomide children to the average population and found the mean I.Q. to be 98. Along with a delay in speech, there was retardation in development of the child's perceptual concept of space and movement.</p> <p>The design and fitting of prosthetic devices for children with multiple limb deformities and the subsequent training and resettlement of the children at home and school are complex activities involving engineers, technicians, prosthetists, therapists, school teachers, social workers, and, not the least, the children and their parents. The establishment of objective and valid criteria for evaluating patient performance in the very young is difficult. The fact that the children are constantly changing as they grow and develop should emphasize the importance of reassessing goals of achievement as well as anticipated attainment.</p> <p>There are three major factors of influence: the personality of the child, the parental influences, and the therapeutic unit managing the child. <a></a></p> <p>Brooks and Shaperman <a></a> devised a "Prosthesis Adjustment Scale" based on the child's use of the prosthesis-the applied use, maintenance, and acceptance. In their experience with the below-elbow congenital amputee, acceptance was interrelated with wearing, use, and skill of applied use. Although they emphasize that the fitting of a unilateral congenital below-elbow amputee before the age of two tends to result in full-time wearing and good acceptance of the prostheses, they also note that the category most closely related to early fitting is full-time wearing. Although indoctrination for full-time wearing is possible for single amputees, it is much more difficult to accomplish for multiple amputees.</p> <p>The almost complete acceptance of lower-limb appliances from an early age reflects the point that if the appliance fulfills a real need, even if inefficiently, the appliance will be accepted.</p> <p>In the case of upper-extremity appliances, there is a definite improvement in partial acceptance and a dramatic improvement with the development of more reliable appliances, less subject to mechanical failure (note the change from P.3. to P.4. in <b>Table 5</b>).</p> <p>In this review, no differentiation has been made between mechanical failure, troubles with control mechanisms, or power packs. Interestingly enough, in this series there was no particular problem relating to the supply and recharging of the gas cylinders. As more function is derived from gas-powered appliances, the supply problem will increase and probably limit the use of this type of appliance. <a></a></p> <p>Brooks and Shaperman <a></a> also note that the acceptance of a prosthesis is closely related to the ability to communicate, and that good communication between parents and child (that is, good family relationships) is probably the major factor in establishing acceptance of appropriate prostheses. Thus the home environment is critical, and in certain circumstances this may be the determining factor. <a></a> In this series, the age of four appeared to be the "watershed." At this age, children can begin to understand the reasons for continuing to use appliances and become at least partially cooperative. They also tend to start to attend nursery school at this age. Children with severe multiple limb deformities may be educated in normal schools or special schools for the physically handicapped, depending upon their clinical or their social needs. <a></a></p> <p>The decision to remove the child to a residential school for the physically handicapped is a major one, and not necessarily associated with improvement in physical function or acceptance of suitable appliances. In this study, it has been noted that normal state schools have accepted these severely disabled children as a personal challenge and have usually gone to great lengths to encourage the children in their rehabilitation, collaborating closely with the hospital therapists and prosthetics departments. By treating the children in this way, they have been permitted, indeed encouraged, to face up to many of the normal challenges and experiences of school life. This seems to have helped the children to be integrated into community living.</p> <p>In this series, a small number of children with limb deformities in special schools for the physically handicapped are not so adapted to their disability as those at normal schools, and prosthesis acceptance is relatively poor. The atmosphere of the schools for the physically handicapped is often more protective and necessarily geared to the most incapacitated. Furthermore, some of these schools have many children who are on the borderline of being educationally subnormal. Appliance training in these schools is usually the responsibility of the physical therapist and not the teachers, and the teachers are reluctant to divert individual attention to appliance training in the presence of more disabled children who are unable to use appliances, for example, victims of cerebral palsy. However, children with severe mobility problems, as well as severe upper-limb dysmelia, may find the special equipment, adapted environment, slower tempo, and special staff of particular help.</p> <p>As a group, these children achieve remarkable levels of manipulative skills using their residual upper limbs, chin, shoulder tips, feet, and mouth. The wearing of an upper-limb prosthesis frequently hampers these skills while only providing a much cruder form of function. However, there has been no experience here in fitting a single multifunctional arm balanced with a cosmetic prosthesis, and there are certain advantages in this approach. <a></a> For children with absent or deformed legs, almost any form of lower-limb appliance gives them an immediate advantage in standing, achieving reasonable height, and—as a bonus—walking short distances.</p> <p>As a general experience, it can be said that patients must obtain an immediate advantage from the appliance for it to be accepted. It is the immediate postfitting phase which appears to be of greatest importance. If the appliance looks unfinished, if the technicians have to make numerous adjustments in the fittings, if it is uncomfortable or scratchy, if mother's face registers horror at the appearance—all these factors have a long-term effect out of proportion to their immediate import. If the antagonistic features even slightly outweigh the advantages, then acceptance is unlikely, or at best partial, and becomes more a matter of deference to authority, or, for children, part of a game rather than a true integration of the appliance into the body image. The immediate advantage gained must outweigh all the antagonistic factors. If this occurs, the patient will persist through further stages of fitting, training, and redevelopment.</p> <p>The swivel walkers are a striking example. These appliances were used experimentally at first because earlier caliper-type lower-limb appliances were breaking so frequently that the children were continually frustrated. The swivel walkers were both more reliable and more immediately efficient, and acceptance was immediate and universal.</p> <p>Cosmesis is often a motivating force in acceptance of any appliance. <a></a> In this series, there was a marked improvement in acceptance on the introduction of a powered hand in preference to a hook (<b>Table 5</b>) even though function might be less. The change from 25 per cent to 75 per cent acceptance associated with the use of a powered hand accentuates the urgent need for a sophisticated, cosmetically acceptable, functional terminal device. This confirms the experience of New York University. <a></a> Children were also pleased when ordinary shoes could be fitted to their lower-limb appliances.</p> <p>Frequently, however, it is the mothers' dominant influences which lead to cosmetic acceptance overriding function, whereas fathers are often more likely to be interested in function. In one instance, a powered prosthesis was frequently returned nonoperational because a father repeatedly attempted to improve its functions. Another father, often at home because of shift work or lack of work, spent many hours training his son to use his upper-limb prostheses.</p> <p>However, acceptance associated with cosmesis might occasionally extend to a pathological acceptance, and there is one child with bilateral upper-limb, unequal-length phocomelia, who insists on wearing a single upper-limb prosthesis in spite of the fact that it prevents him from undertaking many functions he could perform with his two phocomelic limbs. The initial supply was largely at the insistence of the parents, and in retrospect probably should have been refused.</p> <p>One problem that was very unsettling for both child and parents was the involvement of more than one clinical center. Usually, this was due to geographical circumstances. The clinicians near the child's home were unable to provide certain facilities; for example, experienced training, or appropriate surgery or prosthetic devices. Furthermore, in some instances, there was a separation between the provision of upper-limb appliances and lower-limb appliances. In all instances, this diversification of clinical control and lack of unified approach led to difficulties in management and was, not infrequently, a contributory factor in rejection of appliances.</p> <h3>Conclusions</h3> <p>The object of any critical reappraisal of clinical management is to improve the treatment of patients in the future. On the basis of this study, it is possible to lay down some broad general principles for the management of children with congenital limb deformities.</p> <p>In the initial stages, the parents' attitudes are dominant; therefore, early confident collaboration is essential. The parents should have faith in the doctors and should have a clear understanding of the individual responsibilities of the members of the pediatric and prosthetics team, which may vary according to local facilities. The child should be under frequent review by the same clinical team. Each member of the team—pediatrician, prosthetics consultant, therapist, technician, social worker, and psychologist-has contributions to make at all stages.</p> <p>For severely disabled children, introduction to adapted clothing, aids to daily living, and training activities must be tailored to fit the individual child's expected development, and independent activities should, wherever possible, match the accepted "stepping stones" of child development.</p> <p>Lower-limb deformities should be treated by appropriate surgery and prosthetics so that independent mobility is achieved as early and as efficiently as can be matched with normal progress. The size of the appliance should match natural growth as nearly as possible.</p> <p>Upper-limb appliances present a more complex problem. Most children will alternate between accepting and rejecting appliances, depending on their development and needs.</p> <p>Early fitting, at perhaps 12 to 18 months (or even earlier), has some relevance in that it accustoms the child to a somewhat uncomfortable appliance. But the child is unlikely to accept formal training in the use of a sophisticated appliance until more than four years of age. Once schooling starts, training in the use of an appropriate appliance should be part of formalized education, and this demands close collaboration between therapists and teachers, particularly in the school surroundings.</p> <p>The prosthetists and technicians must be prepared to adapt and redesign frequently as the child's needs change. They must accept the need for adequate cosmesis even at an early age. Rejection of appliances must never be regarded as "naughty" or "ungrateful," but as part of natural development. Gentle insistence on regular training sessions may well tide a child over until in later years he understands and appreciates the need for the appliance and can make a reasonable personal decision regarding design and use.</p> <p>There is an urgent need for the development of mechanically reliable, cosmetically acceptable, and functionally sophisticated upper-limb appliances.</p> <p>This development of an awareness of the most suitable design and the appropriate uses of upper-limb prostheses should be the outcome of close understanding between the child, parents, doctors, teachers, and therapists.</p> <h3>Summary</h3> <p>A group of 21 children with multiple limb deformities associated with thalidomide who have been supplied with various upper- and lower-limb prostheses is described. The acceptance and rejection of the appliances are analyzed according to age, family background, and the type of appliance.</p> <h3>Acknowledgments</h3> <p>The powered upper-limb appliances and the swivel walkers were designed and made in the Research Workshops at Mary Marlborough Lodge.</p> <p>Other appliances were made in the Orthopaedic Workshops of the Nuffield Orthopaedic Centre or supplied by the Ministry of Health in various limb-fitting centers.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>Management of the child amputee</i>, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</li> <li>Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, <i>Crisis intervention</i>, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</li> <li>Brooks, M. B., and J. Shaperman, <i>Infant prosthetic fitting</i>, Amer. J. Occup. Ther., 19:6, November and December 1965.</li> <li>Burtch, R. L., <i>A study of congenital skeletal limb deficiencies</i>, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</li> <li>Buttrup, E., <i>Parents of child amputees</i>, Prosthetics International, Vol. 2, No. 1, 1964.</li> <li>Campbell, E. I., and J. C. Bansavage,<i> The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study</i>, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</li> <li>Fishman, Sidney,<i> Studies of the upper-extremity amputee; VIII. Research implications</i>, Artif. Limbs, Autumn 1958, pp. 117-127.</li> <li>Fishman, Sidney,<i> Amputee needs, frustration and behavior</i>, Rehab. Lit., Vol. 20, 1959.</li> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, Part 1</i>, Artif. Limbs, Spring 1964, pp. 28-43.</li> <li>Frantz, C. H., and R. O'Rahilly,<i> Congenital skeletal limb deficiencies</i>, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</li> <li>Friedmann, L.,<i> Special equipment and aids for the young bilateral upper-extremity amputee</i>, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</li> <li>Gesell, Arnold L., et al.,<i> Infant and child in the culture of today; the guidance of development in home and nursery school</i>, Harper, New York, 1943.</li> <li>Gillis, Leon,<i> Thalidomide babies; management of limb defects</i>, Brit. Med. J., September 8, 1962.</li> <li>Goldner, J. L., and Bert R. Titus,<i> An experience with externally powered prostheses for children</i>, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</li> <li>Gouin-Decarie, T., <i>The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers</i>, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</li> <li>Hall, C. B., M. B. Brooks, and M. F. Dennis, <i>Congenital skeletal deficiencies of the extremities</i>, J.A.M.A., 181:590 599, August 1962.</li> <li>Hall, C. B., <i>Corrective surgery for infant hands</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hall, C. B., <i>Recent concepts in the treatment of the limb-deficient child</i>, Artif. Limbs, Spring 1966, pp. 36-51.</li> <li>Haslam, E. T., Joan Hayden, and Jean Dutro, <i>The habituation of a congenital quadruple amputee</i>, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</li> <li>Hebert, B., <i>The psychologist and congenital physical anomalies, Inter-Clinic Information Bull.</i>, Vol. VI, No. 4, January 1967.</li> <li>Henkel, L.,<i> Das Fehlbildungsmuster der Dysmelie</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> <li>Her Majesty's Stationery Office Publication, <i>Deformities caused by thalidomide</i>, 1964.</li> <li>Hunter, J. M., David Subin, and A. J. Plank, <i>Some observations on upper extremity prosthesis applications</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hutt, S., Private communication.</li> <li>Kay, Hector W., and Edward Peizer, <i>Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance</i>, Artif. Limbs, Autumn 1958, pp. 31-87.</li> <li>Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker,<i> The management of upper limb deficiencies in the thalidomide-type syndrome</i>, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</li> <li>McKenzie, D. S., <i>The clinical application of ex- ternally powered artificial arms</i>, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</li> <li>McLaurin, C. A., <i>External power in upper-extremity prosthetics and orthotics</i>, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</li> <li>MacNaughton, A., <i>The role of the occupational therapist in the training of the child arm amputee</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Maier, W. A.,<i> Thalidomide embryopathy and limb defects</i>, Orth. Dis. Child, Vol. 40, 1965.</li> <li>Marquardt, E., <i>The Heidelberg pneumatic arm prostheses</i>, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</li> <li>Mendez, M. A., <i>Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton</i>, Occup. Therapy, Vol. 30, No. 5, May 1967.</li> <li>Motloch, W. M., and Jane Elliott,<i> Fitting and training children with swivel walkers</i>, Artif. Limbs, Autumn 1966, pp. 27-38.</li> <li>Nichols, P. J. R., <i>The development of powered limbs, Special Education</i>, Vol. 44, Winter Issue 1965.</li> <li>Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, <i>Aids to daily living for children with severe multiple congenital limb deformities</i>, in preparation, 1968.</li> <li>Nickel, V. L., and Worden Waring, <i>Future develop- ments in externally powered orthotic and prosthetic devices</i>, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</li> <li>Pearson, F. A., and B. W. Spiers, <i>Teamwork in the management of dysmelic children</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</li> <li>Scott, Stevenson M., <i>Providing for their education</i>, Special Education, Vol. 44, Winter Issue 1965.</li> <li>Sheridan, M., <i>The developmental progress of infants and young children</i>, Ministry of Health Report No. 102, 1960.</li> <li>Siller, Jerome, and Sydelle Silverman, <i>Studies of the upper-extremity amputee; VII. Psychological factor</i>s, Artif. Limbs, Autumn 1958, pp. 88-116.</li> <li>Simpson, D. C, and D. W. Lamb,<i> A system of powered prostheses for severe bilateral upper limb deficiency</i>, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</li> <li>Spock, B., and M. O. Lerrigo, <i>Caring for your handicapped child</i>, Macmillan Co., New York, 1965.</li> <li>Stamp, W. G., S. Mahon, and H. C. Morgan, <i>Problems of management of the child with multiple amputations</i>, Arch. Phys. Med., Vol. 46, May 1965.</li> <li>Swanson, A. B., <i>The Krukenberg procedure in the juvenile amputee</i>, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</li> <li>Swanson, A. B., <i>Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement</i>, Amer. J. Surg., 109, March 1965.</li> <li>Swanson, A. B., <i>Classification of limb malformations on the basis of embryological failures</i>, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</li> <li>Taussig, Helen B., <i>The thalidomide syndrome</i>, Sci. Amer., Vol. 207, No. 2, August 1962.</li> <li>University of California at Los Angeles Staff, <i>Cosmesis: can it be defined?</i> Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</li> <li>Weiss, S. A., <i>Integrating the handicapped child into the community center</i>, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</li> <li>Willert, H. G, <i>Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">University of California at Los Angeles Staff, Cosmesis: can it be defined? Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Weiss, S. A., Integrating the handicapped child into the community center, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">McLaurin, C. A., External power in upper-extremity prosthetics and orthotics, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputee needs, frustration and behavior, Rehab. Lit., Vol. 20, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Campbell, E. I., and J. C. Bansavage, The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Siller, Jerome, and Sydelle Silverman, Studies of the upper-extremity amputee; VII. Psychological factors, Artif. Limbs, Autumn 1958, pp. 88-116.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutt, S., Private communication.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Kay, Hector W., and Edward Peizer, Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance, Artif. Limbs, Autumn 1958, pp. 31-87.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Friedmann, L., Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Hall, C. B., Corrective surgery for infant hands, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, Aids to daily living for children with severe multiple congenital limb deformities, in preparation, 1968.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Swanson, A. B., The Krukenberg procedure in the juvenile amputee, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Swanson, A. B., Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement, Amer. J. Surg., 109, March 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Gesell, Arnold L., et al., Infant and child in the culture of today; the guidance of development in home and nursery school, Harper, New York, 1943.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Sheridan, M., The developmental progress of infants and young children, Ministry of Health Report No. 102, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">MacNaughton, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Pearson, F. A., and B. W. Spiers, Teamwork in the management of dysmelic children, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Haslam, E. T., Joan Hayden, and Jean Dutro, The habituation of a congenital quadruple amputee, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">McKenzie, D. S., The clinical application of ex- ternally powered artificial arms, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Stamp, W. G., S. Mahon, and H. C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med., Vol. 46, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Goldner, J. L., and Bert R. Titus, An experience with externally powered prostheses for children, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fishman, Sidney, Studies of the upper-extremity amputee; VIII. Research implications, Artif. Limbs, Autumn 1958, pp. 117-127.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, Autumn 1966, pp. 27-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Mendez, M. A., Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton, Occup. Therapy, Vol. 30, No. 5, May 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Nichols, P. J. R., The development of powered limbs, Special Education, Vol. 44, Winter Issue 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Marquardt, E., The Heidelberg pneumatic arm prostheses, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burtch, R. L., A study of congenital skeletal limb deficiencies, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and M. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., 181:590 599, August 1962.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Swanson, A. B., Classification of limb malformations on the basis of embryological failures, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Willert, H. G, Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Henkel, L., Das Fehlbildungsmuster der Dysmelie, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Hebert, B., The psychologist and congenital physical anomalies, Inter-Clinic Information Bull., Vol. VI, No. 4, January 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Spock, B., and M. O. Lerrigo, Caring for your handicapped child, Macmillan Co., New York, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, Management of the child amputee, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies; management of limb defects, Brit. Med. J., September 8, 1962.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Hall, C. B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs, Spring 1966, pp. 36-51.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Hunter, J. M., David Subin, and A. J. Plank, Some observations on upper extremity prosthesis applications, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker, The management of upper limb deficiencies in the thalidomide-type syndrome, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Taussig, Helen B., The thalidomide syndrome, Sci. Amer., Vol. 207, No. 2, August 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. G. Stamp, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Department of Orthopaedics, University of Virginia School of Medicine, Charlottesville, Va. 22901; Visiting Professor to the Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>M. S. Clark, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>E. E. Rogers, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Research Assistant, Department of Engineering Science, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. </b></td></tr><tr><td class="clsTextSmall">Director, Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities Creator An entity primarily responsible for making the resource P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. * E. E. Rogers, M.A.O.T. * M. S. Clark, M.A.O.T. * W. G. Stamp, M.D. * https://staging.drfop.org/files/original/6212151a4fd93fa9dfd236829b610b9d.pdf 189fa090d4acf3dfea37b1693a79a780 https://staging.drfop.org/files/original/74352196c91439b746c487380d4c7d77.jpg 05c134f6b80ae4f5c032ba27b11de016 https://staging.drfop.org/files/original/10e30ded97b085e2b2892d7eea9365a3.jpg 25847e110d18fb0e9863908ef7b26efb https://staging.drfop.org/files/original/c14ca2b677fa08c269cdf300b3ac8d05.jpg 6aa3d9f3fdbb8117d775aec6125b3749 https://staging.drfop.org/files/original/56605a5d73b41e6c48d52f069c0109e4.jpg 0d4dd9bf592027776b6b43c7fb8e2dfd https://staging.drfop.org/files/original/8b2233e0b1a3db5f4e26c29029c28d52.jpg c9c9ed230bf33f6d1f48fe13e3d4c838 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_109.pdf Text Any textual data included in the document <h2>The Amputee Athlete</h2> <h5>Richard Riley, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>An increasing number of amputees in the United States are moving beyond mere ambulation into active sports and recreation activities. Estimates of the number of amputees actively involved range from 15,000 to 20,000, with over 5,000 participating in organized competitive sports.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.jpg"><strong>Figure 1. Below-knee amputee, George Lombard, member of the Fisher-Saloman Marathon Team and the U.S. Disabled Ski Team.</strong></a><br /> <p>Ten years ago, the athletic amputee was a unique phenomenon in our practice. Today few practitioners cannot count two or three among their clientele. These amputees are at the cutting edge of our field because they push us as professionals to expand our perceptions of what is possible. They also provide the positive role models that we hold out to the rest of our clients as an example of what can be done.</p> <p>The able-bodied sports world has taken some giant leaps of perception regarding the amputee athlete. No longer is it just "inspirational" to have a disabled person competing in sports. Today there are amputees that compete in world class events alongside the able-bodied. The skiing world has demonstrated this by naming below-knee amputee George Lombard to the Fischer-Saloman Marathon cross country ski team and awarding above-knee amputee Diana Golden with the U.S. Ski Writers Award for Outstanding Alpine Competitor.</p> <p>Not only are there more elite amputee athletes today, there is a much larger body of rec-reationally oriented amputees. The days are gone when the prosthetist and rehabilitation team could be satisfied with being able to get the amputee to just walk. Expectations of our clients have changed. Not only the younger amputee, but also the active geriatric expects to be able to ride a bicycle, play golf, tennis, or jog around the block.<a></a> Our challenge is to meet these expectations.</p> <h3>Psychology of the Amputee Athlete</h3> <p>What causes one amputee to become an elite cross country skier (one of the most demanding physical sports in the world) and another with the same level of disability to be unable to even return to gainful employment? Part of the answer lies in the individual's ability to handle the stress and trauma of amputation. These are factors that we have little control over. The other part of the answer lies with environmental issues and can be addressed.</p> <p>Most amputee athletes are highly motivated individuals with a strong desire to overcompen-sate for their disability. A percentage of these people will rehabilitate themselves with practically no help at all and go on to accomplish great things in their personal lives as well as in sports. Others need the influence of role models to show them that their limitations are what they place upon themselves. One of the most positive experiences for any new amputee is when they meet another amputee with a positive attitude.<a></a> This positive motivation is best facilitated by a support structure of family, friends, and the rehabilitation team. If any one of these aspects is continually placing limits on the amputee, eventually the amputee will accept these limitations. There are physical limitations for the amputee, but these should be discovered not imposed. There are ways around most physical limitations by keeping an open mind and being willing to innovate.</p> <p>Pain is an aspect of amputation that in many cases is initially the greatest barrier to overcome. All athletes know pain through training and the physical exertion of competition. People who are athletic prior to becoming an amputee will generally be able to deal with pain more easily due to their previous development of strategies to perform while enduring levels of pain. The successful amputee will develop ways of minimizing discomfort, either through increasing the conscious tolerance for pain or seeking a lifestyle that reduces trauma to the residual limb.</p> <p>The amputee athlete not only has the pain of general physical exertion to deal with, but also the added trauma of torques and stresses far beyond normal to the skin and bone structure of the residual limb. Most of these athletes have developed very high pain tolerances and their body readily reacts to pain stimuli by releasing endorphines<a></a> (the body's natural pain medication) into the body. These factors enable the amputee athlete to achieve great physical accomplishments. It also sets up potential for serious damage to the residual limb tissue because of overactivity. Pain is the body's message to the brain that something is wrong and many amputees have developed ways to short-circuit this signal. This is a fact we must all be aware of in caring for and guiding the amputee athlete.</p> <h3>Prosthetic Care</h3> <p>For the prosthetic professional, the active amputee can be either a great source of pride and stimulation or a perpetual problem fraught with frustration. Nevertheless, this group of our clientele will continue to occupy a greater share of our patient load and we must develop strategies to successfully accommodate their needs.</p> <p>As important to the success of the athletic amputee as the prosthesis is his knowledge of how it works. Of equal importance are the limitations of the prosthesis and problem solving strategies for residual limb breakdown. The time spent in educating the amputee about his prosthesis and ways to deal with skin problems is always well spent.</p> <p>Regardless of how well fitting a prostheses is, there is a potential for skin breakdown of the residual limb due to overactivity.<a></a> Athletes will continually push themselves to their limits and beyond. If they are armed with methods to deal with skin breakdown, they will benefit greatly.</p> <p>Advances in sports medicine for runners was bound to spill over into prosthetics. Of particular use is a skin protection material called "2nd Skin™" (<b>Table 1</b>). It is a 1/16" thick piece of gel that is applied directly onto the skin. It prevents friction between the skin and any moving surface. It does not stick to normal skin, yet because of its viscosity, will stay where it is placed. It is perforated so as to let the wound breathe as well as being sterile to prevent infection. 2nd Skin™ absorbs secretions, feels cool, alleviates itching, and can relieve pain.</p> <p>2nd Skin™ comes with plastic on both sides of the gel material. Before the plastic is removed, cut a piece one third larger than the area to be covered. This allows coverage of the affected area despite migration. The directions recommend removing the plastic from one side or from both sides. Personal experience has shown that removing the plastic from both sides prevents most migration.</p> <p>Because 2nd Skin™ is so thin, it does not increase pressure on blisters or abrasions. It prevents most friction and can actually promote healing even during heavy usage. 2nd Skin™ comes in a variety of sheet sizes which can be cut to the size needed and has to be kept in the zip-lock container provided. Unfortunately, it can be used only once and has to be cleaned off the sock after use. It works very well on below-knee amputees, especially when used beneath a sheath. In above-knee amputees, only suction wearers will experience difficulty in usage due to excessive migration from pulling into the socket. Second Skin™ is an inert material made from 96 percent water and four percent polyethylene oxide.</p> <p>Another product which provides excellent friction reduction and is also reusable is "Spenco® Skin Care Pad" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg"><b>Table 1</b></a>). This product comes in three thicknesses, 1/2", 3/16", and 1/8". The 1/8" thickness produces the least amount of pressure inside the socket. Spenco® Skin Care Pad acts like a second layer of fat to protect the skin from friction or abrasion. It adheres to the skin without sticking due to its viscosity. Made from a reticulated closed cell elastomer, it can be gas sterilized or washed in soap and warm water. It should also be stored in the zip-lock bag and has a shelf life of two</p> <p>years. It is best used as a preventative measure in circumstances where skin breakdown is a danger.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg"><strong>Figure 2. Applying 2nd Skin™ to a residual limb abrasion.</strong></a><br /> <p>One of the problems with most skin protection materials is that suction socket wearers cannot utilize them. When the amputee pulls into the suction socket, "2nd Skin™" or "Spenco® Skin Care Pads" become displaced and usually do not cover the areas intended. A product that can be of use to suction socket wearers, or any amputee for that matter, comes with a variety of names. It is a transparent dressing with one adhesive side that is paper thin and porous both to air and water. The trade names are "Op-Site," "Bioclusive," "Tega-derm," and "Acuderm" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg"><b>Table 1</b></a>). This material can be applied directly to the skin and acts as another layer of protection, while still allowing normal dermal respiration and perspiration to occur. It can be left on the skin for four to five days before it needs to be removed. If left on much longer, the epidermis does not get an opportunity to slough off properly.<a></a></p> <p>These products work well to prevent friction, but do not provide any relief for pressure problems. The transparency of these materials allow for continual evaluation of the healing process. There is a problem that the adhesive is quite strong and oftentimes pulls hairs out upon removal. Different brands utilize different ad-hesives, but in general it is recommended that some soaking of the covered area in warm water will help remove the covering with minimal discomfort. Careful attention should be paid to the application instructions so as to avoid getting it adhered to itself when applying it. Most brands come with a paper backing and application method that allows it to be cut to the desired size.</p> <p>Until the time when skin abrasions and adherent scars become a thing of the past, we will have the need for skin protection materials. These products can give relief to thousands of prosthetic wearers as well as prevent much discomfort for active amputees. They should become a standard part of the amputee's "survival kit."</p> <h3>Sports Organizations for Amputees</h3> <p>The perceptions that amputees have of their capabilities has risen dramatically in the last decade. Paralleling the growth of competitive sports for amputees has been the organizations that provide the forum for these activities (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg"><b>Table 2</b></a>). Prior to these organizations bringing together amputees from around the nation and the world, there was little opportunity for exchange of ideas on the consumer level.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg"><strong>Figure 3. The United States Disabled Ski Team.</strong></a><br /> <p>Organizations such as the "National Handicapped Sports and Recreation Association," sponsor and provide for competitive sports activities. Competition is based on ability and level of amputation with competitive levels ranging from local races to world class and a parallel Olympic structure.</p> <p>The impact of these organizations on the field of prosthetics has been enormous. All of us have fielded questions concerning amputee athletes and their various prostheses. This direction from the people whom we serve has been healthy for prosthetics for many reasons. First, we have had to expand our horizons and adapt technologies and techniques to accommodate these athletic amputees. Secondly, it has created a demand and thus a market for new components to accommodate extra-ambulatory activities. Third, there now exists a forum for amputees to exchange ideas, compare techniques, and services, as well as push each other to greater accomplishments. Another important contribution is the role model aspect of these athletic amputees. They provide inspiration to all of our clientele to continue to expand their perceptions of what is possible.</p> <p>All of these factors have changed prosthetics. Because of publicity surrounding some of the more astounding accomplishments, not only has the field gained more public recognition, but there is a growing acceptance of us as professionals. These organizations will continue to provide and promote sports and recreation as a normal part of the amputees lifestyle. Not only is it our responsibility and challenge to continue to adapt prosthetics to these activities, but it will play a major role in the future of our profession.<a></a></p> <h3>Conclusion</h3> <p>As leisure time in our society increases, the need to accommodate sports and recreation in our society becomes essential. The perception of the amputee's lifestyle parallels this societal shift. Prosthetics must be able to accommodate this change in our patients' attitudes toward activity. This can best be accomplished through education and communication, as well as further development of componentry geared to the athletically inclined.<a></a></p> <p>The amputee athlete has given rise to a new specialty in our field. The sports prosthetist is now a viable specialist that as professionals we should recognize and refer our patients to. We will continue to provide state-of-the-art prostheses for our active amputees, and armed with information about proper care, they will be among the best athletes in the world.</p> <p><b>References:</b></p> <ol> <li>Riley, Richard, "The Amputee Athlete," <i>Sports Medicine</i>, Volume 4, October, 1984, pp. 31-32.</li> <li>Kegel, Bernice, "Recreational Activities of Lower Extremity Amputees: A Survey," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 61, June, 1980, pp. 258-264.</li> <li>Foort, James, "How Amputees Feel About Amputation," <i>Orthotics and Prosthetics</i>, Volume 28, March, 1974, pp. 21-27.</li> <li>Gaylor, Michael, M.D., personal communication, April, 1987. Presently Professor, Dartmouth College, Specialty in Sports Medicine.</li> <li><a href="poi/1980_01_037.asp">Levy, W. S., "Skin Problems of the Leg Amputee," <i>Prosthetic and Orthotic International</i>, Volume 4, 1980, pp. 37-44.</a></li> <li>Riley, Richard, "Skin Protection Materials," lecture given at American Academy of Orthotists and Prosthetics Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "Sports Organizations for the Disabled and Their Impact on Prosthetics," lecture given at American Academy of Orthotists and Prosthetists Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "A Survey of Active Below-Knee Amputees," study undertaken at Northwestern Orthotic and Prosthetic Research Center, Chicago, Illinois, December, 1980.</li> <li>Kegel, Bernice, <i>Sports for the Leg Amputee</i>, 1986.</li> </ol> <em><b>*Richard Riley, CP. </b> Richard Riley, CP., specializes in sports prosthetics and has a private practice with SportsMedicine Portsmouth, in Portsmouth, New Hampshire. Also a below-knee amputee, Riley is a member of the U.S. Disabled Nordic Ski Team and the Vice President of the National Handicapped Sports and Recreation Association.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 109 - 113 Year 1987 Volume 11 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg Figure 3 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg Figure 4 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 TABLE 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Amputee Athlete Creator An entity primarily responsible for making the resource Richard Riley, CP. * https://staging.drfop.org/files/original/69dcd7caf7126245f67c576a23eed259.pdf b7b6157c3a00c22ce04eab5fcbcd9bd3 https://staging.drfop.org/files/original/cd52e34d44c4e57526a5fce138f7f698.jpg 7a198c7f047f773bbc6304cfba3cf5ca https://staging.drfop.org/files/original/5d7294a2a8e341f658d1da509204af9b.jpg 7bd95a76b3d734667480ec0dfa10627e https://staging.drfop.org/files/original/41aca07379059375c3292b724c20ad74.jpg 1d4152198663676bd39749aa3927f9a9 https://staging.drfop.org/files/original/67da595e2b69a4eddfa254d7f3e4af1b.jpg 37ef26f3aa707b94fe6ce8c247500085 https://staging.drfop.org/files/original/9b09d3285dd63986158fb6ad3ff17829.jpg 1834799a9a45cb6e9a6a14ebdaeaf347 https://staging.drfop.org/files/original/01becc70231689f01d3e23078ca3d426.jpg a30c1c89e6080e63e83f5a4d21259851 https://staging.drfop.org/files/original/c837aee0438447ad78993b03f0c6c200.jpg a8318e44f6a4c5f16bad1e856293ce4f https://staging.drfop.org/files/original/b42005d371ab6bcdfafd2938aebf111f.jpg e14968ee1a57f38cdb7f3d3f58869784 https://staging.drfop.org/files/original/6d838654a7a10c9c607154be00da4967.jpg 6487b2156f041d65856f1b7fbd7fce04 https://staging.drfop.org/files/original/c721165ea01198ee6aef4e31acd0fdac.jpg f2e09c1ac6e6f04fc5b0a5eb66bcbd18 https://staging.drfop.org/files/original/86e71ac88dc77c0fe807c5821fd82c2a.jpg c276be77977e747e8b61adff1578acb7 https://staging.drfop.org/files/original/594db7f923eba326a0a22d4a72240941.jpg 37b19234f934f0937579f96fc8254bfe https://staging.drfop.org/files/original/7911660ec28bd9831354b1be9725eb7d.jpg 83d75d5dd8bf9a0f175a066cfac8db09 https://staging.drfop.org/files/original/2ce46311925780543b5f166aae06734c.jpg 20250700f961fbca04d3a509217ae6f4 https://staging.drfop.org/files/original/51f64afd51e21f05fcb8be1cf6b566a6.jpg 78db7332d104e619ea0153d0faf72faa https://staging.drfop.org/files/original/67dbcbc2d6e97fce74975c8e5425df4d.jpg 9c9248069a2f1eeb39d500e952d2092d https://staging.drfop.org/files/original/d9cb0275b460dcb93313cf0a93e01dc4.jpg 1b87da727d718119cf9f5981c3028001 https://staging.drfop.org/files/original/bbe231086fad6f1a5604ed09094d496d.jpg 284ec9e3ade0dccb3ab0c62ed1ae442e https://staging.drfop.org/files/original/72335cd71fe5e3195663463b7ff672df.jpg 6e71c69d6cb6b4d01362c92378c81350 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_022.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 22 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anatomy and Mechanics of the Human Hand</h2> <h5>Craig L Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Robert J. Schwarz, M.D <a style="text-decoration:none;">*</a><br /></h5> <p>It is obvious to all that the human hand represents a mechanism of the most intricate fashioning and one of great complexity and utility. But beyond this it is intimately correlated with the brain, both in the evolution of the species and in the development of the individual. Hence, to a degree we "think" and "feel" with our hands, and, in turn, our hands contribute to the mental processes of thought and feeling.</p> <p>In any mechanism, animate or inanimate, functional capabilities relate both to structural characteristics and to the nature of the control system available for management of functions singly or in multiple combinations. Just so with the human hand. Analysis of normal hand characteristics therefore requires an understanding of both sensory and mechanical features. Of course whole volumes have been written on hand anatomy, and it is not possible in a short article to describe all elements in detail. It is helpful, however, to review the basic construction of bones and joints and of the neuromuscular apparatus for governing motions and forces. Twenty four muscle groups, controlled by the various motor and sensory nerve pathways, with their rich potentialities for central connection, and acting upon a bone and joint system of great mechanical possibilities, give to the hand its capacity for innumerable patterns of action.</p> <h3>The Functional Structure of the Hand</h3> <h4>The Bones</h4> <p>The bones of the hand, shown in (<b>Fig. 1</b>), naturally group themselves into the carpus, comprising eight bones which make up the wrist and root of the hand, and the digits, each composed of its metacarpal and phalangeal segments (<b>Table 1</b>). The carpal bones are arranged in two rows, those in the more proximal row articulating with radius and ulna. Between the two is the intercarpal articulation. The bony conformation and ligamentous attachments are such as to prevent both lateral and dorsal volar translations but to allow participation in the major wrist motions (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and articulations of the hand, including the interosseus muscles. A, volar view; B, dorsal view. For nomencla ture, see Tables 1 and 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. Bones and Joints of the Hand and Wrist </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Angles of rotation about the wrist. A, extension (or dorsiflexion); B, flexion (or volar flexion); C, radial flexion; D, ulnar flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In each of the digits, the anatomical design is essentially the same, with exceptions in the thumb. Metacarpals II through V articulate so closely with the adjacent carpal bones of the distal row that, although they are capable of some flexion and extension, independence of motion is very limited. The metacarpal shafts are arched to form the palm, and the distal ends are almost hemispherical to receive the concave curvature of the proximal ends of the first phalanges.</p> <p>The metacarpophalangeal joint exhibits a pattern seen also in the interphalangeal joints. As shown schematically in (<b>Fig. 3</b>), the virtual center of rotation lies approximately at the center of curvature of the distal end of the proximal member. The lateral aspects of the joint surfaces are narrowed and closely bound with ligaments, so that lateral rotation is small in the metacarpophalangeal joints and lacking entirely in the phalangeal articulations. Hence, the latter are typical hinge joints. The thumb differs from the other digits first in that the second phalanx is missing and, second, in that there is greater mobility in the carpometacarpal articulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Section through radius, lunate, capitate, and the bony structure of digit III, showing virtual centers of rotation of each segment upon the next more proximal one. When the fist is clenched, the prominence of the knuckles is formed by the head of the more proximal member of each articulation. For nomenclature, see Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Muscles and Tendons</h4> <p>Most of the muscles of hand and wrist (<b>Table 2</b>) lie in the forearm and, narrowing into tendons, traverse the wrist to reach insertions in the bony or ligamentous components of the hand. Generally, the flexors (<b>Fig. 4</b>) arise from the medial epicondyle of the humerus, or from adjacent and volar aspects of the radius and ulna, and then course down the inside of the forearm. They are, therefore, in part supinators of the forearm (<b>Fig. 5</b>).The extensors (<b>Fig. 6</b>) of wrist and digits originate from the lateral epicondyle and parts of the ulna, pass down the dorsal side of the forearm, and thus assist in pronation. The thumb shares in the general flexor extensor scheme, but its extensors and abductors originate from mid and distal parts of radius and ulna.</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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Flexors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Forearm design as related to hand mobility. By virtue of this arrangement, the hand can be rotated through 180 deg., palm up to palm down, with the elbow flexed. With the arm fully extended, participation of shoulder and elbow allows the hand to be rotated through almost 360 deg., palm up to palm up. U, ulna; R, radius; P, pronation; S, supination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Extensors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tendons of wrist and hand pass through bony and ligamentous guide systems, as shown schematically in (<b>Fig. 7</b>). Flexor tendons pass through a "tunnel" bounded dorsally by carpal bones, laterally by the greater multangular and the projection of the hamate, and volarly by the tough transverse carpal ligament. Similarly, the dorsal carpal ligament guides the extensor tendons, and a system of sheaths serves as a guide for flexor and extensor tendons through the metacarpal and phalangeal regions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The anatomy of prehension. Schematic sections through digits I and III show essential relations of muscles and bones. The letters LG indicate the presence of ligamentous guides which channel close to the wrist the tendons of muscles originating in the forearm. Guide line X—X indicates relative position of carpal bases of thumb and fingers. For rest of nomenclature, see Tables 1 and 2. From Taylor.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The intrinsic muscles of the hand, <i>i.e., </i>those with both origin and insertion confined to wrist and hand (<b>Fig. 8</b>), are, with the exception of the abductors of thumb and little finger, specialized for the adduction of the digits and for opposition patterns such as making a fist, spherical grasp, and so on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Volar intrinsic muscles of the hand. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Palmar and Digital Pads</h4> <p>The volar aspect of the palm and digits is covered with copious subcutaneous fat and a relatively thick skin so designed in a series of folds that it is capable of bending in prehension. The folds are disposed in such a way as to make for security of grasp, while the underlying fat furnishes padding for greater firmness in holding. Because, however, slipping of the skin over the subcutaneous fat would lead to insecure prehension, the folds are tightly bound down to the skeletal elements, much as mattresses and upholstered furniture are quilted or otherwise fastened to prevent slippage of the filler.</p> <p>In the hand, the volar skin is tied down by white fibrillar tissue connecting the sheaths of the flexor tendons to the deep layer of the dermis along the lateral and lower edges of the palmar fascia. The folds therefore vary with the relative lengths of the metacarpal bones and with the mutual relations of the sheaths of the tendons and the edge of the palmar fascia.</p> <p>The sulci, or furrows, are emphasized because the subcutaneous fat in any given area is restricted to the interval between the lines along which the skin is tied down. Thus pressure upon any individual montic ulus cannot displace the underlying soft tissue beyond the boundaries established by the fibrillar connections. The relative size of any particular eminence is an indication of the size of the muscle involved and of its relative development through usage, with the exception that the size of the hy pothenar eminence depends in part upon the prominence of the pisiform.</p> <h4>The Dorsal Integument</h4> <p>Unlike the volar surface, the dorsal side of the hand is covered with thin, soft, pliable skin and equally mobile subcutaneous tissue, both capable of yielding easily under tension. Because in flexion of the fingers and in making a fist the covering on the back of the hand must be able to stretch from wrist to fingernails, the dorsal skin is arranged in numerous minute redundancies, which, in the fiat of hand, are manifest in the typical transverse wrinkles, particularly over the phalangeal articulations. Special adaptations in the dorsal skin of the thumb accommodate the distinctive rotational planes of that digit about its carpometacarpal articulation. In the normal, healthy hand, the degree of redundancy in any given area is just such that all wrinkles are dispatched when the fist is clenched. Swelling in any area, dorsal or volar, inhibits flexion extension of the part affected.</p> <h4>Nerve and Blood Supply</h4> <p>Three principal nerves serve the muscles of the hand (<b>Fig. 9</b>). Nerve supply is indicated, except for minor variations and exceptions, in (<b>Table 3</b>). Each of these major nerve trunks diverges into countless smaller branches ending in the papillae of the palmar pads and dorsal skin, and the whole neuromuscular system is so coordinated in the brain that motor response to stimuli is ordinarily subconscious and reflex. Thus an object slipping from the grasp is automatically gripped more firmly, but not so firmly as to damage the hand itself. Noxious stimuli are rejected automatically, as when the fingers are withdrawn from an object uncomfortably hot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nerves supplying the hand. Top to bottom, ulnar nerve, median nerve, radial nerve. See Table 3. </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>The wrist and hand receive their blood supply from the radial and ulnar arteries, which run parallel with the bones concerned, enter the hand through the flexor "tunnel," and then join through a double arch system (<b>Fig. 10</b>). Small branches from the arches serve the digits. The major venous system comprises the basilic and cephalic veins superficially placed on the volar surface of the forearm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Blood supply to the upper extremity. A, above, medial view of the elbow. A, bottom, dorsal veins of the hand. B, superficial veins of the arm. C, arteries of the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Resting Hand Pattern</h3> <p>The resting hand assumes a characteristic posture, a feature easily seen when the hand hangs loosely at the side. The resting wrist takes a mid position in which, with respect to the extended forearm axis, it is dorsiflexed 35 deg. (<b>Fig. 11</b>). It is worth noting that this is the position of greatest prehensile force (<b>Fig. 12</b>, bottom). The mid position for radial or ulnar flexion appears to be such that the metacarpophalangeal joint center of digit III lies in the extended sagittal plane of the wrist (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The resting hand pattern. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12 Effect of forearm-hand angle upon wrist flexion and extension forces and upon prehension forces. Above, relationship between forearm-hand angle and maximum forces of wrist flexion and extension measured at the carpometacarpal joint. Heavy lines, flexion (volar flexion); light lines, extension (dorsal flexion). Solid lines, averages; dotted lines, standard deviations. Unpublished data, UCLA, 15 male subjects. Below, relationship between forearm-hand angle and maximum prehension force measured between thumb and opposing index and middle fingers grasping a 1/2-inch block. Right hand, eight normal male subjects. Solid line, average; dotted lines, standard deviations From a UC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Typically, the conformation of fingers and thumb is similar to that shown for palmar prehension (<b>Fig. 13</b>), the fingers being more and more flexed from index to little finger. The relations between thumb, palm, and fingers are such as to permit grasp of a 1.75 in. cylinder crossing the palm at about 45 deg. to the radioulnar axis. Bunnell<a></a> considers this "an ancestral position ready for grasping limbs, weapons, or other creatures."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Six basic types of prehension, as defined by Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fixed Hand Adaptations</h3> <p>In thrusting or striking actions and the like, the hand may assume fixed and rigid postures while functioning with the arm in support. These represent nonspecialized functions in which the hand serves merely as an adapted "end of the arm." The various forms include the flat of hand, the clenched fist, the knuckle and digital support postures, and so on.</p> <h3>Wrist Mechanics</h3> <p>The wrist joint, composed of the radiocarpal and intercarpal articulations (<b>Fig. 1</b>), has an elliptical rotation field with the major axis in the dorsal volar excursion, the minor in the ulnar radial. No significant torsion occurs. Bunnell<a></a> gives the angular excursions about the radiocarpal and intercarpal articulation as shown in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. Angular Extent of Wrist Flexions" </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rotation within the carpal bones during these movements is too complicated for brief treatment. Not only do the rotations occur at several articulating surfaces, but the virtual axes of rotation lie distal to the contact surfaces owing to gliding motions in the convex concave structure of the joints. Idealization of the motions into those of a simple lever, rotating about a fixed center, as implied in diagrams such as <b>Fig. 2</b>, can be justified only as a convenient approximation.</p> <p>The muscles traversing the wrist include those inserting into the carpus and metacarpus and those mediating flexion and extension of the phalanges. The latter contribute to the wrist action, particularly under loads. In such cases, the finger muscles develop reaction against the object held (or within the hand itself if the fist is clenched) and add their forces to wrist action. The forces, action, and grouping of these muscles are given in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. <br /> ^a From Fick. <a></a> <br /> ^b The palmaris longus, absent in about 15 percent of cases, is omitted from the summed Fick forces of volar flexion.<br /> ^c Averages from measurements of maximum forces normal to the hand, applied at the metacarpophalangeal joint, on 15 young males at the University of California at Los Angeles (unpublished data). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prehension Patterns</h3> <p>It is evident equally from a study of the muscle bone joint anatomy and from observation of the postures and motions of the hand that an infinite variety of prehension patterns is possible. For purposes of analysis, however, it suffices to describe the principal types. Seeking a logical basis for defining the major prehension patterns, Keller et al.<a></a> found that the object contact pattern furnishes a satisfactory basis for classification. From &gt;photographic observation of the prehension patterns naturally assumed by individuals when (a) picking up and <i>(b) </i>holding for use common objects used in everyday life, three types were selected from among those originally classified by Schlesinger.<a></a> These, appearing in (<b>Fig. 13</b>), are palmar, tip, and lateral prehension, respectively. The frequency with which each of these types occurred in the investigation cited is given in (<b>Table 6</b>). While the relative percentages differ in the two types of action, the order of frequency with which the prehension patterns occurred is the same.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. Frequency or Prehension Patterns </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Mechanical Anatomical Basis or Prehension Patterns</h3> <p>It is convenient to analyze digital mechanics in terms of flexion extension variations in the digits, thumb postures, and variations in the radioulnar axis.</p> <h4>Individuation of Digital Flexion Extension</h4> <p>Insertion of flexor and extensor muscle systems into several major segments along the proximal distal axis provides a variety of flexion extension patterns in the digits. In <b>Fig. 7</b>, the essential components are shown schematically for digits I and III. With these attachments, fixation of carpal and metacarpal segments by cocontraction of flexor and extensor carpi muscles provides a firm base for independent movements and fixations of the phalangeal segments. Individual flexions of the second and terminal phalanges stem from separate flexor muscle (<b>Fig. 13</b>). The counterbalancing digital extensor inserts into the two most distal phalanges and, on contraction, rigidly extends the entire finger. Coordinated action between extensor and flexor groups, however, permits fixed intermediate positions of each segment of the system.</p> <p>Two common postures of this system may be pictured. In palmar prehension (<b>Fig. 13</b>), the carpal and metacarpal segments commonly fix the wrist in moderate extension, while the digital configuration, mostly metacarpophalangeal flexion coupled with only slight phalangeal flexion, indicates action of the long flexors, strongly modified by the lumbricals and interossei, which are in position not only to contribute to the metacarpophalangeal flexion but also to maintain the phalangeal xtension. In tip prehension, the action of muscles upon carpal and metacarpal bones is similar, but distributed flexion in all phalangeal segments indicates predominant flexor activity.</p> <h4>Thumb Versatility Patterns</h4> <p>The versatility of the thumb lies, first, in the variety of its flexion extension patterns and, second, in the adjustable, rotatory plane in which flexion extension can take place. The first of these is directly analogous to the digital system for the other four fingers, in that for any given metacarpal position there are numerous possible positions of the phalanges. The second effect is due to the relative mobility of the carpometacarpal joint, which allows the thumb to act in any plane necessary to oppose the digits. The principal oppositions are semidirect, as seen in palmar, tip, and spherical prehensions. Actually, in these cases the plane of the thumb action is inclined 45 to 60 deg. to the palmar plane. In lateral prehension, the plane is approximately parallel to the palmar plane.</p> <h4>Variations in the Radioulnar Axis of the Hand</h4> <p>A third principal mode of variation concerns cross hand alignments. Thus the metacarpophalangeal joints may be drawn into line, and with abducted thumb a flat hand position is assumed. At the other extreme, the hand is cupped for spherical prehension (<b>Fig. 13</b>) as the opponens muscles of thumb and little finger, aided by other adductors and flexors, act to pull these digits toward each other. Similar alignment occurs when a fist is made.</p> <h3>Hand Movements</h3> <p>The large number of muscles and joints of the hand obviously provides the equipment for numerous and varied patterns of movement. Not so evident, but equally important in determining complexity and dexterity of motion, are the large areas of the cerebral cortex given over to the coordination of motion and sensation in the hand. Thus, in the motor cortex the area devoted to the hands approximately equals the total area devoted to arms, trunk, and legs.<a></a> This circumstance ensures great potentiality for coordinated movement and for learning new activities. Similarly, the sensory areas are large, so that they determine such advanced functions as stereognosis, the ability to recognize the shape of an object simply by holding it in the hand. The great tactile sensitivity of the hand is, of course, in large part due to the rich supply of sense organs in the hand surface itself. The threshold for touch in the finger tip, for example, is 2 gm. per sq. mm., as compared to <i>33 </i>and 26 for the forearm and abdomen respectively.<a></a></p> <p>The three major types of movement described by Stetson and McDill<a></a> are in part represented in the hand. They include fixation movements including cocontractions; movements ranging from slow to rapid with control of direction, intensity, and rate; and ballistic movements.</p> <h4>Fixation Movements</h4> <p>In all of the types of prehension described, the hand assumes a fixed position. If the prehended object is unyielding, reactions to the flexion forces are afforded by the object. If the object is fragile, or the hand empty, the hand is maintained in any required prehensile posture by cocontractions of the opposing muscle groups.<a style="text-decoration:none;">*</a></p> <p>The characteristics of balanced muscular action when supporting in the hand loads which produce moments at the wrist have been studied electromyographically by Dempster and Finerty.<a></a> In general, when average potential amplitudes are used to characterize the electrical activity of the muscle, the curves of load action potential are linear. Frequencies range from 35 to 65 per sec. but bear no clear cut relationship to load. Typically, each of the muscles traversing the wrist was found to function as agonist, lateral stabilizer, or antagonist as the moment load was shifted from direct opposition at zero deg. to the 90 deg. and then to the 180 deg. positions. The magnitude of the action potentials associated with each of these roles is approximately in the order 4:2:1.</p> <h4>Slow and Rapid Movements</h4> <p>In movements ranging from slow to rapid, with control of direction, intensity, and rate, there is always some degree of cocontraction to ensure control and to permit changes in force and velocity. A net force in the muscles causes motion. In this category is a long list of activities, such as writing, sewing, tying knots, and pressing the keys of musical instruments. Included are most actions involving differential or integrated motions of the digits.</p> <p>It is of interest to note that the full capacity for these motions is seldom developed by the average individual. With intensive practice, significant increases in the facility of manipulation, even with simple operations, may be achieved, although individuals differ markedly in the amount of training gain. The average individual has latent potential for development of skill, as shown by the feats of manipulation occasionally evidenced. Knot tying, cigarette rolling, and similar complex manipulations may be performed with one hand, as often demonstrated by accomplished unilateral arm amputees. According to Tiffin<a></a>, dexterity differences are correlated neither with mental ability nor with hand shape or dimensions, but Cox<a></a> points out that they have an important effect on the performance of industrial assembly operations.</p> <h4>Ballistic Movements</h4> <p>Ballistic movements are rapid motions, usually repetitive, in which active muscular contractions begin the movement, giving momentum to the member, but cease or diminish their activity throughout the latter part of the motion. It is unlikely that, of themselves, the fingers utilize this type of motion to any marked degree. Barnes<a></a> reviews evidence that in repetitive work finger motions are more fatiguing, less accurate, and slower than are motions of the forearm. Consequently, in repetitive finger activities in which there is a ballistic element, such as piano playing, typing, and operating a telegraph key, wrist and elbow motions predominate while the fingers merely position themselves to strike the proper key.</p> <h3>Hand Dynamics</h3> <p>The hand muscles, their actions, and contractile forces are given in (<b>Table 5</b>) taken from Fick.<a></a> The total Fick force equals the sum mated forces of the individual muscles participating in the action. For each muscle the force is equal to the physiological cross section <i>(i.e., </i>the total cross section of the muscle taken normal to its fibers) multiplied by the force factor of 10 kg. per sq. cm., estimated by Fick to hold for human muscle. These forces are produced along the axis of the muscle and its tendon, but since the effective moment arm upon any of the wrist or hand joints is small, the <i>measured </i>isometric forces are only about 10 percent of the total force.</p> <p>Among the wrist actions, total forces and measured isometric forces assume the same rank order. The variation,. with wrist angle, of both flexor extensor forces in the wrist and of prehensile forces in the hand is of practical importance as well as theoretical interest. The prehensile force reaches a maximum at a wrist angle of about 145 deg. (<b>Fig. 12</b>, bottom). This is approximately the angle at which the maximum forces of wrist flexion and extension occur (<b>Fig. 12</b>, top). It is common experience that the wrist assumes this angle when very strong prehension is required. The lessened forces at wrist angles toward the extreme positions of flexion or extension are attributable to the well known force reductions in the isometric length tension curve as a muscle is markedly stretched or slackened.<a></a> The exception to this rule, seen in the augmented force of flexion at wrist angle 85 deg., apparently means that this degree of wrist extension does not stretch the flexor muscles beyond their force maximum.</p> <h3>Conclusion</h3> <p>This, briefly, constitutes the anatomical basis of hand mechanics, from which it can be seen that normal hand function is the result not only of a highly complex and versatile structural arrangement but also of an equally elaborate and fully automatic system of controls. As will be seen later (page 78), such considerations lay down the principal requirements and limiting factors in the design of reasonably successful hand substitutes. When, in the normal hand, any functional feature, either mechanical or sensory motor, is impaired, manipulative characteristics are reduced correspondingly. In the arm amputee, hand structural elements have been wholly lost, and the most delicate neuromuscular features, those in the hand itself, have been destroyed. Although the lost bone and joint mechanism can be simulated, adequate replacement of the control system defies present ingenuity. Lacking control comparable to that in the natural hand, present day artificial hands are necessarily limited in the mechanical details that can be utilized, which accounts for the fact that the regain in function currently possible in hand prostheses falls far short of duplicating the natural mechanism.</p> <h3>Acknowledgment</h3> <p>The anatomical drawings which accompany this article are the work of John Cassone, medical illustrator at the University of California, Los Angeles.</p> <p><b>References:</b></p> <ol> <li>Barnes, R. M., <i>Motion and time study</i>, Wiley, New York, 1937.</li> <li>Best, C. H., and N. B. Taylor, <i>Physiological basis of medical practice</i>, Williams and Wilkins, Baltimore, 1937. p. 1256.</li> <li>Best and Taylor, op. cit., p. 1418.</li> <li>Bunnell, Sterling, <i>Surgery of the hand</i>, Lippincott, Philadelphia, 1944.</li> <li>Cox, J. W., <i>Manual skill</i>, Cambridge University Press, 1934.</li> <li>Dempster, W. T., and J. C. Finerty, <i>Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study</i>, Am. J. Physiol., 150:596 (1947).</li> <li>Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke<i></i>, Dritter Teil, G. Fischer, Jena, 1911.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle</i>, Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Keller, A. D., C. L. Taylor, and V. Zahm, <i>Studies to determine the functional requirements for hand and arm prosthesis</i>, Department of Engineering, University of California at Los Angeles, 1947.</li> <li>Schlesinger, G., <i>Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen</i>, Springer, Berlin, 1919.</li> <li>Stetson, R. H, and J. A. McDill, <i>Mechanism of different types of movement</i>, Psych. Mono., 32(3): 18 (1923).</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Tiffin, Joseph, <i>Industrial psychology</i>, Prentice-Hall, New York, 1947.</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. Vol. II.</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>8.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 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>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barnes, R. M., Motion and time study, Wiley, New York, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Cox, J. W., Manual skill, Cambridge University Press, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Tiffin, Joseph, Industrial psychology, Prentice-Hall, New York, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Dempster, W. T., and J. C. Finerty, Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study, Am. J. Physiol., 150:596 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">There are many other examples of fixation stales, such as the open claw conformation of the fingers and the extended and rigid index finger for dialing a telephone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Stetson, R. H, and J. A. McDill, Mechanism of different types of movement, Psych. Mono., 32(3): 18 (1923).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Best, C. H., and N. B. Taylor, Physiological basis of medical practice, Williams and Wilkins, Baltimore, 1937. p. 1256.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Best and Taylor, op. cit., p. 1418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Predominance of palmar prehension in both activities accounts for adoption of this pattern in the design of modern artificial hands (page 86).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Keller, A. D., C. L. Taylor, and V. Zahm, Studies to determine the functional requirements for hand and arm prosthesis, Department of Engineering, University of California at Los Angeles, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">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. Vol. II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 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>Robert J. Schwarz, M.D </b></td></tr><tr><td class="clsTextSmall">Instructor in Otolaryngology, College of Medical Evangelists, Los Angeles; formerly Assistant in Engineering Research, University of California, l.os Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_022/table01.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_022/table02.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-17.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-20.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-21.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-22.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-24.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_022/table03.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-27.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-29.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-30.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_02_022/table04.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_02_022/table05.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_02_022/table06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_095.pdf Text Any textual data included in the document <h2>The Anterior Shell Orthosis: An Alternative TLSO</h2> <h5>Carrie L. Beets, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Tom Faisant, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Vernon Houghton, R.T.O.&nbsp;<a style="text-decoration: none;">*</a><br />C. Michael Schlich, C.P.O.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Postoperative spinal management has undergone progressive changes in recent years. The merits of early mobilization following spinal surgery are well documented<a></a> and it is now generally agreed that earlier mobilization leads to quicker and more successful patient recovery. The recent advent of DRGs and predetermined payment to hospitals, regardless of length of hospitalization, adds even more incentive to the concept of earliest possible mobilization.</p> <p>Traditional approaches to postoperative spinal immobilization have been plaster body casts,<a></a> Jewett hyperextension orthoses,<a></a> and Knight-Taylor orthoses.<a></a> More recent approaches include the use of total contact TLSO's (body jackets), either with an anterior or posterior opening, or a bivalved, clamshell design.<a></a> Each of the above orthoses has inherent deficiencies with respect to very early patient mobilization attempts. Briefly, plaster casts lack total contact, lack volume adjustability, and do not promote or allow acceptable skin hygiene. Metal frame type orthoses such as a Jewett or Knight-Taylor do not control motion in all three planes, which is necessary for immediate postoperative mobilization. The ability of these orthoses to control lateral trunk flexion and/or rotary motion of the trunk is questionable. On the other hand, total contact TLSO's provide excellent control, but are very difficult to independently don and doff and, more important, they require rolling the patient into a prone position, or use of a Stryker frame, for molding. An additional deficiency of total contact TLSO's is they are too restrictive or confining, and actually slow the rehabilitation/recovery process by limiting range of motion necessary for independence.</p> <h3>Development And Description</h3> <p>In late 1977, Richard Rosenberger, CP. (deceased March, 1985) and physicians with the Department of Orthopaedics and Rehabilitation at the University of Virginia Medical Center developed the "anterior shell" orthosis as an alternative TLSO, designed to address all of the above mentioned deficiencies found in these other orthotic approaches. As its name implies, the anterior shell orthosis is a TLSO that provides total contact coverage to the anterior three quarters of the trunk, with the anterior trimlines the same as those of any standard body jacket type TLSO, and the lateral trim-lines just posterior to the lateral midline of the trunk (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg"><b>Fig. 1</b></a>). Suspension and immobilization are afforded by this total contact anterior section coupled with a Jewett type posterior pad with adjustable straps and a two inch wide Velcro® posterior strap across the sacral-coccygeal junction of the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg"><b>Fig. 2</b></a>). Although quite flexible upon first impression, this TLSO becomes sufficiently rigid when properly tightened on a patient (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg"><b>Fig. 3</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg"><b>Fig. 4</b></a>), deriving its strength and rigidity from the tubular principle. This orthotic design provides a three point pressure system which is effective from T5 to L5; however, a cervical extension can be added to the orthosis to extend its support to the upper thoracic region. Originally designed for postoperative spinal management following Harrington rod instrumentation secondary to traumatic injury, the anterior shell orthosis permits the cast impression to be taken with the patient comfortably supine without the need for proning or other patient movement.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg"><strong>Figure 1. Anterior view of Orthoplast™ anterior shell orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg"><strong>Figure 2. Posterior view of Orthoplast™ anterior shell orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg"><strong>Figure 3. Anterior view of patient wearing orthosis.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg">Figure 4. Lateral view of patient wearing orthosis. Note Jewett type posterior pad and strap arrangement.</a><br /></strong><br /> <h3>Advantages</h3> <p>In addition to the advantage of not having to move the patient while casting, the anterior shell orthosis is felt to be superior to the bi-valved and circumferential TLSO designs for postoperative management in other respects. Additional .advantages offered by the anterior shell orthosis include ease of donning and doffing the orthosis initially for the nursing staff and later, the ability to independently don and doff the orthosis by the patient while in the supine position (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg"><b>Fig. 5</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg"><b>Fig. 6</b></a>), ease of inspection of the surgical wound site without having to doff the orthosis, increased air circulation to the surgical wound site, and more efficient cooling due to less body containment within the orthosis. The anterior shell orthosis provides anterior, posterior, lateral, and rotary control, however, because there is no posterior section, the lateral aspects are slightly more flexible than in a circumferential design. This quality of slight flexibility facilitates maneuverability during transfers and activities of daily living, yet the orthosis provides sufficient external stabilization to protect the Harrington rod instrumentation.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg"><strong>Figure 5. Patient in supine position donning orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg"><strong>Figure 6. Patient, lying down, rolls to side and fastens the posterior pad and strap. Allowing for the posterior pad and strap to fasten on the same side facilitates donning and doffing in the lying position.</strong></a><br /> <h3>Indications</h3> <p>As the advantages of the anterior shell design were proven with experience with postoperative patients, opportunities were sought for its use with other spinal diagnoses (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg"><b>Table 1</b></a>). Indications for use of the anterior shell orthosis now include various vertebral fractures, treated surgically or non-surgically; vertebral degeneration and pain due to diffused malignancy; progressive kyphosis due to osteoporosis, ankylosing spondylitis, and neurological conditions; degenerative joint disease; and postoperative management of spinal stenosis.</p> <h3>Experience</h3> <p>Over a period spanning 1979-1985, 232 patients were treated orthotically with the anterior shell; 137 of these patients were treated postoperatively (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg"><b>Table 2</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg"><b>Table 3</b></a>). Over this seven year period, no postoperative patients experienced failure of surgical instrumentation while in the orthosis. During the initial development phase in 1978, only one postoperative patient experienced failure of his surgical instrumentation while in the orthosis.</p> <h3>Treatment Regime</h3> <p>Current treatment of thoracic and lumbar spinal cord injuries at the University of Virginia Medical Center includes molding and subsequent fit and delivery of an anterior shell orthosis within a few days post-surgery. Patients are usually maintained supine in bed until the orthosis is fit and delivered, with rehabilitation beginning immediately after fitting and delivery. At two weeks post-surgery, patients are allowed unlimited forward leaning in the orthosis for level and uneven surface transfers (wheelchair to bed, wheelchair to mat, etc.). Once the basic transfers are mastered, appropriately supervised advanced wheelchair transfers are permitted, including wheelchair to floor, floor to wheelchair, ascending and descending stairs in a sitting position, and in and out of a bathtub. At three to four weeks post-surgery, patients are taught independent donning and doffing of the orthosis in the supine position.</p> <h3>Technical Information</h3> <p><i>Material Selection</i></p> <p>At the University of Virginia Medical Center, the anterior shell orthosis is normally fabricated utilizing Orthoplast™. This thermoplastic material offers quick and easy fabrication that permits removal from the mold immediately after cooling without risk of shrinkage or other distortion. This allows for quick fabrication and delivery of the orthosis. Other noteworthy advantages of Orthoplast™ include pre-ventilation for air circulation, light weight, and due to its low temperature thermomolding properties, it is easily adjusted or modified in hospital and clinical settings. In cases where the orthosis is going to be used definitively, thermoplastics such as polyethylene or Vi-trathene are used in lieu of Orthoplast™.</p> <p><i>Patient Molding</i></p> <p>To cast a patient for an anterior shell orthosis, a piece of 12 inch wide stockinette is split lengthwise and placed over the patient with the edges of the stockinette tucked under the patient to prevent shifting during casting. A piece of narrow stockinette is passed carefully under the patient in the lumbosacral region of the back and through to the other side. The two ends are pulled tight over the iliac crests, tied off, and placed under tension as for pelvic traction (<b>Fig. 7</b>). Indelible anatomical markings are made and include the xiphoid process, sternal notch, costal margins, anterior superior iliac spines, and the superior border of the symphysis pubis. Plaster splints ase then applied making sure to cover from the symphysis pubis to the sternal notch anteriorally and down to the surface of the table on the sides, being sure to follow the patient's contours. When hardened, the plaster cast impression is removed and sealed and the positive model is poured.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.jpg"><strong>Figure 7. Patient, in supine position, is ready to be casted. Patient does not have to be rolled or turned to complete casting.</strong></a><br /> <p><i>Model Modification</i></p> <p>The positive model is modified in a normal TLSO modification fashion, including flattening the anterior lower thoracic and abdominal area for increased intraabdominal pressure and defining the area above the iliac crests for good suspension on the pelvis. Plaster buildups are added over the anterior superior iliac spines if the patient is thin. The lateral posterior border is extended two inches in the posterior direction from the iliac crests inferiorally, to cover the gluteals laterally and increase lateral stability.</p> <p>Because the anterior trimline of the orthosis extends to within an inch of the sternal notch, female patients require design variations in the model modification and the subsequent orthosis. For large busted female patients, an opening is frequently designed in the breast area to free the breasts. For smaller busted female patients, the breast area is built up on the plaster model to permit room for the breasts in the orthosis with the patient upright. In both situations, the area superior to the breast area is reduced on the plaster model to ensure good contact within the orthosis; also, the area superior to the breasts is reinforced in the fabrication process to ensure rigidity. When total contact for support and/or dispersement of pressure over a greater area is needed, as in cases of degenerative disease, such as osteoporosis, arthritis, and diffused cancer, the breast area is built up slightly on the plaster model and incorporated into a solid design in the orthosis.</p> <p><i>Fabrication Techniques</i></p> <p>When molded with Orthoplast™, reinforcement is provided by a double thickness of Orthoplast™ in appropriate areas: the anterior superior and the lateral posterior edges. The metal anchor plates for attachment of the posterior pad straps are sandwiched in between layers of Orthoplast™ and later drilled and tapped for 8-32 screws.</p> <p>If vacuum formed using a more durable thermoplastic, reinforcement can be provided with hybrid carbon composite inserts (available from Durr Fillauer). In this fabrication technique, the metal anchor plates for the posterior pad straps can be mounted on the plaster model for incorporation into the vacuum formed shell.</p> <p>In either case, the posterior pad is patterned after the Jewett orthosis posterior pad and has two sets of 1/2 inch dacron straps with 3/16 inch diameter holes, 1/2 inch apart in both ends for connection to the anterior shell. The posterior pad floats freely on the dacron straps, which are permanently attached to the metal anchor-plate on the left side of the orthosis with 8-32 screws and have roller buckles on the right hand ends of the straps. The right side straps, which are attached under 8-32 screw studs, pass through the roller buckles and double back on themselves for adjustable tension control and attachment to the stud-heads of the 8-32 screw studs. The roller buckle system acts as a pulley system, thereby reducing the mechanical force needed to properly tighten the posterior pad.</p> <p>The final component in the system is the two inch wide Velcro® sacral-coccygeal strap, which is permanently attached on the left side of the anterior shell, passes through a two inch stainless steel loop on the right, and doubles back on itself for a secure closure.</p> <p>This adjustable closure system is described as was originally designed by Rosenberger, et al. It is not necessarily deemed to be the simplest. Any of the adjustable closure systems utilized in the available prefabricated spinal extension orthoses should provide a suitable alternative to the above closure system.</p> <h3>Summary</h3> <p>The anterior shell orthosis provides quickly accessible orthotic support for early mobilization of patients with spinal cord injury and other diagnoses, allowing for independent donning and doffing with relative ease. Though sufficiently rigid to protect surgical instrumentation while boney fusion takes place, the anterior shell orthosis allows maximum maneuverability possible for a patient in a TLSO.</p> <h3>Acknowledgments</h3> <p>The authors would like to acknowledge Michael Smith for his efforts in the chart reviews.</p> <p><b>References:</b></p> <ol> <li>Albee, F.H., E.J. Powers, and H.C. McDowell, <i>Surgery of the Spinal Column</i>, F.A. Davis Co., 1945, pp. 213-215.</li> <li>Bauer, R., "Preoperative Correction and Post-operative Fixation Using Harrington Instrumentation," <i>Operative Treatment of Scoliosis</i>, George Chapchal, editor, 1973, pp. 82-85.</li> <li>Bradford, D.S. and R.C. Thompson, "Fractures of the Spine," <i>Minnesota Medicine</i>, 59:1976, pp. 711-720.</li> <li>Dickson, J.H., P.R. Harrington and W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine," <i>Journal of Bone and Joint Surgery</i>, 60A:1978, pp. 799-805.</li> <li><i>The Unstable Spine</i>, edited by S.B. Dunsker, H.H. Schmidek, J. Frymoyer and A. Kaan, pp. 12-15.</li> <li>Edmonson, A.S. et al., "Report: Panel on Spinal Orthotics," <i>Orthotics and Prosthetics</i>, Vol. 31, No. 4, December, 1977, pp. 67-71.</li> <li>Edmonson, A.S., "Spinal Orthotics," <i>Orthotics and Prosthetics</i>, Vol. 31, No. 4, December, 1977, pp. 31-42.</li> <li>Flesch, J.R., et al., "Harrington Instrumentation and Spine Fusion for Unstable Fractures and Fracture-Dislocations of Thoracic and Lumbar Spine," <i>Journal of Bone and Joint Surgery</i>, 59A:1977, pp. 143-153.</li> <li><a href="http://www.acpoc.org/library/1976_01_007.asp">Friddle, W.D. and L.P. Brown, "Greenville Spinal Orthosis, Polypropylene," <i>Inter-Clinic Information Bulletin</i>, 15(9&amp;10):Sept.-Oct. 1976, pp. 7-12.</a></li> <li>Norton, P.L. and T. Brown, "The Immobilization Efficiency of Back Braces," <i>Journal of Bone and Joint Surgery</i>, 39A:1957, pp. 111-139.</li> <li>Van Hanswyk, E.P., H.A. Yuan, and W.A. Eckhardt, "Orthotic Management of Thoraco-Lumbar Spine Fractures With A Total-Contact TLSO," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 3, September, 1979, pp. 10-19.</li> <li>Wallace, S.L. and K. Fillauer, "Thermoplastic Body Jackets for Control of the Spine After Fusion in Patients With Scoliosis," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 3, September, 1978, pp. 20-24.</li> <li>Wharton, G.W., "Stabilization of Spinal Injuries For Early Mobilization," <i>Orthopedic Clinics of North America</i>, 9(2): April, 1976, pp. 271-276.</li> </ol> <em><b>*C. Michael Schlich, C.P.O. </b> C. Michael Schuch, C.P.O. is Assistant Professor in the Department of Orthopaedics and Rehabilitation and Associate Director in the Division of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center in Charlottesville, Virginia.</em><br /><br /><em><b>*Vernon Houghton, R.T.O. </b> Vernon Houghton, R.T.O. is an Orthotic Assistant in the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia.</em><br /><br /><em><b>*Tom Faisant, R.P.T. </b> Tom Faisant, R.P.T. is a Supervisor of Physical Therapy in the Adult Rehabilitation Unit at the University of Virginia Medical Center in Charlottesville, Virginia.</em><br /><br /><em><b>*Carrie L. Beets, CO. </b> Carrie Beets, CO. was formerly with the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia.<br /><br /></em> Page Number(s) 95 - 100 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg Figure 7 Table 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 Table 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg Figure 9 Table 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anterior Shell Orthosis: An Alternative TLSO Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Tom Faisant, R.P.T. * Vernon Houghton, R.T.O. * C. Michael Schlich, C.P.O. * https://staging.drfop.org/files/original/baa690570cdf9103498cc78a51072780.pdf efeb1aaeccfa288eeec9bc5ecd38a00c https://staging.drfop.org/files/original/02116dc22518c1eb39c68be56eeadcbe.jpg 8a184304fcba8cc4b1780900d847a8a3 https://staging.drfop.org/files/original/5d633c5174ca141632fa4a4f1e21747b.jpg 5e04ded931d40f7f74cd630cd3fa88fd https://staging.drfop.org/files/original/d54d587bc683285e12a948e28325014e.jpg 7ac002016da544b27b8905e5ce7e190c https://staging.drfop.org/files/original/2d411a366a5894b21122ede2a2d07a78.jpg c37bdd60e381a074882dba174d8ebb45 https://staging.drfop.org/files/original/b3276065c28d0d1acc9bd4fbbc1682bd.jpg 161db3ea42e5ab5ea0b8020149c71991 https://staging.drfop.org/files/original/634383156fceaec626e209462b0523ec.jpg 846701e1d084860d18e51ec6f7c5a191 https://staging.drfop.org/files/original/3534840b8b9014b939dcf553b7d798a6.jpg 4ccf1cb63eb1401e3b40b6c3e79e7463 https://staging.drfop.org/files/original/cd15263c33b6e8fe70f3974c54e1df63.jpg 0ea4cec660c63647ee6e63d27d767ee7 https://staging.drfop.org/files/original/5b000331efb05bcdc1dbbad2cfa91b16.jpg 3ca6176c57505618b576214526d5f2fd https://staging.drfop.org/files/original/721dba1469c7361d052d71dc63510353.jpg 45e5a147daaf98d9a8290c41165c37e9 https://staging.drfop.org/files/original/1693caaecd751197fb1a87e816bd59c1.jpg b812afdf152beffe304e924d2710b595 https://staging.drfop.org/files/original/7790ac1614e11c427aa22f45d0c2dd52.jpg 073ddc987fa51b9507a6a6c4ab2381e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_004.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_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 Anthropology and Social Significance of the Human Hand</h2> <h5>Ethel J. Alpenfels, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>A definitive study of the anthropology of the human hand has yet to be written. Certain investigators, notably Krogman<a></a>, Schultz<a></a>, Ashley-Montagu<a></a>, Clark<a></a>, and Huxley<a></a>, have done intensive work on specific aspects of the morphology of the human hand. Nevertheless, the paucity of published studies, the fragmentary nature of the research, and the failure to attempt any but the most general conclusions make it difficult to summarize in a short article the present status of the hand in human evolution. Authorities differ both in opinion and in practice as to the value of anthropometric measurements in tracing the lines along which specialization has moved in the evolution of the hand. Published materials on the social significance of the hand are, however, numerous, and the importance of the hand as an organ both of performance and of perception has been recognized in all fields of the social sciences.</p> <p>Man alone has a hand. He uses it as a tool, as a symbol, and as a weapon. A whole literature of legend, folklore, superstition, and myth has been built up around the human hand. As an organ of performance it serves as eyes for the blind, the mute talk with it, and it has become a symbol of salutation, supplication, and condemnation. The hand has played a part in the creative life of every known society, and it has come to be symbolic or representative of the <i>whole </i>person in art, in drama, and in the dance. Students of constitutional types have used the hand as a means of classification, and the correlation between mental ability and manual dexterity has been the subject of much research. At the University of Pennsylvania, Krogman, using x-rays of the hand, currently is demonstrating new and important aspects of the interrelation of a child's growth and mental age. Thus the hand, perhaps because it is also dominant in the world of action, has come to be interpreted and understood best in its social aspects.</p> <p>But in a sense the human hand is a paradox. Although it is said to be the highest achievement of primate evolution, research to date shows it to be no more than a variation of a primitive vertebrate plan. The successive stages of evolution give proof, if proof be needed, that our sensitive and mobile hands, with their opposable thumbs, are part of man's vertebrate ancestry.</p> <p>In the suborder Lemuroidea, both recent and extinct, are found pawlike hands. The fourth digit<a style="text-decoration:none;">*</a> is elongated and, together with the first digit, acts like a pair of pincers to grasp a bough. Hooten<a></a> has pointed out that this is an adaptation found in all the lemurs, enabling them to maintain a more secure hold on boughs of large diameter. In lemurs, all of the digits are flat-nailed (except in the aye-aye, which has kept a number of primitive anatomical features), and several modifications appear in the carpal pattern. <b>(Fig. 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. One conventional method of identifying the digits of the hand. Some authorities prefer to think of the hand as possessing a thumb and four fingers. Both methods of nomenclature occur throughout this issue of Artificial Limbs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suborder Tarsioidea, entirely arboreal, specialization of the hind limbs for hopping frees the hands not only for grasping but for feeding as well. The hind limb is longer than the forelimb, all of the terminal phalanges are flat-nailed, and the terminal digital pads have curious discs, almost like suction cups, enabling the tarsier to support himself on a smooth surface.</p> <p>These and other adaptations foreshadow higher primate development (<b>Fig. 2</b>), but we must look further to find man's place in the primate scheme. The suborder Anthropoidea, the third and highest of the primate group, includes larger arboreal forms. Longer fore limbs, together with a relatively shorter thumb (approaching atrophy in some forms), provide a means of brachiation. It has been suggested that the short thumb is related to the specialization of the hand as a grasping mechanism, permitting a quick release of the hand in swinging from one branch to another. But in this suborder the hands still retain their primitive features, and only in certain of the Old World Monkeys do the proportions of the digits approach those of man. The emancipated hands of the anthropoids, with thumbs that rotate and oppose the other finger tips, are directed by a more complex nervous system and a larger and better developed brain. Liberation of the hand may have been one of the decisive forces in the descent of certain anthropoids to the ground.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparative proportions (not relative size) of the hands of man and of certain related ancestral forms. Top row, left to right, hands of a tarsier, of a lemur, and of a Rhesus monkey. Bottom row, left to right, hands of a chimpanzee, of a human with atypical simian characteristics, and of normal man. In all cases except that of the lemur, the digital formula is 3 &gt; 4 &gt; 2 &gt; 5 &gt; 1. From Jones<a></a>, by permission of Bailliere, Tindall, and Cox, Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Evolution of the Hand</h3> <h4>Links with the Past</h4> <p>Man's hand retains the ancient pentadactyl pattern found in early vertebrates. Geological records show that, during the Devonian period of Silurian times, primitive sharks appeared having typical paired fins corresponding to the paired limbs in man, and these organs were destined to give rise to later and higher forms. But there is a great difference belween the paired limbs of the early forerunners of present-day fishes and the pentadactyl limbs of other vertebrates. All of the steps are not yet clear, and the gap between the ancient fishes and the amphibians has not yet been bridged, but it appears that in the early amphibians the migration from water to land led to adaptations and modifications, especially in the area of the shoulder and pelvic girdles.</p> <p>These early ancestors of the primates had short legs, which grew progressively longer in the mammalian stage<a></a> and they walked flat-footed. The ability of the limbs to rotate brought about changes in the entire body. Striking homologies can be found in the hand and arm of man, the wing of a bat, and the foreleg of the frog. Where there are fewer digits, as in the hoof of the horse or the wing of the bird, the reduction has been due to adaptation to special environmental conditions.<a></a> Such reductions make for greater speed in the specialized limbs of the horse.</p> <h4>Upright Posture and Differentiation</h4> <p>The release of the hand from the requirements of locomotion, accompanied by the specialization of the foot and hind limbs for that purpose, led to upright posture (<b>Fig. 3</b>). Evidences of divergent evolutionary trends in the primate order are clearly distinguishable in the primate hand, especially those relating to limb length and trunk length (<b>Fig. 4</b>). Only the mountain gorilla has a hand shorter than that of man, not only with respect to limb length but in relation to trunk length. The longest hands among the great apes are those of the gibbon, the orangutan, and the chimpanzee. Specialists in the evolution of the hand have attributed the long, slender hands of these genera to brachiation and suspension, behavior that elongates not only the arms but, the hands as well, especially the fingers and the metacarpal bones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The evolution of the hand (top row) and foot (bottom row), as revealed in skeletal structure. A, a primitive reptile; B, C, mammal-like reptiles; D, a lemur, representing a primitive mammalian type; E, man. Note the reduction in the number of joints in the toes, the specialization of the proximal ankle bones in mammals, some reduction in the number of wrist and ankle bones, and the variations in the thumb and great toe From Romer<a></a>, by permission of The University of Chicago Press </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Exact diagrammatic front views of the four largest primates at fully adult age, drawn from detailed measurements on actual specimens, hair omitted, and all reduced to the same trunk height. From Romer<a></a>, by permission of The University of Chicago Press. Originally constructed by A. H. Schultz. Note that, from orang to chimp to gorilla to man, both limb length and hand length generally decrease with respect to trunk height. Only the gorilla has a hand shorter than that of man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for the length of the thumb, man andthe other great apes show sharp divergence, especially when the thumb is considered with respect to hand length. As contrasted with the short thumb of the anthropoid apes, man's thumb is long and well developed. Attempts to explain this difference have led to an either-or position. Either the thumbs of the apes have atrophied as a result of their arboreal life or man's thumbs have lengthened in the evolutionary process.</p> <h4>The Shoulder and Upper Arm</h4> <p>In man the shoulder and upper arm are adapted for strength. As for the other portions of the arm down to and including the hand, the more distal the part the more it is adapted for complex and delicate functions and the less for strength. The pectoral girdle in man consists of three bones. The scapula is directed dorsally, the coracoid process extends forward and downward to meet the sternum, and, anterior to the coracoid, the clavicle connects scapula and sternum. Because the pectoral girdle is not joined directly to the spine, though it may articulate with the sternum, the structure permits great freedom of motion in the shoulder area. Briefly, the human arm, supported and controled by a large number of muscles, together with the elbow and wrist joints, gives freedom to a hand that has become the willing servant of the human intellect.</p> <h4>Man's Opposable Thumb</h4> <p>The powerful and well-developed thumb of man is one of his few uniquely human characteristics. Through successive stages of vertebrate evolution, the thumb has separated from the other fingers and developed specialized musculature. In the Anthropoidea, the feature of opposability led to greater tactile and exploratory facility. Man's thumb, comparatively twice as long as that of some of the anthropoids, reveals a steady increase in absolute and relative length (<b>Fig. 2</b> and <b>Fig. 4</b>) and, at the same time, the steady development of opposability, extensibility, and flexibility. When the "hand" of the ape is compared with the hand of man it becomes, in the words of Krogman<a></a> a "misnomer." In the ape, hands are hands by definition only. Although man's hand, the end-product of our evolutionary development, retains the basic, primitive, pentadactyl pattern common to all land vertebrates, it nevertheless is uniquely human. The earliest animal footprint known (from the Permian of the Tambach in Thuringia) is so similar in appearance to that of the human hand that the animal which left the fossil print was named "Cheirotherium," or the "handbeast" <a></a></p> <h4>Variations of the Human Hand</h4> <p>The morphological pattern of man's hand shows its affinity to the "hands" of other animals. But while man has kept the primitive pattern, other animals have specialized. In birds, for example, the hand has become a wing, in the horse a hoof, in the whale a flipper, in the dog a paw, and so on. According to Hooton<a></a>, Crawford has demonstrated the difference between tool-using, as in man, and tool-growing, as in most animals. Animals use no tools other than those developed out of the materials furnished by their own bodies. Man, however, was<a></a> "the first animal to grow a limb outside himself by making tools out of wood and stone." Furthermore, the limbs of animals are specialized for single purposes only. The horse can run, the mole can dig, but neither can climb; man makes instruments that are imitations of the body tools of other animals a digging stick, an awl, a scraper, or a dagger.<a></a> The power and versatility of the human hand rests, in part, upon its generalized pattern. But it is the human brain, with its intricate and elaborated nervous system, that coordinates man's eye and hand. Thus, man is born with a hand free to do the bidding of his expanded brain.</p> <h3>The Anthropometry of the Hand</h3> <h4>Early Studies</h4> <p>The past fifty years have seen a gradual increase in the literature devoted to the anthropometry of the human body. But until that time, individual investigators had gone their separate ways, and there was little concurrence on standardization of the measurements to be employed, on the way in which these measurements were to be taken, or on the instruments to be used. Furthermore, just as in the osteological studies conducted in anthropological museums, early research on living animals was devoted largely to the head and facial features, and only later was study extended to the remainder of the body. Hence the dearth of anthropometric studies on the hand is easy to understand. Lacking, also, are routine osteometric recordings and systematic measurements and indices that could provide the comparative anatomical data necessary for a definitive work on the evolution of the human hand.</p> <h4>The Lack of Data</h4> <p>Authorities appear to agree that no part of the human body has been as neglected as has the hand.<a></a> The reasons for this situation are many, but perhaps the most important one is the scarcity of fossilized primate hands, probably owing to the fact that these bones are small, fragile, and easily destroyed by the action of the forces of nature. Nor are the anthropological collections of complete hands of the modern anthropoids anywhere near adequate. During the past few years, individual investigators and museums have been attempting to increase the number of complete hands available for study, but the collections still are quite inadequate. Moreover, as was demonstrated at the University of Chicago, skeletons often turn out to be composites of many separate individuals and, therefore, of little use in anthropometric studies.<a></a> These handicaps, together with the complexity and the extreme variations found in the human hand, make it exceedingly difficult to get accurate results.</p> <h4>The New Focus</h4> <p>The early work in comparative anthropometry was devoted entirely lo race differentiation.<a></a> At the present time, however, that interest is lagging, and extensive growth studies of the epiphyseal closures of the metacarpals and the phalanges are being conducted at the University of Pennsylvania.<a></a> The x-ray technique, used for many years, has become the major tool by means of which the anthro-pometrist and anatomist can study living persons. It is dependable and important, especially in studying the highly differentiated parts of the human hand.</p> <h4>Classification</h4> <p>The morphology of the hand has proved useful in classifying hand types. Wechsler's system<a></a> is based upon four hand dimensions (<b>Fig. 5</b>). From all possible combinations of length and three breadths, he derives six index categories, as shown in <b>Table 1</b>. Thus, the long, narrow hand type in man would be, for example, 1-1-1-2-4-3, that of the short, broad hand 4-4-4-4-4-4.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Hand measurements according to Wechsler. From Krogman<a></a>, by permission of Ciba <i>Symposia</i>. </p><ol> <li><i>Stylion radiale, </i>at tip of radial styloid process.</li><li><i>Stylion idnare, </i>at tip of ulnar styloid process.</li><li><i>Interslylion, </i>mid-point of line connecting 1 and 2.</li><li><i>Daclylion III, </i>at tip of third finger.</li><li><i>Metacarpale radiale, </i>at metacarpophalangeal junction of index finger.</li><li><i>Metacarpale ulnare, </i>at metacarpophalangeal junction of little finger.</li><li><i>Proxindicion, </i>at proximal interphalangeal junction of index finger.</li><li><i>Ulnoquintion, </i>at intersection on ulnar side of little finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 7.</li><li><i>Dislindicion, </i>at distal interphalangeal junction of index finger.</li><li><i>Ulnoquartion, </i>at intersection on ulnar side of ring finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 9.</li></ol> <p></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Handedness in Man</h3> <h4>Right and Left - Good and Evil</h4> <p>The cultural world in which man lives, both in preliterate and in technologically advanced societies, tends to be a "right-handed" world. Cross cultural studies reveal that different sides of the body, the left or the right, are associated with different social activities. In India, the right side and the right hand perform tasks considered to be "clean," while the left side and the left hand perform tasks considered to be "unclean." The two types of activities are separated rigidly. The right hand, for example, is used for cooking and eating, whereas the left hand is used in bathing, elimination, or activities associated with sex. Indeed, it is common in many areas of the world to find food related to the right hand, while the left hand is associated with sex.<a></a></p> <p>The right and left hand have come to symbolize good as opposed to evil, gods as opposed to demons. Hence, they are considered as two forces constantly at war with one another. The shadow plays of the Balinese illustrate the widespread association of good and evil with the right and left side respectively. The mystic story teller takes the marionettes out one by one, placing the "good" and "noble" characters at his right side and, at the left, the "evil" and "sinister" characters. In the end, truth and goodness always win, which demonstrates the triumph of the magical powers of the right side. At all important life crisesbirth, death, marriage, initiation ceremoniesthis magic balance between left and right is maintained. Among the Tiv of Nigeria, the afterbirth of a boy child is always buried to the left of the door in order to propitiate the evil spirits residing there. In Bali, a boy's placenta is buried on the right and a girl's on the left side of the entrance to the house.<a></a></p> <h4>Caste and The Hand</h4> <p>The symbolism of the hands in ceremonial rites has, in various ways, come to indicate social class and caste. Among the Balinese, for example, it is a mark of social distinction to wear long nails, but only the priest may wear them on both hands. The giant-god of pre-Hindu times is believed to have carved out all of the caves with the fingernails of his left hand. The Indian caste system is noted for a unique feature in that many of the castes are divided into two sections called the "right-hand" (Balagai) and the "left-hand" (Yedagai) castes. Certain socially lower artisan castes, such as workers in leather, belong to the left-hand subgroup.<a></a> Among the Motu of Papua, the moieties are grouped by the left and right hand. Members of the right-hand moiety have senior status in matters of inheritance, while members of the left hand moiety have junior descent status.<a></a></p> <h4>Other Influences</h4> <p>Music for the piano usually is written in such a way that the melody is carried by the right hand. Threads in bolts, pipes, and even in glass jars are right-handed. Soup and gravy ladles, fish forks, and meat grindersin fact, the majority of our manufactured products are designed for the right-handed individual. Can the custom of men buttoning their coats on the right side and women on the left be a survival from our primitive past when the right was reserved for men because it was "good" and the left for women because it was "evil"? Our society is belatedly recognizing the right of sinistrodextral people to full participation in our culture. Banks are issuing left handed checkbooks, left-handed armchair desks have been introduced in schools, and left-handed scissors and other implements and tools now are available.</p> <h4>Handedness in Early Man</h4> <p>Whatever the reasons for associating right with "good" and left with "evil," the fact remains that man is predominantly right-handed, a fact that appears to have been true even in prehistoric times. Early writers explained the enigma of right-handedness in the Lamarckian sense of "use and disuse." They noted that, since the heart was located on the left side of the body, the warrior carried his shield in his left hand. The right hand was free and, through more frequent use, developed in both size and dexterity. This "acquired" characteristic was passed on to succeeding generations.</p> <p>During the nineteenth century, as the authenticity of plant and animal fossils was established, and with the growth of anthropology as a more exact science, numerous archaeological sites were excavated. By the beginning of the twentieth century, thousands of artifacts had been uncovered, more precise data were available, and the picture of life in prehistoric times began to emerge in greater detail. The oldest implement found in Europe was beveled for grasping between the right thumb and first finger. The implements of primitive Paleolithic sculptors were found to approximate in number and in form those of modern sculptors. All of the tools uncovered in a Spanish cave, said to have been inhabited during Solutrean times, are designed to fit the hand, and, from the almost perfect adaptation of these instruments, we may infer that these ancient artists were right-handed.<a></a> Based upon the frequency of left-handed flint tools found <i>in situ </i>in France, other authorities, Krogman<a></a> for example, note that the incidence of left-handedness increased during the New Stone Age.</p> <h4>Handedness in Apes</h4> <p>During the past three decades, handedness in the apes has been studied extensively in the United States. Yerkes <a></a>, in his classical work on the apes, found that handedness appears in chimpanzees. He points out that they use one hand consistently for certain purposes and the other hand for other activities. He says, however, that right-handed dominance has not been demonstrated and that the three types of motor activity found in man (right-and left-handedness and ambidexterity) occur with about equal frequency.</p> <h4>The Chick Embryo</h4> <p>The problem of left- and right-handedness in chickens has been reported. At about the 38th hour in the chick embryo, certain processes are initiated that result in what may be termed very loosely a "right-handed embryo." In certain chemicals, the molecular structure is "left-handed" in that it is of the nature of the mirror image of the "right-handed" counterpart. After a number of hours of incubation, fertile chicken eggs exposed to such "left-handed" chemicals evidence a "left-handed" type of flexure of the developing brain.</p> <h4>Asymmetry</h4> <p>Yerkes<a></a> holds with the current opinion that asymmetry of the left and right hand (<b>Fig. 6</b>) is related to a general asymmetry of the entire body. The right and left leg in man, for example, also differ in strength and in dexterity. Similarly, the right lung is slightly heavier, the abdominal viscera are heavier on the right side, both the spine and pelvic regions display asymmetry, and hence the center of gravity of the body is slightly to the right. Kahn<a></a> reports a number of experiments which demonstrate that, owing to this asymmetry, every blind wandering ends in a circle. Thus, man cannot write, nor walk, nor drive a car blindfolded without becoming a victim of his physical asymmetry.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Typical difference between the right and left hands of a single individual. The right has a shorter palm and longer fingers, and the long longitudinal line is more marked. From Wolff.<a></a> by permission of Methucn and Co., Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Endocranial casts of the brain cavities of fossil and of modern man support this evidence, and here too asymmetry appears. The left occipital portion of the brain predominates to produce right-handedness, a fact established by Smith.<a></a> One school of thought claims that this asymmetry of the brain represents a primitive character in the higher apes and man. According to Clark<a></a>, however, Keith maintains that, on the contrary, asymmetry represents an evolutionary advance.</p> <p>The general physical asymmetry of the body is associated with a social asymmetry in our human prejudice against the left side. The human preference for right-handed tools and artifacts has, somehow, invaded the social and moral life. There also is a <i>sinistra </i>and <i>dextera </i>view of the world now fixed in our vocabulary.</p> <h4>Handedness in Language</h4> <p>We speak of dexterity (from the Latin "dexter," connoting "right," "favorable") in referring to skill, and this idea has been traced back to Sanskrit, the ancient literary language of India. From the category of physical things, the right hand has reached out to influence many other areas of human life. To be "orthodox" is to follow the "right" or "true" opinion. The concept of legal justice comes from the French "droit," meaning "right" or "law." Contrariwise, the word "left" symbolizes "evil," "weak," "awkward." The word for "left" in French is "gauche," meaning "awkward." The Latin "sinister," meaning "left," rarely applies to that which threatens but, rather, to that which is known to act covertly or insidiously. The bar sinister is the heraldic symbol of bastardy. A man who marries below his social rank gives his left hand, not his right, to his bride. Thus, in our own culture today there survive in our language and customs the social implications that historically have characterized handedness in man.</p> <h3>The Hand as a Sensory Organ</h3> <h4>The Sensory Experience</h4> <p>Although prehension is the major function of the hand, the hand is, at the same time, one of man's primary sense organs. This tactile quality provides sensory experience that may be grouped into four general categories.<a></a> The first consists of "surface sensations" stimulation generated by touching tangible objects. The second is termed "space-filling" stimulation generated by pulling the hand through liquid substance. "Spacelike sensations," comprising the third category, relate to the touch of distinctively shaped objects felt through a heavy material. Finally, there are "penetrable-surface sensations," experienced, for example, by a physician as he palpates some part of the body to locate, through the outer layer of flesh, some abnormal condition in deeper tissue.</p> <p>Movement is indispensable in sensory experience, and experimentation demonstrates that even the "imaginary" touch sensations are located in the finger tips. According to Katz<a></a>, it is quite impossible to call up the image of touch without, in imagination, moving the hand. The moment we imagine our hands at rest, the image becomes uncertain or disappears.</p> <p>When body and ambient temperature are equalized, the hand may be used as an instrument for the perception of the relative levels of heat and cold. Preliminary determination of body temperature can be determined by placing the hand on the forehead. In folk society, for example, where accurate measures of determining fever temperature are not available, a normal hand placed upon the forehead is used to determine the presence of fever.</p> <h4>A Percussive Tool</h4> <p>The human hand can also be used as a percussion instrument. With an apparatus which he called "the percussion phantom,"<a style="text-decoration:none;">*</a> von Gotzen found that vibratory impulses generated by finger percussion can be felt even when the auditory sense is eliminated.</p> <h4>A Vibratory Tool</h4> <p>Vibratory sensations, as perceived by the hand, are of importance in teaching the deaf to speak. By placing one hand on the larynx of a speaker and the other hand on his own larynx, a deaf-mute learns the vibration patterns of speech sounds. When the patterns "heard" by his left and right hand are identical, the student has succeeded in imitating the sound. Helen Keller utilizes the vibratory phenomena when she "hears" music by placing her hand on the piano.</p> <h3>The Human Hand in Art</h3> <p>Through the ages the human hand has appeared in all of the creative arts of every culture.<a></a> A single line, a schematic portrayal, a simple gesture of the hand, and character and personality stand revealed as clearly as they are seen in the human face. Recently, in the Kefauver investigation of crime in New York City, the television camera focused on the hands of a witness, and millions in the television audience watched while hands expressed feelings that man has taught his face to disguise.</p> <p>In the creative arts, the hand speaks, and one senses the tremendous power of the hand to convey human emotions. The hands are the organs of the body which, except for the face, have been used most often in the various art forms to express human feeling. The hands point or lead or command; the hands cry out in agony or they lie quietly sleeping; the hands have moods, character, and, in a wider sense, their own particular beauty. From prehistoric times to our own day, in every society known to science, the hands symbolize cultural behaviors, values, and beliefs.</p> <h4>Painting and Sculpture</h4> <p>Many studies of the hand appear in the traditions of western art. From schematic and conventional hand portraits, the artists of the fifteenth century began to draw anatomically correct hands, and, slowly but surely, the hand was seen as having a personality and a culture of its own. Albrecht Durer (1471-1528) devoted a lifetime to the study of anatomy, and in his studies of hands the lines, the curves, the veins, the wrinkles delineate the complexity of the human hand (<b>Fig. 7</b>). In another medium, the French sculptor Auguste Rodin (1840-1917) deliberately used the hands to create unmatched works of art.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Famed "Hands of an Apostle Praying," by Albrecht Diirer (a.d. 1471-1528). Courtesy The Public Library, Washington, D. C. The original hangs in the Albertina Museum in Vienna. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Prehistoric Artist</h4> <p>Early man left records in shallow caves, in rock shelters, and, in the great period of art during late Paleolithic times, on the walls of the innermost recesses of caves in France and Spain In the ancient engravings and the wall paintings found in caves in eastern Spain, the arms and legs perform animated gestures in running, in drawing a bow, in gathering honey, and in the dance.</p> <p>The human hand appears in quasi magico-religious silhouettes of complete or partially mutilated hands outlined in color on the walls of the grotto of Gargas in the Pyrenees Mountains. The fingers appear to be cut off at the distal end of the first phalanx, with one or more digits missing entirely. Curiously, the thumb never is amputated. The same type of finger mutilation is found in wall paintings in the caves of central Australia. Apparently the practice was customary among the early Aurignacian people of Paleolithic times, and it also is reported in other preliterate tribes. According to Osborn <a></a>, Breuil believes that painting had its beginning in these stencilled contours produced by laying the hands against the limestone walls and spreading red and black paint on the surrounding area. In other examples, the hand was covered with pigment and pressed against the wall.</p> <h4>The Dance</h4> <p>The formal patterns and definite movements of the dance make it one of the greatest of the interpretative arts. It is, apparently, also one of the oldest arts. Whether viewed from a recreational, religious, or aesthetic standpoint, this expression of culture has attained meaning and intensity through movement of the hands. Joint dances between the sexes are rare among primitive tribes, and the hand thus has been liberated for gestures and symbolic movements. In India, the hands can tell an entire story. In Australia, among one of the most technologically simple tribes, the movements of the hands make the dance merge into drama. Indeed, it is difficult to separate the dance from music and from drama, but in each of these art forms it is the hand that gives meaning to words spoken. Perhaps the rhythm produced by the hands in clapping and in slapping the body originally led to music and to the dance.</p> <h3>The Hand in Culture and Society</h3> <h4>Language Abstractions</h4> <p>Because the human hand is an organ of performance, it is not surprising that the hand should "manipulate" ("to lead by the hand") the human vocabulary. The hand receives the "mandate" (from Latin "manus," for "hand," plus "dare," "to give") from the brain, and to "manage" is to govern, direct, or control. Thus, man "commends" (which originally meant "to place in one's hands") and "commands," both words related to "mandate" and, therefore, to the Latin "manus," for "hand."</p> <p>With its basic movements for grasping objects (page 33), the human hand also is "handy" ("dexterous," "to have two right hands") for grasping ideas. To "comprehend" is to "seize" (Latin, "capere," "to seize"), from which we derive such words as "perceive," "conceive," and "receive." Thus, by various shades of meaning, the human hand not only "hands down" information but "picks" it up. The human hand also is an organ of perception and thus lends itself to the most abstract concepts. "Handsome" originally meant "dexterous." "To feel" is connected somehow with the Greek word for hand, "palame." To say in Latin "dicere" means "to point." We touch, feel, handle, finger, thumb, paw, grope, palpate, and stroke objects.</p> <h4>One and One Are Two</h4> <p>Man's hand not only manipulates and grasps, and makes and points, but it counts as well. Counting is very different from what we loosely term "number sense," an attribute that man shares with other animals. In its real connotation, counting appears to be an exclusively human characteristic, and numbers, like so many abstractions, begin with the human body. The old Roman numerals I, II, III, and IIII<a style="text-decoration:none;">*</a> are thought to be representations of the fingers. In certain of the less well-known languages, the word for hand gives us the word for five. "Five" also has come to mean "hand," and in English the slang expression "give us five" once meant "to shake hands."</p> <p>One example of the use of hands in counting is that of the Mafulu mountain people, who do not use pebbles or sticks but instead use the hands and feet.<a></a> Here counting is accomplished by the use of two numerals, "one" and "two." In indicating "one," the hand first is stretched open to indicate "nothing," the thumb then is closed down meaning "one," the first digit closed down meaning "two," and so on, until all of the fingers of one hand are closed. The process is repeated with the other hand, and, to count to 20, the clenched fist points to the feet and to all of the right and left toes. If the count is above 20 (usually only when important occasions demand, such as counting pigs for a ceremony) another man is called to stand beside the first. If the number goes as high as 83, five men join. Four men go through the entire process, and the last man closes the first three digits.</p> <h4>Man the Measuree</h4> <p>Equally important has been the use of the hand as a unit of measurement. Tables showing the use of body organs as units of measure have been established for volume, surface. width, and length (<b>Fig. 8</b>). The earliest records show that the use of the index finger for indicating length was a widespread custom. In Europe the height of a man was estimated by a definite number of finger lengths based upon the measurement of the middle finger. In Latvia, the length of the middle finger was used to measure lengths for women's stockings or woolen socks (three times the length of one's middle finger). Sixteen times the length of the middle finger equals the normal human stride. The hand and thumb were used to measure width, 12 thumb widths being equal to one foot. Tools were made by the eldest member of the family and adjusted to the hand grasp. Thus, a scythe blade for an adult man was as long as nine or ten widths of the clenched hand, eight for an adult woman, and seven or eight for an adolescent (<b>Fig. 9</b>). The same pattern is found through much of eastern and northeastern Europe today.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Natural units of measure, still in use by Latvian and other European peasants. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The method, common among Latvian and other European peasants even today, of arriving at the proper dimensions for farm tools using the hand as the unit of measurement. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Tribal Customs</h4> <p>In the Sun Dance of the Plains Indians of the United States, finger joints were occasionally pledged as a thank-offering for recovery from illness or to ensure revenge for a slain relative.<a></a> Cole<a></a> reports that individual warriors among the tribes of Mindanao carried home a hand as evidence of a successful fight and that at such times festivals were held to celebrate the event. Among the Tinguian tribes of the Philippine Islands, joints of the little fingers were added to ear lobes and brains to make a liquor that was served to the dancers. Here, as in most areas of the world, the brew was consumed not for nourishment but in order to secure that part of the enemies' bodies thought to house strength and valor.</p> <p>Such reports may throw light upon the presence of the mutilated hands found on the walls of the European caves and dating from late Paleolithic times. The scarcity of drawings of the human form in cave paintings may be related in some way to the belief, still found among certain of our "primitive" contemporaries, that realistic portraits might give an enemy magic power. Possibly, through some similar process of sympathetic magic, the hand has already become a symbol to be portrayed realistically in religious ritual.</p> <h4>The Fingerprint</h4> <p>Human hands have been used in various cultures as a means of positive identification. In ancient China, fingerprints were used to sign or to autograph paintings. They are doubly valuable as "signatures" because they cannot be altered or forged, and the intricate patterns of whorls, circular and folded loops, and arches differ from finger to finger and from individual to individual. As the person grows, his individual fingerprint patterns increase in size but do not change in geometric proportions. In 1882, Bertillon, a young French anthropologist, began to develop his famous system for identification of criminals by a physical description based upon eleven anthropometric measurements, deformities, and impressions of lines and markings of the finger tips. The Bertillon system of fingerprints has been used internationally and has proved valuable for physical identification.</p> <h3>Some Other Considerations</h3> <h4>Occultism, Symbolism, and Ritualism</h4> <p>In an anatomical sense, each hand is unique. Every hand betrays its possessor by characteristic mo/ement patterns, by peculiarities of gesture, or by occupational stigmata arising from physical and mechanical causes. From these characteristics, palmistry and a branch of occultism known as "chiromancy" have, for centuries, attempted to read the past, present, and future of individuals. Since early antiquity, numerous scholars of repute have concerned themselves with studies in palmistry. According to D'Arpentigny<a></a>, Plato, Aristotle, Galen, Albertus Magnus, the Ptolemies, Avicenna, Averroes, Antiochus Tibertus, Tricasso (<b>Fig. 10</b>), Taisnier, Belot, and others have handed down lengthy treatises on the subject, and the observations of these early writers still prevail in our own modern times (<b>Fig. 11</b>). Palmists are interested chiefly in the surface of the handlines, stars, crosses, islandsand have divided the life line into seventy parts, each part symbolic of one of man's allotted seventy years of life. Chirognomists study the shape and form of the entire hand, in addition to surface characteristics.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Principal lines and mounts of the hand as charted by Patritio Tricasso da Cerasari (Tricassus the Mantuan), a celebrated chiromancer of the sixteenth century. From Lenssen<a></a>, by permission of The Studio Publications, Inc., New York City. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The mounts and principal lines of the hand and the interpretative functions traditionally assigned to the several areas. Authorities differ in detail, but all follow the same general pattern. In palmistry, which dates from antiquity and which has been the subject of serious discussion by numerous scholars, including Aristotle, the relative development of the mounts and lines is considered to show the comparative ability of the subject to implement the talents and qualities associated with the individual features. Generally the mounts are seven in number, the eighth (Mount of Neptune) occurring in a comparatively small number of cases. Reference to the sun, moon, and planets relates, of course, to the influence which, in early philosophy, these celestial bodies were thought to exercise upon the course of an individual's life. Modern astrology calls upon similar relationships. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>But it is in the realm of quasi magic and symbolism that the hand reaches its highest cultural significance. For the great majority of mankind who think in concrete rather than in abstract terms, graphic representations of superhumanity are related to the human body. The Hindu of India symbolizes this super-humanity by the multiplication of the most important parts of the body, which, to him, are the head, the arms, and the hands. Since arms and hands are extremely useful, a twelve-armed god demonstrates the power and the strength denied a two-armed god. Such thinking may appear grotesque to the Westerner, but the Hindu, accustomed to symbolic thinking, knows that man is not so constructed, nor does he wish that he were. He simply recognizes that power and wisdom and strength may be expressed quantitatively.<a></a>The Moslem often wears a small image of the hand around his neck to ward off the evil eye.</p> <p>Not only in the eastern world does the hand play an important part in the ritual usages but in western culture as well. The pentagram, the five-pointed star, is said to have been derived from an ancient custom of covering the face with the open fingers of the hand. That practice gradually was replaced by invoking the numeral "five," a convention that persists today in countries in central Europe. In Latvia, for example, the pentagram now appears on barns as a protective device.</p> <p>Finally, the hand has become symbolic of human sentiment. We bless and we salute by raising the hand in various ways. The gentle laying on of hands is at once a symbol of benediction and, as among certain religious sects, the means of curing the sick and of drawing out the evil spirits that reside within the body. In legal practice, oaths are taken in court by the simultaneous use of both hands, right hand up and the left hand on the Bible. We close a bargain by shaking hands, we raise our hands in salutation, and a man takes a woman's hand in marriage. Contrariwise, the hand may express condemnation, malediction, and final judgment. In cursing we point the hand at the enemy. In ancient Rome, thumbs down ("pollice verso") sentenced the gladiator to death. Thus, the hand has become an expository of human sentiment. It can express love, hate, doubt, questioning, hospitality, judgment, rejection, or acceptance.</p> <h4>The Hand and Good Health</h4> <p>The handshake may become an index to personality and representative of the <i>whole </i>person. The cold, limp hand, the strong, firm grasp, the moist palm, the dry palm, all help us to create a mental image of personality. To the trained hand of the physician, the cold, moist, flabby handshake often reveals clues relating to physical condition. Such a handshake often is a symbol of physical illness or an indication of an emotional disturbance. To the trained eye of the doctor the hand tells even more. The coloring, texture, lines, and creases sometimes reveal sickness or health. A trembling, warm, moist hand may mean overactivity of the thyroid, redness may indicate gout, a bluish appearance may indicate a certain kind of heart disease, and bad cases of malnutrition and diet deficiency frequently are reflected in the hand. There are many variations in the appearance of each hand, but the danger signals can be read only by the skilled hand and eye of a physician.</p> <h4>The Hand in Expression</h4> <p>The hand has also become associated with certain ethnic and nationality groups, for specific hand gestures have been associated with certain cultural types. Indeed, it has been said of the Italians that they never speak a language, that they caress it. Because movement of the hands serves to emphasize the spoken word, all of us find it difficult to speak while our hands remain perfectly still. A dramatic presentation of the use of the hand in conversation was portrayed through the medium of modern dance in a performance by a group at New York University involving an interpretation of an adolescent the telephone (<b>Fig. 11</b>). talking over No word was spoken, but the wide variety of gestures made clear to everyone what the performer was saying. The cult and the culture of the "teen-ager" in our country was delineated as sharply through the dance as it could have been through the medium of the written word.</p> <h3>Conclusion</h3> <p>From its basic use, prehension, which grew out of anatomical development, the human hand gradually has evolved until it is now also an effective instrument for symbolic and aesthetic interpretation. Man's capable and sentient hand not only serves as a tool but it wields tools as well, and it has in addition the ability to take the place of other body organs. Because of its remarkable adaptability to functional requirements, as compared with the specialization in the forelimb of other animals, the hand is largely responsible for the creative manifestations that characterize the human species and that distinguish it from all other known forms of life. The hands are, as Kant is reported to have said, "man's outer brain."</p> <h3>Acknowledgment</h3> <p>For valued help in obtaining the illustrations which accompany this article, the author is indebted to Marian Blumler, staff member of the Library, National Academy of Sciences National Research Council, who conducted a search of source material and arranged for loan of the necessary documents.</p> <p><b>References:</b></p> <ol> <li>Adam, Leonhard, <i>Primitive art</i>, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</li> <li>Ashley-Montagu, Francis M., <i>On the primatethumb</i>, Am. J. Phys. Anthropol., 16(2):291 (1931).</li> <li>Boas, Franz, <i>Primitive art</i>, H. Aschehoug, Oslo, 1927. pp. 344, 349.</li> <li>Boyd, William C, <i>Genetics and the races of man; an introduction to modern physical anthropology</i>, Heath, Boston, 1950. pp. 16-17.</li> <li>Clark, W. E. Le Gros, <i>Early forerunners of man; a morphological study of the evolutionary origin of the primates</i>, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</li> <li>Cole, Fay-Cooper, <i>Lectures</i>, University of Chicago, 1940-41.</li> <li>D'Arpentigny, C. S., <i>The science of the hand</i>, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</li> <li>Drillis, Rudolf J., <i>Darba riki [Tools]</i>, in <i>Lalviesu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</li> <li>Drillis, Rudolf J., <i>Mcri [Units of measure]</i>, in <i>Latvieiu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</li> <li>Flory, Charles D., <i>Osseous development in the hand as an index of skeletal development</i>, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</li> <li>Hodges, Paul C, <i>An epiphyseal chart</i>, Am. J. Roentgenol., 30(6): 809 (1933).</li> <li>Hooton, Earnest A., <i>Up from the ape</i>, Macmillan, New York, 1931.</li> <li>Huxley, J., <i>From fin to fingers: the evolution of man's hand</i>, Illustrated London News, December 1930. pp. 1138-39.</li> <li>Jones, Frederic Wood, <i>The principles of anatomy as seen in the hand</i>, 2nd ed., Williams and Wilkins, Baltimore, 1942.</li> <li>Kahn, Fritz,<i> Man in structure and function</i>, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</li> <li>Katz, David, <i>On the psychology of the human hand</i>,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, <i>The vibratory sense and other lectures</i>, The University Press, Orono, 1930. pp. 75-78.</li> <li>Krogman, Wilton M., <i>The anthropology of the hand</i>, Ciba Symposia, 4(4):1294 (1942). '</li> <li>Lenssen, Heidi, <i>Hands in nature and art</i>, Studio Publications, New York, 1949.</li> <li>Mead, Margaret, el al., <i>Cultural patterns and technical change</i>, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</li> <li>Mierzecki, H., <i>Symbolism and palhognomy of the hand</i>, Ciba Symposia, 4(4):1319 (1942). '</li> <li>O'Malley, L. S. S., <i>Indian caste customs</i>, Macmilan, New York, 1932. pp. 21-22.</li> <li>Osborn, Henry F., <i>Men of the Old Stone Age, their environment, life, and art</i>, 3rd ed., Scribner, New York, 1919.</li> <li>Personal communication from Margaret Cormack, Brooklyn College.</li> <li>Reininger, W., <i>The hand in art</i>, Ciba Symposia, (4):1323 (1942).</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, University of Chicago Press, Chicago, 1933.</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</li> <li>Rosenstiel, Annette, <i>The Motu of Papua-New Guinea: a study of successful acculturation</i>, Ph.D. thesis, Columbia University, 1953. Microfilm.</li> <li>Schultz, Adolph H., <i>Characters common to higher primates and characters specific for man</i>, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</li> <li>Schultz, Adolph H., <i>The skeleton of the trunk and limbs of higher primates</i>, Human Biol., 2(3):303 (1930).</li> <li>Smith, Grafton E., <i>The evolution of man</i>; essays, 2nd ed., Oxford University Press, 1927.</li> <li>Wilder, Harris H., <i>A laboratory manual of anthropometry</i>, Blakiston, Philadelphia, 1920. pp. 84-109.</li> <li>Wiser, Charlotte V., and William H. Wiser, <i>Behindmud walls</i>, Harper, New York, 1930.</li> <li>Wolff, Charlotte, <i>The human hand</i>, Methuen, London, 1942.</li> <li>Wright, W. B., <i>Tools and the man</i>, George Bell and Sons, Ltd., London, 1939.</li> <li>Yerkes, Robert M., <i>Chimpanzees; a laboratory colony</i>, Yale University Press, New Haven, 1943.</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>23.</b> </td><td class="clsTextSmall">Personal communication from Margaret Cormack, Brooklyn College.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Lenssen, Heidi, Hands in nature and art, Studio Publications, New York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Mierzecki, H., Symbolism and palhognomy of the hand, Ciba Symposia, 4(4):1319 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">D'Arpentigny, C. S., The science of the hand, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Wiser, Charlotte V., and William H. Wiser, Behindmud walls, Harper, New York, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Darba riki [Tools], in Lalviesu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Drillis, Rudolf J., Mcri [Units of measure], in Latvieiu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">IV is a later development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Adam, Leonhard, Primitive art, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Boas, Franz, Primitive art, H. Aschehoug, Oslo, 1927. pp. 344, 349.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Reininger, W., The hand in art, Ciba Symposia, (4):1323 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Katz (16) describes the apparatus as a square wooden box, about 60 centimeters long by 8 centimeters deep, and open at the top. Around the top edge a strip of felt is fitted, and over the whole a thick cardboard square is fastened; this side of the box is clamped on with metal clips. The cardboard is strong enough to resist considerable pressure without sagging. On the underside of the cardboard, i.e., inside the box, objects of different shapesfor example, round, elliptical, or heart-shaped objectsare pasted to substantial pieces of lead which appear either as matrices or as patrices, i.e., they are cut into or cut out of lead. The thickness of the plate is chosen according to the degree of difficulty of the percussion task to be presented to the student. In general, the thicker the plate, the easier the task. The plates are so arranged that the figure is located in the middle of ihe underside of the cardboard. Each cardboard is fitted with one figure (if necessary, composed of two parts), so that there are as many cardboards as there are figures required for the test. Students were asked to determine, through percussion alone, the form of figures cut into or out of the lead plates.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Smith, Grafton E., The evolution of man; essays, 2nd ed., Oxford University Press, 1927.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Wolff, Charlotte, The human hand, Methuen, London, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kahn, Fritz, Man in structure and function, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Rosenstiel, Annette, The Motu of Papua-New Guinea: a study of successful acculturation, Ph.D. thesis, Columbia University, 1953. Microfilm.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">O'Malley, L. S. S., Indian caste customs, Macmilan, New York, 1932. pp. 21-22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mead, Margaret, el al., Cultural patterns and technical change, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Boyd, William C, Genetics and the races of man; an introduction to modern physical anthropology, Heath, Boston, 1950. pp. 16-17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Flory, Charles D., Osseous development in the hand as an index of skeletal development, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Wilder, Harris H., A laboratory manual of anthropometry, Blakiston, Philadelphia, 1920. pp. 84-109.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Wright, W. B., Tools and the man, George Bell and Sons, Ltd., London, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Jones, Frederic Wood, The principles of anatomy as seen in the hand, 2nd ed., Williams and Wilkins, Baltimore, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Meaning that digit corresponding to the ring finger in man. Among anatomists generally, at least two systems for identifying hand digits are in accepted scientific usage, often interchangeably by the same writer. A common convention is to number the digits from I to V, beginning with the thumb as digit I and ending with the little finger as digit V (Fig. 1). But many competent writers, thinking of the hand as having a thumb and four fingers, label the fingers as first, second, third, and fourth, meaning the index finger, the middle finger, the ring finger, and the little finger or pinkie, respectively. Throughout this issue of Artificial Limbs, it is considered that the normal hand has five digits, one of which is a thumb, the other four being fingers. A digit is here referred to with the understanding that digit I is the thumb Fingers are referred to as being numbered beginning with the index finger as the first finger.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>28.</b> </td><td class="clsTextSmall">Schultz, Adolph H., Characters common to higher primates and characters specific for man, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Schultz, Adolph H., The skeleton of the trunk and limbs of higher primates, Human Biol., 2(3):303 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ethel J. Alpenfels, D.Sc. </b></td></tr><tr><td class="clsTextSmall"> Professor of Anthropology, 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/1955_02_004/1955-MayOCRBatch-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_004/table1.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-12.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 Anthropology and Social Significance of the Human Hand Creator An entity primarily responsible for making the resource Ethel J. Alpenfels, D.Sc. * https://staging.drfop.org/files/original/0af497bc37cfab2a9a00a17b1ca6d86f.pdf cf8cb41e194e0ee4499e4051dda5f85e https://staging.drfop.org/files/original/5ea3581f6ee975d42c43106821fad3e2.jpg 313f93afd5728940fede23af77bc8aeb https://staging.drfop.org/files/original/2716c0dfa81b724004f4e14015781792.jpg 6e2dfd49d5e2c1b0b0b628b8a3211b60 https://staging.drfop.org/files/original/576707f40e83237ed35a081d709ab88c.jpg aa88f323501ce5eda2721634bd997f66 https://staging.drfop.org/files/original/581c053fd31ab1f812407ca84373b090.jpg cd646856608dc4c29841ec43ea7d2aa1 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_018.pdf Text Any textual data included in the document <h2>The Application of Ionomer Resins in Definitive Below Knee Prostheses: A Limited Study</h2> <h5>Bruce P. McCleUan, CPO&nbsp;<a style="text-decoration: none;">*</a><br />Susan Kapp, CP&nbsp;<a style="text-decoration: none;">*</a><br />Melvin Stills, CO&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>INTRODUCTION</h3> <p>For the past 30 years, polyester resins have been the material of choice for socket fabrication and exoskeletal lamination for all types of prostheses.<a></a> Without question, these thermosetting plastics have proven to be strong, durable, and effective for such application, and, at the time of their introduction, thermosetting plastics provided a quantum leap forward from the age of wood. The advent of plastics allowed for a more hygienic and less bulky prosthesis. More importantly, lamination provided a medium for duplicating a modified replica of the patient's residual limb. Thus, a more intimate fitting socket with greater weight-bearing characteristics was possible. In fact, the use of thermosetting resins continues today as the accepted state-of-the-art.</p> <p>As with any material, the polyester resins have certain characteristics which are not ideally suited for all situations. With this as a basis, the University of Texas Health Science Center at Dallas, in conjunction with the Dallas Rehabilitation Institute, began investigating the use of alternative materials for definitive prosthetic design. One of the most attractive substitutes appeared to be thermoplastics. A clinical study was undertaken to evaluate the group of thermoplastics known as ionomer resins and their role in definitive prosthetic application, as opposed to the polyester resins in use today.</p> <h3>Thermosetting Resins</h3> <p>As indicated, thermosetting-resins such as 4110 laminae have many positive attributes when used in the prosthetic arena. Some of the negative characteristics which prompted the investigation into other materials are equally impressive. The toxicity of the fumes given off during the lamination stage is certainly a matter of concern. The ability to modify a socket fabricated from polyester resin to accommodate residual limb change or pressure on bony prominences is essentially limited to grinding away an area for relief, or adding material to reduce socket dimensions. The cured polyester resin also is fairly rigid in nature—a factor which formed the major emphasis for research into the area of alternative materials.</p> <h3>Ionomer Resins</h3> <p>The thermoplastics which were utilized in this particular study of prosthetic application are classified as ionomer resins. The resins are based on copolymers of ethylene and metha-crylic acid, which are partially reacted with metallic salts to form ionic crosslinks between acid groups of single chain or between neighboring chains.<a></a> The name Surlyn® is the registered trademark of the ionomer resins produced by DuPont and was the material used in the fabrication of the prosthetic sockets. Some of the characteristics which made Surlyn® an attractive option for prosthetic use are as follows:</p> <p><b>Clarity</b></p> <p>Surlyn® is virtually transparent even in thicknesses up to 1/4 inch. This allows the prosthetist to evaluate socket fit visually while the patient is standing with full weight bearing on the residual limb (<b>Fig. 1</b>).</p> <strong><a href="/files/original/5ea3581f6ee975d42c43106821fad3e2.jpg">Figure 1</a>. Symes amputee with clear Surlyn® prosthesis.</strong><br /> <p><b>Adjustability</b></p> <p>The nature of ionomer resins is compatible with heat induced molding which greatly facilitates modifications to the socket. Areas of pressure over bony anatomical structures are simply heated and relieved with no adverse affect on integrity or clarity of material. Surlyn® may also be buffed, sanded, drilled, and riveted in the same manner as the laminates.</p> <p><b>Ease of Fabrication</b></p> <p>Surlyn® comes in a sheet form and is heated and softened in an oven to allow drape vacuum forming. Unlike other thermoplastics, Surlyn® can be formed directly over a wet cast with no need for a lacquer coating or nylon stocking interface. This differs greatly from polycarbonates which require prefabrication dehydration and a dry cast for good results. Additionally, no post-fabrication curing is required to drive off skin irritating styrene gas, as in the case of polyester resin which has a greater than 25 percent flexible resin content. Additional fabrication time is required, however, in the case of long below knee and Symes level amputations because of the need to weld the posterior seam of the Surlyn® socket.</p> <p><b>Flexibility</b></p> <p>This factor has proven to be the most significant advantage of ionomer resins from the patient's standpoint. Sockets fabricated from Surlyn® have much greater flexibility than those fabricated from polyester resin. Patients report that the socket feels more like a part of them and is appreciably more comfortable. The exact deformation occuring in the socket during ambulation has not been quantitatively measured at this point, but clinical trials indicate that anatomical weight-bearing surfaces are not adversely affected by the dimensional changes.</p> <h3>Clinical Applications</h3> <p>Initially, the ionomer resin sockets were used only as "test" sockets prior to fabrication of an intermediate or definitive prosthesis. Later, use broadened to include intermediate prostheses, and eventually definitive application. The move toward definitive use was prompted by the patients themselves. Those who had been wearing intermediate prostheses made of Surlyn® complained of the rigidity of the laminated socket when their permanent prosthesis was delivered. This provided a significant clue as to the direction which should be taken in regard to providing a more comfortable definitive prosthesis.</p> <h3>FABRICATION PROCEDURE</h3> <p>Though the technique is very similar to standard vacuum forming of orthotic devices, some specific steps are employed when making the definitive prostheses. To prepare the Symes cast for vacuum forming, the Symes foot retainer is attached to the modified positive model with plaster, using the vertical fabrication jig for alignment. A small hole is drilled into the popliteal area and the patellar bar of the cast to assure a good vacuum in these depressions. A piece of cotton stockinette is stapled above the trimline and stretched over the cast mandrel and the holes in the hand drape pipe. Pressure sensitive tape is used to hold the stockinette in place on the pipe.</p> <p>The thickness and dimension of the Surlyn® sheet to be used will vary according to type of prosthesis (i.e., Symes or BK) and the size of the patient. Most Symes casts require no more than a 24" x 24" sheet of 3/16" Surlyn® (for the lighter or less active patient 1/8" Surlyn® may be sufficient). The sheet is heated on a teflon rack for approximately seven minutes in a 350°F oven. The heated sheet is draped over the cast and sealed down the posterior side with the vacuum turned on. Excess plastic is cut away and trimmed almost flush with the socket before it is allowed to completely cool, eliminating the need for excessive grinding. Once cool, the posterior seam is grooved in preparation for welding. Three welds are run over the entire seam. The socket is then removed from the cast and trimmed. The foot is attached and the prosthesis is ready for fitting and delivery.</p> <p>The below knee prosthesis is fabricated in the same manner one would fabricate a thermoplastic test socket. It is frame draped with a 12" x 12" sheet of 1/2" Surlyn.® Care must be taken to not create webs below the trimline. It is then formed onto the Berkley alignment fixture for dynamic alignment. The socket may be permanently incorporated into an endo skeletal system or be finished in an exo skeletal manner using acrylic resin for the outside lamination. Using acrylic resin will not impair the flexibility of the socket to the extent that polyester resin will.</p> <h3>CLINICAL RESULTS</h3> <p>The fittings of the ionomer resin sockets for definitive use began in April, 1982. Of the ten patients who were definitively fitted with Surlyn,® eight were Symes level amputees. The remaining two patients were below knee amputees (<b>Fig. 2</b>).</p> <strong><a href="/files/original/2716c0dfa81b724004f4e14015781792.jpg">Figure 2</a>. Below knee type prosthesis with ionomer resin socket.</strong><br /> <p>In the Symes amputee group, five of the eight patients experienced failure of the prosthesis at the ankle/foot juncture (<b>Fig. 3</b>). The shortest use time until breakage was 14 days and the longest was five months, with a mean of 11 weeks for the group experiencing breakage. Two of these patients were refitted with a second Surlyn® definitive, one of which failed again after two months, while the other prosthesis continued to function one year after a modified ankle/foot juncture was devised (<b>Fig. 4</b>). The modification made was one of reinforcing the distal end of the socket with glass cloth adhered with acrylic resin.</p> <strong><a href="/files/original/576707f40e83237ed35a081d709ab88c.jpg">Figure 3</a>.</strong>&nbsp;<strong>Stress fracture at ankle/foot juncture of Symes prosthesis.</strong><br /><br /><strong><a href="/files/original/581c053fd31ab1f812407ca84373b090.jpg">Figure 4</a>. Closed socket design type now being used with reinforced ankle. Suspension is provided by a closed-cell polyethylene shim or pad encompassing the leg proximal of the malleoli and retained in place with a cast sock. Prosthetic socks are worn beneath the shim as usual.</strong><br /> <p>This same method has since been used on two other prostheses in the Symes group. However, over a period of one year, both of these prostheses failed at a level just proximal to where the glass cloth reinforcement stopped. The remaining patient in this group was an elderly lady who is a limited household ambulator and has experienced no known problems to this date.</p> <p>One of the two below knee patients wore his Surlyn® socket prostheses for 11 months before a crack developed. That patient weighed in excess of 230 pounds and participated in sports on a routine basis. His socket developed a crack in the proximal posterio-lateral corner which eventually migrated down the posterior wall. He was subsequently refitted with a polyester laminate socket. The other BK amputee was a 110 pound woman in her twenties who continues to ambulate with her Surlyn® socket prosthesis one year and seven months after fitting.</p> <h3>CONCLUSION</h3> <p>As indicated by Stills and Wilson,<a></a> Surlyn® may not be ideal for applications where high unit stresses are anticipated. Although this seems to have been borne out in this initial group of patients, we still believe that ionomer resins might play an important role in definitive prosthetic fittings. This may be accomplished by reinforcement at crucial stress points, a variation in the ionomer resin itself, or by finding a different material that is better suited to long term stresses. The frame type design being used in the above knee Scandinavian socket may also hold significant promise in a below knee configuration.</p> <p>The potential benefits of ionomer type resins to the amputee population are too great to dismiss without further evaluation and clinical analysis. It is hoped that others in our profession will actively participate in seeking viable materials for definitive socket application.</p> <p><b>References:</b></p> <ol> <li>Aylesworth, R. Dean, ed., <i>Manual of Upper Extremity Prosthetics</i>, Artificial Limbs Project, University of California, Los Angeles, 1952.</li> <li>DuPont, E.I. De Nemours and Company (Inc.), <i>Surlyn® Ionomer Resins Industrial Extrusions Manual</i>, p. 3.</li> <li>Stills, Melvin, and A. Bennett Wilson, Jr., <i>A New Material in Orthotics Prosthetics</i>, Vol. 34, No. 3, pp. 29-37, September 1980.</li> </ol> <div style="width: 400px;"><b>Melvin Stills, CO </b> Melvin Stills, CO, Assistant Director, University of Texas Prosthetics-Orthotics Program.<br /><br /><b>Susan Kapp, CP </b> Susan Kapp, CP, Prosthetic Instructor, University of Texas Prosthetics-Orthotics Program.<br /><br /><b>Bruce P. McCleUan, CPO </b> Bruce P. McClellan, CPO, Assistant Professor and Director, University of Texas Prosthetics-Orthotics Program, School of Allied Health Sciences, Health Science Center at Dallas, 5323 Harry Hines Blvd., Dallas, Texas 75235.<br /><br /><br /></div> Page Number(s) 18 - 21 Year 1984 Volume 8 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_03_018/1984_03_018-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Application of Ionomer Resins in Definitive Below Knee Prostheses: A Limited Study Creator An entity primarily responsible for making the resource Bruce P. McCleUan, CPO * Susan Kapp, CP * Melvin Stills, CO * https://staging.drfop.org/files/original/900c406bee3adcda50bf8b6267359ead.pdf df82042fb3ac474e9dedb922d4912194 https://staging.drfop.org/files/original/fe114a930bf052972f072f3dceff189a.jpg baf11ca27502acca8baaf54e3ca55687 https://staging.drfop.org/files/original/2bea6a4071dcb885ee29cf80b031c21d.jpg 495cb08e3d3b7f57cf3c08c8ab99bd81 https://staging.drfop.org/files/original/6ce3fbdbe8f4750a79fc8b18340555b4.jpg 863124825991da3ae0b5ba0c515a41e1 https://staging.drfop.org/files/original/022c06bc2eadf40c0f1e04c53578a7a1.jpg b890e5d134886cf5f9630c735ed31b4d https://staging.drfop.org/files/original/488da4aeb82fd8a32ad0e2ca277a641f.jpg bce900c1fcc880b0989b617b2ee94ea5 https://staging.drfop.org/files/original/3bf5f22ba09b4acc4594ca080bb9a838.jpg 95b37754f135d90549bda9247fbc0e23 https://staging.drfop.org/files/original/3d8f97204bb2bb16ed9d02d6d9f40501.jpg 03284aa41c6c0b02c4a6f995614ac73b https://staging.drfop.org/files/original/d634c2d774e6dd2826a9839c7f153913.jpg d5757b210e0771bb37226bdf6cc6bbe1 https://staging.drfop.org/files/original/362e4848532095e03dc40255afdfc1f2.jpg 42bc04ccce92bc21e883090f6981081a https://staging.drfop.org/files/original/bd7d7e55042feb7315cc9b240e582e1a.jpg 5cebe71dc1c91759df3936df3c824f98 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_025.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 25 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_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>The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis</h2> <h5>Clyde M. E. Dolan, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In warm or humid climates, the problem of heat and perspiration within a nonporous plastic laminate prosthesis covering a substantial area of the body is particularly troublesome. The accumulation of sweat in a patellar-tendon-bearing (PTB) socket or a shoulder cap, combined with the inability of the laminate to permit evaporation or diffusion of water vapor, frequently causes mild to severe discomfort and even skin lesions sufficiently severe to require that the use of the prosthesis be suspended. Moreover, when a rubber (Kemblo) and leather liner is used, the sweat may cause it to deteriorate.</p> <p>Initial efforts of the U.S. Army Medical Biomechanical Research Laboratory (AMBRL) to produce porous plastic laminates for prosthetic applications were well received when applied to upper-extremity devices; <a></a> but, when the same technique was applied to PTB prostheses, the strength and durability of the material proved to be inadequate <a></a> In addition, problems of low porosity, nonreproducibility, and increased fabrication time were cited as serious deficiencies in the technique. <a></a></p> <p>In 1966, AMBRL reported on the development of an epoxy porous laminate which when fabricated according to the instruction manual <a></a> offered the following claimed advantages over prior techniques utilizing polyester resins:</p> <ol> <li>The new laminates were two and one-half times stronger under laboratory test conditions.</li><li>The new technique produced laminates which were twice as porous as prior versions.</li><li>The fabrication procedure was simpler, required only one curing temperature, and could be reproduced more reliably.</li></ol> <h3>Description of the Technique</h3> <h4>Stump-Casting Procedures</h4> <p>The stump-casting and cast-modification procedures are essentially the same as those taught in the various prosthetics educational programs. However, the positive stump model is prepared for a suction lamination. This technique, which involves the use of a vacuum pump to make the PVA bag conform to the socket contours, is familiar to many pros-thetists but is not a routine procedure in the fabrication of a PTB socket with soft insert.</p> <h4>Fabrications Procdedures</h4> <p>The procedures for fabricating a porous epoxy laminate PTB socket with a soft distal end differ from those used in the polyester lamination system as follows: the utilization of Silastic Elastomer 385 and Foam Elastomer 386 to form the soft distal end, and the procedure of impregnating the Banlon and nylon stockinette with a predetermined quantity of resin mixture consisting of epoxy EPON, Versamid, pigment, and methylene chloride.</p> <p>Preimpregnation of the stockinette and evaporation of the solvent prior to layup result in a stronger, more porous socket.</p> <h3>Finishing Procedures</h3> <p>Standard finishing procedures are not used because they would reduce the porosity of the socket. A procedure in which indexing pins are used to align the porous shank with the socket is detailed in the 1963 AMBRL instruction manual <a></a> and is incorporated in the NYU revision of the 1966 AMBRL manual. <a></a></p> <p>The one variation from the AMBRL procedure that was introduced in the finishing process by NYU was the use of polyurethane as a buildup material over the socket instead of A.C. polyethylene wax (steps 51 and 52 in the 1966 AMBRL manual). Polyurethane foam was believed to offer the prosthetist a faster method for accomplishing the external buildup over the socket. The foam also permits the use of power equipment for shaping, which the wax does not.</p> <h3>Preliminary Evaluation</h3> <p>A preliminary evaluation completed at NYU in March 1967 <a></a> critically considered the epoxy porous laminate procedure in the following respects on the basis of four fittings on below-knee amputees: the fabrication process, amputee reactions, durability, and laboratory tests. The fittings were carried out in the New York metropolitan area during a period of very hot, humid weather in the summer of 1966, which afforded ideal conditions for investigation of amputee reactions to socket porosity.</p> <p>In summary, the conclusions of the preliminary evaluation were:</p> <p>That the May 1966 AMBRL instruction manual was generally clear and easy to follow. However, the finishing procedures lacked the completeness of those set forth in the June 1963 AMBRL manual. A revision of the former was prepared, incorporating details of this part of the technique. The procedures were consistent with accepted prosthetics practice, and no unusual equipment was necessary.</p> <p>That the actual time required for fabrication was approximately one and a quarter hours longer than that required for fabrication of the conventional PTB prosthesis. The bench time can be reduced somewhat if the suction hose is inserted into the oven, eliminating the necessity of setting up the undercut areas of the stump model prior to placement of the socket in the oven for curing.</p> <p>That the coloring and the finish of the experimental prostheses were uniform, and the porosity was highly acceptable. Since no socket liner is used in this procedure, but rather a soft distal end, the amputee's tolerance to a "hard" socket was incidentally investigated. None of the amputee subjects in this preliminary evaluation noted any adverse reaction to the lack of a soft insert. All reported a significant reduction in discomfort associated with perspiration during the period of wear, remarking that the stump socks were much less saturated at the end of the day.</p> <p>That the experimental prostheses were significantly lighter in weight, with an average reduction of 32 per cent. The prostheses showed no signs of breakdown or clogging of the pores over a six- to 12-month period of wear, and showed excellent retention of original conformation. All are still being worn satisfactorily after 18 months.</p> <p>On the basis of this preliminary evaluation, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development recommended that a field study be initiated to evaluate the porous laminate technique on a broad sample of juvenile subjects.</p> <h3>Scope and Objectives of the Field Study</h3> <p>Six clinics (Atlanta, Birmingham, Durham, Memphis, New Orleans, and Orlando), all located in hot, humid climates in the southern and southeastern sections of the United States, were invited to send a prosthetist representative to a three-day course in the fabrication of the AMBRL porous laminate PTB prosthesis, conducted at New York University in May 1967. Each clinic agreed to fit five subjects during the summer of 1967 with porous PTB prostheses fabricated by or directly under the supervision of the prosthetist attending the course.</p> <p>The field study was designed to evaluate the AMBRL porous laminate used in the following respects:</p> <ol> <li>Fabrication procedures.</li><li>Subjective reactions (comfort and cosmesis).</li><li>Medical considerations (stump hygiene and skin condition).</li><li>Durability and adjustments.</li></ol> <h3>The Sample</h3> <p>The sample consisted of 20 subjects-11 males and nine females between four and 20 years of age. Five were from Atlanta, three from Birmingham, three from Durham, two from Memphis, and seven from New Orleans. There were seven right and ten left below-knee amputees, two bilateral amputees (one right below-knee and left Syme's; one bilateral below-knee), and one unspecified. Eleven of the amputations were congenital, ten acquired, and one unspecified. All subjects were experienced prosthesis wearers, the prior prosthesis having been worn for seven months to three years.</p> <p>The types of prostheses worn by these subjects prior to the study are listed as follows:</p> <table> <tbody><tr> <td> <p><b>PTB sockets</b></p> </td> </tr> <tr> <td> <p>With side joints and lacer, without liner</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, with liner</p> </td> <td> <p>   8</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, without liner</p> </td> <td> <p>   6</p> </td> </tr> <tr> <td> <p>Syme's prosthesis</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Other or unspecified</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p> </p> </td> <td> <p> </p> </td> </tr> <tr> <td> <p><b>TOTAL: </b></p> </td> <td> <p><b>  22</b></p> </td> </tr></tbody></table> <h3>Methodology</h3> <p>At least, five clinic visits by each amputee subject were required for the appropriate evaluations. An outline of the procedures follows.</p> <h4>First Visit (Screening and Prescription)</h4> <p>At the first visit, clinic personnel discussed the purpose of the study with patient and parents, indicating the type of data that would be requested. A porous laminate PTB prosthesis was to be prescribed at this time. For purposes of uniformity, all experimental limbs were to use supracondylar suspension. General biographical information was recorded, as well as subjective comments concerning the previously worn prosthesis.</p> <h4>Second Visit (Delivery)</h4> <p>The porous laminate prosthesis was delivered at the second visit, and initial reactions of the subject and the clinic team were recorded. The prosthetist's report was initiated and retained by the prosthetist for submission at the termination of the study, as a means of recording fabrication and maintenance problems.</p> <h4>Third Visit (One Month Postdelivery)</h4> <p>The child's stump was examined to ascertain if any dermatological changes had occurred which might be attributable to the porous socket. Subjective reactions to the experimental prosthesis and reactions of the subject to the prosthesis as compared with the previously worn prosthesis were recorded.</p> <p>At this time the experimental prosthesis was rendered nonporous by the application of Saran Wrap, duplicating the procedure used in the preliminary evaluation at NYU. The prosthesis was then worn under these conditions for a two-week period of hot weather.</p> <h4>Fourth Visit (After Wear with Saran Wrap)</h4> <p>The stump was examined for dermatological changes. Any differences reported by the subjects as a result of eliminating socket porosity were assessed. The Saran Wrap was then removed.</p> <h4>Fifth Visit (After Six Weeks' Wear of the Porous Prosthesis without Saran Wrap)</h4> <p>Subjective and comparative reaction were once more elicited. The prosthetist's report was submitted.</p> <h3>Field Study Results</h3> <p>During the NYU course of instruction in this technique, one prosthetist was adversely affected by the epoxy resin. The difficulty had been noted occasionally in earlier studies. The developer has recognized the potential hazard, and appropriate handling precautions must be carefully observed. <a style="text-decoration:none;">*</a></p> <p>The epoxy resins (EPON 815) and curing agents (T-l) and, to a lesser extent, Versamid 140, are primary skin irritants. When in contact with the skin for a sufficient period of time, these materials are capable of producing a contact dermatitis in most individuals. In a relatively few hypersensitive workers, they can produce an allergic type of dermatitis in a relatively short period of time.</p> <p>Intermittent skin contact with these materials will not usually cause a dermatitis among normal workers; however, because of the occasional hypersensitive individual who cannot always be identified in advance, the precautionary measures suggested above should be used at all times.</p> <p>In addition to the foregoing precautions, good general ventilation is highly recommended.</p> <p>The first case of dermatitis usually indicates that proper handling procedures are not being observed, although in a very hypersensitive individual this is not necessarily true. The dermatitis should be treated promptly, and the source of contact should be ascertained and eliminated. The rash may be alleviated in most instances by soaking with warm Burow's Solution for 15-30 min., three or four times daily. Rashes that do not respond to treatment should be seen by a physician</p> <p><i>Based upon Handling Precautions for the Resin-Solvent System Used for Preparing Porous Laminates, an intramural memorandum issued by AMBRL in May 1967.</i></p> <h4>Fabrication Procedures</h4> <p>Telephone contacts with the participating prosthetics facilities during the course of the field study indicated that, with one exception, the fabrication procedures posed no serious problems. One facility was unable to duplicate the procedures because of difficulties with equipment. (Adequate temperature control is mandatory for successful preparation; this facility's oven temperature could not be reliably maintained for precuring the layup material.) Prosthetists' fabrication reports were received from five of the participating clinics.</p> <p>All reports indicated that two or three additional hours were required to fabricate a porous PTB prosthesis. Phases of the process cited as time-consuming were the weighing, processing, and curing; breakouts and reassembly; finishing; and the preparation of the soft distal end.</p> <p>No criticisms were made of the instructions contained in the manual. The process, however, was evidently more demanding than the conventional technique. Close attention to accuracy and detail is essential for successful preparation of the porous laminate.</p> <p>The increased fabrication time and effort, the need for some special materials, and the necessity for adequately ventilated work areas may result in some cost increases. One clinic expressed concern about the attitude of the local state agency in this respect, and one prosthetist suggested that the increased cost be borne in mind when the prescription is written.</p> <h4>Reactions of Subjects and Clinic Personnel</h4> <p>The experimental limbs were generally considered superior to the previously worn prostheses in several respects. Initial reactions to the porous prostheses, elicited immediately after delivery, are shown in <b>Table 1</b> and <b>Table 2</b>. After a one-month period of wear, corresponding reactions of the subjects and the clinics were recorded; these results appear in <b>Table 3</b> and <b>Table 4</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Examination of <b>Table 2</b> and <b>Table 4</b> (comparative reactions) indicates few changes from the positive first impression as wear increased, with a trend toward more emphatic positive comments.</p> <p>One month after delivery, the patient, his parents, and the clinic were asked their preference between the previously worn prosthesis and the experimental prosthesis. The results are shown in <b>Table 5</b>. In addition, the clinics were asked if they would prescribe a porous laminate prosthesis for other patients. Three clinics said "Yes," one said "No," and one said "Probably."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After four weeks of wear, the prostheses were covered with Saran Wrap to eliminate the porosity of the sockets while leaving the prostheses intact. No change was made in fit, weight, alignment, or other factors that might affect reactions. The subjects were asked to wear the experimental limbs under these conditions for a two-week period of hot weather. Seventeen subjects reported data for this test period. The majority indicated that perceived heat within the socket increased and that perspiration became a problem (introducing dermatological problems and discomfort). <b>Table 6</b> lists the reactions of the subjects regarding the test period utilizing the Saran Wrap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of <b>Table 6</b> with <b>Table 2</b> shows a significant change in the perception of heat within the socket. Of those subjects offering opinions, 90 per cent considered the experimental prosthesis very satisfactory or satisfactory prior to the application of Saran Wrap, and 10 per cent considered it unsatisfactory. With the Saran Wrap, only 27 per cent reported the prosthesis satisfactory, and 73 per cent considered it unsatisfactory or very unsatisfactory-certainly a very dramatic reversal of reactions on the part of the wearers.</p> <p>Since no changes were introduced in fit, weight, or alignment, it was not expected that perception of socket comfort would change significantly under the test conditions, except to the extent that comfort might be affected by heat in the socket. Prior to the test period 95 per cent reported satisfactory reactions to comfort, while 5 per cent considered the prosthesis unsatisfactory; with the use of Saran Wrap, 83 per cent considered the experimental limb satisfactory and 17 per cent unsatisfactory.</p> <p>An uninterrupted six-week wear period followed the study of the effects of the Saran Wrap covering. At this time, subjects and clinic teams were asked to submit a non-comparative assessment of the experimental prosthesis and a separate questionnaire comparing the experimental prosthesis to the one worn before the field study. The results appear in <b>Table 7</b> and <b>Table 8</b>. These data were received regarding 17 experimental prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a three-month period of wear, subjects and clinics were asked to indicate preferences as to the type of prosthesis to be worn in the future (<b>Table 9</b>). When clinics were asked if they would recommend the porous laminate prosthesis for other patients, three said "Yes," one said "No," and one said "Possibly."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Medical Considerations</h4> <p>A definite decrease in stump hygiene difficulties was specifically reported for two subjects in the study, leading to a recommendation by one clinic that the porous laminate be considered in cases presenting dermato-logical problems. There were no instances of deterioration of stump condition that could be related to the porous laminate, although socket adjustments were required in some cases.</p> <h4>Durability and Adjustments</h4> <p>Two clinic chiefs and their prosthetists expressed doubt that the porous laminate prosthesis would be sufficiently durable for patients who give their prostheses extremely heavy use. No such problems were encountered in an 18-month follow-up of the adult patients participating in the original NYU study of the epoxy porous prosthesis. The developer implies that adequate strength can be provided with this technique, even for heavy subjects, although only limited supporting data for this contention are available.</p> <p>One prosthesis fitted with side joints and thigh corset, which compromised the requested supracondylar suspension, showed repeated breakdown. If side joints are to be provided, the porosity of a substantial socket area must be sacrificed in order to provide adequate strength. Consequently, porous lamination may not offer as significant an advantage for these patients. In view of this problem, reservation of the porous laminate procedure for the PTB-type of fitting without side joints may be indicated. This point merits further investigation.</p> <p>One prosthesis was reported to have de-laminated between the insert and the outer wall. However, it appears that this complaint referred to a failure of the bond between socket and shell and not to delamination <i>per se. </i>Two other prostheses showed marked wear during the period of study, although no functional problems were encountered.</p> <p>Adjustments are more difficult to perform on the porous laminate socket, since it is impossible to fill in an area without sacrificing porosity. It is also more difficult to relieve an area. Because the finished laminate is so much thinner than conventional products, reducing the area may render it too weak for normal use.</p> <h4>Discussion</h4> <p>The high level of acceptance of the experimental prosthesis is supported by repeated references to three principal factors.</p> <p>"Increased comfort" is a broad term which encompasses, both directly and indirectly, the decreased weight of the porous limbs compared to the previously worn prostheses, decreased perspiration (with concomitant dermatological improvement) and reduction of heat within the socket, and the added comfort of the soft distal end.</p> <h4>Weight</h4> <p>To confirm the subjective impression of lighter weight, the weights of previously worn prostheses and experimental prostheses were compared. <b>Table 10</b> indicates the percentage of weight reduction for the 14 prostheses where such data were available. It can be seen that the average reduction is approximately 25 per cent.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Perspiration and Heat</h4> <p>Approximately one-third of the reasons cited for the preference of the porous laminate for future use related to the diminution of perspiration and the perception of the experimental limb as cooler. The results of the two-week test period (experimental socket covered with Saran Wrap) dramatically illustrate the importance of socket porosity in this regard.</p> <h4>Soft Distal End</h4> <p>In their preliminary testing, both the developer and New York University found no serious problems occasioned by the change from an insert to a hard socket with soft distal end. The observation was borne out in the field study during which the incidental investigation of the soft distal end elicited several positive comments (one clinic, although recommending a standard laminate in the future fitting of a patient to provide greater durability, would recommend that the new prosthesis incorporate the soft distal end procedure).</p> <h4>Amputee and Clinic Reactions</h4> <p>Patients and their parents were almost unanimous in their acceptance of the porous prosthesis (nearly 95 per cent of the patients and their parents preferred the experimental technique), whereas the clinics exhibited much less enthusiasm. At the close of the study, only two of the five clinics would definitely prefer the porous laminate for future use. It is important to note that the two clinics which recommended the porous laminate for future use accounted for the fitting of 11 of the 17 subjects who completed this phase of the study. Reluctance to prescribe the porous laminate resulted in extremely limited samples from the three clinics who preferred the standard technique.</p> <p>Two of the clinics rejecting the porous laminate for the future use of the patients fitted in the study might, however, recommend the porous prosthesis for <i>other </i>patients. Therefore, only one clinic categorically rejected the experimental prosthesis.</p> <p>Several suggestions may be advanced to help resolve this apparent discrepancy of opinion. During the study, as early as one month postdelivery, four reports were received which indicated dissatisfaction with the appearance of the experimental limbs. The poor appearance was specifically related to difficulties in keeping the comparatively rough surface clean. It was noted that the porous prostheses tended to appear dirty after only a short period of use, with one experimental prosthesis being rejected for this reason. Interrogation cf adult patients involved in the preliminary laboratory study showed that the prostheses are in fact difficult to clean and that they gather varying amounts of dirt, but none of the patients spontaneously complained of this problem. It might be expected that children would be less sensitive to this problem than adults.</p> <p>A further explanation for the clinics' less emphatic endorsement may lie in the increased cost factors (due to two to three hours' increase in fabrication time and materials), the need for some specialized equipment, and the occasional allergenic reactions of shop personnel to the uncured resin-solvent system. Therefore, the prosthetists' reluctance to utilize the technique may have been transmitted to the clinics.</p> <h3>Summary</h3> <p>The AMBRL porous laminate technique as applied to the PTB prosthesis was evaluated over a three-month period on 20 children at five juvenile amputee clinics in the southern section of the country. Essential aspects investigated were the fabrication process, subjective reactions, medical considerations, adjustments, and durability.</p> <p>The data indicated that porous laminate PTB prostheses were generally well accepted by patients and parents but less so by clinic personnel. The developer's claims of reduced perspiration, added comfort, decreased der-matological problems, and lighter weight were generally corroborated; weight reduction was the most consistently reported advantage.</p> <p>Increased fabrication time and some increase in the complexity of the fabrication process were cited as problems. Cosmetic characteristics elicited both favorable and unfavorable remarks; the propensity of the porous laminate to collect and trap dirt particles caused some dissatisfaction, while the textured appearance of the porous laminate was preferred in some instances.</p> <p>Concern was expressed regarding the durability of the porous laminate, particularly when applied to a prosthesis which was subjected to arduous use, although the experimental evidence was apparently insufficient for such concern.</p> <p>Based upon patients' and parents' preference for the experimental limbs, including instances of improvement in stump condition, it appears that the porous laminate PTB is a significant and worthwhile addition to prosthetics technology. Other applications of the porous laminate may also be recommended, particularly for those patients with substantial body areas enclcsed within a socket, with severe perspiration problems, or where a lightweight prosthesis is indicated. Shoulder caps, transthoracic sockets, above- and below-elbow sockets, or hip-disarticulation and hemipelvectomy applications may be considered. Informal observations of several upper-extremity fittings have again indicated that the porous laminate offers distinct advantages in terms of decreased perspiration and weight.</p> <p><b>References:</b></p> <ol> <li>Dolan, Clyde M. E., <i>The AMBRL porous laminatepatellar-tendon-bearing prosthesis</i>, New York University, Prosthetics and Orthotics, Post-Graduate Medical School, March 1968.</li> <li>Hill, James T.,<i>A manual for the preparation of above and below elbow porous prostheses</i>, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plasticlaminates for upper-extremity prostheses</i>, Artif. Limbs, Spring 1963, pp. 17-30.</li> <li>Plumb, Robert E., and Fred Leonard,<i> Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</li> <li>Plumb, Robert E., and John J. Urban, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 1962.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot, <i>Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot,<i> Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</li> <li>New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, <i>Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis</i>, May 1965.</li> <li>New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,<i>Preliminary evaluation: AMBRL porous laminate PTB prosthesis</i>, March 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Disposable gloves should be worn when handling all resins and solvents. Face shield or goggles are advisable when pouring or mixing the resins.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,Preliminary evaluation: AMBRL porous laminate PTB prosthesis, March 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Plumb, Robert E., and John J. Urban, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 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>2.</b> </td><td class="clsTextSmall">Hill, James T.,A manual for the preparation of above and below elbow porous prostheses, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plasticlaminates for upper-extremity prostheses, Artif. 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>Clyde M. E. Dolan, M.S. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, NYU Post-Graduate Medical School, 317 East 34th St., New York, NY. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Clyde M. E. Dolan, M.S. * https://staging.drfop.org/files/original/02e028e3e75d48a51464d262823def1c.pdf d29d6d36d9bfa48369439bb49c9a0cc0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_199.pdf Text Any textual data included in the document <h2>The Basis of Orthotic Management in Quadriplegia</h2> <h5>John H. Bowker, M.D.&nbsp;</h5> <p>Statistics indicate that there are 150,000-200,000 spinal cord injured persons in the United States.<a></a> Each year, approximately 10,000 newly injured are added to this figure. About 80% are males under the age of 40 years, while slightly more than half (53%) are quadriplegics, with low cervical injuries being most common.<a></a> In recent years, improved medical management has led to an increase in post-injury life expectancy in spinal cord injury to a probable 30 to 40 years.<a></a> This ever-increasing national prevalence of spinal cord injury poses major problems in rehabilitation, several of which will be addressed in this issue of <i>Clinical Prosthetics and Orthotics</i>.</p> <p>When the spinal cord team first confronts a person with a cervical spine injury, the first two priorities are preservation of life itself and prevention of further damage to the spinal cord and spinal nerve roots. Immobilization of the neck, followed by traction-reduction of vertebral malalignment, is carried out concomitantly with physiologic stabilization. Special studies, including magnetic resonance imaging, are then done to determine the need for immediate surgical relief of extrinsic pressure on the cord due to residual vertebral malalignment and/or fragments of bone or intervertebral disc. Intraoperative imaging with ultrasound further aids in the identification and removal of fragments causing extrinsic pressure. The preservation or restoration of function of just one nerve root by precise surgery of this sort can make the crucial difference between a modicum of independence and total dependence in self-care. Depending on the specific injury and the surgeon's preference, stabilization of the spine may be accomplished by means of a halo external fixation system alone or by internal fixation with wires and bone grafts, supplemented by an orthosis. In either case, stabilization will expedite the rapid mobilization of the patient. At this point, a decision can be made regarding the appropriateness of orthotic fitting.</p> A brief mention has been made of the functional significance of each residual cervical nerve root in the quadriplegic. This may be further elaborated upon as follows:<br /><br /> <ul> <li><b>Fourth cervical root (C-4):</b> innervates the diaphragm, allowing independent breathing.</li> <li><b>Fifth cervical root (C-5):</b> innervates the deltoid and biceps/brachialis, providing shoulder abduction/flexion and elbow flexion, respectively.</li> <li><b>Sixth cervical root (C-6):</b> innervates the radial wrist extensors, permitting wrist dorsiflexion and a passive opposition of thumb and fingers by "tenodesis effect" of the finger flexors.</li> <li><b>Seventh cervical root (C-7):</b> innervates the triceps, wrist flexors and finger extensors, allowing elbow extension, wrist volar flexion, and finger extension, respectively.</li> <li><b>Eighth cervical root (C-8):</b> innervates the finger flexors, allowing a gross grasp.</li> <li><b>First thoracic root (T-1):</b> innervates the intrinsic muscles of the hand, resulting in complete hand function, including grip and a precise thumb to finger pinch.</li> </ul> <p>It is important to note three features of this progressive classification to develop a clearer understanding of its relative limitations. Firstly, many muscles are supplied by two roots. The root associated with a given muscle in the list above is that which primarily innervates that muscle. The preservation of the next lower root provides not only an additional distal function, but also greater strength in the muscle just above, due to the activation of additional motor units by this secondary nerve root. Again, this argues for preservation of every possible root. Secondly, preservation of root function is often asymmetrical. For example, a quadriplegic may have a functional level of C-5 on one side and C-6 on the other. In this case, an orthotic prescription for one side will be totally inappropriate for the other. Thirdly, with nerve fiber (axon) regrowth, improvement in strength of a given muscle may occur over time. Occasionally, even the next higher root may recover as well. Monitoring by repeated muscle testing can thus lead to a progressive change in orthotic prescription. The occupational therapist, by virtue of her close daily contact during the rehabilitation process, is often the first team member to note these changes. To aid in the prognosis of muscle return, it is now possible, by advanced biofeedback techniques, to find functioning motor units in muscles considered "paralyzed" by conventional muscle testing techniques. Following identification of working motor units, it may be possible to strengthen them with bio-feedback-directed exercise. This often results in the addition of another useful upper limb function with or without the help of an orthosis.</p> <p>Before an upper limb orthosis can be used, the quadriplegic must be positioned so that visual feedback allows contact between a partially insensate hand and the object to be manipulated. A properly designed and carefully fitted wheelchair can, therefore, be considered the basic orthosis for the quadriplegic. Lateral trunk supports or a corset may also be essential for functional sitting posture, freeing the upper limbs from supporting the trunk.</p> <p>Throughout the process of rehabilitation, the orthotist should work closely with all members of the team, but especially the occupational therapist, physical therapist, psychologist, and physician if acceptance and use of orthotic devices is to be achieved. Successfully fitted orthoses are useful not only for self-care, but can also play a major role in achieving the ultimate goal of rehabilitation, the return to gainful employment. Many types of electronic devices, including computers, are manipulated more easily with an orthosis.</p> <p>In conclusion, it is hoped that this issue will be helpful in not only delineating the unique role of the orthotist in the care of the quadriplegic, but equally importantly, in demonstrating the need for communication and cooperation among all team members, if we are to offer optimum care to our patients.</p> <p><b>References:</b></p> <ol> <li>DiVivo, M.J., Fine, P.R., Maetz, H.M., and Stover, S.L., "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," <i>Archives of Neurology</i>, 37:1980, pp. 707-8.</li> <li>Eisenberg, M.G. and Tierney, D.O., "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," <i>Paraplegia</i>, 23:1985, pp. 335-343.</li> <li>Green, B.A., Callahan, R.A., Klose, K.J., and DeLa-Torre, J., "Acute Spinal Cord Injury: Current Concepts," <i>Clinical Orthopaedics and Related Research</i>, 154:January-February, 1981, pp. 125-135.</li> <li>Young, J.S., Burns, P.E., Bowen, A.M., and McCut-chen, R., <i>Spinal Cord Injury Statistics: Experience of the Regional Spinal Cord Systems</i>, 1982, pp. 13-14.</li> </ol> Page Number(s) 199 - 200 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Basis of Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource John H. Bowker, M.D.  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/2af24d33498f903f19fea2c5675a74ef.pdf d4e6f2d65239910f25cf126d68e7c8dc https://staging.drfop.org/files/original/4d3ddcf7651fff9ec5dd9c3427c58e15.jpg 2749c27e2446e4f746ea4e1d8d08afea https://staging.drfop.org/files/original/eb71c2538c5e88109be6c357c40e60cd.jpg a33087cc766f88e31bed11c95885bb6e https://staging.drfop.org/files/original/92f0b57c8b3defb346a3497604e47f3f.jpg 603429119911e70056b4450ef18b92d0 https://staging.drfop.org/files/original/5f498a6651b7e9b8f1eec1ea73532e91.jpg 9fdf9004b81b54e8652950012ccb0165 https://staging.drfop.org/files/original/b041422d191f77298643b52ef852617e.jpg 17c5cb478f84c50ccb8cd4e0527884cd https://staging.drfop.org/files/original/7fe13473de8d4000ed8c8f18cd3c0b4d.jpg 2a4e79271e4ba7bbbe536c18ab728781 https://staging.drfop.org/files/original/2297ac77954f4047d113992c6d45458d.jpg 2cf1cf57dd83112d6fbeee8a32f2027e https://staging.drfop.org/files/original/e8e3e367a8c90615a071af926d0dcc43.jpg a5aa4351b6ee2371ba40f0cf38df6840 https://staging.drfop.org/files/original/aa16b41fd406f041938dd06c277015c2.jpg 649eaeff89a5184e2def9092077444fe https://staging.drfop.org/files/original/121e62ebcf3c71973c3482ab42e53c83.jpg 15b4270a6585a213d7aedf6a76d60520 https://staging.drfop.org/files/original/9a57f9be025587ccf0193133556036ad.jpg 168fdb2039020ed045f4a822c8e13c6b https://staging.drfop.org/files/original/d83a4fc2a02d05be889604c2340a00a2.jpg f4fc363ce2a8acfc59cc24e5042d33da https://staging.drfop.org/files/original/c60c52b30ad7a3259df529b2acf883a3.jpg 8ccb20f11781e2ba1dbbce79edefa8b0 https://staging.drfop.org/files/original/8a8b1b1c51d20c3232be371241d1e215.jpg 12ee4710b77effd0f0bd2c647a1b1aca https://staging.drfop.org/files/original/a876719fff8467e1a527e2a73d31a30b.jpg 2b985f3fea23eaa471be8fac044cb345 https://staging.drfop.org/files/original/6449892d298e50c73e338beea299bbc0.jpg ac35194aca22c469e31de504b9bed2b5 https://staging.drfop.org/files/original/5ed18cbfc520ac464095a32b721c6849.jpg 759e2b53115fae6bf241f4d450875a36 https://staging.drfop.org/files/original/076402ce0eaaee6760087a9c8a6b61a6.jpg 8100a1578a04f465b946f59287bb3d36 https://staging.drfop.org/files/original/ff64515284519fe251c8dd39ea00d384.jpg 74b1d12ca12689370d20ffc2f18789bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_004.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 4 - 25 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_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 Biomechanics of Control in Upper-Extremity Prostheses</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the rehabilitation of the upper-extremity amputee, structural replacement by prosthetic arm and hand is an obvious requirement, and it poses a comparatively easy task; functional replacement by remote control and by substitute mechanical apparatus is more elusive and hence infinitely harder. For the purposes of functional utility, remaining movements of upper arm, shoulder, and torso must be harnessed, and use must be made of a variety of mechanical devices which amplify remaining resources by alternators, springs, locks, and switching arrangements. The facility of control attained through this apparatus is the key to its ultimate value.</p> <p>The future of upper-extremity prosthetics depends upon an ever-increasing understanding of the mechanics of the human body by all who minister to the amputee-prosthetist, surgeon, and therapist alike. It must always be stressed that the final goal is an amputee who can function. Too often there is a tendency to put undue faith in the marvels of mechanism alone, when in fact it is the man-machine combination that determines performance. It is in this broad frame of reference that the biomechanical basis of upper-extremity control must be approached.</p> <h3>Prosthetics Anthropometry</h3> <h4>Surface Landmarks</h4> <p>If successful control is to be obtained, the various components of the prosthesis must be positioned with a good degree of accuracy.</p> <p>To do so requires reference points on the body, of which the most satisfactory are certain bony landmarks. Most of these skeletal prominences protrude to such an extent that location is easily possible by eye. Others require palpation, and this method should be used to verify observation in every case. The bones most concerned in upper-extremity anthropometry are the clavicle, the scapula, the humerus, the ulna, and the seventh cervical vertebra. Surface indications of protuberances, angles, or other features of these bones constitute the landmarks, the locations and definitions being given in <b>Fig. 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and external landmarks in the upper extremity. Definitions: <i>seventh cervical vertebra, </i>most prominent vertebra in the neck region; <i>acromion, </i>extreme lateral edge of the bony shelf of the shoulder; <i>inferior angle of scapula, </i>lowest point on shoulder blade; <i>epicondyles, </i>lateral and medial bony points at the pivot of the elbow; <i>ulnar styloid, </i>projecting point on little-finger side of the wrist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Arm and Trunk Measurements</h4> <p>The typical male torso and upper extremity are shown in <b>Fig. 2</b>, which, together with <b>Table 1.</b>, was derived from average measurements on Army personnel.<a></a> Such an average form serves to establish harness patterns and control paths. The arm, forearm, and epicondyle-thumb lengths constitute the basis of sizing prostheses.<a></a> (In everyday language the word "arm" is of course taken to mean the entire upper extremity, or at least that portion between shoulder and wrist. In anatomical terms, "arm" is reserved specifically for the segment between shoulder and elbow, that between elbow and wrist being the "forearm." Although in the lower extremity the word "leg" commonly means the entire lower limb, whereas anatomically the "leg" is that segment between knee and ankle, confusion is easily avoided because we have the special word "shank." No such spare word is available to describe the humeral segment of the upper limb.-Ed). Arm length places the artificial elbow; forearm length locates the terminal device. The epicondyle-thumb length is an important over-all sizing reference because in the unilateral arm amputee it is customary to match hook length (and, in the case of the artificial hand, thumb length) to the length of the natural thumb <b>(Fig. 3)</b>.The bilateral arm amputee can be sized from body height by means of the Carlyle formulas<a></a>, which employ factors derived from average body proportions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic anthropometry of the male torso and <b>upper extremity. </b>See 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. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Correct lengths for upper-extremity prostheses. In the unilateral case, hook length is made to coincide with normal thumb length, as is also the thumb length of the artificial hand. For bilateral arm amputees, <i>A = </i>0.19 X (body height); <i>B + C </i>= 0.21 X (body height). After Carlyle (J). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Anatomy</h4> <p>The human torso, shoulder, and upper extremity are exceedingly complex structures. In any dealing with these elements of anatomy, therefore, it is desirable to sort out from the mass of detail those features important to the particular area of study and application. Where prosthetic controls are concerned, the mechanism of movement is the central subject of consideration. This functional anatomy treats of the aspects of bone, joint, and muscle structure that together determine the modes and ranges of motion of the parts. It is a descriptive science, and while to escape dependence upon nomenclature is therefore impossible, the purpose here is to convey a basic understanding of the operation of the upper-extremity mechanisms without undue use of specialized terminology. In any case, the reader should have available basic anatomical references such as <i>Gray's Anatomy</i><a></a> or kinesiology texts such as those of Steindler<a></a> and of Hollinshead. <a></a></p> <h4>Elementary Motions of the Upper Extremity</h4> <p>The geometry of each joint is complex, and most movements involve an interaction of two or more joints. Consequently, a motion nomenclature based on joint movements would be unnecessarily complicated. More simply, the motion of each part upon its proximal joint may be described with respect to the principal planes which intersect at that joint. In this system, moreover, one may define a standard position in which the trunk is erect, the arms hang with their axes vertical, the elbows are flexed to 90 deg., and the wrist planes are vertical to assume the "shake-hands" position. <b>Fig. 4</b> presents the angular movements possible in the three planes of space. The shoulder-on-chest, arm-on-shoulder, and hand-on-wrist actions take place through two angles, as if moving about a universal joint. Geometrically, the arm motions are more precisely defined by a spherical coordinate system where the segment position is given by longitude and colatitude angles. For descriptive purposes, however, the anatomical nomenclature is commonly used. It should be recognized that, for multiaxial joints, flexion-extension and elevation-depression angles describe motions in the major orthogonal planes only, and intermediate angular excursions must be thought of as combinations of these motions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Simplified movement system in the upper extremity. Wrist flexion is omitted since ordinarily it is not involved in upper-extremity controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified movement system depicted in <b>Fig. 4</b> is incomplete in many ways. Not included are such movements as twisting of the shoulder due to various scapular movements, anterior-posterior swings of the arm in positions of partial elevation, and the slightly conical surface of revolution of forearm flexion.(It deserves to be noted here that, taken literally, expressions such as "forearm flexion-extension," "arm flexion-extension," and "humeral flexion-extension" represent questionable nomenclature. To "flex" means to "bend." Limb segments do not bend very readily without breaking. Joints are <i>designed </i>for flexion. In the lower extremity, for example, one speaks not of "shank flexion" but of "knee flexion," not of "thigh flexion" but of "hip flexion." That is, one uses "flexion" or "extension" not with reference to motion of the distal segment but with reference to the more proximal joint. Although Webster accepts the expression "to flex the arm," he obviously uses the word "arm" in the everyday sense of meaning the entire upper extremity, or at least that portion between shoulder and wrist. Because this loose terminology in the upper extremity is so widely established, not only among workers in prosthetics, it is used throughout this issue of Artificial Limbs, with the understanding that "forearm flexion" means "elbow flexion," "arm flexion" and "humeral flexion" mean "flexion of the glenohumeral joint (and associated structures) " See page 9 <i>et seq.</i>-Ed.). These details may, however, be ignored in the interest of the simplicity of description that is adequate for the purposes of upper-extremity prosthetics.</p> <h4>The Shoulder Girdle</h4> <p><i>Skeletal Members and Joints</i></p> <p>The scapula and clavicle are the chief bones making up the shoulder girdle. Secondarily, the proximal portion of the humerus may be included, since the close interarticulation of all three bones at the shoulder joint gives a considerable degree of coordinated activity among them and also extends to the complex as a whole the actions of many of the muscles inserting on the individual members.</p> <p>Details of the skeletal anatomy involved are shown in <b>Fig. 5</b>. There are in the system two joints and one pseudo joint. In the sternoclavicular joint, the clavicle articulates with the sternum in a somewhat saddle-shaped juncture recessed in a concavity within the sternum. The biaxial surfaces permit movements in two planes. Ligaments crossing the joint prevent displacement of the clavicle anteriorly and laterally. The elevation-depression range is 50 to 60 deg., the flexion-extension range from 25 to 35 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Skeletal anatomy of the shoulder region, <i>a, </i>Anterior view. <i>b, </i>Posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the acromioclavicular joint, the distal end of the clavicle articulates with the scapula in an elliptical juncture which permits a ball-and-socket type of action. The acromioclavicular ligaments bind the joint directly. Strong ligaments from the clavicle to the coracoid process give important additional stabilization. The range of movement is small, being only about 10 deg. in the frontal and sagittal planes.</p> <p>The pseudo joint, the scapulothoracic, is a muscular suspension which holds the scapula against the thoracic wall but which at the same time permits translatory and rotatory movements. A large factor in maintaining this joint in position is barometric pressure, which is estimated to act upon it with a force of 170 lb.</p> <p><i>Muscles and Movements</i></p> <p>The complex arrangement of bony elements is rivaled by the involved nature of the muscles of the shoulder girdle and by the intricate ways in which they act upon it. The schematic view of <b>Fig. 6</b> presents the fundamentals. Elevation of the shoulder is seen to be brought about principally by elevators and downward rotators of the scapula, such as the upper trapezius, the levator scapulae, and the rhomboids. Although the rhomboids assist in elevation, they do not contribute to upward rotation. Depression of the shoulder is mediated by muscles inserted on the scapula, the clavicle, and the proximal end of the humerus. Anteriorly the lower fibers of the pectoralis major, the pectoralis minor, and the sub-clavius, and posteriorly the lower trapezius and latissimus, act as depressors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic kinesiology of the shoulder girdle. <i>L, </i>latissimus; <i>LS, </i>levator scapulae; <i>LT, </i>lower trapezius; <i>MT, </i>medial trapezius; <i>PM, </i>pectoralis major; <i>Pm, </i>pectoralis minor; <i>RM, </i>rhomboid major; <i>Rm, </i>rhomboid minor; <i>SA, </i>serratus anterior; <i>SC, </i>subclavius; <i>UT, </i>upper trapezius. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the scapula upward <i>(i.e., </i>right scapula, viewed from the rear, rotates counterclockwise) or downward <i>(i.e., </i>right scapula, viewed from the rear, rotates clockwise) is brought about by a special combination of the elevators and depressors. As shown in <b>Fig. 6</b>, two portions of the trapezius, together with the serratus, cause upward rotation. Conversely, the pectorals, the latissimus, and the rhomboids cooperate to cause downward rotation. As will be seen later (page 13), the mechanical principle of the couple applies in these rotatory actions upon the scapula.</p> <p>Flexion and extension of the shoulder involve as principal elements the abduction and adduction, respectively, of the scapula. The flexor muscles acting on the shoulder complex are the pectoralis major and minor, which swing the clavicle and acromion forward. The serratus anterior aids strongly by abducting the scapula. The extensors, placed posteriorly, include the latissimus, which pulls posteriorly and medially on the humerus, and the trapezius and rhomboids, which pull medially on the scapula.</p> <p>The forward and backward shrugging of the shoulders with abduction and adduction, together with some upward and downward rotation of the scapulae, constitutes a major control source. Even in above-elbow amputees who use humeral flexion for forearm lift and for terminal-device operation at low elbow angles (page 22), scapular abduction is utilized for terminal-device operation at large angles of elbow flexion <i>(e.g., </i>when the terminal device is near the mouth). In shoulder amputees, both these operations depend wholly upon scapular abduction augmented by upward rotation.</p> <h4>The Arm</h4> <p><i>The Humerus and the Glenohumeral Joint</i></p> <p>The humerus, together with its joint at the shoulder, comprises the skeletal machinery of the arm. As noted in <b>Fig. 4</b>, it is capable of flexion-extension, elevation-depression, and rotation upon its proximal joint. The glenoid cavity, a lateral process on the scapula, receives the spherical surface of the humeral head. The glenohumeral articulation is therefore of true ball-and-socket character. The fibrous joint capsule is remarkable in that it envelops the humeral head and the glenoid margins in complete but rather loose fashion, so that a wide range of movement is possible. To some extent barometric pressure, but to larger extent the musculature spanning the joint, is responsible for keeping the articular surfaces together in all angular positions. A group of muscles including the subscapularis, the supraspinatus, and the infraspinatus function principally in this holding action.</p> <p><i>Muscles and Movements</i></p> <p>The kinesiology of the arm is closely associated with that of the shoulder girdle, nearly all natural movements involving a coordinated movement between arm and shoulder. It is helpful, however, first to describe the pure movements of the arm. Schematics of the muscles acting upon the arm are presented in <b>Fig. 7</b>. Elevation is effected by the lateral deltoid and the supraspinatus, depression by the latissimus, the pectoralis major, the long head of the triceps, and the teres major. In both actions, the contributions of individual muscles differ according to the angle of the arm. And it should be noted that, with insertions near the pivot point of the humeral head, the rotatory moments are proportionately small, thus accounting for the large number of muscles necessary to give adequate joint torques. Arm flexion and extension are brought about by two groups of muscles. The biceps, the coraco-brachialis, the anterior deltoid, and the clavicular fibers of the pectoralis major mediate flexion, while the posterior deltoid, the long head of the triceps, the latissimus, and the teres major effect extension. Rotation of the arm depends upon muscles that insert on the surface of the humerus and then pass anteriorly or posteriorly around it to impart medial or lateral torsion. As would be expected, rotational forces are greatest when the arm hangs at the side; torque is reduced drastically when the arm is elevated over the head and the twisting angles of the muscles tend to disappear.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Schematic kinesiology of the arm. <i>AD, </i>anterior deltoid; <i>B, </i>biceps; <i>CB, </i>coracobrachialis; <i>IS, </i>infraspinatus; <i>L, </i>latissimus; <i>LD, </i>lateral deltoid; <i>PD, </i>posterior deltoid; <i>PM, </i>pectoralis major; <i>S, </i>subscapularis; <i>SS</i>, supra-spinatus; <i>T, </i>triceps; <i>TM, </i>teres major; <i>Tm, </i>teres minor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Combined Arm and Shoulder Movements</i></p> <p>In most natural arm movements, such as arm elevation, arm flexion, forward reaching, and to-and-fro swings of the partially elevated arm, both arm and shoulder girdle participate. In full arm elevation of 180 deg., for example, 120 deg. are contributed by rotation of the arm on the glenohumeral joint, 60 deg. are contributed by upward rotation of the scapula.<a></a>In forward reaching, involving partial arm flexion, the shoulder flexes and the scapula abducts and rotates slightly. Properly managed, this motion, the common flexion control motion of both the above- and the below-elbow amputee (pages 19-22) can give marked gracefulness to prosthetic operation.</p> <h4>The Forearm</h4> <p><i>Skeletal Members</i></p> <p>The radius and ulna together constitute a forearm lever which can rotate about the elbow axis. By virtue of the arrangement at the proximal head of the radius and at the distal end of the ulna, the forearm can also carry out torsion about its longitudinal axis to produce wrist rotation. With the aid of the mobility at the shoulder and at the wrist, it is possible to place the hand in space in an almost unlimited number of positions. The skeletal anatomy of the elbow is shown in <b>Fig. 8</b>, the articulations being the ulno-humeral and the radiohumeral. Participating in forearm rotation is the radioulnar joint at the wrist.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The right elbow joint, viewed from in front. The thin capsular ligament is not shown. Note that the ulna, with its posteriorly projecting olecranon, forms a hinge joint with the humerus, while the head of the radius is free to rotate within the annular ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The ulnohumeral joint has an unusual structure. The complex surfaces of articulation between ulna and humerus are such that the axis of rotation of the forearm is not normal to the long axis of the humerus. As the elbow is flexed or extended, therefore, the forearm does not describe a plane. Instead, the ulna swings laterally as the elbow is extended, until at full extension the cubital angle is about 170 deg. Xevertheless, only small error is involved in considering the motion to be essentially that of a simple hinge with an axis of rotation perpendicular to ulna and humerus and allowing the ulna to swing through about 140 deg. of flexion.</p> <p>In the radiohumeral joint, the slightly concave proximal end of the radius articulates with the hemispherical capitulum placed somewhat laterally on the anterior surface of the distal end of the humerus. The radius is free to move with the ulna through the complete range of flexion and, in addition, to rotate with forearm pronation and supination. In the radioulnar joint, the distal end of the ulna forms a curved surface against which the radius opposes an articulating concavity. As the forearm goes through a pronation-supination range of about 170 deg., the radius "swings like a gate" about the distal end of the ulna.</p> <p><i>Muscles and Movements</i></p> <p>As shown in <b>Fig. 9</b>, the musculature for providing forearm flexion and extension is comparatively simple, while that for pronation-supination is somewhat more involved. Flexion of the forearm is effected principally by the biceps, originating on the scapula and inserting on the radius, and by the brachialis, spanning the elbow from humerus to ulna. Secondarily, the brachioradialis and other muscles, originating distally on the humerus and coursing down the forearm, contribute to flexion. Extension is largely the function of the triceps, originating on both the scapula and humerus and inserting on the leverlike olecranon process of the ulna. A small extensor action is added by the anconeus.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Schematic kinesiology of the forearm. <i>A, </i>anconeus; <i>B, </i>biceps; <i>BR, </i>brachialis; <i>BrR, </i>brachioradialis; <i>PT, </i>pronator teres; <i>PQ, </i>pronator quadratus; <i>Su, </i>supinator; <i>T, </i>triceps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the forearm is a function of many muscles. Some, such as the supinator, evidently are designed for the purpose, while others, as for example the finger flexors, have different principal functions, the contribution to forearm rotation being only incidental. <b>Fig. 9</b> presents the major rotatory muscles only. Supination is mediated by the brachioradialis, the supinator brevis, and the biceps, pronation by the pronators quadratus and teres. Of great importance to upper-extremity prosthetics is the fact that rotation of the forearm is a function of total forearm length. With successively shorter stumps, not only are the rotation limits of the radius and ulna reduced, but also the contributions of muscles are eliminated as their insertions are sectioned.</p> <h4>Musculoskeletal Mechanisms</h4> <p>The upper extremity having been considered from the standpoint of functional and descriptive anatomy, attention may now be turned to a more mechanical view of its operations. Typical elements of mechanism in the upper extremity include joints (bearing surfaces), joint-lining secretions (lubricants), bones (levers and couple members), tendons (transmission cables), and muscles (motors). The arrangement of these elements makes up a complex machinery capable of such diverse activities as precise orientation in space, performance of external work, fine digital manipulations, and so on.</p> <h4>Typical Joint Mechanics</h4> <p>The elbow joint embodies the essential structures of diarthrodial joints. The bearing surfaces are covered with a thin layer of articular cartilage that is continuous with the synovial membrane lining the whole joint capsule. Subsynovial pads of fat serve to fill up the changing spaces that occur during movement of the joint (<b>Fig. 10</b>). It is believed that these fatty deposits serve as "pad oilers" to maintain the continuous film of synovial fluid over the articular surfaces.<a></a> This fluid contains mucin (a glycoprotein which serves as a lubricant for the joint) and other material constituting a nutritional medium for the articular cartilage. Considerable uncertainty exists concerning the method of formation and distribution of the fluid to the joint, but its mechanical function is clear and the normal joint performs as a well-oiled bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Typical change in joint spaces with flexion-extension, as revealed by the elbow. Redrawn from Steindler <i>(17), </i>after Fick. <i>A, </i>Gap of the medial border of the olecranon surface with elbow in extreme extension. <i>B, </i>Gap of the lateral border of the olecranon in extreme flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bones and Their Mechanical Function</h4> <p>The bones of the upper extremity, besides forming a support for soft tissue, provide a system of levers which makes the arm an important mechanism for the performance of gross work, such as lifting, slinging, and thrusting. The arm bones serve further as positioners of the hand, in which other, finer bones constitute the intricate articulated framework of the manipulative mechanism. Two main features of bones merit discussion here-their internal composition and construction and their external shape and adaptations that permit them to serve as members of mechanical systems.</p> <p><i>Internal Structure</i></p> <p>There is much evidence that the gross internal structure of bone is eminently suited to withstand the mechanical stresses placed upon it by the compressive loads of weight-bearing, by the tensions of tendons and ligaments, and by the lateral pressures of adjacent tissues.<a></a>The nature and orientation of the trabeculae in cancellous bone have, for example, long been held, in theory, to provide the maximum strength along the lines of major stresses. This idea, originally suggested by von Meyer, has been championed by many, including Koch, who carried out a stress analysis on the femur.<a></a> Objections to the von Meyer theory have dealt largely with the frequent and incautious extension of the concept. It is now believed that genetic and growth factors determine the essential form and dimensions of bone. Mechanical stresses serve secondarily to mold and modify it to give added strength where stresses are greatest. One must grant from even a superficial examination of the internal structure of bone that Nature has done an admirable job of designing for maximum strength with minimum weight.</p> <p><i>Members of Mechanical Systems</i></p> <p>The second principal feature of bones, that of serving as rigid members in a complex of mechanical systems, is the one that has engaged the most attention. It is surprising that the simple lever concepts of Archimedes have persisted in anatomy and kinesiology texts to the present day. Thus, the forearm-flexor system is said to act as a third-class lever, the extensor system as a first-class lever. Although these assertions are of course true, both of these systems are, in the more complete language of Newtonian mechanics, parts of force-couple systems in which equal and opposite components of force are transmitted through the bones and joints (<b>Fig. 11</b>). Elft-man<a></a> has emphasized this view. The magnitude of the couple is given by the product of the force (either of the equal but opposite forces) and the distance between them, which also is numerically equal to the torque of the muscle force. The concept of the couple calls attention to the existence of the equal and opposite forces in joints and emphasizes the loads placed upon them by muscular work. Another and more complicated application of the couple is seen in scapular rotation. Here, as described by Inman <i>el al.</i><a></a> and as shown in <b>Fig. 12</b>, the pull of the lower fibers of the serratus anterior upon the scapula is such as to give it upward rotation, while the thrust of the clavicle, acting through the acromioclavicular joint, holds a pivot for the rotation. Simultaneously, the pull of the upper trapezius fibers causes the clavicle to undergo angular rotation about the sternoclavicular joint. The result is that, at least through the first 90 deg. of arm elevation, the motion is shared by coordinated angular rotations of scapula, clavicle, and humerus. As a basic part of this rotatory action, the scapula acts as the moment arm of a force couple, the trapezius and serratus providing components of force which are equal and opposite.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Force couples at the elbow. Tensile forces in biceps and brahialis are associated with equal, opposite, and parallel forces through the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Muscle forces acting on the shoulder, anterior view. The trapezius, acting diagonally, gives a supportive component. <i>Fy</i>,<i>, </i>and a horizontal component, <i>Fx, </i>which together with the opposite force from the serratus, 5, comprise an upward rotatory force couple on the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Tendons and Muscles</h4> <p>The specific functions of tendons are to concentrate the pull of a muscle within a small transverse area, to allow muscles to act from a distance, and in some instances to transmit the pull of a muscle through a changed pathway. The mechanical importance of this tissue is nowhere more evident than in the arm, where a large degree of versatility of motion in the segment distal to each joint is preserved by "remoting" the action of muscles through slender, cablelike tendons over joints. By this means lines of pull are brought near the joint axes, thus providing a lever arm consistent with the tensile force of the muscle at all joint angles and also giving at low joint angles an increased angular motion for a given linear contraction. Other advantages of remoting the muscles are seen in the forearm and hand. In order to afford the variety and complexity of interdigital movements, many independent muscle units are necessary, and critical space problems are avoided because muscles such as the common flexors and extensors of the fingers are placed at some distance up the forearm.</p> <p>The predominant function of tendon as a tension member in series with muscle, which is a tension motor, is seen in early growth stages. An undifferentiated cellular reticulum of connective tissue is everywhere found in embryonic tissue. The parent cells are fibroblasts; they elaborate and extrude the collagenous material of which white fibers are made. <a></a> At this point the presence of mechanical tensions in the tissue influences the rate, amount, and direction of the resultant fiber formation. At maturity the tendon is composed almost entirely of white collagen fibers, closely packed in parallel bundles, to form a cablelike strand. It is contained within a sheath which forms a loose covering lubricated continuously by a mucinous fluid to reduce friction with surrounding tissues.</p> <p>Mutual adjustment of the characteristics of muscle and tendon is shown in many respects. The musculotendinous juncture varies with the arrangement of the muscle fiber. It shows a simple series arrangement for fusiform muscles like the biceps, or it comprises a distributed attachment zone by continuation of the tendon into intramuscular septa where pinni-form fibers may insert (<b>Fig. 13</b>). In some unexplained way the relative lengths of muscle and associated tendon are so composed that the shortening range of the muscle is that necessary to move the segment distal to the joint through its maximum range.<a></a> The capacity to adapt the ratio of muscle length to tendon length has been demonstrated in an experiment in which the pathway of the tibialis anterior tendon in the rabbit was shortened. The result was that the tendon shortened while the muscle lengthened to regain the normal joint range.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Muscle fiber patterns. <i>A, </i>Fusiform. <i>B, </i>Bipinniform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The relative strengths of muscle and of tendon also show an approximate compatibility, the tensile strength of tendon, measured at from 8700 to 18,000 lb. per sq. in.<a></a>, being greater than that for muscle. Strength tests of excised muscle-tendon systems show that failure commonly occurs in the belly of the muscle, or at the musculotendinous juncture, or at the bone-tendon juncture, but never exclusively in the tendon itself. Analysis of clinical cases indicates that muscle is still the site of failure even when it is maximally tensed.<a></a> It is clear, then, that of the muscle-tendon combination the tendon is normally always the stronger.</p> <h4>Forearm-Fexor Mechanics</h4> <p>The forearm-flexor system is well suited to serve as an example of biomechanics because the bone-joint system comprises a simple uniaxial hinge while the flexor muscles, though five in number, can be reduced to a single equivalent muscle whose geometry and dynamics can be specified from measurement data. <b>Fig. 14</b> illustrates the lever system on which the equivalent muscle acts. The angle between the axis of the muscle and that of the forearm bones, <i>i.e., </i>the "angle of pull," theoretically ranges from 0 deg. at full extension to 90 deg. at 100 deg. of elbow angle, and since the moment arm is continuously proportional to the sine of the angle of pull the mechanical advantage of the lever also is proportional to it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Forearm-flexor mechanics. Insert gives the geometry of the idealized flexor system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are of course departures from this idealized geometry. For one thing, the angle of pull and the elbow angle are not exactly equal. Moreover, at small elbow angles the torque component does not actually drop to zero because the muscles must always pass over the elbow joint at some finite distance from its center. Finally, the force-length curve<a></a> of the equivalent muscle must also be taken intoaccount in expressing the effective torque. For these and other reasons, actual torque measurements take precedence over theoretical calculations, and the composite curve of <b>Fig. 14</b> has been plotted from the results of a number of investigators. Whereas the moment arm peaks at an elbow angle of 100 deg., the muscle force is declining throughout the elbow-flexion range, and the net effect, as reported by Miller ,<a></a> is a maximum torque of about 625 lb.-in. at from 80 to 90 deg. Clarke and Bailey<a></a> found a peak of about 400 lb.-in. at between 70 and 80 deg., and the author has obtained 550 lb.-in. just under 90 deg. in a group of subjects. Wilkie's data give a value of about 525 lb.-in. at 80 deg., measured on himself.<a></a> These variations can be explained as resulting from the effect of a limited sampling of an inherently variable characteristic. Greater consistency probably could be obtained in a larger series of measurements.</p> <h4>Maximum Torques in Major Aactions</h4> <p>Because they express the fundamental output characteristics, and because they are most easily measured, the muscle torques about the major joints represent the most significant and practical aspects of the statics and dynamics of the musculoskeletal system. Not only is muscular power a concept of uncertain validity but also it is very difficult to measure. The combined effect of muscle and lever, however, can easily be measured in many subjects, so that statistical stability can be achieved in the results. Because muscle agonists change length with joint angle, and because they are thus caused to work on different parts of their length-tension diagrams, joint torques vary as a function of joint angle. As demonstrated by Clarke<a></a>, this phenomenon, shown in <b>Fig. 14</b> for the forearm-flexor system, holds more or less for all major actions about the joints. But these details may be neglected in summarizing the maximum torques throughout the upper-extremity system (<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 /> <h4>The Functional Role of Sockets</h4> <p>The socket is the foundation of the upper-extremity prosthesis. It obtains purchase upon the most distal segment of the remaining member and should be stable, though comfortable, in its fit with this member. The socket must bear weight both axially and in all lateral directions. It is the attachment member for mechanical components and for control guides and retainer points. Hence the socket must be a sound structural member as well as a custom-fit, body-mating part. Finally, the socket extends the control function of the member to which it is fitted, giving movement and direction to the prosthesis. In any discussion of prosthetic controls, therefore, the starting point is the socket.</p> <p>The requirement of formability and strength in sockets has been met satisfactorily by the introduction of polyester laminates.<a></a> These materials permit close matching of the stump impression, and variations in strength can be introduced by increasing the number of laminate layers. The double-wall construction<a></a> provides a stump-fitted inner wall, with an outer wall that can be designed to structural uniformity and cosmetic requirement. Sizing to achieve this aim has now been reduced to standard practice. <a></a> Finally, the texture and coloring of the plastic laminate can be controlled to achieve satisfactory cosmetic results.</p> <h4>The Below-Elbow Socket</h4> <p>The peculiar feature of the forearm, that pronation-supination is a function of the whole forearm length, places a special limitation on the below-elbow socket. Although for stability in flexion the whole remaining forearm stump is best sheathed in the socket, to do so prohibits forearm rotation. In the case of the longer below-elbow stumps, therefore, some sacrifice in stability can be afforded in the interest of retaining forearm rotation. The proximal portion of the socket is fitted loosely to give freedom for forearm rotation while the distal portion is fitted snugly to provide a stable grip. <b>Fig. 15</b> shows the amount of forearm rotation available at various levels of the natural forearm and that remaining in below-elbow amputees of various types. Because of torsion of the flesh, however, and because of slippage between the skin and the socket, effective socket rotation is lost in stumps which are only 50 percent of forearm length. The effective socket rotation remaining in the wrist-disarticulation case is only about 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Below-elbow amputee types, based on average forearm length, epicondyle to styloid. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further adaptations of below-elbow sockets to suit the functional requirements at the various levels are shown in <b>Fig. 16</b>. In the long below-elbow stump, the elliptical cross-section of the forearm near the wrist permits a "screw-driver" fit of the socket to yield the maximum in rotational stability. With the shorter stumps, the possibility of effective rotation is reduced and is lost completely at about 50 percent of forearm length. At this level, the problem of forearm rotation is outweighed by that of providing flexion stability. Dependence upon a rigid or semirigid hinge system is necessary in the short below-elbow stump, and finally, in the very short stump, effective forearm flexion is so reduced that a split socket with step-up hinge becomes a necessity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematics of below-elbow prostheses. For each type, an insert gives the cross-sectional anatomy 1 in. from the end of the stump. Sections are taken from the normal anatomy of the forearm. Sockets, hinges, cuffs, and suspensions are for <i>a, </i>single socket; <i>b, </i>rotation type; <i>c, </i>double-wall socket; and <i>d, </i>split socket. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The goal of below-elbow socket design is to regain as completely as possible the control function of the forearm, which includes <i>(a) </i>positioning of the hand by forearm flexion and <i>(b) </i>hand rotation by means of pronation-supination. In the below-elbow prosthesis, adequate forearm flexion is obtained rather easily; rotation is limited to the potential available in the longer stumps. Manual wrist rotation, of course, supplements the remaining natural rotation. In the below-elbow prosthesis, then, control of the terminal device in space depends in fair measure upon the role of the socket in preserving the residual flexion and rotation of the below-elbow stump.</p> <h4>The Above-Elbow Socket</h4> <p>Unlike the below-elbow case, the above-elbow stump presents no problem of diminishing rotation with diminishing stump length because arm rotation is confined wholly to the gleno-humeral joint. Socket design for the above-elbow case is therefore related principally to the requirement of fitting the stump closely so that the humeral lever can be fully effective in controlling the prosthesis. <b>Fig. 17</b> shows the minor variations corresponding to above-elbow type, including the elbow disarticulation. Sockets for the latter must take account of the bulbous end of the stump. They must provide snug fit around the epicondyle projections but maintain sufficient room in the region just above, where the stump cross-section is reduced, to permit insertion of the stump in the socket. In both the elbow-disarticulation and the standard above-elbow cases, the upper margin of the socket is terminated below the acromion for freedom of movement at the shoulder. In the short above-elbow case, the socket is carried up over the acromion to obtain additional stabilization and suspension from the shoulder, as required by the very limited stump area. The control function of the above-elbow socket is twofold. As in the below-elbow case, the socket extends the slump to the next more distal joint and thus gives range and direction to this component upon which the positioning of the still more distal segments depends. But in addition to this feature, the above-elbow socket also has a power function. Through its attachments to shoulders and torso, it provides the forces and displacements needed to produce forearm flexion, terminal-device operation, and elbow lock. To fulfill these functions, the socket must have stable purchase on the stump in both flexion and extension. Hence, for elbow-disarticulation and above-elbow types, the socket should continue to the axillary level; for short-above-elbow amputees, it should come up over the acromion (<b>Fig. 17</b>). Finally, medial and lateral rotation of the socket are necessary for further functional positioning. Close fit and good suspension are required to give stability in these actions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Schematics of above-elbow sockets, including elbow disarticulation. For each type, an insert gives the cross-sectional anatomy at the indicated level. Dashed lines show stump contour and inner wall of the socket. Standard and short above-elbow cases have a double-wall socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Shoulder Socket</h4> <p>In the range of amputation sites from transection of the humeral neck to complete removal of the shoulder girdle, the socket form changes from shoulder cap to thoracic saddle. As displayed in <b>Fig. 18</b>, the bearing area increases as the remaining shoulder elements are reduced; similarly, the amount of "build-out" needed to preserve shoulder outline increases with increasing amputation loss. With disarticulations and all more extreme losses, sectional plates may be introduced at the axillary parasagittal plane. This arrangement makes it possible to fabricate the prosthesis in two sections, a matter of considerable advantage to the limbmaker, and it also affords the functional advantage of a preposition swivel of the humeral section upon the saddle section to simulate flexion-extension of the arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematics of shoulder sockets. Solid lines show residual bony structure, dashed lines the body contour and inner wall of the socket. Disarticulation and forequarter sockets may be two-piece with sectional plates at <i>a.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The functional aspects of the shoulder socket are to some extent secondary to the structural; yet there are certain definite functional ends to be served. Shoulder and scapular mobility in elevation, flexion, and extension should be preserved to the highest possible degree. In humeral-neck and shoulder-disarticulation cases, aid can be given to the shrug control (biscapular abduction), and at least a small range of motion can be given to the elbow, but of course no such function can be expected in forequarter or partial-forequarter amputees.</p> <h4>Major Arm and Shoulder Controls</h4> <p>The common method of operation of upper-extremity prostheses is by means of shoulder harness which provides suspension and which also transmits force and excursion for control motions. In this manner such operations as forearm flexion-extension, terminal-device operation, and elbow lock are managed. <b>Fig. 19</b> presents the essential features of the major harness controls. In principle, each effective control must begin with a point stabilized on shoulder or torso, pass over a voluntarily movable shoulder or arm part, and thus provide relative motions with respect to the origin. At the movable point, the control cable enters the Bowden-type housing, which transmits the relative motion independent of movements of the distal segments. Controls may be used singly or in combination, depending upon the level of amputation, amputee preference, and other practical considerations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Major harness controls. The points stabilized by harness (x) are beginning points for the control cable, which passes into a Bowden-type housing at movable points (¦). The relative motion is transmitted via the Bowden cable to distal points on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides the relative motions between various segments of the human body, still another source of energy for operation of upper-extremity prostheses can be made available by the surgical procedure known as cineplasty, <a></a> in which a skin-lined tunnel is fashioned in the belly of a muscle group. In various experimental programs conducted both here and abroad, muscle tunnels have been made in the forearm flexors, the forearm extensors, the biceps, the triceps, and the pectoralis major.</p> <p>Of all the various combinations tried, the biceps tunnel in below-elbow amputees has proved to be the most successful. Failure of other cineplasty systems has been due in some cases to inability of designers to overcome the mechanical problems involved in harnessing the energy thus provided and in other cases to the inherent properties of the particular muscle group concerned. In the below-elbow case, use of the biceps tunnel eliminates the need for shoulder harness and permits operation of the prosthesis with the stump in any position. It has given excellent results in many instances and has been made available to those beneficiaries of the Veterans Administration who can make effective use of the procedure.<b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Coordinated control motions for elbow lock. Simultaneously the humerus is both extended <i>(a) </i>and abducted <i>(b) </i>while the shoulder is depressed (c) and the trapezius is bulged <i>(d) </i>by downward rotation of the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cineplasty tunnel in the biceps of the average male will provide sufficient force and excursion to operate modern terminal devices-an average maximum force of 50 lb. and 1 1/2 in. of useful excursion. It is not unusual for some individuals to be able to build up the force available to a value in excess of 100 lb., but such a high force normally is not required.</p> <h4>The Nature and Operation of Ccontrol Systems</h4> <p><i>The Below-Elbow Single-Control System</i></p> <p>The single control for the below-elbow amputee is powered by arm flexion to provide terminal-device operation. This control motion, used by the above-elbow amputee also, depends upon a coordinated flexion of the humerus and abduction of the scapula on the amputated side; little shoulder activity is required on the sound side. It is substantially the same motion as that used in normal unilateral reaching. The displacements of humerus and scapula are additive, so that the resulting motion is quite natural. With full Bowden-cable transmissions of power from arm cuff to forearm socket, there is no influence of elbow angle, and the operation is mastered easily by all amputees with stumps of 35 percent or more of normal forearm length.</p> <p><i>The Below-Elbow Dual-Control System</i></p> <p>(Although the terminology commonly used to describe the several control systems could well afford to be better systematized, it is adopted here because it is now so well established throughout the field of prosthetics. One <i>may </i>think of "dual control" as meaning that two control sources are involved in the provision of all necessary functions, but according to convention it means that two functions, specifically elbow flexion and terminal-device operation, are provided by a single control source, the third function, elbow lock, if needed, being managed by an additional control source. Yet "triple control" (page 22) in the accepted sense means not that three functions are furnished by a single control source but that three control sources are used to provide three functions, one for each.-Ed.)</p> <p>In harnessing below-elbow stumps shorter than 35 percent of normal forearm length, it generally is necessary to use an auxiliary type of lift to help the amputee flex the forearm. This procedure is applicable to a split-socket type of prosthesis. It merely is an adaptation of the above-elbow dual-control system (page 22) using a lever loop positioned on the forearm section so that arm flexion may be utilized to assist in forearm lift. The cable housing is split and assembled so that when the arm is flexed the elbow will flex. The elbow hinge has no locking mechanism, the short below-elbow stump being used to stabilize the forearm. Normally, sufficient torque is available about the elbow axis to give adequate stability in all usable ranges.</p> <p>In prescribing for a new amputee with this level of amputation, it might be advisable first to have the amputee try a split-type prosthesis without the below-elbow dual-control system. If, at time of initial checkout, the amputee cannot lift his forearm, or if he complains of painful contact with his stump, then of course the dual system is indicated. After the assist lift has been worn for some time, the remaining muscles of the stump may have hypertrophied, in which case the amputee might be able to discard the dual system and convert to the below-elbow single control.</p> <p><i>The Below-Elbow Biceps-Cineplasty System</i></p> <p>Force and excursion provided by the biceps muscle tunnel are harnessed by inserting into the tunnel a cylindrical pin of a nontoxic material and attaching a cable to each end of the pin. As in the other types of control systems, the Bowden-cable principle is employed to maintain a constant effective distance between the source of energy and the mechanism to be operated, regardless of relative motions occurring between body segments. In order that conventional terminal devices may be employed, it is necessary to join the two cables before attachment to the mechanism. Several devices for making this coupling are available commercially.</p> <p>Suspension of the socket is provided by an arm cuff, which is attached to the socket by any of the various hinges normally used in fabrication of below-elbow prostheses. The arm cuff is fashioned in such a manner that forces tending to pull the prosthesis from the stump are absorbed by the condyles of the elbow rather than by the muscle tunnel.</p> <p><i>The Above-Elbow Dual-Control System</i></p> <p>In above-elbow amputees, the humeral stump furnishes the motive power for the three operations of the prosthesis-flexion of the forearm, operation of the terminal device, and management of the elbow lock. The first two operations are so linked mechanically that a single control motion, arm flexion, produces either terminal-device operation or forearm flexion, depending on whether the elbow is locked or unlocked (<b>Fig. 20</b>). Although the control motion by arm flexion in the above-elbow case is similar to that described for the below-elbow amputee, there are several differences. Because the cable passes through a lever loop on the forearm to give torque about the elbow, it is affected by elbow position. As the forearm is flexed, arm-flexion excursion is used up, and the excursion needed to operate the terminal device must come from scapular abduction (shrug), as in shoulder cases. Typically, the above-elbow amputee manages a full range of free forearm flexion by a normal arm-flexion movement. But in the elbow-angle range of from 90 to 135 deg., with elbow locked for terminal-device operation, he must call upon supplementary excursions from biscapular abduction. With the terminal device at the mouth, practically all operation depends upon shoulder shrug.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Operation of above-elbow and shoulder dual controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the above-elbow dual-control system, operation of the elbow lock depends upon humeral extension and associated coordinations. When the forearm has been flexed to the position desired, the elbow lock is engaged by the arm-extension movement. Skill is needed to maintain tension on the arm-flexion cable so that the arm does not drop during the locking control motion. Well-trained amputees elevate the arm moderately to compensate for the humeral extension and thus maintain the elbow angle. The extension control motion is complex. The humerus is simultaneously extended and elevated so that it moves obliquely to the side. During this phase, the point of the shoulder must be stabilized, or even moved forward, and the trapezius is bulged by downward rotation of the scapula (<b>Fig. 21</b>).<b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Location of the proximal retainer for both above- and below-elbow cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Above-Elbow Triple-Control System</i></p> <p>The triple-control system has been devised to separate terminal-device operation from forearm lift. When the dual-control system is used, the amputee must select, by the use of the elbow lock, either terminal-device operation or forearm lifting. By separating forearm flexion and terminal-device operation, the triple control makes it possible for the terminal device to be controlled by an independent body motion. Although in general an above-elbow amputee fitted with triple control has an elbow lock, a few such cases are able to separate prehension from forearm flexion without use of the lock.</p> <p>A control cable from the terminal device is so attached and positioned that biscapular abduction or merely shoulder shrug will operate the terminal device through its full range of prehension. To lift the forearm the amputee uses arm flexion. Elbow-lock operation is accomplished in the same manner as in the dual-control system, that is, by arm extension.</p> <p>It is apparent that this arrangement will work best with a comparatively stable socket and a relatively long above-elbow stump. The chief advantage of the triple-control system is that at full forearm flexion the terminal device may still be operated through its complete range.</p> <p><i>The Shoulder Dual-Control System</i></p> <p>In the absence of the humeral lever, the shoulder becomes the major power source, biscapular abduction controlling both forearm and terminal device in the dual-control system. The control path courses horizontally across the scapulae, and either opposite-axilla loop or basic chest-strap harness (page 46) captures the action satisfactorily. The combination afforded by the dual principle also is illustrated in <b>Fig. 20</b>.</p> <p>The shoulder amputee has a special difficulty in obtaining the combination of full forearm flexion and terminal-device operation because, unlike the above-elbow amputee, who can add the excursions of humeral flexion and scapular abduction, he must obtain all movement from biscapular abduction. Shoulder amputees with broad shoulders and wide chests usually achieve this action satisfactorily; others must accept the limitation of partial terminal-device operation at full forearm flexion. Partial-shoulder and fore-quarter amputees must depend upon the sound shoulder entirely, and in this case the action range of the terminal device typically is limited to not more than 90 deg. of forearm flexion.</p> <p>In shoulder amputees, operation of the elbow lock must be managed by various special arrangements. The waist control, utilizing shoulder elevation; the perineal strap, based on relative motion between shoulders and pelvis; the nudge control, requiring either manual or chin operation; extreme shoulder flexion on the sound side; and extension of the shoulder on the amputated side complete the array of known feasible possibilities. It is evident that with this class of amputees control motions will be slower and deliberately sequential. They are therefore necessarily more noticeable and awkward.</p> <p><i>The Shoulder Triple-Control System</i></p> <p>The harness required for the triple-control shoulder-disarticulation system consists of a chest strap for forearm flexion, a waist strap to operate the elbow lock, and an opposite-shoulder loop for prehension. The amputee must have excellent scapular abduction and must be able to separate it from extreme opposite-shoulder shrug, and he must have available good shoulder elevation on the amputated side. The chief advantage of the triple control in the shoulder-disarticulation case is identical to that of the triple control in the above-elbow case, namely, that the terminal device may be operated fully in the vicinity of the mouth. To operate the prosthesis from an extended position, the amputee first produces biscapular abduction, thus raising the forearm. Then, with the forearm held in place, he elevates the shoulder on the amputated side to lock the elbow. To operate the terminal device, he then flexes the sound shoulder. Excursion for terminal-device operation is thus unaffected by forearm flexion.</p> <p>Unfortunately this system must be restricted to humeral-neck and shoulder-disarticulation cases. For lack of sufficient excursion on the amputated side, it is unlikely that a forequarter amputee would be able to use triple control.</p> <h4>Mechanical Application of the Major Controls</h4> <p>To elucidate practical amputee biomechanics, it is necessary to refer to several aspects of the connecting mechanism between amputee and prosthesis in the power-transmission system. Of first importance are the proximal retainers, which are located at the point where the cable from the shoulder harness enters the cable housing. These retainers are the beginning points of the transmission systems indicated in <b>Fig. 19</b>. In both below- and above-elbow cases, the proximal retainer is positioned in accordance with the ratios shown in <b>Fig. 22</b>. For all above-elbow stumps of greater than 50 percent of acromion-to-epicondyle length, the proximal retainer point is placed slightly lower than half way down the arm, the reason being that the control passes naturally through this point in its course from opposite shoulder, across the scapula, and thence to the lever loop on the forearm shell. The humeral lever power is quite adequate at this point (<b>Table 3</b>), and no practical advantage is gained by a lower placement. With above-elbow stumps less than 50 percent as long as the normal arm length, acromion to epicondyle, the proximal retainers must be placed at the level of the stump end in order to prevent undue tipping of the socket, as would occur if forces developed beyond the end of the stump.</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>In shoulder cases, the control path is directed horizontally at approximately the midscapular level and brought to the arm section at the axilla. The control motion is purely biscapular abduction, and consequently the proximal retainer is placed on the prosthesis at the midscapular level. The resulting force and excursion are given in <b>Table 3</b>.</p> <p>Arm-extension forces are potentially quite high, as also shown in <b>Table 3</b>. Because only 2 to 6 lb. of force and 1/2 in. of excursion are required to operate an elbow lock, normally there is a generous power excess. The principal concern in harnessing arm-extension control is to obtain operation with minimal movement and thus to avoid awkwardness.</p> <h3>Conclusion</h3> <p>The central purpose of this article has been to outline the biomechanical basis of control in upper-extremity prostheses. Consequently, emphasis has been placed upon the normal and residual functional anatomy and kinesiology underlying this service. The particularized biomechanics of prosthesis control has been defined, and the limitations incurred in amputations at high levels have been stressed. The major message is that a thorough understanding of the motions of control available to each type of patient is necessary to the proper prescription, fitting, and training of the upper-extremity amputee. Thus only can full advantage be taken of the improved functional features to be found in modern arm components.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasly, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carlyle, L. C, <i>Using body measurements to determine proper lengths of artificial arms, </i>Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Clark, W. E. Le Gros, <i>The tissues of the body; an introduction to the study of anatomy, </i>3rd ed., Clarendon Press, Oxford, 1952.</li> <li>Clarke, H. Harrison, and Theodore L. Bailey,<i>Strength curves for fourteen joint movements, </i>J. Assoc. Phys. &amp; Ment. Rehab., 4(2):12 (1950).</li> <li>Cronkite, Alfred Eugene, <i>The tensile strength of human tendons, </i>Anat. Rec, 64:173 (1936).</li> <li>Elftman, H , <i>Skeletal and muscular systems: structure and function, </i>in <i>Medical Physics, </i>O. Glasser <i>el al., </i>eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</li> <li>Haines, R. W., <i>On muscles of full and of short action,</i> J. Anat., 69:20 (1934).</li> <li>Hollinshead, W. H., <i>Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, </i>Saunders, Philadelphia, 1951.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, <i>Observations on the function of the shoulder joint, </i>J. Bone &amp; Joint Surg., 26:1 (1944).</li> <li>Koch, John C, <i>The laws of bone architecture, </i>Am. J. Anat., 21:177 (1917).</li> <li>Lewis, Warren H., ed., <i>Gray's anatomy of the human body, </i>24th ed. revised, Lea and Febiger, Philadelphia, 1942.</li> <li>McMaster, Paul E., <i>Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, </i>J. Bone &amp; Joint Surg., 15:705 (1933).</li> <li>Miller, D. P., <i>A mechanical analysis of certain lever muscles in man, </i>Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</li> <li>Newman, R. W., and R. M White, <i>Reference anthropometry of Army men, </i>Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body tinder normal and pathological conditions, </i>Charles C Thomas, Springfield, Ill., 1955.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasly, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>Unpublished data, UCLA.</li> <li>Wilkie, D. R., <i>The relation between force and velocity in human muscle, </i>J. Physiol., 110:249 (1949).</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">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasly, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 19.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasly, Chapter 12 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>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Wilkie, D. R., The relation between force and velocity in human muscle, J. Physiol., 110:249 (1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Miller, D. P., A mechanical analysis of certain lever muscles in man, Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 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>14.</b> </td><td class="clsTextSmall">McMaster, Paul E., Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, J. Bone &amp;Joint Surg., 15:705 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Cronkite, Alfred Eugene, The tensile strength of human tendons, Anat. Rec, 64:173 (1936).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Haines, R. W., On muscles of full and of short action, J. Anat., 69:20 (1934).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, Observations on the function of the shoulder joint, J. Bone &amp;Joint Surg., 26:1 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elftman, H , Skeletal and muscular systems: structure and function, in Medical Physics, O. Glasser el al., eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Koch, John C, The laws of bone architecture, Am. J. Anat., 21:177 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hollinshead, W. H., Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, Saunders, Philadelphia, 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>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Lewis, Warren H., ed., Gray's anatomy of the human body, 24th ed. revised, Lea and Febiger, Philadelphia, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 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>2.</b> </td><td class="clsTextSmall">Carlyle, L. C, Using body measurements to determine proper lengths of artificial arms, Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 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>16.</b> </td><td class="clsTextSmall">Newman, R. W., and R. M White, Reference anthropometry of Army men, Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 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>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-2.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-19.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 The Biomechanics of Control in Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * https://staging.drfop.org/files/original/49c94e40d4d54801334c52a842ace4ed.pdf dfd86192aa56e645f99a7c566fa941e8 https://staging.drfop.org/files/original/cce24bee2b5fe0991388af212606ef74.jpg ef1c0dca41b0ab7c44300e6d6091dd63 https://staging.drfop.org/files/original/199ca305134e9005ef91d638f8f25894.jpg 4d0d5f177626a693aa2a260770eb3efe https://staging.drfop.org/files/original/3b360735bbb0fa0e3625db6dd8935a67.jpg 8bdbbe6dafaf8a396b30924bdd787d52 https://staging.drfop.org/files/original/dc137a63c334eca56c849eda853b7319.jpg 7b8647f7d925ec33f9fa8a9a30a7d76f https://staging.drfop.org/files/original/58a988e3c29cc1d77b5365f3b12fe7d6.jpg 11bfd9c94220dbf30ca3160cb92e64f0 https://staging.drfop.org/files/original/4104cbcff18b94957f89ad19c3538698.jpg 8f1672e6e9c7dcacb675b2c54346f4cf https://staging.drfop.org/files/original/f86a93f16d5cf433387b83c39de6baa1.jpg 1ba6d10dde2dbe083655de3498ff8947 https://staging.drfop.org/files/original/fe9962a5d48a6f8a2f401747a9d789e2.jpg 18e845753cbf9ac4c03f05dccf0a62a0 https://staging.drfop.org/files/original/a69de05bc1f9b589ef237d17add3a5ea.jpg 5423422d8380b01fc0c804ba17696ffa https://staging.drfop.org/files/original/bd3186304f87a62dee0927d9e017c4a7.jpg 323ef747f37e5e92fd66564ce31dd76b https://staging.drfop.org/files/original/221f45275c014c8446f733e660935c09.jpg 9104d70c79a83ac6f37205e2e6128e18 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_029.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 29 - 38 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_029.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Establishment of a rational procedure for the proper fitting of a leg prosthesis to an amputee at <i>any </i>level of amputation requires careful consideration of many factors. The process of evolution of a new and satisfactory method of fitting of prostheses has generally been a lengthy one involving trials on amputees by a number of experimenters over a period of many years. Recently, both in the United States and in foreign countries this process has been accelerated through the efforts of research teams, which through a combination of the skills of personnel from the fields of medicine, prosthetics, and engineering have attempted to solve problems in a more logical, scientific manner. The Canadian-type hip-disarticulation prosthesis is an excellent example of an improved device that has resulted from the efforts of organized research in limb prosthetics.</p> <p>In a technical discussion of the principles of fitting of <i>any </i>prosthesis, it is often convenient first to describe the biomechanics involved, the term "biomechanics" referring both to the residual functional anatomy and to the mechanical implications of wearing a prosthesis applied to the stump. The biomechanical analysis establishes the pattern of force trans- mission between the prosthesis and the stump. Once the force pattern is known, physiological and anatomical factors must be considered in determining whether or not the proposed areas of force transmission are pressure-sensitive or unsatisfactory for other reasons. If there are no physiological contraindications, it then becomes the responsibility of the pros-thetist to fit and align the prosthesis in a functional and comfortable manner as dictated by the biomechanical and physiological requirements. Comfort is generally achieved by a distribution of any individual contact force over an area of the socket large enough to reduce the pressure on the stump to a tolerable magnitude.</p> <p>The biomechanical analysis of the Canadian-type hip-disarticulation prosthesis can be divided conveniently into two parts: first, an evaluation of the stump-socket forces required to support the torso in the stance phase and, second, a review of the dynamic behavior of the combined amputee and his prosthesis in level walking.</p> <h4>Principles of Mechanics</h4> <p><b>Force</b></p> <p>A "force" is the physical action of one body upon a second body which tends to change its position in space (<b>Fig. 1</b>). In interpreting the diagrams to follow, it will be necessary to consider the concept of force as a vector quantity. Force vectors, for example that shown in <b>Fig. 2</b>, must be specified by magnitude (indicated by length of a particular force arrow), sense or direction (indicated by the <!--Page 30--> arrow head), and the line of action (indicated by location of the shaft of the arrow).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Force" defined. A "force" is the physical action of one body upon a second body. It may be either a push (compression) or a pull (tension). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The "force vector." The one shown here represents a 100-lb. force applied by a "second body." The force acts to the right, through point <i>A, </i>along a line inclined 10 deg. from the horizontal line <i>AB. </i>The scale factor for this force vector is 100 lb. per inch of length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PRESSURE</b></p> <p>"Pressure" is a measure of the distribution of force over an area. Since pressure is defined as force per unit area, it is calculated by dividing the force by the area over which it acts. This would give an "average" pressure. Pressure is seldom uniform, and its variation is often indicated by a series of pressure vectors such as shown by the smaller arrows in <b>Fig. 3</b>. Where both force and pressure vectors are shown on the same diagram, the force vector indicates the "resultant," that is, the sum of the effects of the distributed pressures in a particular region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. "Pressure" defined. "Pressure" is force supported per unit area. A broad area of support results in lower values of average pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>EQUILIBRIUM</b></p> <p>In force analyses, use is made of two fundamental principles of analytical mechanics: the concept of "force equilibrium" and the concept of "moment equilibrium."</p> <p><i>Force Equilibrium</i></p> <p>The principle of force equilibrium, first stated by Newton, can be interpreted in the following form: In order for a body to remain at rest (fixed, relative to a point in space) the vector sum of all forces acting upon it must be zero (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Force equilibrium" defined. In force equilibrium, the vector sum of all forces is equal to zero. The force diagram must form a closed polygon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 31--> <p><i>Moment Equilibrium</i></p> <p>A "moment" is the product of a force acting through some perpendicular distance from a reference point or "moment center." A moment tends to cause a physical body to rotate. In the simple lever shown in <b>Fig. 5</b>, the force <i>F </i>exerts a moment <i>F </i>X <i>a </i>about the point <i>O. </i>In order for the body to have no tendency to rotate, the sum of all moments acting upon it must be zero, such as when a force <i>P </i>on one end of the lever, acting through distance <i>b, </i>balances a similar force <i>F </i>on the opposite end, acting through distance <i>a, </i>as in <b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Moment equilibrium" defined. For moment equilibrium, the moments acting about a center of rotation must be in balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FREE-BODY DIAGRAMS</b></p> <p>Another useful concept is the "free-body diagram" used extensively in engineering mechanics. When a system or structure involves more than one distinct physical body, the parts are often shown separately, as in <b>Fig. 6</b>, and the effect of each mating part is accounted for by a vector representing the force exerted by it on the part being considered as a free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Free-body diagrams of the individual, isolated bodies, with the action of the second body represented by a force vector. Note that "action" on one body results in a "reaction" on the second. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Description of the Canadian-Type Hip-Disarticulation Prosthesis</h4> <p>The functional features of the original design of the Canadian-type hip-disarticula-tion prosthesis are shown in <b>Fig. 7</b>, which is reproduced from the Canadian report of March 1954. Although there has since been minor modification of the methods for fitting and <!--Page 32--> alignment of the device, its functional features remain unchanged (<b>Fig. 8</b>). They include:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Original design of the Canadian-type hip-disarticulation prosthesis. From McLaurin <i>(1).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Canadian-type hip-disarticulation prosthesis as modified at the University of California (Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>A continuous, laminated-plastic socket-waistband. </i>The socket-waistband is fitted so as to provide three reaction points (points of suspension), as shown in <b>Fig. 7</b>. The weight-bearing area of the socket is constructed of rigid plastic laminate, while the waistband is made flexible to permit easy donning of the prosthesis.</p> <p><i>Alignment stability. </i>A unique arrangement of joint locations results in improved security against buckling of the knee in any normal walking situation, the hip joint being located below and forward of the normal axis of the hip (<b>Fig. 7</b>). With the hip joint so located, the effective length of the leg is the same in both standing and sitting. A reference line extended through the hip and knee joints passes a minimum of 1 in. behind the heel, so that as long as the prosthesis bears weight the load transmitted between the foot and the hip joint always passes ahead of the knee joint, thus ensuring knee security. When required, flexion of the knee is initiated by contact of the elastic hip bumper (attached to the bottom of the socket) with a stop on the upper posterior portion of the thigh. As long as the hip bumper is not in contact, the knee joint is always completely stable.</p> <p><i>Full-width hip joint. </i>The full-width hip joint allows a much stronger connection between socket and thigh. The hip joint is similar to a prosthetic knee joint and is highly effective in resisting lateral bending at the connection between socket and thigh piece.</p> <p><i>Hip-joint motion. </i>In level walking, the hip joint allows approximately IS deg. of relative motion between socket and thigh. The amount of motion is limited by the hip-flexion control strap (shown as "elastic band" in <b>Fig. 7</b>). This arrangement allows the leg to assume a natural inclination at heel contact without backward tilting of the pelvis.</p> </blockquote> <!--Page 33--> <h4>Functional Sequence in Use of the Prosthesis</h4> <p>The manner in which the amputee walks on the prosthesis can be described by dividing the stance phase of walking into three parts: heel contact, mid-stance (roll-over), and push-off.</p> <p><i>Heel Contact</i></p> <p>As the leg swings forward preparatory to heel contact, the hip-flexion control strap limits the free hip-joint motion to approximately 15 deg. This hip-joint motion, in combination with a slight pelvic motion, allows the leg to assume a natural backward inclination as the heel makes contact. The amputee moves forward over the prosthesis, and the heel is planted on the floor without hesitation.<a style="text-decoration:none;">*</a> The weight-bearing prosthesis is extremely stable owing to the alignment of the hip, knee, and ankle joints, and the objective is to attain knee security by having an appreciable amount of force transmitted through the prosthesis at the instant of heel contact. Where additional security is desired, the amputee leans forward slightly at the time of heel contact. Doing so results in an increased tension in the hip-flexion control strap, which helps to hold the knee in full extension.</p> <p><i>Mid-Stance (Roll-Over)</i></p> <p>As the amputee rolls over the extended prosthesis during the mid-portion of the stance phase, knee security is increased as the weight-bearing line moves forward toward the ball of the foot. Hip-joint motion causes the hip-flexion control strap to relax, and the amputee rides forward with the socket balanced on the free hip joint. Pelvic stability is maintained by the momentum of the torso.</p> <p><i>Push-Off (Start of Knee Flexion)</i></p> <p>At the end of the stance phase, the prosthesis must be propelled forward into the swing phase. The amputee using a tilting-table prosthesis does this by a lifting and internal rotation of the pelvis on the side of the amputation. A normal individual achieves knee flexion at the time of push-off by combined hip and ankle action. The amputee using the Canadian-type hip - disarticulation prosthesis initiates flexion by a method somewhat similar to that used by an above-knee amputee wearing a suction socket. As the prosthesis inclines forward with the weight borne through the ball of the foot, the angle of hip flexion is reduced until contact is made between the elastic bumper system at the rear of the hip joint. As the socket continues to progress forward in a straight line (without pelvic rotation), continued forward inclination of the thigh causes an increase in the compression in the bumper system. The moment thus developed about the hip joint eventually disturbs the knee stability and causes the knee to flex forward into the swing phase. By proper adjustment of the stiffness and point of contact of the hip-bumper system, a very natural knee flexion at the time of push-off can be achieved. The amputee should never lift the pelvis and swing the leg forward by internal pelvic rotation. Rather, the recommended action is exactly the opposite. The amputee "sits hard" on the prosthesis in order to start the knee flexing. Where more rapid knee flexion is desired, a slight backward rotation <!--Page 34--> of the socket to increase the compression of the hip bumper will propel the prosthesis forward forcibly. If weight is transferred to the natural leg simultaneously, there should be no feeling of insecurity at this time.</p> <h4>Action of the Socket in Lateral Support of the Torso</h4> <p><i>Foot Position</i></p> <p><b>Fig. 9</b>, a series of free-body diagrams, shows, as viewed from the front, the rather simple force system which is acting when an amputee is walking on a Canadian-type hip-disarticulation prosthesis, the situation depicted being the period of mid-stance on the prosthesis when mediolateral dynamic effects are negligible. <b>Fig. 9</b>A shows the system of externally applied forces acting on the prosthesis alone. <b>Fig. 9</b>B shows the forces acting on the combination of the amputee and the prosthesis.<a style="text-decoration:none;">*</a> <b> Fig. 9</b>C shows the external force system acting on the amputee considered as an isolated free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mediolateral force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on the prosthesis (exerted by floor and stump); <i>B, </i>forces acting on combination of amputee and prosthesis (exerted by floor and gravity); <i>C, </i>forces acting on amputee (exerted by prosthesis and gravity). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 9</b>B involves the simplest force system and is therefore discussed first. Two forces are involved-the supporting floor reaction and the downward force of the body weight. The vertical component of the floor reaction is equal in magnitude to the downward force and hence just balances the body weight. The body can therefore be assumed to be in force equilibrium in the vertical direction. But the floor reaction, being inclined generally inward, has an inward component along the floor, which means that the entire body is being accelerated toward the sound side. This acceleration would result in a change in direction of motion of the torso, that is, in a movement toward the amputee's normal side. Such mediolateral oscillating motion of the body as a whole is characteristic of normal subjects as well as of amputees. To maintain mediolateral motion within normal limits in the amputee, the inclination of the floor reaction to the plane of progression must be minimized, and the hip-disarticulation prosthesis is therefore aligned to give a narrow walking base. Experience has shown that the walking base should be less than 4 in. from heel center to heel center.</p> <p><i>Stump-Socket Forces as Viewed from the Front</i></p> <p>The consideration of forces acting on the stump, which result in part from the requirement of a narrow walking base, is more complicated. As can be seen in <b>Fig. 9</b>C, four forces act on the combined stump and torso of the hip-disarticulation amputee-the downward force of the body weight acting through the center of gravity, the distributed vertical support pressures acting upward on the ischial-gluteal region, and distributed socket pressure between stump and socket-waistband acting on both normal and amputated sides. A single force vector is used when necessary to approximate the effects of the actual pressure distribution.</p> <p><b>Fig. 9</b>A shows the forces acting on the prosthesis considered as an isolated free body. It is to be noted that the body weight, that is, the effect of the downward pull of gravity, does not act on the socket <i>per se. </i>The effect of the body weight is made apparent by the opposite reaction (acting downward) of the vertically upward ischial-gluteal support seen acting on the stump-torso in <b>Fig. 9</b>C. If the body weight and ischial-gluteal support forces were the only two forces acting on the torso, the body would have a tendency to rotate about the point of support and to drop toward the unsupported normal side. This tendency is counteracted by the moment of the couple formed by the two mediolateral forces <i>H </i>and <i>S. </i>For moment equilibrium, taking the summation of moments about point 2 equal to zero, <i>W </i>X <i>b = H </i>X <i>a. </i>Or,<br /> <b>H=(b/a)W</b><br /> Thus the magnitude of the reaction against the normal hip, or the tension in the waistband, or both, can be reduced by increasing the distance <i>a. </i>Moving the concentration of lateral forces on the stump to a lower level by alteration of fit is practical only within certain limits. Too low a position would result in shear forces along the bottom of the stump and in considerable relative motion between stump and socket. It is also apparent that, owing to the limitations on increasing dimension <i>a, </i>the lateral forces <i>H </i>and S are of the same order of magnitude as the vertical forces <i>W </i>and <i>I</i>, since dimensions <i>a </i>and <i>b </i>would be approximately equal.</p> <p><i>Stump-Socket Forces as Viewed from the Side</i></p> <p><b>Fig. 10</b> shows the pattern of forces acting on the amputee and/or his prosthesis as viewed from the side during level walking. <b>Fig. 10</b>A indicates the force system acting on the prosthesis isolated as a free body at heel contact. <b>Fig. 10</b>B shows the forces exerted by the socket on the stump-torso, plus the action of the body weight, during the three major divisions of the stance phase in level walking-heel contact, mid-stance, and push-off. <b>Fig. 10</b>C is a free-body diagram of the isolated prosthesis at push-off. Again the use of free-body diagrams allows a clear distinction between forces acting on the amputee and forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Anteroposterior force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on prosthesis at heel contact; <i>B, </i>forces acting on stump at heel contact, mid-stance, and push-off; C, forces acting on prosthesis at push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At the time of heel contact on the prosthesis, the normal leg is completing push-off. The force acting on the normal foot is then transmitted through the normal leg to the pelvis. This thrust of the normal leg is shown in <b>Fig. 10</b>B acting on the normal side of the pelvis. Shown in addition to the force from the normal leg are the force of body weight and the distal, posterodistal, and anteroproxi-mal stump-socket forces. The floor-reaction force is not transmitted directly to the stump but results in the system of stump-socket forces shown acting on the socket in <b>Fig. 10</b>A and <b>Fig. 10</b>C. For example, the isolated prosthesis must be in equilibrium under the action of stump contact forces plus the floor reaction. The same system of stump contact forces <i>react </i>to appear as forces applied in the opposite sense in the diagrams of <b>Fig. 10</b>B. Because of the offset lever arm between body weight and the line of vertical support through the ischium, as shown in <b>Fig. 10</b>B, a counter- acting stabilizing force is required in the anteroproximal region. The thrust of the normal leg tends to increase the unbalanced moment about the distal point of support and hence to increase the need for anteroproximal counterpressure in the inguinal region.</p> <p>In the mid-stance phase, the normal leg is off the floor, and the four forces shown in the middle diagram of <b>Fig. 10</b>B are acting. The anteroproximal pressure on the stump is reduced as compared to that existing in the heel-contact phase. This circumstance indicates that errors in fitting would be more noticeable at the time of heel contact than in the succeeding mid-stance phase. If the dynamic effects of acceleration are ignored, two forces are acting on the combined amputee and <!--Page 37--> prosthesis during the mid-stance phase- the body weight and the upward floor-reaction force on the sole of the foot. This situation prevails until the normal foot again contacts the floor ahead of the prosthesis.</p> <p>At about the same time that the normal foot strikes the floor, the hip-bumper system in the prosthesis makes contact and tends to flex the knee forward. During this push-off phase, there is again a thrust on the pelvis from the normal leg, this time from the front, as shown in <b>Fig. 10</b>B. The thrust of the normal leg counteracts the offset body weight and further reduces the need for anteroproxi-mal support from the socket. This feature gives the amputee a greater degree of perceptive control of the prosthetic knee, since the stump-socket forces are reduced and the effects of the hip-bumper force acting on the bottom of the socket are therefore more readily distinguishable. With a properly adjusted hip-bumper system, the amputee is able to exercise a more than adequate control and timing of knee flexion even though some of the body weight is still being carried by the prosthesis at this time.</p> <p>Owing to the ever-changing nature of the stump-socket force system as viewed from the side, it is necessary to fit the distal portion of the socket snugly in the posterior region in order to prevent relative motion between stump and socket in the more highly stressed areas of vertical support under the ischial tuberosity.</p> <h4>Surgical Implications</h4> <p><b>Fig. 11</b>A and <b>Fig. 11</b>B show front and side views of a typical hip-disarticulation stump. Cross-hatching on the surface of the stump indicates those areas where biomechanical analysis shows a functional need for supporting or stabilizing contact pressure between stump and socket. Clearly indicated are those areas where surgical incisions should be avoided, in particular the ischial-gluteal, inguinal, and lateral-distal areas. The incision and resultant scar should be located along the anterodistal portion of the stump, as shown in <b>Fig. 11</b>A. This area is not required to tolerate localized pressure and is generally relieved during the fitting process in order to avoid pressure-sensitive areas over bony prominences in the pubic region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical dynamic pressure distribution on the hip-disarticulation stump when wearing the Canadian-type hip-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Implications for Fitting</h4> <p>Biomechanical force analysis shows certain regions over the stump where particular attention must be paid to socket fit. They include the ischial-gluteal, inguinal, and waistband contact areas.</p> <p>In the ischial-gluteal area, functional pressures must be developed on a bony prominence and a neighboring area of atrophied gluteal musculature. This requirement calls for careful location and fitting of the bony prominence of the tuberosity. In order to develop pressure on the soft tissues, considerable modification of the cast is required. This displaces the soft tissues upward in the socket, and the necessary functional contact pressure is achieved. The pressure in the gluteal area is an absolute necessity in order to stabilize the distal end of the stump on the bottom of the socket. Otherwise chafing due to shearing motions between stump and socket will result.</p> <p>The inguinal region must provide a major contribution to the anteroposterior stabilization of the torso. An inaccurate fit in this region will result in concentration of pressure at a lower level in the generally sensitive pubic areas. The soft tissues of the inguinal and abdominal areas must be displaced inward if the proper functional stump-socket pressure is <!--Page 38--> to be achieved. This is most easily accomplished by wrapping the cast in this region while the patient is supine.</p> <p>The mediolateral force which must be transmitted by the waistband extending around the normal hip approaches the body weight in magnitude. The waistband must be fitted very carefully to avoid local concentration of pressure on bony prominences.</p> <h4>Training Implications</h4> <p>Training a hip-disarticulation amputee to walk on a properly fitted, aligned, and adjusted Canadian-type prosthesis is not a difficult or time-consuming process. If the therapist is thoroughly acquainted with the functional principles of the prosthesis and with the methods of fitting and adjustment, a well-coordinated amputee should walk unaided, without a cane, after less than 10 hours of training. Proper adjustment of the hip bumper, hip-flexion control strap, and ankle-foot characteristics is absolutely essential for efficient use of the prosthesis. For this reason, therapist and prosthetist should work together during the initial training sessions.</p> <p>Particular points which should be stressed by the therapist in working with the amputee are:</p> <ol> <li>Develop confidence in the stability of the knee at heel contact. Emphasize the necessity for a confident placing of the prosthetic heel and simultaneous weight-bearing. Show that the knee stability will increase in direct proportion to the amount of force transmitted by the prosthesis.</li><li>Show the action of the three-point mediolateral support of the torso. Do not allow the amputee to bend his trunk over the prosthesis. If painful pressure develops over a bony prominence, have the prosthetist provide relief or padding.</li><li>Place considerable emphasis on the timing and use of the pelvis to propel the prosthetic knee forward. Remember that the amputee "sits" to flex the knee while the prosthesis continues to bear a portion of the body weight. The amputee should not lift the prosthesis off the floor and then propel it forward by internal rotation of the pelvis.</li></ol> <h4>Summary</h4> <p>A biomechanical analysis is presented for the forces involved when an amputee stands and walks with a Canadian-type hip-disarticulation prosthesis. The results of the analysis are applied to the specialized topics of stump surgery, socket fitting, and training of the amputee.</p> <p><b>References:</b></p> <ol> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis, </i>Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto. Canada, 19 March 1954.</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">In Fig. 9B contact forces between stump and socket are internal forces which cancel out when the combined system of amputee and prosthesis is considered.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 foot should not swing up and then snap back into contact with the floor.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-011.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 Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/596f5df1b45e5408aef2d2e48e214ce0.pdf 89788688822cc599a338f475aef91c26 https://staging.drfop.org/files/original/557b90124720a7da30c19930ed30060d.jpg 9d2990c77123a6377d72a6b73da5ddd1 https://staging.drfop.org/files/original/7f2ea2a39e9b4dc64c65b4067f43bef1.jpg 6533d942da6c283ee8488e49fbe0c9cd https://staging.drfop.org/files/original/ac090bbd79cd145e52cb323e58c729c5.jpg dc2fb43cee750c93112f0affc4206428 https://staging.drfop.org/files/original/ccee007808b1dde739c36d5b00a84e55.jpg ca28e413c0c22d65eae31d5c57c751e0 https://staging.drfop.org/files/original/42d540eb5f7d243a2ca53cb4bf06d76e.jpg b70baead32291e81c86a0750b9e4a4b3 https://staging.drfop.org/files/original/2ef9ffb0acc6dbf9ca7315d0af0b65e0.png 68b444d713762deb48fee990e6b67351 https://staging.drfop.org/files/original/d13990334d94f8492f71d5cfd1dbbd52.png d823f6dba920fa93bfa85d199b314ec6 https://staging.drfop.org/files/original/c715bcdfcce079d9e580963d051d2093.png bb37d520b9116d9fec4491ee5cbe2f09 https://staging.drfop.org/files/original/5bb4495a35e6ed75542b508319864f8c.png 86e9e1f85b2b7cf997340d8727376efe https://staging.drfop.org/files/original/05bf1a813e6795e969c67bfdf70beb0f.png a40d28845357c57383853d91eff35f12 https://staging.drfop.org/files/original/32b9476d17d9fdde664b335970aa3fe5.png a60199a7436285575bd5b6846f9edf04 https://staging.drfop.org/files/original/d09c868f1688a0ecaf1d9c45b742c1e6.png aea7141fd41b96043e2bf8c7e583b38d https://staging.drfop.org/files/original/453f7876178baebff0b7b7e77820263e.png 2215c16b82603b81bd349d1814c50193 https://staging.drfop.org/files/original/11dff246699d89e686eaade91a2ea9bb.png 3828c0ac5b26e697a16be78c5dd19ca0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_008.pdf Text Any textual data included in the document <h2>The Biomechanics of the Foot</h2> <h5>André Bähler&nbsp;<a style="text-decoration: none;">*</a></h5> <p>"The human foot is one of nature's works of art and as such, it has not yet been fully recognized and explained. It will require a deal of scientific investigation before this structure is fully understood."</p> <p>These words of the old master of orthopaedics, Georg Hohmann, from his book "Fuss und Bein" are still applicable today. Thirty years later, the biomechanics of the foot have still not been completely explained, and there are many questions yet unanswered.</p> <p>The many, more or less articulated connections of the foot allow a variety of changes which make it difficult to understand the movement as a homogeneous process. Too many factors can only be qualified, but not quantified.</p> <p>Nor may we forget the reciprocal influence of the position of the foot, knee, and hip joints. Each change in the position of one of these joints automatically involves a change in the position of the other two joints.</p> <p>For example, in the upright position, the neck of the femur forms a posteriorly open angle of approximately 20 degrees. This is determined by the anatomical factors in relation to the frontal plane of the body. The direction of the axis of the hip joint corresponds fairly accurately to the connection inner-malleolus/ outer-malleolus, which have an exterior rotation of approximately 20 to 30 degrees in relation to the frontal plane. Consequently, there is a conformity between the ankle axis and the hip axis.</p> <p>In the upright position, the knee is practically locked due to the automatic rotation, so the position of this axis is of minor importance. When walking, the pelvis rotates approximately 20 degrees forward. As the lower leg also rotates inwardly in relation to the upper leg during flexion, the ankle axis rotates inwardly and the foot takes up a straight position in the swing phase.</p> <h3>Characteristics Of The Foot</h3> <p>The foot has the characteristics of a triple axial joint which allows it to assume any position. The three main axes of movement converge in the talus area (<a href="staging.drfop.org/files/original/557b90124720a7da30c19930ed30060d.jpg"><b>Fig. 1</b></a>). Particularly during rotational movements to adapt the foot to an uneven surface, all the joints are involved to some extent; nevertheless, the ankle joint, although formed as a hinge joint, forms the main joint for locomotion.</p> <p>According to Kapandji, the foot can be compared architectonically to a vault, which is supported by three arches. Other authors criticize this vault-concept on the basis that it is too static. However, the vault-structure is very meaningful as an aid to analyzing the foot in general (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg"><b>Fig. 2</b></a>). The arrow shows the direction and position of the main weight, which is first taken by the calcaneus (A) and then transferred to the forefoot: inside on metatarsal I (B) and outside on metatarsal V (C). The front transversal vault can also be understood as a supporting construction: on the one side the two corner stones (metatarsal I and metatarsal V) and on the other side, the transverse vault (metatarsal II, III, and IV). This construction enables the forefoot to take a great amount of weight and at the same time allows the foot to adapt to uneven surfaces.</p> <p>Furthermore, it can be seen that when the feet are put together, the position of both cal-canei can be regarded as a vault structure. The position of the calcaneus together with a slight valgus position serves to stabilize the body, particularly during the walking motion of the leg (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg"><b>Fig. 3</b></a>).</p> <h3>The Joints</h3> <p>The joints themselves pose some problems. Let us take for example the development of the inclination of the trochlea of the talus, and the distal tibial epiphyseal cartilage to the longitudinal axis of the lower leg in the frontal plane as described by Lanz Wachsmuth.</p> <p>Left in the infant and right in a two year old (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg"><b>Fig. 4</b></a>), it can be seen that the axes of the ankle joint and the talocalcaneonavicular joint and that of the epiphyseal cartilage are developing. In the 12 year old, left, and in the adult, right, the axis becomes horizontal during normal growth process, stabilizing the support system of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg"><b>Fig. 5</b></a>). The changes in the various process-, movement-, and development-axes of the ankle during the development of the child are probably one reason for the controversial views over the biomechanics of the foot.</p> <p>Biomechanically we are interested in the joints, and in particular, those used when walking.</p> <p><i>The Ankle Joint</i></p> <p>The ankle joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-06.jpg"><b>Fig. 6</b></a>) is of particular importance, because in at least one direction it secures a movement without which it would be impossible to walk. This joint could also be described as a hinge joint with a diagonal axis of rotation, which allows a movement of about 20 degrees up and down. This inclination of the ankle joint certainly contributes to stability when carrying weight and can only be fully understood when considered in connection with the talocalcaneonavicular joint.</p> <p><i>The Talo-Calcaneonavicular Joint</i></p> <p>The movement of the talocalcaneonavicular joint is decidedly more difficult to understand. Whereas the axis of the ankle joint can easily be defined, the axis of the talocalcaneonavicular joint is drawn obliquely from lateral posterior to medial anterior. It is surprising that both articular surfaces of the talocalcaneonavicular joint are congruent only in the mid-position. An incongruence develops between the two articular surfaces by both eversion and inversion. This incongruence cannot be maintained for long periods when carrying weight.</p> <p>The ankle joint and the talocalcaneonavicular joint must be regarded as a functional unit. The possible movements of these two joints can be compared to a spheroid joint which can be moved freely within its range of motion: flexion, supination, pronation, abduction and adduction which in some respects corresponds to a rotation.</p> <p><i>Chopart's Joint</i></p> <p>The talocalcaneonavicular joint, comprising the talus and the navicular, and the joint which is formed from the calcaneus and the cuboid, together all form a sort of working unit. These two joints comprise Chopart's joint which allows a rotational movement of the fore-foot.</p> <p><i>Lisfranc's Joint</i></p> <p>The Lisfranc joint is a collective joint where the three cuneiform bones and the cuboid bone on the one side, and the five metatarsal bones on the other side, are united to form an articular connection. The small deflectionary movement can be described as in an obliquely situated hinge exhibiting dorsal and plantarflexion.</p> <p>The Chopart and the Lisfranc joints are connected by taut ligaments so that there is hardly any friction between them. They serve primarily to give elasticity to the foot during pressure and allow it to adapt better to uneven surfaces.</p> <p><i>The Transversal Anterior Vault of the Foot</i></p> <p>From metatarsal I to metatarsal V, the metatarsal bones form an oblique arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-07.jpg"><b>Fig. 7</b></a>). This arch tends to drop due to excessive pressure, which can partly be attributed to walking on level ground. This "even" walking, which always puts pressure on the same points of the foot, leads to over-exertion of the individual metatarsal heads.</p> <p><i>The Toe Joints</i></p> <p>The toe joints are limited spheroid joints. That is, they are capable of sideways movement within certain limits, but are primarily intended as hinge joints with movement upwards and downwards.</p> <h3>The Ligaments</h3> <p>It is known that the structure of the foot is held together with muscles and ligaments. These ligaments are so constructed as to be able to withstand the extreme pressures exerted on the foot (long jump and high jump).</p> <h3>The Muscles</h3> <p>Long and short muscles hold and move the foot. If one of the muscles gives way, it is immediately visible from the gait how important the interaction of each muscle group is for locomotion. However, descriptive anatomy is not the theme here and so a further discussion of this aspect must be omitted.</p> <h3>The Mechanics Of Depression Of The Foot</h3> <p>Experience has shown that not every valgus of the calcaneus results in an equivalent drop of the longitudinal vault.</p> <p>The talipes valgoplanus is a collective term for different inadequacies which arise when the foot is under pressure. These can be classified according to different characteristics: (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-08.jpg"><b>Fig. 8</b></a>)</p> <ol> <li> <p>The pronation position of the calcaneus;</p> </li> <li> <p>Inward rotation of the ankle joint;</p> </li> <li> <p>A forward and inward drop of the talus;</p> </li> <li> <p>Abduction of the fore-foot; and</p> </li> <li> <p>Supination, i.e., a turning upwards of the first metatarsal.</p> </li> </ol> <p>These five basic characteristics of the talipes valgoplanus lead to a variety of outward manifestations, which must be taken into consideration when deciding on a course of action. This wide variety is one reason why the kinematics of the foot eludes an exact biomechanical and mathematical analysis.</p> <p>When pressure is applied in valgoplanus, the calcaneum gives way but the fore-foot remains flat on the ground, regardless of the extent of the flexion. Congenital and ischaemic valgoplanus are exceptions to this but they are not included in the discussion here (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-09.jpg"><b>Fig. 9</b></a>).</p> <p>Between the calcaneus, rear-, and fore-foot there is a distortion or rotation. If pressure is removed from the foot, the calcaneus falls into a vertical position, but the fore-foot then rotates to the same degree. Consequently the position of the rear-foot relative to the fore-foot remains a constant deformity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-10.jpg"><b>Fig. 10</b></a>).</p> <p>What then is the role of the shoe in the standing position and swing-phase? In the standing position, more pressure is exerted medially on the rear part of the shoe (the counter and the heel), depending on the extent of the valgoplanus. However, the front of the shoe remains flat on the ground regardless of the extent of the deformity.</p> <p>In the swing-phase, the distortion between the fore- and rear-foot influences the alignment of the shoe. If the heel is too big or badly fitting, the fore-foot dictates the position of the shoe and as a result there is an unwanted deflection of the heel of the shoe from the heel of the foot.</p> <p>This means that the heel-strike is lateral and as pressure is exerted, it then turns inwards and adapts to the surface whereby it has returned to the original standing position. The distortion between the fore- and rear-foot, combined with an inadequate heel counter, produces a potential risk of injury. A stone on an inclined surface can easily lead to a strained joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-11.jpg"><b>Fig. 11</b></a>). This phenomenon is particularly significant for sportsmen and joggers who train in open country. After suffering such strains, the fear of further injury can hinder training.</p> <h3>Deformity Of The Fore-Foot (Talipes Transversoplanus)</h3> <p>During growth, there is a slight biomechanical change in the lateral metatarsal arch. The first metatarsal rotates pronatorally and this leads to a greater arching in adults.</p> <p>Congenital ligament or tissue weakness can cause this lateral arch to flatten under pressure and so result in a broadening of the fore-foot. Here, the length of the various metatarsal bones compared to the different patterns of pressure exerted on the fore-foot is of significant importance. Depending on the type of foot, the first or second metatarsal will be under greater pressure depending on which is the longer of the two. Instability between the fore- and rear-foot can also result if the inclination between metatarsal one and metatarsal five is too great. This type of foot tends to tilt sideways during the propulsion process of walking.</p> <p>In the case of the high-arched foot, the angle between the metatarsal and the ground increases, resulting in a greater load to the individual metatarsal heads.</p> <h3>The Shoe</h3> <p>From a biomechanical point of view, the shoe plays a significant part in the process of walking and standing. The height of the heel as well as the thickness of the sole greatly influence the conveyance of the weight and consequently influence locomotion itself. This sphere of influence must be duly considered, particularly in cases of static deformity. A build-up of the shoe, i.e., constructing a rocker bottom must be compensated for at the heel, otherwise the relationship between the heel-height and sole-thickness in the front of the shoe will be disturbed, thus having a negative effect on the roll-over process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-12.jpg"><b>Fig. 12</b></a>).</p> <h3>Cushion-Heel</h3> <p>The attachment of a cushion-heel also changes the roll-over process in that it acts as a shock absorber at heel strike and at the same time increases the roll-over (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-13.jpg"><b>Fig. 13</b></a>).</p> <h3>Heel-To-Toe-Roll For The Whole Sole</h3> <p>A heel-to-toe roll sole can be attached to the shoe to protect the ankle joint and Chopart's joint. Measured radially from the knee, this allows a complete roll of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-14.jpg"><b>Fig. 14</b></a>).</p> <h3>The Use Of Insoles</h3> <p>The insole and the shoe must form a unit with the level ground. Whether the foot is neutral, in pronation or supination, is of no significance.</p> <p>When insoles are made of solid material, their length and shape are important. It is of particular importance with handicapped patients that the insoles are kept somewhat longer in order to reduce the risk of tilting sideways. This pronatory support, especially in the forefoot region, gives the patient a feeling of security.</p> <p>The correction of the talipes valgus should be differentiated from the correction of the talipes varus. With talipes valgus, the rear of the foot should be supinated and the fore-foot pronated in order to achieve a rotation of the foot. With talipes varus, this is not possible. Here, the whole foot must be pronated, i.e., the rear- and fore-foot must be included in an homogenous correction.<br /><br /><em><b>*André Bähler </b>André Bähler is an Orthotist/Prosthetist from Zurich, Switzerland.</em></p> <p><b>References:</b></p> <ol> <li>G. Hohmann, <i>Fuss und Bein</i>, ihre Erkrankungen und deren Behandlung, Verlag von J.F. Bergmann 1951.</li> <li>J. Lang, W. Wachsmuth, <i>Praktische Anatomie</i>, Bein und Statik, Springer-Verlag AG.</li> <li>I.A. Kapandji, <i>The Physiology of the Joints</i>, Churchill Livingstone.</li> </ol> Page Number(s) 8 - 14 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource The Biomechanics of the Foot Creator An entity primarily responsible for making the resource André Bähler * 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/b49a7d60a8722dcfdaf97025e92ca74f.pdf 5e63ea89230fc95a4cad21e843a948ef Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_001.pdf Text Any textual data included in the document <h2>The Canons of Ethics and Professionalism</h2> <h5>James Fenton, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Every society must have a set of rules or laws by which it governs itself. Without laws, society does not exist. The American Board for Certification in Orthotics and Prosthetics, Inc. is a society of sorts. It has a governing body, it has several different departments (committees), with department heads (committee chairmen), and it has citizens (certifees). It has laws by which it governs. It also has a department of justice in the form of the character and fitness committee. The one thing that our society does not have is a police department.</p> <p>If there is no police department, how effective can our society be? The answer to that question is at the very heart of the word professionalism. There are several dictionary definitions of professionalism. However, I have a very strong inner feeling that professionalism is not defined by words alone. I believe that professionalism in our society is a commitment to do the very best job that you are capable of doing on each and every case. This is not to say that you have to live up to any individual standard, but you must live up to the standards of practice in your community. If you're capable of doing better, then you should commit yourself to that level of excellence to which you're capable. I also believe that professionalism involves a commitment to your community: being an active participant in community affairs, being cognizant of the needs of the underprivileged of your community, and doing your fair share to alleviate their suffering.</p> <p>Professionalism demands that a practitioner keep current of the knowledge of his profession by continued reading of technical manuscripts and attendance at seminars.</p> <p>Professionalism is wanting to help in the day-to-day activities of the society by committee membership, by helping in the examination procedure, and by doing site evaluations.</p> <p>All of these are ways in which I believe we can define professionalism in an idealistic way. The Canons of Ethics of the American Board of Certification does not really attempt to set standards of professionalism but it does set standards of conduct that, if breached, can lead to punitive action being taken.</p> <p>Each and every certifee has received at least one copy of the Canons and if we all try to live up to the standards set forth in them, our patients will receive a better quality of care.</p> <p>These standards are directed to the way in which we conduct ourselves in the day-to-day management of our patients as well as the manner in which we conduct our businesses and ourselves in general.</p> <p>Rather than being idealistic, these standards are real. They were always meant to be the absolute minimum that our profession expects from us. Anyone who cannot live up to these standards should not receive the respect and recognition of his peers or the community.</p> <em><b>*James Fenton, CPO </b> President, American Board for Certification in Orthotics and Prosthetics, Inc. Fenton Brace and Limb Co., Inc. Miami, Florida<br /><br /><br /></em> Page Number(s) 1 - 1 Year 1983 Volume 7 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Canons of Ethics and Professionalism Creator An entity primarily responsible for making the resource James Fenton, CPO * https://staging.drfop.org/files/original/3474e7ecce4c2562d559a2ef5a3224c3.pdf 752179c0caddf3dd354a38e5884fa076 https://staging.drfop.org/files/original/091d1855d334557fc5d055ca98125283.jpg 99405891fc0b427f417be5fcdd10911e https://staging.drfop.org/files/original/623d2eb93d60e3d4c25639ae39dbf858.jpg fa3d556e9fe28696987a8f633f4776bd https://staging.drfop.org/files/original/60653bedb7f2f194a3abf694e94b72d4.jpg 25e03e2ad856469b5230d75e9fbff306 https://staging.drfop.org/files/original/40d8e3d76404f9b60a1a92c7c194361a.jpg 4e59435fca4d2ecb3e37e2073e385370 https://staging.drfop.org/files/original/a673985d199872ddfb5ca0cf2df6a4c2.jpg 38aca28e8cd192cd8b5cb162dd8163fa https://staging.drfop.org/files/original/10477ecf47f98610dc14231a7fb101f2.jpg a738c99a5bd4d53e10f1c4bb9632e49b https://staging.drfop.org/files/original/1ae495556d9d18674597daab58f7343a.jpg f53f76de628d841c6b8c1c15925fc8c6 https://staging.drfop.org/files/original/5c970469f1caacd2dc19113bb317726a.jpg 4289918c2044368e7b9555ecf174aed6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_011.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 11 - 15 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_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>The CAPP Electric Cart: Recent Developments</h2> <h5>Carl Sumida, C.P.O. <a style="text-decoration:none;">*</a><br />Yoshio Setoguchi, M.D. <a style="text-decoration:none;">*</a><br />Julie Shaperman, M.A., O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Since the development of the first Child Amputee Prosthetics Project (CAPP) electric cart<a></a> the device has been completely redesigned. A limited number were produced in 1968-69, and a field test was conducted by New York University. This article describes the mechanical changes that have been made in the cart. The report of the field test is presented elsewhere in this issue.</p> <p>The changes in no way altered the basic concept of the cart, and the design is still consistent with the original criteria: (1) the cart should be a powered vehicle which provides mobility to severely limited, limb-deficient children; (2) the controls should be simple to operate; (3) the cart should be compact, highly maneuverable, yet very stable and transportable; and (4) it should require minimal maintenance, and be attractive in appearance without resembling a wheelchair.</p> <p>Earlier models of the cart are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. These prototypes were built between 1962 and 1966. The changes made since prototype III have made the production of the 14 carts needed for the field test less costly. <b>Fig. 4</b> and <b>Fig. 5</b> show the cart produced in 1968-69 for the field test. The differences between this model and the 1966 prototype are described below.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Prototype I, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Prototype II, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Prototype III, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Field-test cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Field-test cart folded. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Structural Changes</h3> <p>The chassis, redesigned to simplify construction, is built of 1-in.-square mechanical tubing. The seat frame is made of 1/4-in. square, chromed mechanical tubing. The front axle was redesigned to allow torsional or vertical movement by means of a central pivot stud that is located at the center of the axle, which allows the chassis to travel over an uneven surface and still maintain four-wheel contact and stability.</p> <p>A new folding-seat arrangement makes the cart more compact for transport and adds lateral support from the side arms. The arms are set back far enough to allow the cart to be placed close to a table, desk, or washbasin. The frame for the backrest can be folded flat by lifting it slightly out of its locking notch and allowing it to fold forward onto the seat cushion.</p> <p>A shell made of metallic-green fiber glass covers the chassis and power equipment. The upholstery for the seat cushion and backrest is black Leatherette (TM). The seat frame is slightly larger than the seat cushion, thus leaving a small space for storage behind the cushion. Eight-inch, spoked casters with one-inch, solid-rubber tires (wheelchair type) are used on all four wheels.</p> <h3>Power-System Changes</h3> <p>The two drive motors are positioned independently on each side of the chassis. Each motor drives a specially designed worm-gear reduction box. The rear wheels are mounted directly on the output shaft of the gearbox, which is bolted to the frame. Power is fed into the gearbox through a Browning gear belt.</p> <p>A third motor powers seat raising and lowering. This motor is mounted adjacent to the right drive motor and is connected to the two rear screw jacks by a Browning gear belt and to a single front screw jack by a flexible shaft. These screw jacks raise the seat platform nine inches.</p> <p>The battery is positioned between the rear wheels and is easily accessible from the rear of the cart. This arrangement is more convenient than the side opening in the previous model, but it necessitated repositioning the motors and gear boxes, which had been a single package at the rear of the cart in prototype III.</p> <p>The control box is a specially designed unit developed at CAPP. It has toggle switches for directional control and a separate switch to raise and lower the seat. A circuit breaker was added to prevent an overload of the drive system. The switch controls are housed in a compact cylindrical unit that is mounted at the end of an reshaped control arm, which is attached to the left side of the seat frame and extends to the child's chin. The control arm can be adjusted for height and distance from the seat back. The chin receptacle is positioned next to the seat-elevation-control lever and is foam-padded (see <b>Fig. 4</b> and <b>Fig. 5</b>). The control arm is held in position in front of the child by a ramp lock. When lifted slightly, the control arm swings out for seat folding, the child's use of the table top, or transfer.</p> <p>The specifications for the cart's power equipment, size, turning radius, etc., are shown in <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Dimensions and specifications of CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Changes Since Field Test</h3> <p>In November 1970, two additional changes were made. (The modified cart, with the new wheels and control unit, is shown in <b>Fig. 7</b>.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Cart with solid rear wheels and new control unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>A new solid-state proportional control unit, now available commercially, was selected to replace the previous control unit. This new unit (manufactured by the Motorette Corporation of Reseda, California) provides proportional (variable-speed) control and an on-off master switch. The manufacturer provided a control for raising and lowering the seat so that the unit could be used with the electric cart. The control box can be positioned for control by the chin or an extremity. The circuitry unit fits on the storage rack behind the seat.</li><li>The rear drive wheels were changed from spoke casters to specially designed cast-aluminum wheels to eliminate the possibility of breakage due to high torques, but they have the same solid-rubber tires as the front casters. Although the use of pneumatic tires is being considered, solid-rubber tires have been retained for the present because they provide less rolling resistance and thus prolong the life of the battery. Also, solid-rubber tires are more reliable for a testing program because no problems arise from variations in air pressure.</li></ol> <h3>Production</h3> <p>The gear box, control box, chassis, body, and seat-lifting mechanisms for the carts used in the field test were specially de- signed by Mr. Carl Sumida at the Child Amputee Prosthetics Project at UCLA. These items were manufactured by subcontractors, and other components were purchased from commercial sources. The fourteen carts were assembled for the field test at the CAPP (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Assembly of field-test carts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the field test, all mechanical repairs were made at CAPP. At the end of the test, all the carts were rechecked, new control boxes were installed, and new wheels were applied. The carts have been returned to the children who participated in the field test, who will continue to use them as long as necessary.</p> <p>Attempts are now being made to find a commercial manufacturer for the electric cart because it has proven to be an extremely valuable aid to the mobility of the severely limb-deficient child.</p> <p><b>References:</b></p> <ol> <li><i>Artificial Limbs </i>8:2:42-44, Autumn 1964.</li> <li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, <i>Eighth Annual Report 1962, </i>pp. 51-53.</li> <li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, <i>Ninth Annual Report 1963, </i>p. 20.</li> <li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, <i>Tenth Annual Report 1964, </i>pp. 1-10.</li> <li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, <i>Eleventh Annual Report 1965, </i>pp. 9-11. (Reprinted in <i>Inter-Clinic Inform. Bull. </i>5:9:12-14, 1966.)</li> </ol> <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">Artificial Limbs 8:2:42-44, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, Eighth Annual Report 1962, pp. 51-53.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, Ninth Annual Report 1963, p. 20.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, Tenth Annual Report 1964, pp. 1-10.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, Eleventh Annual Report 1965, pp. 9-11. (Reprinted in Inter-Clinic Inform. Bull. 5:9:12-14, 1966.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Julie Shaperman, M.A., O.T.R. </b></td></tr><tr><td class="clsTextSmall">Mrs. Shaperman is a research therapist with the project.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Yoshio Setoguchi, M.D. </b></td></tr><tr><td class="clsTextSmall">Mr. Sumida is a research prosthetist.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carl Sumida, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Dr. Setoguchi is the medical director of the Child Amputee Prosthetics Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-11.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-13.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-14.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-15.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-16.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-17.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The CAPP Electric Cart: Recent Developments Creator An entity primarily responsible for making the resource Carl Sumida, C.P.O. * Yoshio Setoguchi, M.D. * Julie Shaperman, M.A., O.T.R. * https://staging.drfop.org/files/original/c4f7c87a6d3b45eaeeb780028322aac3.pdf 2f3019f3a58522e9c6c9ef279008e662 https://staging.drfop.org/files/original/e3fa45ed04f25031b0eae1b1ae3563f7.jpg 1d480fe476876e4ae28210d460878f00 https://staging.drfop.org/files/original/8d9753f4b6b5322d836534694564a736.jpg 18e2d169d78ebf6f59e41dce49306715 https://staging.drfop.org/files/original/ba2d5caaf2bb5a526891c65720e02f75.jpg 4c419b14d2f5c2e8b85e998eec950f1e https://staging.drfop.org/files/original/1bb426ed68464888794dcdf4a783cf53.jpg d1da7506184096c8d68116798a87facd https://staging.drfop.org/files/original/1c12f7dc0e21d73986874eddb77e705e.jpg 6f0727ef350636789bc9df62f3eccbf4 https://staging.drfop.org/files/original/00d157335a62ec44dbfdf98f9c624906.jpg f4e81019aca87bb8e609ca049e7db794 https://staging.drfop.org/files/original/5e53449d0db91f56ed12371c0939588b.jpg 38d62fb95c884d54aa066fc874713827 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_101.pdf Text Any textual data included in the document <h2>The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets</h2> <h5>Albert F. Rappoport, M.A., CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>The fabrication of a prosthesis continues to be a labor intensive process. The advent of prefabricated components, together with the use of central fabrication, has allowed many prosthe-tists to utilize their time more effectively. Time saving devices have always been welcomed by the prosthetic practitioner, especially when the quality of work is not compromised.</p> <p>Removal of an above-knee socket from a plaster model is a common procedure in most prosthetic facilities. There are several methods for removing the socket from the cast. These methods will be addressed later in the text and the problems of each discussed. The most improved method is the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg"><b>Fig. 1</b></a>). The Cast Off Valve uses compressed air, linking it directly to the above-knee socket (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg"><b>Fig. 2</b></a>). The female coupling of the air hose is attached to the male connector of the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg"><b>Fig. 3</b></a>). The Cast Off Valve is then threaded into the suction valve housing of the above-knee socket. This method saves manpower, time, and energy by allowing removal of the socket from the cast in a matter of seconds. It is also effective in the duplication of any definitive above-knee suction socket. The concept is credited in its design to Judd Lundt, B.S.A.E., Assistant Director at UCLA's Prosthetic Education Program.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg"><strong>Figure 1. The Cast Off Valve.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg"><strong>Figure 2. Female couple of air hose to male connector on Cast Off Valve.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg">Figure 3. Cast Off Valve attached to female air hose coupling.</a><br /></strong><br /> <h3>Methods Of Removing Socket From Cast</h3> <p>Several methods have been used, with varying degrees of success, in removing an above-knee socket from a plaster model. The oldest method involves breaking the plaster out of the socket with a cold chisel and hammer, or air chisel. This is a labor intensive process which is still practiced by many prosthetists (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg"><b>Fig. 4</b></a>). This process is not always necessary to facilitate the removal of a definitive socket.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg"><strong>Figure 4. Age old method of removing socket by breaking out plaster by hand.</strong></a><br /> <h3>Bivalving</h3> <p>Many times, the prosthetist would like to save the plaster model for further modification or reference. One approach to saving the model is to bivalve the socket with a cast saw (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg"><b>Fig. 5</b></a>). Once the socket has been bivalved, the cast can be touched up with minor plastic additions and used again. After the socket is bivalved, it cannot be reused. This process is not only time consuming, but can be eliminated in many circumstances.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg">Figure 5. Bivalving socket to retain cast.</a><br /></strong><br /> <h3>Compressed Air</h3> <p>The use of compressed air is by far the most popular method. It saves labor, time, sockets, and casts. A newly formed check socket or laminated socket may be easily blown off using an air gun. The newly fabricated socket must be trimmed just proximal to the desired trim line. A hole must then be drilled at the distal end of the socket to correspond in size to the tip of the air gun (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg"><b>Fig. 6</b></a>). One person holds the air gun with compressed air in the hole at the distal end of the socket, while the other person gently taps, trying not to fracture the socket, at the proximal brim. This is continued until the air is forced through the socket and assists in forcing the socket off the cast. Some radical socket shapes may prevent the ease of this technique, in which case it may be helpful to attempt this procedure while the socket is still warm or to refer back to the previously mentioned methods. The compressed air technique is an effective way to remove the socket from the cast without damaging either one. Two drawbacks to this method are: 1) it requires two persons to remove the socket, and 2) it is possible for air to leak through the hole where the air gun is held at the socket's distal end.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg"><strong>Figure 6. Removing socket from cast using compressed air. This two-person operation requires one person to use air gun to direct air through hole in bottom of socket and second person to tap proximal socket.<br /></strong></a><br /> <h3>Cast Off Valve</h3> <p>The use of the Cast Off Valve can improve the effectiveness of the compressed air method (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg"><b>Fig. 7</b></a>). This improved technique can be employed whenever a valve housing is used in either a laminated socket or clear check socket. The Cast Off Valve is designed to fit the valve housing and link the air hose coupling directly to the socket. This approach allows a stronger air pressure to be obtained and little chance for air leakage. The use of this method requires only one person, freeing the hands of a second person who holds the air gun in the hole (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg"><b>Fig. 6</b></a>). First, the proximal brim of the socket should be trimmed with a cast saw. Once the Cast Off Valve is installed, the air hose can then be connected and the socket will blow off without any further effort. One may need to gently tap the proximal brim with a piece of wood dowling and hammer to assist the removal. (Note: certain radical socket shapes may prevent the use of this method.) In summary, the Cast Off Valve requires only one person to remove a socket from the cast with a minimum amount of effort, reduction of time and improved results over methods previously discussed.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg">Figure 7. The Cast Off Valve is threaded into valve housing and air hose is connected to blow socket off with minimum effort and maximum results.</a><br /></strong><br /> <h3>Socket Duplication</h3> <p>The Cast Off Valve also is excellent when an above-knee suction socket is to be duplicated from a definitive limb. No longer is an alginate impression or use of duplicating foam necessary. The patient's socket should be filled with plaster and a holding pipe inserted once the plaster has set. The valve housing must be cleared of any material so the Cast Off Valve can be inserted. The air hose coupling can then be hooked up and the socket is blown off in a matter of seconds. The socket is duplicated exactly in plaster and ready for lamination or check socket fabrication.</p> <h3>Summary</h3> <p>The Cast Off Valve has been well accepted and tested clinically with great success for the past two years by the staff at UCLA's Prosthetic Education Program and Prosthetic-Or-thotic Laboratory. The UCLA prosthetic staff has found this device to be valuable, in many cases, in removing an above-knee socket in both quadrilateral and CAT-CAM designs. This method allows the cast to remain undamaged for further reference and can be useful when duplicating a definitive socket. When working with an appropriately shaped cast, the Cast Off Valve allows the removal of the socket from the cast with improved results from the previously aforementioned methods.</p> <h3>Acknowledgments</h3> <p>This work is supported by VA Contract #633P-1667 Rehabilitation Research &amp; Developmental Funds. Special thanks to Shirley M. Forsgren for the photography on this article and to Diane I. Lyons for preparation of the manuscript. Special thanks also to Dr. Ernest M. Burgress for his continued support in the research and development of advancing prosthetics. Thanks to Christopher Hoyt, CP, David Litig, CP, Mark Yamaka, CP, Richard Boryk, CPO, and Kenneth Neal, O/P Technician for their clinical evaluation of the cast-off valve at UCLA's Prosthetic-Orthotic Laboratory.</p> <p><em><b>*Albert F. Rappoport, M.A., CP. </b> Albert F. Rappoport, M.A., CP., is Chief of Research Prosthetics with the Prosthetics Research Study, 1102 Columbia Street, Room 409, Seattle, Washington 98104, (206) 622-7717. He is formerly Senior Prosthetist-Orthotist at UCLA's Prosthetic-Orthotic Laboratory in Los Angeles, California.<br /><br /><br /></em></p> <br /> <div style="width: 400px;"></div> Page Number(s) 101 - 105 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.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 Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets Creator An entity primarily responsible for making the resource Albert F. Rappoport, M.A., CP. * https://staging.drfop.org/files/original/0f0eaf91a93d152fbbcaca14c3b43ebf.pdf 55a8a6c2698543a33379820f8c99af27 https://staging.drfop.org/files/original/9176ea93fc7422b272a48674e92598f3.jpg 64903f5b4a3cce6fe54c1ab66a83c375 https://staging.drfop.org/files/original/51e118cc092de53ecec3404a4302acab.jpg 9678319e36fff07a4dd43313518ea0b2 https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg fb3cc03c33fbe565141cc63e008bcd97 https://staging.drfop.org/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg 0187a66c7a3b525a915dd5b9ad929a30 https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg 3520f17845a67a7b7af87cc94edfc339 https://staging.drfop.org/files/original/48af58273ca7d023d458415c3ede334c.jpg 73e1144efc791b010d100d5826ea86b0 https://staging.drfop.org/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg 2ac620871d4d7649e10c2cd6805c9efa https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg 7fb7b789229f3de781290a709a8c9c1c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_119.pdf Text Any textual data included in the document <h2>The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients</h2> <h5>John Sabolich, B.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Thomas Guth, B.A., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The innovative features of the CAT-CAM™ above-knee socket design were outlined in the Fall, 1985 issue of <i>Clinical Prosthetics and Orthotics</i>, Volume 9, Number 4. Shortly afterwards, RGP of San Diego and the Sabolich Prosthetic Research Center in Oklahoma City combined efforts to develop a CAT-CAM™ type hip disarticulation prosthetic socket design. It was intended that this new socket would hold the ischial tuberosity and descending ramus in a special compartment of the socket. RGP worked primarily on the suspension system, and Sabolich worked on the ischial ramus containment.</p> <p>The conventional hip disarticulation socket differs from the CAT-CAM™ type in that the old design has a flat inferior floor upon which the ischial tuberosity sits. Even worse, many times the tuberosity sits on the very edge of this table. As described in the original 1985 CAT-CAM™ article and in terms of the above-knee socket, this is not a desirable biomechanical situation because, first, the bone is touching a flat tangential surface rather than a contoured surface that conforms to the complex bony shape and thus distributes the load over a wider area and, second, because it does not provide medial-lateral stability. The new socket affords much more bony contact not only to the ischial tuberosity, but to the descending pubic ramus as well (<b>F</b><b>ig. 1</b>and <b>Fig. 2</b>). Experience has shown that the ramus turns out to be of more importance than the ischial tuberosity when it comes to enhancing medial-lateral and rotational stability. Only the inferior pubis-ramus is allowed to exit the socket at the medial inferior dip of the medial wall (<b>Fig. 3</b>).</p> <strong><a href="/files/original/9176ea93fc7422b272a48674e92598f3.jpg">Figure 1.</a> Demonstrates depth of ischial seat area relative to medial brim. Also shows how the ischium and ramus are in the socket.</strong><br /><br /><strong><a href="/files/original/51e118cc092de53ecec3404a4302acab.jpg" target="_blank" rel="noopener">Figure 2.</a> Postero-medial view of transparent diagnostic test socket on the patient with a patch of white paper delineating the ischial-ramus compartment.</strong><br /><br /><strong><a href="https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg" target="_blank" rel="noopener">Figure 3.</a> Medial view with rulers at the inferior-most point in the dip of the medial brim.</strong><br /> <p>In order to better understand the new hip disarticulation design, it must first be understood that the CAT-CAM™ above-knee design is not a narrow ML socket at the proximal portion. On the contrary, the proximal ML diameter of the CAT-CAM™ above-knee socket, which contains the pelvic bones, is wider than the mid and distal portions of the socket, which then narrows to conform to the medial-lateral thigh dimension in order to supply soft tissue compression. The new hip disarticulation socket follows this SCAT-CAM™ principle. Thus, it provides a better bony locking effect. Also, these bony pelvic structures are more fully encapsulated as a result of a V-shaped medial contouring of the socket and provide the hip disarticulation patient with a feeling akin to the above-knee socket, rather than that which results simply from sitting on a flat hard seat.</p> <p>Some of the principles of the CAT-CAM™ total flexible brim are also utilized in this type of hip socket. The entire socket is flexible except in the area where the hip joint is attached. This can be accomplished in two ways: first, with a rigid frame and a flexible inner socket much like with the CAT-CAM™ and SCAT-CAM™ above-knee design; second, by a heterogeneous monolithic polyester socket that is rigid in the joint area and then gradually becomes flexible throughout the remainder of the socket (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <strong><a href="/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg" target="_blank" rel="noopener">Figure 4.</a> Laminated socket demonstrating flexibility of the contralateral portion of the socket. Superior portion of amputated side is flexible as well.</strong><br /><br /><strong><a href="https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg">Figure 5.</a> View similar to Figure 4 showing flexibility of socket. Also shows "V"-shaped contour of medial brim in sagittal plane.</strong><br /> <p>Like the SCAT-CAM™ design, the hip socket is more bone and muscle contoured than the traditional bucket shaped hip disarticulation design (<b>Fig. 6</b>). The new socket has a concave contour in the area of the ilium on the amputated side. On the contralateral side, there is a concave contour between the ilium and trochanter. This increases medial-lateral stability and results in improved gait when combined with the containment of the ilium, ischium, and ramus bones within the socket. This is contrasted to most conventional designs which bulge out and follow the flow of the soft tissue on both lateral sides of the socket rather than conforming to the body contours.</p> <strong><a href="/files/original/48af58273ca7d023d458415c3ede334c.jpg" target="_blank" rel="noopener">Figure 6.</a> Schematic cross-section through the frontal plane. Vectors 1 and 2 demonstrate the suspension principle and also refer to the dark lines which represent the socket walls. Notice how the superior edges of the socket do not come above the ilium crests and the concave contouring inferior to the illiae. Vector 3 refers to the bony lock.</strong><br /> <p>The "Inter Ilio Trochanteric Effect"<a style="text-decoration: none;">*</a> is one of the reasons it has been possible to suspend the socket in most cases without extending it above the iliac crests of the pelvis. Instead, the suspension is gained by conforming the socket into the notch between the ilium and trochanter and creating a counter pressure with the opposite concave shaped side of the socket. Of course, it is more difficult to suspend the socket in this manner when fitting heavy people with excessive adipose tissue.</p> <p>Normally with a conventional hip disarticulation, it is easy for a prosthetist to pull the prosthesis off the patient by sliding it into abduction, away from contact with the residual limb and the ischial tuberosity, when the prosthetic pylon is abducted off the floor. However, with the CAT-CAM-H.D.™ design, this maneuver is more difficult, and the socket resists this abduction tendency due to the bony lock about the ramus (<b>Fig. 7</b>).</p> <strong><a href="/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg">Figure 7.</a> Medial view of the transparent diagnostic test socket showing height of medial brim relative to inferior most portion of the socket.</strong><br /> <p>In the last four years, a combined number of 67 CAT-CAM hip disarticulation sockets have been fit in Oklahoma City and San Diego. These patients report that they do not feel like they are "sloshing around in a bucket" and have a "greater feeling of security and stability" (<b>Fig. 8</b>). Three of these patients can run with their new prosthesis in a hop, skip fashion which has been recorded during video gait analysis. Two patients have been able to manage limited step over step running.</p> <strong><a href="https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg" target="_blank" rel="noopener">Figure 8.</a> Posterior view of completed socket.<br /></strong><br /> <h3>Acknowledgments</h3> <p>It should be noted that Mike Wilson, C.P.O., was the first person who suggested to me the principles of lateral pressure between the ilium and the trochanter on the contralateral side. He called it an "Inter Ilio Trochanter Effect."</p> <p>Appreciation is given to Don Landis, B.S., R.P.T., for his editorial help in preparing this manuscript.</p> <p>Appreciation is also given to Glenn Hutnick, C.P.O., and Alan Finnieston, CP., who will be contributing to the next phase of research in hip disarticulation designs.</p> <b>Footnote</b> See acknowledgments.<br /> <p><em><b>*Thomas Guth, B.A., C.P.O. </b> Thomas Guth, M.D., C.P.O., is with RGP Orthopedic Appliance Co., 6147 University Avenue, San Diego, California 92115.<br /></em></p> <em><strong>*John Sabolich, B.S., C.P.O. </strong>John Sabolich, B.S., C.P.O., is President of Sabolich Prosthetic and Research Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma, 73106.<br /></em><br /> <div style="width: 400px;"></div> <div style="width: 400px;"></div> Page Number(s) 119 - 122 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-8.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 CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * Thomas Guth, B.A., C.P.O. * https://staging.drfop.org/files/original/7e93e0bcdf041bdab2526ad50b967102.pdf 67579faec9e3dcdd1e35e26939cf8fcb https://staging.drfop.org/files/original/e1b9eed5d68adfbea036b532c62633f8.jpg 56019fdc49083b59c5913801b8cb4f31 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1972_01_020.pdf Year 1972 Volume 16 Issue 1 Page Number(s) 20 - 50 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1972_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1972_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management</h2> <h5>Barbara L. Sypniewski <a style="text-decoration:none;">*</a><br /></h5> <h3>Introduction</h3> <p>This independent-study honors project dealt with congenital skeletal limb deficiencies. This paper discusses and reviews the literature concerning the prosthetic management of the individual with unilateral terminal transverse partial hemimelia of the upper extremity. Specific topics considered are: a general description of the entity, including etiology and incidence; psychological factors affecting the limb-deficient child and his parents; normal and abnormal biomechanics of the upper extremity; components of the prosthesis (terminal devices, wrist units, elbow hinges, cuffs, harnessing, and sockets); prosthetic prescription and fitting; the trend toward early fitting; preprosthetic therapy; and prosthetic training. One section discusses the information elicited from a survey conducted by letters and questionnaires that were sent to the 28 clinics participating in the Child Prosthetics Research Program, conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development to ascertain the age of the congenitally skeletally limb-deficient child at the time of his initial fitting for a prosthesis. An analysis of the data from the 12 clinics replying is presented, along with the developmental criteria for fitting.</p> <p>The scope of this paper is limited to the unilateral upper-extremity, below-elbow congenital amputee. Bilateral amputees, cineplasty, surgical conversion, or externally powered prostheses are not considered. The literature review was limited by time to the books and journals published in 1960 or later, with selected earlier articles. Articles published before 1960, as well as those not available at the Albany Medical College Library or through the inter-library loan system, are listed in the "Bibliography." Both reference lists were compiled from <i>Index Medicus; Amputees, Amputations, and Artificial Limbs </i>(published by the Committee on Pros-thetic-Orthotic Education of the National Academy of Sciences-National Research Council, Washington, D.C.); and the bibliographies of articles I reviewed.</p> <p>Terminal transverse hemimelia indicates congenital absence of the entire distal part of the limb below the elbow. The term is part of the modified Frantz-O'Rahilly<a></a> classification nomenclature. Hemimelia is the absence of a large part of a limb, from the Greek <i>melos </i>meaning limb and <i>hemi, </i>half. <i>Partial </i>hemimelia indicates that less than half the limb is missing. The defect we are considering is transverse rather than longitudinal, presenting a short or very short stump similar to that of an acquired below-elbow amputation.</p> <p>The etiology of skeletal limb deficiencies is largely unknown, except for the well-documented teratogenic effects of thalidomide. The thalidomide tragedy has led to an increased interest in, and awareness of, what can be done for the congenital amputee. <a></a></p> <p>The list of proposed etiological factors includes environmental conditions such as drugs, maternal health and nutrition, genetic factors or predisposition, and chromosomal aberrations.<a></a> Most congenital defects have their origin during the first eight weeks of embryonic life.<a></a></p> <p>Glessner<a></a> indicates that there are two distinct groups of congenital absence of limbs: (1) spontaneous intrauterine amputation after limb formation, caused by focal deficiencies, and (2) limb-bud arrests or agenesis of the terminal part of the limb. Amniotic bands wrapped tightly around part of an extremity may lead to necrosis and eventual intrauterine amputation.<a></a> Terminal deficiencies due to limb-bud arrests are by far the most common type of congenital absence.<a></a> The terms <i>congenital amputation </i>and <i>congenital skeletal limb deficiency </i>are used interchangeably in the literature.</p> <p>Terminal transverse partial hemimelia is the most common type of congenital limb deficiency. There is unexplained preponderance of left-sided absence (2 or 3 to 1), and females are involved more frequently than males. Studies by Bergholtz,<a></a> Davies, Friz, and Clippinger,<a></a> Munson and Dolan, <a></a> and Gehant<a></a> failed to show the greater incidence in females exhibited in Kay and Fishman's report.<a></a></p> <p>The measures of prosthetic management in habilitation of a congenital amputee are somewhat different than those employed in the rehabilitation of an "acquired" amputee. The child must learn functional skills that he never possessed, rather than relearning substitute functional activities. The fact that the juvenile amputee is neither skeletally nor emotionally mature is an important consideration in the prosthetic management. The growth and development of the limb-deficient child is essentially the same as that of the normal child; the environmental stimuli to motor development are not decreased significantly by unilateral deficiency. Ideally, prosthetic management should extend from birth through vocational training.</p> <p>Function of the upper extremity is extremely complex and relatively independent of the contralateral extremity. With unilateral absence, there is an increased use of the remaining extremity, since the ability of a prosthesis to compensate for the loss of an arm is significantly less than is possible in the lower extremities. Below-elbow amputees are least in need of externally powered prostheses.<a></a> They can effectively use body power to activate the prosthesis and receive the benefits of sensory feedback through the socket and harness. The prosthesis should be considered as an assistive device in bimanual activity. Because absence of one extremity can be easily compensated for, getting the unilateral amputee to use his prosthesis presents a great challenge. Fitting and training should be started as early as possible, before these compensations can develop.</p> <p>It is generally believed that a team approach is most successful in the management of the limb-deficient child. The foremost members are the mother, who spends the most time with her child and influences him the most,<a></a> and the child. Other possible members of this interdisciplinary team are the physician, orthopedist, prosthetist, occupational therapist, physical therapist, psychologist, social worker, and biomedical engineer. Each child presents unique problems to be met. Epps and Brennecke<a></a> outlined a sequence of treatment that includes referral, history and medical examination, intake evaluation, preprosthetic physical and occupational therapy, prescription, fabrication, thorough check-out by the team, training, and regular recheck every three or four months.</p> <p>Factors influencing the cost of the prosthesis are: age at initial fitting, regular maintenance, frequency of harness adjustment, wearing pattern, operating skill, acceptance, and components prescribed.<a></a>Average service for a prosthesis ranges from two to three years, but a child fitted during infancy may require three to five prostheses before school age.<a></a> The additional cost of early fitting is compensated for over the years,<a></a> especially in regard to the benefits of skill and acceptance.</p> <h3>Psychological Aspects</h3> <p>The importance of parental attitudes towards the child, his disability, and the idea of a prosthesis, and their effect on the eventual acceptance or rejection of a prosthesis, has been emphasized throughout the literature. There is no direct correlation between the degree of the child's deficiency and the mother's perception of the child's abnormality, her feelings toward him and the way she handles him.<a></a> The way in which parents deal with the birth of a limb-deficient child depends to a great degree on how they have coped with previous crises. Replacement of a missing extremity with a well-functioning artificial one is valuable only if the parents can accept the idea of a prosthesis. Often, children have rejected prostheses because the parents, consciously or unconsciously, could not accept the fact that it was necessary.<a></a></p> <p>The way in which the parents are informed of the child's deficiency may influence their later reactions. If he desires to do so, the father should be allowed to inform the mother, in the presence of a physician.<a></a> Mothers can be profoundly influenced by the reactions of the delivery-room staff.<a></a> The training of the limb-deficient child can best begin by providing the parents with a detailed, factual, realistic, and sympathetic appraisal of their baby and his prospects for future educational, vocational, and social rehabilitation.<a></a> Unrealistic claims that modern prosthetics and engineering can provide artificial devices as natural-looking and as efficient as the human hand can seriously hinder the habilitation program. The first few hours after the birth of the child are crucial; it is during this period that parents form attitudes and defenses that can have tremendously far-reaching effects.</p> <p>With the birth of a deformed child, the parents suffer a severe psychological shock, for which they are totally unprepared. Certain emotions have been commonly expressed by parents of congenital amputees: guilt, hopelessness, death wishes, fear, anger, rejection, despair, shame, repulsion, grief, shock, hostility, and abandonment.<a></a> The need for prompt, professional assistance is crucial. </p> <p>Parents are extremely sensitive to the reactions and attitudes of others, and they need help to know that they and their child are accepted. In addition to individual counseling by a psychologist, social worker, or other qualified persons, group sessions have been established.<a></a> Parents benefit from the opportunity to verbalize their feelings and receive support and help in handling their emotions and in developing constructive attitudes. Wallace<a></a> noted the impact of these group-therapy sessions on the fathers, citing fewer absences, less hesitation about expressing their feelings, and awareness that their attitudes affect the child's adjustment and help to mold his self-image.</p> <p>If, instead of realistic acceptance, strong defense mechanisms are built up by the parents during this early period, they will not be able to communicate with their child when he becomes aware of and questions his deficiency. One indication of the mother's acceptance of the child is the way she handles the baby. Some important factors to look for in observing parental behavior are: avoidance of direct contact with the baby, ritualistic organization and emphasis on cleanliness, barriers to communication, aggression toward professionals, and subconscious refusal to accept the existence of the child's abnormality.<a></a> The mother will eventually become the child's best therapist, and the early months must provide a basis for her later role. Parents must be aware of the importance of their love in the future rehabilitation of their child. Hall<a></a> and Mongeau and others<a></a> advocate that children become an integral part of the family immediately. Mongeau found that children taken home directly from the hospital after birth have shown greater capacity for adaptation than those who were institutionalized. A strong family basis can be of great help to the child when he may later face repeated hospitalizations for prosthetic training or other reasons. According to Gesell and Amatruda,<a></a> a child's basic behavior traits are fairly well established by the time he is a year old. Some of these traits are hereditary and some are absorbed from the attitudes of the family.</p> <p>Crisis intervention, as described by Brooks and others<a></a>, is the awareness of impending crises in the development of the limb-deficient child and the intervention by qualified professional personnel to aid in making those transitory periods as easy as possible. One such crisis is that of homecoming. The curiosity and concern of relatives and friends must be faced. The effect of the birth of a limb-deficient child naturally has a great impact on his siblings.<a></a> They too must be aided in adjusting to this stress situation. Other potential crisis periods are prosthetic fitting, entering school, and adolescence.<a></a> During the child's period of growth and development, he has the same needs for independence and self-sufficiency that normal children have. Dependence and overprotection must be avoided. Discipline must be consistent and realistic, neither extremely permissive nor extremely restrictive. The profound effects of the parents on the child cannot be overemphasized.</p> <p>The manner and degree to which the child is influenced by his deficiency is determined before he reaches conscious awareness of his condition. If he has been provided with a sense of security, acceptance, and love, he will have a strong basis from which he can develop a positive self-image and achieve independence. The limb-deficient child faces the same problems and sequence in emotional and social development as normal children, but each crisis is likely to be of greater intensity and magnitude.<a></a> The child who has received encouragement and support from his family will expect the same type of relationship from outsiders and will approach social contacts spontaneously, rather than attempting to avoid them. The child will attain a balance between the dominance of his parents' influence and the satisfaction he gains from his independence.<a></a> He should be encouraged to enter into social relationships with a minimum of special attention.</p> <p>Taylor<a></a> has discussed at length the psychological needs of handicapped children. In addition to the fundamental needs of love and acceptance, she cites the needs for adventure and exploration, rebellion to release pent-up frustration, limitation of freedom, friends and social experience, privacy, achievement as a basis of self-esteem, and the need for awareness of the child as a person. These needs are the same as those operating in all nonhandi-capped individuals.</p> <p>Gouin-Decarie<a></a> recognized that a pertinent problem in studying the psychology of a limb-deficient child relates to his conception of space, which is closely associated with the formation of the body image. She found that these children made use of a visual, rather than a tactile, image in recognizing familiar objects. Several authors have discussed the concept of body image, or schema, in child amputees.<a></a> All have indicated the absence of marked distortion of body image in most of these individuals. Alteration of body image is, however, a significant problem in noncongenital amputees. Centers and Centers<a></a> analyzed the results of a draw-a-person test administered to congenital amputees. The majority of amputees represented themselves realistically, either leaving out the missing limb or including the prosthesis. They concluded that, while body images differed in a matter-of-fact way, they did not differ markedly in signs of greater conflict, anxiety, or defensiveness. The study did not support the authors' hypothesis that amputee children will have more conflict and defensiveness about their bodies than will nonamputee children.</p> <p>The body image is critical in relation to the acceptance or rejection of a prosthesis. Congenital amputees experience the same processes in the formation of body image as normal children. The earlier the child is trained to wear a prosthesis, the easier it will become a part of his body image.<a></a> One factor in the ready incorporation of the prosthesis is that modern prostheses are functionally adequate for many of the activities engaged in by young children.<a></a> A prosthetic device is never really useful until it is integrated into the body schema. Acceptance and rejection of the prosthesis is more extensively considered in the section on early fitting.</p> <p>The question of the possibility of the phenomenon of phantom sensation in congenital amputees is an interesting one. A discussion of the theories concerning the cause of this phenomenon is beyond the scope of this paper. Hoover,<a></a> Lambert,<a></a> and Simmel<a></a> believe that neither phantom-limb sensation nor pain exists in this group of individuals. Lambert bases his belief on the principle that nerve endings going to the distal limb have never developed. Simmel attributes the impossibility of phantom sensation to the fact that the absent part has never been represented in the body schema. In their census of the juvenile-amputee population, Kay and Fishman<a></a> reported three instances of phantoms in congenital amputees, but these could not be substantiated by further interrogation. Weinstein and Sersen<a></a> reported phantoms in 5 out of 30 children with congenital deficiencies. If the presence of a phantom reflects the "need" of the child to experience a missing part, it should have functional properties. The phantoms reported in this study were usually shrunken, telescoped parts with gaps and missing appendages.</p> <p>Certain other psychological aspects can best be discussed as they relate to the chronological age groups of the congenital amputee. The significant divisions are: preschool, entry into school, latency, and adolescence.</p> <p>In the preschool category, a period of negativism and resistance occurs around two years of age. This is a normal reaction; the child is trying to establish his personality and achieve a little independence.<a></a> This period of negativism often conflicts with prosthetic-training procedures, especially terminal-device activation.</p> <p>Entry into school is an important milestone for any child. He moves from the security of his home environment into a competitive social society. The limb-deficient child needs a reliable basis for dealing with this new group of people. This is provided by his parents and family during the early childhood years. In his group experience, the child will test and validate ways of dealing with people outside his family <a></a>. Adjustment is facilitated if the teacher and class are prepared and informed in advance. Healthy curiosity is the most frequent reaction of classmates, and a factual explanation of the prosthesis and its use should lead to acceptance by the classmates and increased self-confidence of the limb-deficient child. Wilson <a></a> expresses the belief that it is preferable for the limb-deficient child to attend regular school. Unnecessary special consideration should be avoided. The handicapped child may experience feelings of social devaluation, which any member of a minority group feels.<a></a> Centers and Centers<a></a> discuss the results of a social-discrimination questionnaire. The hypothesis that peer-group children express more covert rejecting attitudes toward amputees than toward nonamputee children was supported. They attribute this finding to the fact that one of the most significant variables operating in social interaction is personal appearance. Centers and Centers conducted their study almost ten years ago. It would be interesting to retest this hypothesis in light of recent social trends toward greater acceptance of minority groups and increased emphasis on individual merit as opposed to sterotyped generalizations.</p> <p>The preadolescent latency period is relatively calm, with no major crisis periods. The normal child experiences many conflicts during adolescence, many of which are associated with appearance. These conflicts are all compounded in the limb-deficient child. During this period, a cosmetic hand is often prescribed for the adolescent amputee to replace the functional hook for social occasions. Vocational guidance becomes increasingly important during this period of adolescence.</p> <h3>Normal and Abnormal Biomechanics</h3> <p>The arm enables the hand to be placed in position for skilled functional activities. The most commonly recognized forms of prehension include tip, palmar, three-jawed-chuck, lateral, hook grasp, cylindrical grasp, and spherical grasp. Palmar prehension employing opposition of the thumb predominates in picking up objects and holding them for use. Long tendons with muscles at a distance permit the great variety of motion characteristic of the human hand. In addition to skill, the hand frequently functions in support postures. Sensation is another major function of the hand. The hand is richly supplied with sensory-nerve endings mediating touch, temperature, pain, and position. Large areas of the cerebral cortex represent the complex sensory and motor function of the hand. Boivin<a></a> advocates investigation into the prehension patterns and sequences commonly used in activities of daily living. Stabilization of the wrist in various positions aids prehension. For example, the wrist assumes an angle of 145° when very strong prehension is required.<a></a> Finley, Wirta, and Cody <a></a> studied the synergic action of muscles of the upper extremity resulting in a better understanding of the relationship between central and peripheral control of movement. The three major components of the response phenomenon that they noted were: cognitive, ballistic-type physical displacement, and apparent sensing to compare, confirm, or adjust to assure successful accomplishment of the desired act. The information regarding time sequences is useful as reference material in studying pathomechanics.</p> <p>Finger and hand movement, wrist flexion and extension, and varying degrees of pronation and supination are lacking in the congenital below-elbow amputee. Prosthetic replacement of the wrist and hand is poor, only crude prehension and positioning are possible, and there is no substitution for the lack of sensory feedback. Maximum utilization of the residual biomechanics is essential in prosthetic replacement.<a></a> The biggest challenge is to design an upper-extremity prosthesis that (1) can be powered by and controlled with little effort, (2) can perform through the almost spherical range of a normal arm, (3) has a terminal device that can achieve prehension, (4) will respond to sensation, and (5) is cosmetically acceptable.<a></a> Upper-extremity prosthetics are significantly deficient in all of these areas. Because of the fixed prehension pattern of the terminal device and the fixed wrist, nearly all fine orientation movements must be made at levels higher than the forearm by compensatory motions of the elbow, hand, and shoulder .<a></a> Prosthetic controls permit only the simplest motions decomposed into their basic elements and executed slowly, in series, one at a time.</p> <p>Stoner<a></a> notes that no prosthesis accomplishes any of the wrist-flexion movements. The reasons for this neglect of wrist replacement are: (1) usually no controls from the harness are available to furnish the power, (2) wrist motions are used in fine movement of the hand and are not essential to bring the hand into the major spheres of action about the body, and (3) loss of wrist flexion can be compensated for grossly by other arm motions. Preposition flexion devices are available and are useful for activity close to the body.</p> <p>Pronation and supination are functions of forearm length. Wrist joints allow passive positioning for the most advantageous angle of terminal-device operation. With shorter forearm stumps, the mechanical advantage of flexion is decreased, in addition to the loss of pronation and supination.</p> <p>Joint motions in congenital amputees are often bizarre<a></a>. Kruger and Breyan<a></a> report that, in an X-ray evaluation of 16 extremities with terminal transverse partial hemimelia, 13 showed dislocation of the head of the radius. Of these, 77% showed dislocation before prescription of the initial prosthesis. It is therefore concluded that the phenomenon is inherent in the disability itself. The dislocation is asymptomatic. The authors offer two possible explanations for the phenomenon: deficiency of the ligamentous structures, or unopposed action of the biceps brach-ialis muscle. They consider the latter explanation the more likely. In short stumps, the pronator teres muscle is absent, and the biceps in flexing and supinating meets no opposition, thereby dislocating the radial head.</p> <h3>Harnessing</h3> <p>Harnessing techniques for upper-extremity prostheses must be based on bio-mechanical analyses of the remaining movements. Successful use of the prosthesis requires a harness that allows the most efficient use of those movements that are available. The socket limits some of the residual motion of the stump itself, and the harness limits the motion of the sound extremity to some extent. The harness should distribute the weight of the prosthesis evenly over a wide area and be functional in as many positions of normal use as possible. It should transmit power with a minimum of interference and be operable by relatively inconspicuous body motions. Power is provided by the stump itself (elbow flexion) or by the relative motion between two body parts (glenohumeral flexion and/or scapular abduction). Control-cable systems transmit this power from the amputee's body to the prosthesis. The suspension system may use a figure-of-eight, figure-of-nine, or shoulder-saddle chest-strap type of harness. The most common suspension is a figure-of-eight harness with a Northwestern ring-type cross.<a></a> The Northwestern ring allows adjustment of individual harness straps. The figure-of-nine harness is often used for power transmission with Munster-type sockets, which do not require a great deal of additional suspension. The chest strap is useful in spreading the load in heavy work<a></a> and maintaining the prosthesis in the proper position in the presence of baby fat. The harness provides some degree of feedback from the environment. O'Shea<a></a> has described a shoulder-saddle chest-strap harness with the primary advantage of increased comfort. Hile<a></a> described the adaptation and reinforcement of a brassiere to replace the chest-strap harness when breast development occurred.</p> <p>Requirements for suspension and harnessing vary from individual to individual, and skillful use of the available power sources is essential to good prosthetic use. Rapid rate of growth and limited power are critical factors in designing harnesses for congenital amputees.<a></a> Frequent adjustment by the prosthetist assures optimum harness and prosthetic function.</p> <h3>Components of the Prosthesis</h3> <h4>Terminal Devices</h4> <p>Two major considerations in the design of a prosthesis for a child are the continual neuromuscular and skeletal changes due to growth and the child's limited sources for power and control. Linear growth is more rapid than circumferential growth. The prosthesis can be fabricated to allow for later adjustments for growth, thus extending the functional life of the device. The components must be sturdy enough to withstand vigorous use, yet must be light enough to be controlled by the child. Some of the problems involved in the prosthetic replacement of human body parts are control, feedback, reliability, size, and appearance.<a></a> Upper-extremity prostheses for children are essentially scaled-down models of adult types. However, Hall<a></a> and Wilson<a></a> note that recent advances in children's prosthetics include improved design and function of terminal devices, lightweight plastic sockets and shells, and more efficient harnessing methods. There are a large number of mechanical components available that can be combined to best meet the needs of the individual child. Split mechanical hooks stress the restoration of function at the expense of abnormal appearance, while artificial hands with cosmetic gloves attempt to combine modest levels of function with near-normal static appearance. Both hooks and artificial hands should be given the same care as the normal hand; since sensation is absent, they are more prone to damage.</p> <p>There are two mechanisms of terminal-device operation: voluntary opening and voluntary closing. In the voluntary-opening type, tension on the control cable opens against a variable spring force, while in the voluntary-closing type, control-cable tension closes against the spring force. Hooks and hands are available with either mechanism. Voluntary opening is the simplest form of prehension mechanism: the prehension force is provided by special heavy rubber bands. Among the disadvantages of this type are the inability to handle delicate or heavy objects, and the fact that this mechanism is opposite to the prehension of the normal hand. An advantage of the voluntary-closing terminal device is that it more accurately simulates normal prehension, and pressure can more easily be graded to the object to be grasped. Formerly, manually controlled locks were employed, but now automatic locking is available. The fact that, to release the lock, the cable pull must be greater than the pull that closes the terminal device may be a disadvantage. Neither mechanism has been proved superior in a wide range of activities,<a></a> but research to improve both types for juvenile amputees is continuing.</p> <p>Ritter and Sammons<a></a> have elaborated on the advantages of voluntary-closing devices for children's prostheses. The fact that normal prehension is simulated is especially relevant in bilateral grasping. Performing different hand patterns simultaneously, as is necessary with voluntary-opening devices, is particularly difficult for the preschool child to learn, since he is still developing refinement of prehension. A description of the Army Prosthetics Research Laboratories (APRL) voluntary-closing hand, which provides palmar prehension of the three-jaw-chuck type, has been presented by Stoner.<a></a> Teska and Swinyard<a></a> have described a test to evaluate its functional capacity, versatility, and durability. Research is also being conducted concerning the Robins-Aid voluntary-opening hand.<a></a> The concept of cosmesis, or the appearance of the prosthesis, is difficult to define, but is very important. It is a very individualized concept, having varying importance for different people. Function, cosmesis, and acceptance are almost inextricably allied.<a></a> The area of compromise between function and cosmesis is a delicate and crucial one. Those professionals vitally concerned with function must be careful not to look down on the parents who may seem to be overly concerned with cosmesis. Several new plastics have been reported<a></a> that, while not identical to the color and texture of the human skin, do convey an idea of softness and warmth. These new terminal-device designs represent an attempt to combine improved function with an aesthetically satisfactory appearance, but without trying to imitate representationally the characteristics of the missing part.</p> <p>It was formerly common practice to provide the congenital amputee with a plastic mitt or wafer as the initial terminal device. Dean,<a></a> Lineberger,<a></a> and Watkins and Ford <a></a> have presented arguments supporting this practice. Among the major reasons given are: cosmetic appeal, flexibility, support without slipping in creeping, avoidance of injury to the child himself or others during play, and other factors supporting early fitting in general.</p> <p>The infant passive hook is now considered the better choice as an initial terminal device. Some of the reasons for its preferred function are listed by Blakeslee<a></a>: (1) it provides for gross palmar prehension and body-support activities with skill equal to the mitt, (2) it allows the infant to hook over objects for support in pulling to a standing position, (3) it provides a holder for small objects that are placed in it, (4) it helps the infant to develop bilateral prehensile awareness, being recognized as a device to hold objects, and (5) parents who were willing to accept a prosthesis for their child readily accepted the passive hook. Shaperman<a></a> reported the results of an evaluation of the passive mitt and the passive hook with similar results. She also noted improved skill and increased speed of learning when the control cable was added to the passive hook. Initially, the hook presented a slightly greater safety hazard, but the injuries that did occur were minor. Shaperman noted that the hook was one ounce heavier than the mitt, but it appeared to be well within the limits of the infant's ability to lift and manipulate it easily.</p> <p>Hooks are available in a variety of sizes, shapes, and weights. The Dorrance 12P or 10P hook are commonly provided for the unilateral juvenile amputee. They are canted and plastic-covered. Proponents of prescribing hooks cite the advantages of greater prehensile function, with greater visibility and facility available. Numerous authors <a></a> have expressed a preference for the use of the hook rather than the hand. Edelstein maintains that the cosmetic appeal of a skillfully used hook is greater than that of a cadaverous-looking glove. The idea that the hook can only be accepted as a tool, and that therefore it is hard to see the need for a more cosmetic socket, has been expressed by Boivin .<a></a> Research toward improved hook design and function is being carried out. The literature reveals progress reports in the development of the Sumida hook,<a></a> the Northwestern University Center control hook,<a></a> the Steeper split hook no. 65,<a></a> and other more recent advances in prosthetics.<a></a> Carroll<a></a> conducted a study to analyze the prehension force needed by child amputees. The test items were related to function and varied with the age of the child. Most items tested static prehension only; the individual could either hold the object, or it slipped out of the hook because of insufficient prehension force. Dynamic prehension, or the child's ability to control the prehension force, was tested by the ability to hold a paper cup with water in it. The results of this study showed that more children were fitted adequately in regard to the size of the terminal device than in relation to the prehension force. None of the children were found to be wearing an excessive number of rubber bands. With the exception of the toddler group, the prehension force was found to be inadequate for performance of one or more of the test items. One result of this study was a set of suggested pinch forces for below-elbow amputees:</p> <table> <tbody> <tr> <td> <p><b><i>Age (years)</i></b>   </p> </td> <td> <p><b><i>Pounds of force</i></b>   </p> </td> </tr> <tr> <td> 2-4</td> <td>2.25 </td> </tr> <tr> <td> 3-9</td> <td>3.5 </td> </tr> <tr> <td> 5-9</td> <td>4 </td> </tr> <tr> <td> 8-17</td> <td>5 </td> </tr> <tr> <td> 15-20</td> <td>6 </td> </tr></tbody></table> <p>Greater consideration needs to be given to the adequacy of prehension forces for the functional activities of congenital amputees.</p> <p>Cosmetic hands are often prescribed when the juvenile amputee reaches adolescence. Interlocking wrist-unit mechanisms are available that permit the use of a hook for functional activities and a more cosmetic hand for social occasions. These hands usually provide a modified three-jaw-chuck prehension between movable index and middle fingers and a thumb that can lock in position. Hands available for children include the Dorrance no. 2 hand<a></a> and the APRL-Sierra child-size no. 1 hand.<a></a> One disadvantage that must be considered is the greater weight of the hand as compared to the hook. The APRL-Sierra no. 1 hand weighs 170 grams, while the Dorrance 10x hook weighs 60 grams.<a></a> This is especially important, considering that this additional weight has the mechanical advantage of a long forearm lever and the congenital amputee does not possess a great deal of muscle power.</p> <p>The APRL-Sierra no. 1 hand was developed to meet the need for a functional and cosmetically acceptable hand for juvenile amputees. It is a voluntary-opening mechanism with a hand shell of cast aluminum, articulated index and middle fingers, a two-position thumb, and nonarticulated but flexible ring and little fingers.<a></a> In this field study, only 7 of 77 children rejected the hand completely. The remaining participants fell into four groups: those that used the hand exclusively, those that used the hand predominantly, those that used both equally, and those that used the hook predominantly. The authors suggest that the age of the child is a major factor regarding hook or hand preference. Younger children may experience difficulty with hand weight and opening forces, may be more careless in their use of the hand, and may be less subject to social pressures toward cosme-sis. Sex appeared to be an even greater consideration than age. Girls of all ages appear to be potentially the best candidates for the Sierra-APRL no. 1 hand, while younger boys would seem least likely to accept the device. Fishman and Kay <a></a> performed a study to delineate the relative usefulness of the hook and the hand. The results were at variance with previous clinical impressions, which indicate that a hand is a significantly less functional terminal device than a hook. In an extensive evaluation of the Dorrance no. 2 hand in 72 bimanual activities, Gorton<a></a> found that no definite trends emerged to indicate that the hook was measurably more functional than the hand or that the hand was significantly more functional. The test employed by Fish-man and Kay analyzed general and specific patterns of grasp by means of functional activities. The rating scale for performance of activities was somewhat subjective, but the detailed analysis of the results was excellent. From this study, the authors concluded that: (1) the APRL-Sierra no. 1 hand was heavier and, in most cases, more difficult to operate than the previously used hook, but these were not serious drawbacks for the majority of subjects; and (2) the hand provided somewhat less pinch force than most of the hooks and a less precise grasp. While the majority of children reported that they could perform more activities better with the hook, they also were able to specify a number of activities that were performed better with the hand, such as picking up a pencil, grasping paper, and holding silverware for eating.</p> <p>Constant research and re-evaluation of prostheses is essential.<a></a> Boivin<a></a> has written an excellent article criticizing present artificial-hand design. He maintains that an inherent belief exists that the refinement of the normal hand cannot presently be reproduced, leading to the assumption that it can never be reproduced. He cites the apparent lack of coordination and integration in biomedical engineering research, and proposes that a reason for this is that the goal is providing normal hand function, but that this is being attempted without sufficient consideration for the actual anatomical and physiological functions of the hand according to the kinesiological data presently available. One example is the fact that artificial hands flex only at the metacarpophalangeal joint, while the flexor digitorum profundus, the most active finger flexor, flexes at the interphalangeal joints as well. Boivin presents two suggestions for modification of artificial-hand design: first, that the normal transverse arch be reproduced in artificial hands, adding to cosmesis and function; and second, that artificial hands be made smaller and covered with a soft subcutaneous tissue-like material under the glove. Besides improved cosmesis, this would improve grasp by allowing better molding of the fingers over the object to be grasped. This second approach is presently being used by the Otto Bock Orthopedic Industry, Incorporated, in their new modular arm. The catalogues illustrate an above-elbow arm, but it is quite possible to employ this system for below-elbow amputees by fabricating the socket, attaching the proper length tube and the terminal device. This "System Arm" can be used for every level of upper-extremity amputation except wrist disarticulation and extremely long below-elbow amputations. Child-size systems are available. (This information was received from personal communication with Otto Bock Orthopedic Industry, Incorporated.)</p> <h4>Wrist Units, Elbow Hinges, and Sockets</h4> <p>Wrist units perform the dual function of attaching the terminal device to the prosthetic forearm and providing terminal-device rotation for manual preposi-tioning. There are manual-friction, manual-lock, and active-rotation units. Manual-friction is the most commonly used type. A rubber washer and a metal washer are compressed as the terminal device is screwed into place. Behavior of the unit is unpredictable because of the uneven compression and the easy accumulation of dirt, but it has the advantages of simplicity and easy maintenance. Manual-lock units allow rotation and locking of the terminal device by separate steps through the use of cylindrical inserts that have index teeth around their circumference.<a></a> The inserts are threaded to fit the terminal-devicestud. Active-rotation devices use stump rotation to produce rotation of the terminal device and are able to amplify residual stump rotation.<a></a> Wrist-flexion units that provide partial replacement for lost palmar and dorsal flexion of the wrist are available. By adding the extra degree of freedom, they can minimize the need for compensatory motions at higher levels. These units are presently only suitable for light duty.<a></a> Clarke, Kral, and Shaperman <a></a> evaluated wrist-flexion units for children. The advantages of the addition of a wrist-flexion unit to an upper-extremity prosthesis include: (1) the ability to bring the arms close to the body for self-care activities,(2) the ability to bring the arms together in the midline for bimanual activities, and(3) less need for body exertion and bending to accomplish these activities. The authors found that one angle of flexion or flexion and radial deviation is sufficient for all activities. Wrist flexion of 25° or less is comfortable and useful, and there is no advantage above 25°. They advocate that the conventional wrist unit be laminated into the forearm unit in a flexed position, after careful evaluation to determine the most advantageous angle. This overcomes the disadvantages of wrist-flexion units for children, such as added weight of the terminal device, an additional component to preposition, and mechanical unreliability. It would seem that the need for dorsiflexion at the wrist for functional activities should be further evaluated, since this study only considered variable degrees of palmar flexion.</p> <p>Flexion of below-elbow prostheses is provided by hinges of various types; the main classes are "rigid," "semirigid," and "flexible." They can be made of metal, leather, or metal cable. Some elbow hinges are polycentric and have a step-up ratio to provide a greater range of motion for a short below-elbow amputation. This is useful if adequate power is available, since flexion strength is lost through this mechanism. When both power and range are insufficient, it is possible to utilize the stump power to activate a locking hinge. Flexion of the forearm is then provided by humeral flexion.</p> <p>Most below-elbow prostheses require an upper-arm cuff made of leather to help to stabilize the connection between the amputee and the prosthesis necessary to adequate control.<a></a> The most common types are the very light triceps pad and the open cuff. These would be the most useful for congenital amputees; the heavy-duty closed cuff would not usually be necessary.</p> <p>The socket is the foundation of all upper-extremity prostheses. The standard socket designs are used for juvenile amputees, but they may fit poorly because of the large amount of soft tissues in the child and the lack of well-developed bony prominences. It is through the socket that power and control are transmitted from the stump to the prosthesis and some degree of feedback is received. Double-wall construction allows a stump-fitted inner wall with an outer wall designed for structural uniformity and cosmesis. Retention of pronation and supination in short and very short below-elbow amputees is usually not a consideration, since pronation and supination are factors of forearm length. Another important matter is stability in flexion. In short and very short stumps, a single-axis hinge helps to provide this stability.</p> <p>Among the types of sockets available are single-socket, split-socket, preflexed socket, and Munster-socket designs. Single sockets are often lacking in the necessary flexion stability for congenital amputees. Because of limited range of motion, a short or very short stump may require a split socket with a step-up hinge. One degree of stump movement gives 2° or 3° of prosthesis movement, thereby increasing the range of motion, but two or three times normal force is needed to accomplish this. VanDer-werker and Rosenberger<a></a> described the mechanism and installation of a flexor assist for use with the step-up split socket. Pellicore <a></a> noted the unfavorable cosmesis of the split socket, which was later largely replaced by the use of a preflexed forearm. This improved the cosmesis somewhat and increased the functional forearm power, but the range of motion was limited to 100°-110° instead of the normal 135°.</p> <p>A great deal of the recent literature is devoted to a description and discussion of the Munster-type socket. The technique, involving intimate encapsulation of the stump, was developed by Dr. O. Hepp and Dr. G. G. Kuhn of Munster, Germany, and introduced into the United States in 1958. Short below-elbow stumps present a small attachment area, poor leverage, and a decreased useful range of motion. Some of the characteristics of the Munster technique that help to overcome these deficiencies are: (1) the elbow is set in a preflexed position yielding the most useful range of motion, usually about 35 deg., (2) a channel is provided at the antecubital space for the biceps tendon to avoid interference between the socket and biceps tendon during flexion, and (3) the posterior aspect of the socket is fitted high around the olecranon and the epicondyles, taking advantage of these bony prominences to provide attachment and stability to the socket.<a></a> These characteristics eliminate the need for split sockets with step-up hinges, giving improved prosthetic control and feedback, and often eliminate the need for a harness for suspension purposes. Younger congenital amputees may require more harnessing to maintain the prosthesis in place.</p> <p>Epps and Hile<a></a> described the fabrication techniques and evaluated the Munster prosthesis. Among the favorable points they found were: simplified harnessing, light weight, no perspiration problem, and excellent stability under axial-load testing. They also noted the elbow hyperextension characteristic of the individual with terminal transverse partial hemimelia. They concluded that the Munster-type prosthesis is the fitting choice for the child with a unilateral short or very short below-elbow amputation. In their investigation of the applicability of Munster-type fittings, Fishman and Kay<a></a> found that all of the subjects were definitely in favor of this type of prosthesis. The decrease in flexion range had no appreciable effect on prosthetic function for unilateral amputees. (Some modifications, such as lowering the anterior trim line and provision of a wrist-flexion device, may be necessary for the bilateral amputee.) Among the advantages cited are the facts that the stump does not slip out while performing overhead activities, and that less energy is required in operation of the prosthesis. They suggest that this type of fitting is functionally advantageous for amputees with very short to medium below-elbow stumps. Two factors limit the applicability of this technique for stumps of longer lengths: (1) the pronation and supination in these stumps cannot be harnessed with a Mun-ster prosthesis, and (2) the proximal socket opening at a sharp angle to the shaft presents increasing difficulty in donning and doffing the prosthesis as stump length increases.</p> <p>Gazeley, Ey, and Sampson<a></a> reviewed four cases of fitting children with Munster sockets and concluded that the technique is not satisfactory for bilateral amputees, because of the limited flexion. Except for that, they were very pleased with its use. Gorton,<a></a> Kay and Fishman, <a></a> and Pellicore<a></a> have all cited the usefulness of the Munster-type prostheses in fitting short and very short below-elbow stumps. Gorton found the positive factors to be: increased stability and socket retention, socket comfort with minimal stump motion within the socket, harness comfort with the elimination of the triceps pad and front support strap, and improved cosme-sis due to the minimization of the harnessing system. The negative features listed were: decreased range of motion (limited to about 70°), limited elbow flexion, and harness discomfort due to the control strap riding low across the back. The other authors discovered similar findings. With the limited range of motion, it is necessary to make this the most functional range. Partial flexion is necessary to keep the prosthesis on the stump. Complete extension is not as essential to functional activity as an adequate flexion range.</p> <p>The use of sockets that do not completely enclose the stump is more extensive in Germany than in the United States. With this type of prosthetic fitting, the end of the stump remains free for gripping and touching. According to Fletcher <a></a> and an article in the <i>British Medical Journal, </i><a></a> in congenital limb deficiency the end of the limb has a tactile sensation equivalent to that of a normal fingertip, even when the distal two-thirds of the forearm is missing. He attributes the prosthetic rejection by many children to the fact that standard prostheses rob them of this important sense of touch. He feels that fitting such an individual with an artificial limb is, in effect, performing a physiological amputation. Kuhn<a></a> and Jentschura, Marquardt, and Rudel<a></a> have described an open-end socket that enables the patient to use the sensory surface of his stump as well as the terminal device. The socket is provided with a friction joint on the dorsum of the prosthesis so that the terminal device can be bent away from the end of the stump. The economic advantage of an increased "life span" of the prosthesis, as well as the functional advantages of the open socket, have been presented by Jaramillo and Lehneis.<a></a> The preservation of tactile sensation is an important consideration in upper-extremity prosthetic design. Increased research on open sockets is indicated, since they seem to provide a critical advantage over the standard prostheses, especially for the bilateral amputee.</p> <h3>Prosthetic Prescription and Fitting</h3> <p>The prescription of a prosthesis for a congenital amputee, as for any amputee, is best achieved by a team approach. The child's functional needs and developmental status must be ascertained in order to provide the optimum combination of components. Actual fabrication is followed by a final check-out of the compatibility of the amputee and the prosthesis.</p> <p>The physician, prosthetist, and physical and occupational therapists are the main members of the prosthetic-clinic team.<a></a> The physician, in writing the prescription, must combine his knowledge of the individual with the results of evaluations performed by other members of the team. The prosthetist advises about possible solutions to the case, measures the patient, fabricates the prosthesis and harness, and evaluates the functional results of fitting. The physical and occupational therapists evaluate motor development, range of motion, and muscle strength, advise the physician and pros-thetist of available body power for control, suggest possible solutions to fitting problems, and perform the final checkout evaluation.</p> <p>As a functional replacement for the missing limb, the prosthesis must be a simple, lightweight device that will enable the child to perform certain tasks, but not necessarily all tasks. Stamp, Mahon, and Morgan<a></a> found that, with the unilateral below-elbow amputee, the use of a prosthesis improves the function of the opposite, normal extremity. The combination of a normal extremity and a prosthesis is much more functionally efficient than is the combination of a normal extremity and a stump.</p> <p>The functional needs of the child must be determined in order to provide a prosthesis that will fill these needs. Self-care needs are an important part of the functional evaluation. Observing the compensatory patterns that the child has naturally developed for holding or reaching yield an indication of his specific functional needs. One approach to functional evaluation<a></a> has been to observe which parts are missing and to formulate a prescription on the theory that these are the parts that need to be replaced prosthetically. This theory assumes that, once these are provided, the child will meet all of his activity needs. It is important that the total effect of the prosthesis is a significant gain in function. The advantages and disadvantages for each individual must be carefully considered.</p> <p>It is necessary in the early examination to determine the developmental status of the child.<a></a> This evaluation bears a significant relationship to the timing and type of prosthetic fitting. In much of the literature, the achievement of a secure sitting balance is designated as an important criterion to upper-extremity prosthetic fitting. (The criteria for fitting are discussed more completely in the section on the trend toward early fitting.) An important part of the evaluation is the observation of the infant's prehension patterns. The infant's ability to control and relate his various arm, hand, and body movements predicts his pattern of prosthesis operation and use <a></a>. The development of compensatory prehension patterns is one of the positive indications for fitting the child with a cable-operated hook. The child's interest, attention span, and coordination must also be determined. All of this information aids in prescribing a prosthesis and planning a training program.</p> <p>In addition to this evaluation of neuromuscular development, the therapist must also determine muscle strength and range of motion. The prosthetist needs to know which structures are present and which are absent, and what sources of power are available. Muscle defects may accompany skeletal defects, as pectoral agenesis occasionally accompanies below-elbow deficiency.<a></a> Some of the abnormalities of neuromuscular-system function to notice are: involuntary motion, deviations in the speed of motion, resistance to passive movement, atrophy, fatigue, and static or dynamic postural deviations.<a></a> Functional muscle testing as described by Daniels, Williams, and Worthingham<a></a> provides valuable information. Range-of-motion tests are useful in noting any contractures or other factors limiting the range and in determining the scapular movement available to operate the devices prescribed. Sequential testing and accurate recording are necessary in functional, motor-developmental, muscle-strength, and range-of-motion evaluations.</p> <p>Exact body measurements, both longitudinal and circumferential, are often made by the prosthetist at the time of fitting. In the unilateral amputee, the epicondyle-to-thumb length is important as a sizing reference for the total length of the finished prosthesis.</p> <p>The choice of the components for the prosthesis is based on a thorough knowledge of the functional needs and the potentials of the individual. It was formerly accepted practice to prescribe a passive mitt, but this practice has been replaced by the use of a passive, plastic-covered hook. The hook gives the child the opportunity to incorporate the concept of a prehensile device from the start. The manual-friction wrist unit is often useful for congenital amputees. At first it can be positioned by the parents, and later by the child himself. Sockets that permit rotation are not usually indicated in short below-elbow stumps, since residual pronation and supination is minimal. The Munster-type socket, or modifications of it, as well as conventional below-elbow double-walled laminated sockets, seem to be successful in fitting the individual with terminal transverse partial hemimelia. Harnessing and suspension are highly individualized and can make the difference between successful and unsuccessful prosthetic prescription. Some of the greatest problems in prescribing and fitting the congenital amputee arise from his rapid, uneven rate of growth, the presence of baby fat, the lack of well-defined bony prominences, and the almost constant mobility of all young children. It must be emphasized that good prescription of prosthetic components must be based on a thorough knowledge of the individual. The prosthesis should allow him to function at his highest level in his environment. For the congenital amputee, this may mean providing him with the opportunity to assume a normal pattern of development of bimanual activity. In unilateral amputees, the prosthesis functions as a helper, not as the dominant hand.</p> <p>Fabrication and interim fittings are performed by the prosthetist. After careful initial measurements, a plaster cast of the stump is made. This is used to make a mold of the stump. A full description of the techniques for fabricating the prosthesis is beyond the scope of this paper; however, a step-by-step account of fabrication is given in the <i>Manual of Upper Extremity Prosthetics.</i><a></a> There is no universally acceptable check-out procedure for the child amputee. The standardized adult forms are not useful, because child prosthetics is a relatively new field in which improvements in techniques are constantly being made<a></a>. Additional contraindications to a standardized form are the varied ages and developmental levels of the children, philosophies of case management and prescription which may vary from clinic to clinic, and the fact that so many modifications of the prostheses for congenital amputees are needed. The standard check-out forms must be adapted if they are to be used for child amputees. The clinic team must evaluate the fit and function. The pros-thetist's primary interest is the mechanical aspects, the therapist's is the child's functional benefit. The physician must coordinate the efforts of all of the paramedical personnel. Blakeslee<a></a> has presented some of the important considerations regarding check-out for the juvenile amputee.</p> <p><i>Prosthesis fit</i></p> <ol> <li>Is the prosthesis cosmetically acceptable? Is it well made, and does the workmanship follow all of the specifications of the prescription?</li><li>Is the prosthesis of the proper length, and is the socket fit satisfactory? Do bony prominences have sufficient space? Do the component controls appear to be within reach of the amputee?</li><li>In the upper-extremity prosthesis, is the harness adjusted properly and is it comfortable?</li><li>When the prosthesis is removed, are there any excessive pressure points in the socket area? </li></ol> <p><i>Functional considerations</i><br />All components must be checked to make certain they are in good working order, and must be adjusted for efficient operation by the child and/or adult. Some of the primary functional considerations are:</p> <ol> <li>Is the prosthesis properly aligned?</li><li>If it is an upper-extremity device, is the control system appropriate for this child? Will he be able to control the arm and operate the controls in the desired range of motion? Is the terminal device in good condition and does it operate smoothly? Does the harness appear to be correctly positioned and in balance?</li><li>Can the prosthesis be applied with ease? Is the amputee comfortable in the standing, sitting, and walking positions and while performing functional activities?</li></ol> <p>These check-out procedures emphasize the points to consider in preprosthetic evaluations, prescription of components, and fabrication. The prosthesis must be made to fit the needs of the child; the child should not be expected to adapt to the prosthesis.</p> <h3>The Trend Toward Early Fitting</h3> <p>A great deal has been written concerning the advantages of early fitting, and a variety of developmental criteria for fitting have been described. This section deals with the advantages of early prosthetic fitting for the upper-extremity juvenile amputee, a brief discussion of normal motor development, and a discussion of fitting at various ages. The age levels can be roughly grouped as follows: before school age, nine to twelve months, six to eight months, four to six months, and three months or younger. This grouping is the distribution that occurred naturally in the literature. The concept of prosthetic acceptance or rejection is also discussed in this section.</p> <p>The philosophy of early fitting is the dominant theme of much of the literature. The difference exists in the definition of the term <i>early. </i>Before this concept was accepted, prescription of an artificial limb was not advised until the patient reached the middle or late teens,<a></a> in order to avoid the expense of purchasing a device that soon would be outgrown. More recently, the child was fitted just prior to school age,<a></a> but still after the child had become oriented to one-handed function. Frantz<a></a> has presented a brief history of the management of the juvenile amputee during the past twenty years.</p> <p>Mongeau and others<a></a> recommend that the habilitation of congenitally deformed children be initiated at an early age. Many other authors have proposed reasons for early fitting. Friedmann<a></a> lists the following advantages: (1) to stimulate bilateral function, (2) to help the child and parents to accept the prosthesis for function or cosmesis, (3) to incorporate the prosthesis into the child's body image, (4) to improve balance, (5) to get the child accustomed to the normal length of the limb, (6) to prevent scoliosis and other skeletal abnormalities due to asymmetry, (7) to make the child aware of prehensile function, and (8) to promote eye/hand control. In addition to the advantage of greater acceptance, Blakeslee<a></a> cites the fact that early fitting leads to a more normal development of the residual parts and diminishes atrophy caused by disuse and hypogenesis. The prosthesis encourages physical activity, which increases growth and strength. The avoidance of substitute patterns of grasp, such as holding objects in the axilla or elbow-bend and working in an awkward or energy-consuming position, was noted as an advantage by Blakeslee<a></a>, Brooks and others,<a></a> Gillis,<a></a> and Klopsteg, and Wilson et al..<a></a> More of the movement patterns of the upper extremity are acquired than in the lower extremity, thus increasing the importance of early fitting. Gillis maintains that the movement patterns necessary to control the prosthesis are most perfectly developed at the same time as those for the natural limb. The possibilities of atrophy through disuse and the development of contractures are greater with later prosthetic fitting.<a></a> As the result of a study conducted at the Rehabilitation Institute of Montreal, Gingras and others<a></a> found that in a majority of cases there was hypotrophy of the deficient limb. They found an average difference of one centimeter between the lengths of the humeri. The hypotrophy was attributed to disuse because it had been observed that patients who had early prosthetic training were enabled to put their muscles to greater use and therefore they showed less limb-length inequality. An additional advantage of early fitting mentioned by Edelstein<a></a> is that it aids the limb-deficient child in crawling. Children learn to use the upper-extremity prosthesis as well as, if not better than, adults.<a></a> The advantages of skill in prosthetic use resulting from early fitting have been cited by Brooks and others,<a></a> Dean,<a></a> and Mayo.<a></a> Some of the favorable results of early prosthetic fitting for the unilateral below-elbow amputee presented by Brooks and Shaperman<a></a> include: (1) full-time wearing of the prosthesis, (2) skillful operation of the prosthesis, (3) natural and spontaneous patterns using the prosthesis and including it in normal activities, (4) good habits of prosthesis maintenance, and (5) good acceptance of the prosthesis by the child, family, and community.</p> <p>In reviewing the literature, the author noted that earlier fitting was advocated more often for children with bilateral and multiple limb deficiencies than for those with unilateral deficiencies. One possible explanation for this may be the comparatively greater need for sensory input for development and function by the former group. The supposition of earlier fitting was substantiated in a census study by Kay and Fishman.<a></a> They suggested that this may be related to the greater need by multiple limb-deficient individuals for prosthetic assistance.</p> <p>The developmental norms of Gesell and Amatruda<a></a> form the basis of much developmental evaluation. They are especially relevant to the unilateral congenital amputee. For instance, he may first be aware of his missing limb at about three months of age, when he attempts two-handed grasp. Vitali<a></a> cautions that a limb-deficient child should not be expected to achieve standards of developmental performance before others in his age group.</p> <p>In an analysis of data collected over a two-year period ending on June 30, 1967, Davies, Friz, and Clippinger<a></a> noted that a relatively high percentage (32%) of congenital amputees were not fitted until after their eleventh birthday. Since the current philosophy is to fit congenital amputees at a very early age, it would be interesting to know the reason for this delay. The authors could not determine whether the fault lay with the amputee clinics or with parents who were reluctant to take their children to clinics or ignorant of the prosthetic opportunities available to them.</p> <p>In discussing the advantages of early fitting, there is variability in the definition of <i>early. </i>Brooks and Shaperman,<a></a> Kay and Fishman,<a></a> and Watkins and Ford <a></a> support the idea of fitting the unilateral below-elbow amputee before school age, at the latest. Of those authors advocating fitting when sitting balance has been achieved, some are referring to independent sitting without support (about ten months of age) and others to sitting with support (about six months). In either case, this leaves the upper extremities free in a functional position. The group of proponents includes Aitken,<a></a> Brooks and others<a></a>, Caine and Reeder,<a></a> Catto and MacNaughtan, <a></a> Jansen,<a></a> Shaperman,<a></a> and Wilson.<a></a> Several authors indicate a preference for fitting at six to eight months of age. Among these are Blakeslee<a></a>, Gillis,<a></a> Hall,<a></a> Kempner,<a></a> Lineberger,<a></a> and Vitali.<a></a> Lineberger and Gillis have cited the benefit of having a prosthesis to aid in crawling and pulling to a standing position.</p> <p>Encouraging bilateral movement patterns and establishing familiarity with and tolerance for the limb are advantages of prosthetic fitting between four and six months of age. This is considered the best age for fitting by Edelstein,<a></a> MacNaughtan,<a></a> Martin,<a></a> and Mayo.<a></a> Lambert and others<a></a> maintain that the congenital amputee should be fitted with a prosthesis as soon as he needs it. For the unilateral upper-extremity amputee, this may be as early as three months. According to Gingras and others,<a></a> fitting this early is based not only on considerations of function, but also on the idea of helping the child incorporate the presence of an artificial arm into his body image and to accept it better. Tolerance and adaptation to the prosthesis as well as aid in developing sitting balance has been stressed by Nichols and others.<a></a> Prosthetic acceptance or rejection is a very complex concept. It is an accepted psychological principle that an individual is better able to achieve adequate adjustment to a total loss of function than to a partial one, yet prosthetic devices restore partial function. The relationship of the amputee to his prosthesis is that of man to machine. It is an intimate and long-term contact between a human being and a mechanical device. The gadget tolerance of the individual is of great importance, especially as the child grows older and develops greater skill in using the prosthesis. Both the visual consideration of cosmesis and the auditory factors of a mechanical device, such as the sound of a terminal device closing on an object, play major roles in the formation of the individual's attitude toward his prosthesis. If the prosthesis is regarded as a tool that makes him less different and gives him a better opportunity for integration into his peer group, then the child is more likely to wear and use his prosthesis. If he believes that the prosthesis accentuates the difference between himself and others, it is likely that he will reject it.<a></a> Throughout the literature, it has been emphasized that children usually accept a prosthesis without too much difficulty .<a></a> It helps if the individual can gain immediate satisfaction from its use, rather than feeling that it is a deterrent to his activity. A child can be helped to appreciate the usefulness of the prosthesis by providing him with toys and chores that require two hands. Both a full-time wearing pattern and the ability to talk freely and openly about the prosthesis are good indicators of acceptance.</p> <p>Several authors have emphasized the positive relationship between early fitting and good prosthetic acceptance. A patient most easily accepts a prosthesis if he obtains it before becoming accustomed to one-handed activity.<a></a> Kempner,<a></a> Mongeau and others,<a></a> and Wilson <a></a> believe that early fittings lead to complete patient and family acceptance. In evaluations by Brooks and Shaperman<a></a>, children with short below-elbow stumps fitted before two years of age received the best scores for "acceptance." Gingras and others<a></a> found that rejection is a common occurrence if prosthetic fitting takes place after adolescence, while Blakeslee<a></a> found excellent acceptance and utilization if the child was fitted before four years of age, and increased rejection after that age.</p> <p>Congenital amputees experience the same structuring process in regard to body image as do normal children. If a child is presented with a prosthesis during the critical stage when his body image is forming,, he will incorporate the limb into his pattern of activity and self-image.<a></a> Centers and Centers<a></a> note that modern prostheses are functionally adequate for many of the activities engaged in by children. This may be a factor <i>in </i>the incorporation of the prostheses into their body images. Personality factors are directly related to acceptance of a prosthesis.</p> <p>In the case of the congenital amputee, his parents' attitudes affect his personality and his acceptance or rejection of a prosthesis. Parental influence cannot be overemphasized. It is within the family structure that all of the child's attitudes are developed. A clear view of parental influence is presented by Brooks and Shaperman<a></a> in their discussion of a group of children who had rejected their prostheses. The group was characterized by a lack of parental support and guidance in the child's general behavior. There was a great deal of emphasis on the child's accomplishments without the prosthesis. These parents expected less of their children than their potential, openly expressed dislike for the appearance of the prosthesis, and had a limited ability to communicate feelings and problems. One review<a></a> indicated that the better-educated middle-class families are most likely to help their children accept prosthetic appliances.</p> <p>All of these considerations regarding acceptance and rejection are interrelated.</p> <h3>Questionnaire Survey Concerning Age at Initial Fitting</h3> <p>The questionnaire survey sought to document a trend toward earlier initial fitting of upper-extremity prostheses in the congenital amputee. As the most frequently occurring limb deficiency, unilateral terminal transverse partial hemimelia was selected as the focus of consideration. An extensive review of the literature had seemed to indicate a trend toward earlier fitting. While children were formerly fitted just prior to school age or even during the middle or late teens, the achievement of independent sitting balance is now a widely accepted criterion for prosthetic prescription. According to Gesell and Amatruda's studies of motor development,<a></a> the norm for the achievement of this maturational level is nine months (36 weeks).</p> <p>It was the belief of the author that (1) even earlier fittings are being performed in significant numbers, (2) a passive hook is most frequently prescribed, and (3) the development of the Münster-type socket has played a role in the trend toward earlier fitting.</p> <p>Questionnaires were mailed to the 28 clinics participating in the Child Prosthetics Research Program, a cooperative endeavor conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development. The information requested was of three types: age at time of initial fitting, type of socket and terminal device most frequently prescribed, and basic developmental levels considered essential for fitting the prosthesis.</p> <p>The sample consisted of 40 new patients with upper-extremity terminal transverse partial hemimelia who were initially fitted between March 1, 1969, and approximately March 1, 1971. The frequency of fittings is indicated in <b>Table 1.</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One clinic whose data arrived too late to be included in the chart reported fitting more than 200 cases. A relatively small number (between 15 and 20) were fitted between the ages of 6 and 9 months, and a much larger number (50 or 60) were fitted after the age of 12 months. Two other clinics indicated that the information needed to complete the questionnaire was not readily available. (One of these stated that all of their children were fitted after the age of 12 months.) In requesting the data, no upper limit was set on the last interval (later than 12 months). For this reason, no statistical analysis of the central tendency (mean or median) was possible. The return on this survey was 43%, the low response level being partly attributable to the fact that no date was designated for the return of the questionnaire.</p> <p>The frequency distribution indicated that 65% of the children were fitted under one year of age. Using nine months as the age for reaching the developmental level of independent sitting, the data indicates that 37.5% were fitted before that age. It is also interesting to note that 20% of the sample was fitted before six months and 7.5% before three months. This information indicates a trend toward fitting earlier than the widely accepted criterion of independent sitting balance. The very important concept of parental attitudes and other intangible factors were not considered, nor was the age when the child was first seen at the clinic taken into account in this study. If it were, perhaps an even stronger trend toward earlier fitting would be noticed.</p> <p>Regarding the type of terminal device, seven clinics prescribed a Dorrance 10P or 12P passive hook most frequently. One fitted a nonfunctioning hand (mitten) initially and changed to a hook at about two years of age. The other clinic listed both the passive hook and the passive hand in their response. Five of the clinics prescribed a conventional double-walled plastic-laminate socket most frequently, and four clinics most often prescribed a Münster or modified Münster socket.</p> <p>An interesting outcome of this survey was the compilation of the developmental criteria for fitting employed by the various clinics. In the following chart, the list of criteria is paired with the developmental norms described by Gesell and Amatruda.<a></a> </p> <table> <tbody> <tr> <td> <p><b><i>Developmental Criteria</i>      </b></p> </td> <td> <p>      <b><i>G and A Norms (mo)</i>  </b></p> </td> </tr> <tr> <td> <p>Beginning to prop on elbows</p> </td> <td>      3 </td> </tr> <tr> <td> <p>Readiness for bimanual activity</p> </td> <td>      4 </td> </tr> <tr> <td> <p>Head control</p> </td> <td>      5 </td> </tr> <tr> <td> <p>Object transfer</p> </td> <td>      7 </td> </tr> <tr> <td> <p>Beginning sitting</p> </td> <td>      8 </td> </tr> <tr> <td> <p>Independent sitting balance</p> </td> <td>      9 </td> </tr> <tr> <td> <p>Controlled voluntary grasp and release</p> </td> <td>      9-12</td> </tr></tbody></table> <p>One clinic responded that they did not adhere to any developmental criteria, but felt that as soon as the child was three or four months old, a prosthesis could be fabricated with adequate socket fit. It was their belief that the earlier the socket was fitted, the better.</p> <p>The data collected on this sample did not establish a relationship between the development of the Münster-type socket and the trend toward earlier fitting.</p> <p>It is hoped that persons responsible for prescribing prostheses might consider the criteria proposed by other clinics for fitting of prostheses for congenital upper-limb amputees. The advantages that prompted the change from pre-school-age fitting to fitting at the developmental level of independent sitting continue to exert an influence toward still earlier fitting. The greatest advantage claimed is that of acceptance of the prosthesis. Logically, if the artificial limb is provided before a one-handed activity pattern is developed, changes for acceptance are increased. It would further seem logical that, when the capacity for two-handed grasp in the midline develops (at approximately four months), a prosthetic limb should be there to oppose the normal limb. The proximal stability necessary for control is developed previously in the on-elbows position. Many factors interact to affect the age of initial fitting. The age at which the limb-deficient child is referred to the clinic is certainly a significant one. Parental attitudes are closely associated with this consideration. The development of prosthetic parts specifically designed for children is important, as is the increase in knowledge in the entire field of prosthetic management of the juvenile amputee. Dissemination of this knowledge to the related health fields, especially to those individuals in contact with the mother of the newborn child with limb deficiencies, may promote earlier referral to the appropriate prosthetic team.</p> <p>It is believed that the trend toward earlier fitting is advantageous. A difference in the practice of various clinics has been noted. A polarity exists with a tendency for some clinics to fit predominantly at a very early age range and others only later. Three of the clinics indicated fitting only after 12 months. It would be useful for all the clinics that participate in the management of congenital amputees to carefully evaluate their criteria for prosthetic fitting and training.</p> <h3>Preprosthetic Therapy</h3> <p>Preprosthetic care should begin as early as possible. Hall<a></a> believes that physical and occupational therapy should be started as soon as the child begins to take part in his environment. A highly individualized treatment program to correct the deficiencies in range of motion, posture, and muscle strength is an important goal of preprosthetic therapy. The evaluations described earlier as prerequisites to prescription are also a part of the preprosthetic therapy program. Jaramillo and Lehneis<a></a> suggest that the child's poor attention span or negativism may be due to the lack of preprosthetic training by means of a good exercise program, rather than to poor family cooperation.</p> <p>Several authors have emphasized the important role the mother plays as the therapist.<a></a> She can be the best therapist for her child, since she spends more time with him than anyone else. She must understand the purposes of the therapy program and carry out the program at home. A good home program will facilitate prosthetic training. A well-informed mother can help to prevent contractures and postural deviations and to correct existing problems. It is a significant psychological asset for the mother to be an active member of the prosthetic team. An additional consideration that is the mother's responsibility in the early stages of habilitation is stump hygiene. The stump should be washed, rinsed, and dried thoroughly and inspected daily for any minor irritation or abrasion. The limb-deficient child perspires more than normal because of reduced body area. <a></a> He should be dressed in light, unrestrictive clothing for cooling and to allow freedom of movement.</p> <p>Limitations of range of motion do not occur as often in the upper extremity, and when they do occur, they do not as markedly affect its use.<a></a>The best treatment is prevention. This can be accomplished by instructing the parents in positioning and active exercises to prevent contractures and build strength and endurance. Extreme caution should be used in stretching any joints in the congenital limb-deficient child. The elbow is especially vulnerable, and passive stretching is contraindicated. (The tendency for radial-head dislocation has already been discussed.) The best techniques for increasing range of motion are those that achieve relaxation of the shortened group by heavy resistance to the antagonist muscle group. The PNF techniques of repeated contractions, slow reversal, slow reversal-hold, rhythmic stabilization, hold-relax, or slow reversal-hold-relax, as described by Knott and Voss would be appropriate. Since the young child is more flexible in his muscular structure, it is easier to reverse the adaptive shortening of the muscles than it would be in adults. Blakeslee<a></a> also notes the use of passive stretching, casts, and braces for the correction of flexion contractures.</p> <p>The delay in the early neuromuscular development of children with congenital skeletal limb deficiencies has been noted by Blakeslee<a></a>, Hall <a></a>, Jaramillo and Lehneis <a></a>, and Steele.<a></a> The child may be delayed in the development of head and neck control, rolling over, creeping, and sitting. He may need assistance in achieving developmental tasks. For example, if the child lacks head and neck stability, placing a small pillow under his chest allows development of the trunk and neck extensors. During this early period, assistance may be needed to help strengthen the neck and trunk flexors, extensors, and rotators. Later, it may be necessary to stimulate bimanual activity, especially gross grasp, by providing large objects for the child to hold. The upper-extremity amputee may need help in pulling to a standing position so that he can adequately develop his lower-extremity musculature.</p> <p>Essential muscle groups are exercised to maintain mobility and increase strength. Specific muscle groups must be strengthened in order to provide sufficient power to operate the prosthesis. Bates and Honet<a></a> and Montero <a></a>advocate the use of isometric exercises for this purpose. Exercises for neck and back extensors, flexors, and rotators are best accomplished through play activity. Catto and MacNaughtan <a></a> suggest using mirrors to stimulate the desired movement. The sound side should be included in the exercise program. Emphasis on strengthening the shoulder-girdle musculature for elevation, depression, scapular abduction and adduction, and general chest expansion (respiratory exercises) is important, since these muscles are needed to operate the prosthesis.<a></a> For the below-elbow amputee, strengthening elbow flexion and extension and any available pronation and supination is of prime importance.<a></a> Blakeslee<a></a> has emphasized the importance of general conditioning. Limb-deficient children tend to have a low energy output. This was observed even in below-elbow amputees who were otherwise normal in appearance and physiognomy. Greater than average endurance and output are required to operate a prosthesis. He also mentions that individual and group sports and other group activities have been successful in increasing energy output and improving general physical condition. Swimming has been found particularly advantageous.</p> <p>A preprosthetic therapy program provides a good foundation for later training of the child in the use of the prosthesis.</p> <h3>Prosthetic Training</h3> <p>Prosthetic training begins when the congenital amputee receives his prosthesis and continues periodically through vocational training. The initial training and orientation with a passive terminal device is essentially the same as that with an active terminal device, so both are considered together in this section.</p> <p>Training is one of the most difficult and important phases in the management of the congenital amputee. It is essential that the child is enabled to handle his environment rather than adapting the environment to his needs. Training a congenital amputee is very different than training a traumatic juvenile or an adult amputee who once had a functional extremity. The functional level of a normal child of the same age should be the basis of achievement goals.<a></a> The program progresses naturally from gross bimanual grasp to skilled functional activity. Factors affecting training are the child's neuromuscular development, attention span, functional requirements, and parental cooperation.</p> <p>The parents play an important role in the training of the juvenile amputee. The care and function of the prosthesis must be carefully explained to the parents, and they must be very aware of what it can and cannot do. The importance of the parents in prosthetic training has been emphasized by many authors.<a></a> Unless contraindicated by medical or other reasons, full-time wearing of the prosthesis from the first application should be the aim. According to Blakeslee,<a></a> one advantage to achieving a full-time wearing pattern as early as possible is the avoidance of the habit of removing the prosthesis for little or no reason. Later in childhood, the wearing pattern will be interrupted for repairs and refitting, so a stable pattern is desirable. Infants accept prosthesis-wearing easily, unless there is discomfort or the parents do not allow the prosthesis to be worn all day. Mac-Naughtan, <a></a> Shaperman, <a></a> Steele,<a></a> and Watkins and Ford<a></a> advise a gradual increase in tolerance leading to full-time wear except for sleeping, bathing, and rough contact sports. This seems to be a more logical approach than to expect immediate full-time wearing after the child has become accustomed to complete freedom of movement. During the period when the child has a passive prosthesis, he should be encouraged to use it as a "helper" in bimanual grasp, crawling, and pulling to a standing position. Toys are an excellent medium for encouraging bimanual activity. The infant amputee who receives his prosthesis during the first year of life shows remarkably early proficiency in gross arm movements; he develops habits of including the arm as a total unit rather than any specific part of the arm such as the hook, tip, or elbow.<a></a> An awareness of the hook's holding function should be developed as early as possible.</p> <p>In response to the questionnaire survey conducted by the author, the University of California at Los Angeles included a discussion of the criteria for the addition of a cable. Some of the factors proposed as prerequisites for terminal-device activation are: the readiness for bimanual activity, a reasonable attention span (approximately five minutes), the ability to follow two-step directions, tolerance of handling by the therapist, the presence of sufficient neuromuscular development to operate the cable, a full-time prosthesis-wearing pattern, and an awareness of the hook's holding function. At UCLA, the cable is usually added at a developmental age of two or two and one-half years.</p> <p>Like the variations observed in the age of choice for initial fitting, similar variability occurs in the age at which the terminal device is activated. The usual age seems to be about two years. Mac-Naughtan<a></a> has expressed the opinion that training should be conducted at the 14-to-20-month age. Depending on the ability of the child and the nature of his deformity, active control can be accomplished at 16 to 24 months, according to Hall<a></a> and Kempner. <a></a> Edelstein<a></a> cites 18 months, and Lambert<a></a> cites 18 to 24 months for the below-elbow amputee. By the age of 21 to 24 months, the child has developed a two-handed functional pattern, and he shows signs of a need to develop a pinch grasp as opposed to purely palmar prehension. <a></a> By two years of age, according to Blakeslee<a></a>, the child is ready for effective terminal-device activation, although this is typically a period of profound negativism. Dean <a></a> and Mayo<a></a> suggest that a single control cable be activated at 24 to 30 months, while Gingras and others<a></a> believe that, if active prosthesis training is begun by age two or three years, control can be achieved by four years of age.</p> <p>A study by Trefler<a></a> reveals the drawbacks of normally fitting around two years of age. Some of these considerations are that the child is ready for bilateral grasp before that age; he may be difficult to work with at the "terrible twos" stage of hyperactivity and negativism, and he may have already developed compensatory patterns, which are more easily prevented than broken. The advantages of terminal device activation at 15 months of age with a goal of spontaneous terminal-device use are: (1) the child is easy to work with for short periods of time (he has an attention span of one to two minutes), (2) when the cable system is applied to the child's prosthesis, it often helps to eliminate the problem of excessive external rotation of the socket, and (3) the availability of active grasp can enhance the activity pattern of an intelligent child. No disadvantages of early terminal-device activation were discovered. The cable did not restrict the child's movement during play at all.</p> <p>Wendt and Shaperman<a></a> conducted an interesting study to determine whether an infant amputee with unilateral below-elbow deficiency who was fitted initially with a prosthesis that included a cable would achieve purposeful control of the terminal device as part of his normal developmental progression without formal training. The results indicated that only a minority of the patients (approximately 25%) did achieve spontaneously the degree of skill usually acquired after formal training. Some patients partially learned skills, and others remained unaware of the function of the hook. It is possible that some children were negatively conditioned by the experience of trying to operate the terminal device and finding that they were unable to do so because of a lack of skill and guidance and concluding that the hook was a poor and unreliable tool. An alternative method of case management that has been suggested is to add the cable when manual hook-opening appears and then to allow natural development of terminal-device control. If the skill does not develop spontaneously, the therapist should intervene with the training program. This emphasizes manual hook-opening as a relevant step toward the eventual development of active opening. It was found that children who do learn terminal-device operation without training develop good skill and use patterns. If they are going to do so independently, they give evidence of this well before two years of age and achieve a well-established pattern by that time. It seems that, if a child is ready to develop the skill for terminal-device operation naturally, he should be allowed to do so.</p> <p>Prosthetic training once the control cable has been added is composed of two parts: training in the control of the terminal device and later functional training in activities of daily living. The child's ability to operate a hook relates primarily to his maturity.<a></a> Because of the child's short attention span, brief, frequent training sessions are desirable. Patients may sometimes be required to enter the hospital for the initial training sessions and occasional retraining later. At home, the mother can encourage these brief, frequent practice sessions. The child can best learn the correct control operations and realize the potentials of this prosthesis through play. There is a tendency for the child to continue to use his prosthesis as a passive device even after active control has been added.<a></a> Early training before the control cable is added should establish the concept of the prehensile function of the prosthesis. Manual hook-opening, at first by the parent and later by the child, and placing toys into the hook, should be encouraged. Flexion of the humerus opens the terminal device. The child must be helped to achieve the awareness of the relationship of these two incidents. The concept of stabilizing the sound shoulder in order to operate the terminal device is a difficult one to grasp. Having the child reach toward the terminal device with his sound arm may be helpful, or the therapist may need to stabilize the harness. The technique of immobilization seems to be mastered abruptly and inexplicably<a></a>, but it may take a great deal of time. The important objective is to get the child to open the hook, no matter how awkwardly it is accomplished. It may be necessary to cut down on the number of rubber bands on the hook to enable the child to open it; at this point in training, a large prehension force is not needed. The therapist can help hy offering objects to the child and placing them so that the hook will open when he reaches for them. One of the most difficult things for a child to learn is to pick up objects from a horizontal surface.</p> <p>The sequence of learning grasp and release with the prosthesis has been described by Blakeslee<a></a>, Richardson and Lund,<a></a> Shaperman,<a></a> and Wendt and Shaperman.<a></a> Although there may be variations in the pattern among individuals, it is agreed that a pattern does exist for learning terminal-device operation. A brief summary of the patterns observed by the above authors is presented here.</p> <p>Children learn first to actively maintain the hook in an open position and then to initiate hook-opening actively. Early opening is often accomplished by abducting and internally rotating the arm rather than by flexing the shoulder. This closely resembles grasp by the normal infant. The child finds it easier to open the terminal device with the elbow extended than in any other position. There is a tendency for the child to place objects into the hook with the sound hand. The ability to actively close the hook around an object develops before active release. At first, release of objects is accomplished by pulling them out of the hook with the sound hand. The child seems to be unaware that he can open and close the hook for release and that this requires the same motions that were used for grasp. It takes a long time and a great deal of practice for a child to become proficient in the use of the prosthesis. He must learn how far to open the hook to accommodate objects of different sizes and shapes, to position the hook accurately, and to properly time the release of an object. The child must also learn to extend the prosthetic arm and still maintain grasp on an object by releasing his sound shoulder so it no longer acts as the reaction point for control. The younger child cannot be expected to learn these more complex skills.</p> <p>Training hints have been offered by many therapists. The most frequent suggestion is the use of toys that require bimanual activity.<a></a> A lengthy list of toys suitable to each age group and each desired activity can be compiled. It was also mentioned that feeding time has been found to be one of the most successful training periods. Drill activities cannot be neglected, but relating them to functional play activities as soon as possible is desirable. <i>The Limb-Deficient Child</i><a></a> contains an excellent and extensive section on prosthetic training.</p> <p>Three prime functions that require prosthetic training are feeding, toilet care, and dressing. Other functional patterns that add to patient independence and satisfaction are: playground, household, and schoolroom activities, sports, musical instruments, card playing, and any other activities commensurate with the child's age. Special assistive devices are available commercially or can be fabricated when necessary.<a></a> Vocational training and preparation is a major consideration as the child grows older. For the unilateral amputee, the prosthesis is a helping or assisting device, and the sound arm is the dominant one in all activities. The part of functional training described in this paper is donning and removing the prosthesis. It is not practical to expect the very young amputee to be able to put on his prosthesis independently from the beginning. This is in contrast to the training procedure in adults, which would begin with this skill. Application is accomplished in the same manner as putting on a coat.<a></a> The socket is grasped with the sound arm and the stump is slipped under the inverted-Y strap. If the prosthesis is raised above the head so that the harness hangs down, the sound arm can reach back through the axilla loop, and the harness then can be properly placed. To remove the prosthesis, the child raises both arms over his head and grasps the socket with his sound arm. He can withdraw the stump while pulling up on the socket and then remove the axilla loop. Although a stump sock is usually worn to absorb perspiration, prevent suction, and allow greater comfort in the socket, it is a matter of individual preference. Some children with below-elbow deficiencies prefer not to wear a stump sock.<a></a> It is recommended that a T-shirt be worn under the harness to decrease local pressure and irritation, especially in the axilla, and to absorb perspiration.</p> <p>Successful training will permit the child to function freely and independently in his environment. Additional training may be required when the needs of the individual change.</p> <p>Follow-up studies of juvenile amputees after long-range treatment from infancy to adulthood have been conducted by Davies, Friz, and Clippinger,<a></a> Hamilton,<a></a> and Lambert, Hamilton, and Pellicore.<a></a> All three indicate the excellent results of long-term prosthetic management as indicated by good social adjustment, excellent prosthetic utilization, high employment rates, and high levels of educational achievement. Increases in these favorable results can be expected as children with congenital limb deformities are referred to prosthetic centers for treatment earlier and earlier.</p> <h3>Conclusion</h3> <p>This paper has discussed the prosthetic management of the congenital amputee with upper-extremity terminal transverse partial hemimelia. Psychological aspects, components of the prosthesis, prescription and fitting, the trend toward early fitting, preprosthetic therapy, and prosthetic training have been considered. A review of the literature and a questionnaire survey were completed. Several questions are raised and areas for further research are suggested as a result of this study.</p> <p>Research concerning the etiology of congenital limb deficiencies is indicated, including the unexplained phenomenon that the highest incidence of these deficiencies involve terminal transverse partial hemimelia of the left upper extremity in females.</p> <p>Information regarding phantom sensation in the congenital amputee is lacking. Study in this area might help to explain the phenomena of phantom pain and sensation in traumatic amputees.</p> <p>Reports regarding peer attitudes toward juvenile amputees show some disagreement. Some authors maintain that the attitude exhibited is one of healthy curiosity easily satisfied by an explanation, while a study by Centers and Centers showed more covert rejecting attitudes toward this group of individuals. It would be interesting to retest this hypothesis of social discrimination in the light of recent changes in attitudes toward many minority groups, since this study was conducted nearly ten years ago.</p> <p>A great deal of research is indicated and is being conducted in the area of prosthetic design. The results of biomechanical and kinesiological studies must be incorporated in the design of components. Analysis of the forces used in prehension and the most frequent types of prehension employed would be beneficial in improving terminal-device design. Further evaluation of the hooks and hands presently available and the voluntary-opening and voluntary-closing mechanisms are needed to determine which is most efficient and to delineate areas for further research. Some work has been done regarding optimum wrist-flexion (palmar) angles for functional activity close to the body. However, no consideration has been made as to the need for dorsiflexion, which is used very frequently in functional activity of the normal hand. The field of plastics offer a great source for improvements in fabrication of prostheses. Durable hooks with improved cosmesis may be a possibility with the new plastic materials available, as it has already aided in light weight and durable socket design and fabrication. The open-ended sockets that permit the use of the sensation at the tip of the stump seem to be an excellent development, especially for the bilateral amputee. Investigation into the advisability of increased use in the United States is indicated.</p> <p>Some disagreement exists concerning the development of prosthetic tolerance by the juvenile upper-extremity amputee. It is not, however, a significant controversy, since the goal of full-time wear is agreed upon, with differing opinions only concerning the rate at which this goal is reached.</p> <p>The results of the questionnaire survey indicate a trend toward earlier prosthetic fitting of the congenital amputee. Among the most interesting and valuable of all the information received was the developmental criteria for fitting. This information should be made available to the clinics participating in the Child Prosthetics Research Program, thereby enabling each of them to re-evaluate their criteria in light of this newly accumulated knowledge. Perhaps this can be accomplished through the <i>Inter-Clinic Information Bulletin.</i>The survey conducted did not consider the important factors of parental attitudes and age at time of referral to the prosthetic center. Any future study should incorporate these factors. Another study might better be able to establish or negate a relationship between the development of the Münster-type socket and the trend toward early fitting.</p> <p>Additional information concerning activation of the terminal device is needed. The proposal by Wendt and Shaperman of allowing natural development of the terminal device control once manual opening occurs, then intervening with formal training if control is not established by two years of age, merits consideration.</p> <p>Prosthetics for congenital amputees is a relatively new area, largely developed since the thalidomide tragedy of a few years ago. It has many areas requiring further research, such as the need for lightweight prostheses that can be operated with the available muscle power and the constant consideration of rapid growth. Research in this specific field of prosthetics for congenital amputees will contribute to and continue to benefit from the ongoing research in prosthetics in general. The goal of this research is improved functional ability for individuals with congenital skeletal limb deficiencies of varying degrees of severity and for all amputees.</p> <h3>Addendum</h3> <p>Three additional responses from the questionnaire survey were received after the statistical analysis had been completed and the article had been prepared. These brought the total return to 53.5%. A summary of the information received is presented here.</p> <p>The results were generally similar to those previously reported, with a number of individuals fitted at each interval except the first (less than three months).</p> <p>The developmental criteria presented were: bilateral gross grasp, beginning to sit, independent sitting, and (not previously mentioned) initiation of hand-eye coordination, as with holding a bottle, blocks, and general grasp for objects.</p> <p>Two of the clinics indicated that they usually fit a first prosthesis at six months of age if the developmental level allows it. Those fitted later in the statistics returned were not referred to the clinics until after that age.</p> <h3>Acknowledgments</h3> <p>I would like to thank Miss Dorothy Page, my advisor, for her help and guidance during this project. I would especially like to thank Miss Mildred C. Ey, O.T.R., Director of Occupational Therapy at Sunnyview Rehabilitation Center Hospital; and Mr. Klaus H. Lohman, C.P., of LaTorre Orthopedics Laboratory. I also extend my appreciation to Dr. Sidney Fishman, Mr. Hector W. Kay, the A. J. Hosmer Corporation, the Dorrance Company, the Otto Bock Company, and the clinics answering the questionnaire.</p> <p><b>References:</b></p> <ol> <li>Aitken, George T., Management of severe bilateral upper limb deficiencies, <i>Clin. Orthop. </i>no. 37:53-60, 1964.</li> <li>Amputations and substitutes for limbs, <i>Brit. Med. J. </i>2:195-196, Apr. 22, 1967.</li> <li>Bates, Marion D., and Joseph C. 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Forum </i>7:411-423, 1968. </li> <li>Stoner, Emery K., Functional evaluation of the upper extremity, in <i>Handbook of Physical Medicine and Rehabilitation, </i>ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </li> <li>Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, <i>Clin. Orthop. </i>no. 37:82-97, Nov.-Dec. 1964. </li> <li>Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, <i>Amer. J. Surg. </i>109:294-299, Mar. 1965. </li> <li>Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, <i>Inter-Clinic Inform. Bull. </i>3:6:1-4, 1964. </li> <li>Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in <i>Selected Articles from Artificial Limbs, </i>Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </li> <li>Taylor, Isabelle Wagner, Psychological needs of the handicapped child, <i>Inter-Clinic Inform. Bull. </i>9:8:9-17, 1970. </li> <li>Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, <i>Amer. J. Occup. Ther. </i>15: 17-18, Jan.-Feb. 1961. </li> <li>Trefler, Elaine, Terminal device activation for infant amputees, <i>Inter-Clinic Inform. Bull. </i>9:9: 11,14, 1970. </li> <li>VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, <i>Inter-Clinic Inform. Bull. </i>3:1:1-3, 1963. </li> <li>Veterans Administration Prosthetics Center, Semiannual report, <i>Bull. Pros. Res. </i>10-3:135-136, Spring 1965. </li> <li>---------, Semiannual report, <i>Bull. Pros. Res.</i> 10-4:157-159, Fall 1965. </li> <li>Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, <i>Inter-Clinic Inform. Bull. </i>2:7:7-12, 1963. </li> <li>Wallace, Maxine T., Group therapy for parents of congenital amputees, <i>Inter-Clinic Inform. Bull. </i>5:2:10-14, 1965. </li> <li>Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, <i>Arch. Phys. Med. Rehabil. </i>43:293-296, June 1962. </li> <li>Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, <i>Neurology </i>11:905-911, Oct. 1961. </li> <li>Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, <i>Amer. J. Occup. Ther. </i>24:393-402, Sept. 1970. </li> <li>Wilson, A. Bennett, Jr., Limb prosthetics— 1967, <i>Artif. Limbs </i>11:1:1-46, Spring 1965. </li> <li>---------, Limb prosthetics —1970, <i>Artif. Limbs</i> 14:1:1-52, Spring 1970. </li> <li>---------, The prosthetics and orthotics program, <i>Artif. Limbs </i>14:2:1-18, Autumn 1970. </li> <li>For an Additional Bibliography, please refer to the PDF at the top of this page.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Hamilton, Robert C, A vocational evaluation of juvenile amputees who have attained the age of twenty-one years: a preliminary report, Inter-Clinic Inform. Bull. 3:7:8-9, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Spring, John M., and Charles H. Epps, Jr., The juvenile amputee: some observations and considerations, Clin. Pediat. 7:76-79, Feb. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">---------, Learning techniques applied to prehension, Amer. J. Occup. Ther. 14:70-74, Mar.-Apr. 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Richardson, Geraldine, and Aida Lund, Upper extremity prosthetic training for the young amputee, Amer. J. Occup. Ther. 13:2:57-63, Mar.-Apr. 1959. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr><tr><td class="clsTextSmall"><b> 93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bates, Marion D., and Joseph C. Honet, Isometric exercises for the upper-extremity stump, Journal of the American Physical Therapy Association 44:1093-1094, Dec. 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Kyllonen, Ronald R., Body image and reaction to amputations, Conn. Med. 28:19-23, Jan. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Knapp, Miland E., Upper-extremity amputations: surgical considerations, Postgrad. Med. 45:2:237-240, Feb. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Martin, J. K., Congenital malformations associated with thalidomide and their management, Amer. Heart J. 67:284-285, Feb. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Jansen, Knud, Amputation: principles and methods, Bull. Pros. Res. 10-4:5-41, Fall 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Caine, Donald, and A. J. Reeder, The problem of the congenital amputee, Med. J. Aust. 50: 1:301-305, Mar. 2, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Management of severe bilateral upper limb deficiencies, Clin. Orthop. no. 37:53-60, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116 .</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b> 79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Frantz, Charles H., An evolution in the care of the child amputee, Artif. Limbs 10:1:1-4, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b> 119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Daniels, Lucille, Marian Williams, and Catherine Worthingham, Muscle Testing: Techniques of Manual Examination, 2nd ed., W. B. Saunders, Philadelphia, 1956. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Epps, Charles H., Jr., Upper extremity limb deficiency with concomitant infantile structural scoliosis, Inter-Clinic Inform. Bull. 5:2:1-9, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">McGraw, Myrtle B., Neuromuscular Maturation of the Human Infant, Columbia University Press, New York, 1943. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Stamp, Warren G., Sharon Mahon, and Harry C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med. Rehabil. 46:354-368, May 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Jentschura, G., B. Marquardt, and E. M. Ru-del, Inter-Clinic Inform. Bull. 4:9:11-14, 1965. (Reprinted from Behandlung und Vorsorgung bei Fehlbildungen und Amputationen der oberen Extremitdt, Georg Thieme Verlag, Stuttgart, 1963.) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">Kuhn, Gotz Gerd, Treatment of the child with severe limb deficiencies, Inter-Clinic Inform. Bull 10:3-S:l-26, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Amputations and substitutes for limbs, Brit. Med. J. 2:195-196, Apr. 22, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">---------, Malformations of the upper limb, Proc. Roy. Soc. Med. 62:1:55-56, Jan. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">---------, Dorrance model 2 hand field study, Inter-Clinic Inform. Bull. 6:8:11-13, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gazeley, William E., Mildred C. Ey, and William Sampson, Follow-up experiences with Muenster prostheses, Inter-Clinic Inform. Bull. 7:10:7-11, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Epps, Charles H., Jr., and John H. Hile, Experience with the Muenster-type below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 7:10:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hart-mann, and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs 9:2:4-25, Autumn 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Sammons, Independent-control harnessing in upper-extremity prosthetics, Artif. Limbs 7:1:11-16, Spring 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Clarke, Susan, Carole Kral, and Julie Shaperman, Built-in wrist flexion for children's prostheses, Inter-Clinic Inform. Bull. 9:5:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">McWilliam, R., and S. R. Montgomery, Artificial arms—are they practical?, Med. Biol. Illus. 19:4:200-201, 1969. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Mitchell, C. Leslie, Amputation and prosthesis: past research and future needs, Clin. Orthop. no. 37:110-112, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Carroll, Leila, Sizing and prehension forces of Dorrance voluntary opening devices, Inter-Clinic Inform. Bull. 2:9:7-10, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Contini, Renato, Engineering in medicine, Bull. Pros. Res. 10-8:4-19, Fall 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Veterans Administration Prosthetics Center research report, Bull. Pros. Res. 10-12:331-333, Fall 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Semiannual report, Bull. Pros. Res. 10-3:135-136, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 113.</b> </td><td class="clsTextSmall">---------, Semiannual report, Bull. Pros. Res. 10-4:157-159, Fall 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">---------, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-10:270, Fall 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ritter, Diane, and Fred Sammons, An interesting terminal device modification, Inter-Clinic Inform. Bull. 4:9:7-10,19, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>121.</b> </td><td class="clsTextSmall">---------, The prosthetics and orthotics program, Artif. Limbs 14:2:1-18, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The challenge of replacing human parts and functions, Bull. Pros. Res. 10-3:4-19, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Hile, John, Below-elbow harness without axillary loop, Inter-Clinic Inform. Bull. 6:5:7-8, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">O'Shea, Barbara, A chest strap harness for the below-elbow child amputee, Inter-Clinic Inform. Bull. 6:7:1-4, 18, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Kruger, Leon M., and Nicholas R. Breyan, A study of radial-head dislocation in children with transverse partial hemimelia of the upper limb, Inter-Clinic Inform.Bull.10:1:1-4, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in Selected Articles from Artificial Limbs, Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Finley, F. Ray, Roy W. Wirta, and Kevin A. Cody, Muscle synergies in motor performance, Arch. Phys. Med. Rehabil. 49:655-660, Nov. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>117.</b> </td><td class="clsTextSmall">Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, Neurology 11:905-911, Oct. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Simmel, Marianne L., The absence of phantoms for congenitally missing limbs, Amer. J. Psychol. 74:467-470, Sept. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Hebert, Bernard, the psychological implications of traumatic amputation in children, Inter-Clinic Inform. Bull. 7:4:7-10, 21, 1968. </td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">Taylor, Isabelle Wagner, Psychological needs of the handicapped child, Inter-Clinic Inform. Bull. 9:8:9-17, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">McCollough, Newton C., Interpersonal problems of the handicapped child, Inter-Clinic Inform. Bull. 4:11:1-4, 16, 1965. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Observations and findings concerning upper-extremity prosthesis wearers, Inter-Clinic Inform. Bull. 3:8:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Janelle, Claire, The role of the social service worker in the rehabilitation of the juvenile amputee, Inter-Clinic Inform. Bull. 7:4:20-21, 1968. </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Cohen, Pauline C, Impact of the handicapped child on the family, Social Casework 43:137-142, Mar. 1962. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputation, in Psychological Practices with the Physically Disabled, ed. James F. Garrett and Edna S. Levine, Columbia University Press, New York, 1962. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Sokolow, Jack, Management of the amputee in practice, Med. Clin. N. Amer. 53:3:659-664, May 1969. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Gehant, Barbara A., Patient Census at Child Amputee Clinics—1968, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Oct. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Munson, Nancy K., and Clyde M. E. Dolan, Patient Census at Child Amputee Clinics— 1967, Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Davies, Elizabeth J., Barbara R. Friz, and Frank W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull. 9:3:6-19, 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bergholtz, Susan G., Patient Census at Child Amputee Clinics—1969, Prosthetics and Orthotics, New York University Post-Gradu-ate Medical School, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, Clin. Orthop. no. 37:82-97, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Gingras, G., and C. Corriveau, Modern amputations and prosthetics, Appl. Ther. 9:537, June 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Burtch, Robert L., A study of congenital skeletal limb deficiencies, Inter-Clinic Inform. Bull. 2:7:1-6, 1963. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">---------, The classification of congenital skeletal limb deficiencies: a preliminary report, Inter-Clinic Inform. Bull. 3:1:4-9, 1963. </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Frantz, Charles H., and Ronan O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.) 43-A:8:1202-1224, Dec. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Barbara L. Sypniewski </b></td></tr><tr><td class="clsTextSmall">This article was prepared as part of an honors project at Russell Sage College - Albany Medical College SChool of Physical Therapy, Troy, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1972_01_020/1972_01_020-01.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management Creator An entity primarily responsible for making the resource Barbara L. Sypniewski * https://staging.drfop.org/files/original/4bc63286a052815b611c768021f481ba.pdf f1ec48cc2c9ab7ffffb5c555da764187 https://staging.drfop.org/files/original/f6478fbe791a100f3c1e5cc7f7ab632b.jpg de9916706b45884b00e9ba6dd49f8cac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_006.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 6 - 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/1971_02_006.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_006.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 Children's Prosthetics and Orthotics Program</h2> <h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5> <p>During the early 1950s, pioneering clinicians in the management of the child amputee repeatedly insisted that children were not miniature adults, to whom modes of fitting developed for adults could be applied indiscriminately. The physicians argued that these children had characteristics and problems that required special study and treatment. Primarily because of the missionary efforts of these men, the Committeee on Prosthetics Research and Development in February 1956 moved from an indirect role in the area of children's prosthetics to an active and dynamic one by the establishment of a standing Subcommittee on Child Prosthetics Problems (SCPP). The first chairman, Charles H. Frantz, M.D., guided the activities of the subcommittee until 1965, when he was succeeded by George T. Aitken, M.D. The current membership of the subcommittee appears at the end of this article.</p> <p>Concurrently with the establishment of the SCPP, the Child Prosthetics Studies program at New York University was created under the direction of Sidney Fish-man, Ph.D. From its inception, the New York University program has been closely related to the activities of the Subcommittee on Child Prosthetics Problems. In essence, New York University has acted as an executive arm of the subcommittee in implementing many of its recommendations. This relationship led to the initiation and completion of numerous significant studies, some of which were: (1) extensive laboratory and field evaluations of various models of the APRL-Sierra no. 1 hand; (2) tests of the Dorrance juvenile hand, size no. 2; (3) studies of the application of the quadrilateral suction socket to the juvenile above-knee amputee, and of the patellar-tendon-bearing prosthesis to the skeletally immature below-knee amputee; (4) a field evaluation, preceded by the development of a fabrication manual and an instructional course, on the Minister-type fitting for the below-elbow amputation stump; and (5) laboratory and field studies of the CAPP electric cart.</p> <p>Significant nonevaluation activities included studies of the prosthetic fitting of children amputated for malignancy, numerous surveys and census-type studies of children under treatment, and follow-up studies related to the early work of Frantz and O'Rahilly in the classification of congenital limb deficiencies, with efforts to achieve an internationally acceptable system.</p> <p>As a result of the activities of the subcommittee and of the studies conducted at its instigation by New York University, a number of important by-products have emerged:</p> <ol> <li>The treatment of the limb-deficient child has become a recognizable subspecialty in medicine that has attracted many competent physicians.</li><li>The principle of fitting the child with congenital limb deficits at a very early age has been well established.</li><li>The early fitting of the juvenile who loses a limb because of malignancy, other diseases, or trauma has also become generally accepted.</li><li>Developers and manufacturers have been encouraged to produce prosthetic components for all age levels of the child-amputee population.</li></ol> <h3>Cooperative Clinic Program</h3> <p>A significant early action of SCPP was to bring together in August 1958 a group of persons with a known interest in the treatment of the child amputee. Included were the chiefs of 11 existing child-amputee clinics who agreed to cooperate in studies seeking improved treatment for the limb-deficient child. The participants in this historic meeting were:</p> <ul> <li>Gen. F. S. Strong, Jr., Washington, D.C.</li> <li>Tonnes Dennison, Beverly Hills, Calif. </li> <li>George T. Aitken, M.D., Grand Rapids, Mich.</li> <li>Carleton Fillauer, Chattanooga, Tenn.</li> <li>Charles H. Frantz, M.D., Grand Rapids, Mich.</li> <li>Colin A. McLaurin, Chicago, HI.</li> <li>Charles Radcliffe, Ph.D., Berkeley, Calif.</li> <li>Harry Campbell, Los Angeles, Calif.</li> <li>Leon DeVel, M.D., Grand Rapids, Mich.</li> <li>Edward Hitchcock, New York, N.Y.</li> <li>Bertram Litt, New York, N.Y.</li> <li>Edward Peizer, Ph.D., New York, N.Y.</li> <li>Anna M. Bahlke, Albany, N.Y.</li> <li>Milo Brooks, M.D., Los Angeles, Calif.</li> <li>Capt. Thomas Canty, Oakland, Calif.</li> <li>Carleton Dean, M.D., Lansing, Mich.</li> <li>George G. Deaver, M.D., New York, N.Y.</li> <li>Sidney Fishman, Ph.D., New York, N.Y.</li> <li>Col. Maurice Fletcher, Washington, D.C.</li> <li>James Glessner, M.D., Newington, Conn.</li> <li>J. Leonard Goldner, M.D., Durham, N.C.</li> <li>Richard E. King, M.D., Atlanta, Ga.</li> <li>Claude N. Lambert, M.D., Chicago, HI.</li> <li>Arthur J. Lesser, M.D., Washington, D.C.</li> <li>Robert Mazet, Jr., M.D., Los Angeles, Calif.</li> <li>John R. Moore, M.D., Philadelphia, Pa.</li> <li>Frank Potts, M.D., Buffalo, N.Y.</li> <li>Frederick Vultee, M.D., Richmond, Va.</li> </ul> <p>Subsequently, other child-amputee clinics sought affiliation with the cooperative program, and, upon meeting the criteria or standards established by the subcommittee, additional clinics have been accepted into the cooperative research endeavor. Thirty clinics, broadly distributed, have now been accepted.</p> <p>A large proportion of the studies authorized by the subcommittee have been carried out by the participating clinics under the guidance of New York University.</p> <p>In addition to the 30 clinics currently enrolled in the cooperative program, contact is being maintained with 36 other child-amputee clinics.</p> <h3>Projects</h3> <p>By the mid-1960s, it had become apparent that significant advances had been made in prosthetics generally. Many of the improved fitting techniques that had been developed were found to be applicable to children, and numerous components of advanced design had been made available for use by the child amputee. As a result, children with less severe or with uncomplicated limb deficits, of either congenital or acquired origins, could be treated, and reasonably satisfactory results could be expected. However, the management of the child with severe losses, particularly those affecting both upper limbs at high levels, left much to be desired. The solutions to these problems were considered to be in the successful application and control of externally powered devices. Although available components and systems of this type were (and are) relatively crude, they are regarded as the hope of the future, and a major evaluation and redevelopment effort is being mounted. Already in progress or about to be initiated as a result of prior action by the Subcommittee on Child Prosthetics Problems are a number of studies of great potential value in the evaluation of improved devices and treatment procedures.</p> <p>Studies will be conducted by New York University, through the participating clinics, on the Ontario Crippled Children's Centre (OCCC) coordinated electric arm, an advanced model of the Michigan Crippled Children Commission feeder arm, the OCCC electric elbow, the Rancho Los Amigos Hospital electric elbows, the Otto Bock myoelectric hand, and the Viennatone myoelectric hand.</p> <p>At the request of SCPP, New York University has conducted an annual census of the child amputees who are being treated at the cooperating clinics. For 1969, the data indicated that the total population under treatment was 4,625-an increase of 236 over the prior year. An expanded census relative to the calendar year 1970 has been completed. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Specialized Fitting Centers</h3> <p>At its meeting on October 21, 1967, the Committee on Prosthetics Research and Development approved a proposal by the Subcommittee on Child Prosthetics Problems that an ad hoc committee be established to develop a detailed plan for the creation of specialized prosthetics fitting centers for severely handicapped children. At its meeting on June 12, 1968, CPRD received the report of the committee, which presented criteria for operation of the centers. This plan, which had been previously approved by the child-amputee clinics, was also approved by CPRD.</p> <h3>Children's Orthotics</h3> <p>At its meeting on November 4-5, 1969, the Committee on Prosthetics Research and Development charged the Subcommittee on Child Prosthetics Problems with the responsibility for enlarging its sphere of activities to include children's orthotics. An ad hoc committee of SCPP was appointed to investigate the implications of this new responsibility and to make recommendations for its implementation. It should be noted that the Subcommittee on Design and Development of CPRD had already conducted a number of meetings and workshops on orthotics topics, particularly in the area of lower-extremity bracing, which was the first segment of the orthotics field to be investigated, and many items with possible applications to orthopedically disabled children were beginning to emerge from this work.</p> <p>Upon the recommendation of the ad hoc committee, a number of selected lower-extremity orthotics items that had emerged from the design and development effort and several bracing and ambulation aids that had been developed at the Ontario Crippled Children's Center were demon- strated at a meeting of amputee-clinic chiefs on June 11, 1970, and the clinic chiefs were polled as to their interest in clinical applications of the items demonstrated. Their responses were tabulated by New York University and revealed considerable interest in virtually all items. The Subcommittee on Child Prosthetics Problems reviewed these findings at its October 16, 1970, meeting and recommended that NYU undertake the recruitment of a nucleus of clinics interested in a cooperative research program on treatment devices for cerebral palsy, Legg-Perthes disease, and myelomeningocele. It was further recommended that orthopedic surgeons currently participating in the program be surveyed to identify clinics they knew to be interested in these problems. Subsequently, NYU reported that three clinics in the New York City area had indicated an interest in participating, and that discussions were being held with these clinics to develop a format for the initiation of a mutually useful program.</p> <h3>Education</h3> <p>A major requirement for participation in the cooperative clinical program has been that clinic personnel attend the appropriate upper- and lower-extremity courses at one of the three universities offering such programs. Moreover, since December 1961 at Northwestern University, and since 1964 at the University of California at Los Angeles, 26 courses in the management of the child amputee have been offered to 864 students, including 450 physicians, 238 therapists, and 146 prosthetists. New York University has offered special lectures in the management of the child amputee in its regular prosthetics courses. In connection with the evaluation of specific items where special application skills are required, courses of instruction have been given to the participants.</p> <p>All these educational activities have tended to provide an increasingly higher level of competence among physicians and others in the management of the child with limb deficiencies. Moreover, the Child Amputee Program has been a direct par- ticipant in, and contributor to, the general transition procedures governing the overall prosthetics research and education program. These procedures have served to bring new research-derived information directly and expeditiously to the consumer through courses of instruction and published materials.</p> <h3>Publications</h3> <p>In May 1961, at a meeting of the 12 clinic chiefs then participating in the cooperative program, the chairman of the Subcommittee on Child Prosthetics Problems proposed the creation of a bulletin or newsletter that would serve as a medium for the exchange of information between the clinics. The idea was received enthusiastically by the clinic chiefs, who undertook to provide articles on a scheduled basis. The first issue of the <i>Inter-Clinic Information Bulletin </i>was published in October 1961. It was six pages long, and 100 copies were distributed. Now, 10 years later, the <i>Bulletin </i>is a 16-page printed booklet with circulation in excess of 2,700 copies per issue.</p> <p>Initially, <i>ICIB </i>dealt solely with amputees and prosthetics management. In the past year, however, in line with the general trend, the scope of the <i>Bulletin </i>has been enlarged to include orthotics topics. Since 1967, <i>ICIB </i>has been catalogued in the Library of Congress (Catalogue Number 67-304).</p> <p>At the last four annual meetings of the chiefs of the cooperating clinics, a feature of the program has been a symposium on a selected area of child-amputee management. The proceedings of the symposia held in 1967 <i>(Normal and Abnormal Em-bryological Development), </i>1968 <i>(Proximal Femoral Focal Deficiency), </i>and 1969 <i>(Surgical and Prosthetic Management of Lower-Extremity Anomalies) </i>have been published and distributed to clinicians, medical schools, and other interested groups. The proceedings of the 1970 meeting <i>(The Child with an Acquired Amputation) </i>are being prepared for printing.</p> <p>Effective communication with and between the clinics has been maintained by means of the <i>Inter-Clinic Information Bulletin, </i>the annual meeting of clinic chiefs, and personal contacts through CPRD and NYU staff. These factors have been critical elements in the extremely successful operation of the cooperative child-amputee research program. As the scope of the endeavor now expands to include conditions requiring orthotic assistance, the same elements may be used to develop an equally successful program for children with orthopedic disabilities other than amputation.</p> <h3>Subcommittee on Child Prosthetics Problems, CPRD</h3> <ul> <li>George T. Aitken, M.D., Chairman, Grand Rapids, Mich.</li> <li>Charles H. Epps, Jr., M.D., Washington, D.C.</li> <li>Sidney Fishman, Ph.D., New York, N.Y.</li> <li>Cameron B. Hall, M.D., Los Angeles, Calif.</li> <li>Douglas A. Hobson, P.Eng., Winnipeg, Canada</li> <li>Leon M. Kruger, M.D., Springfield, Mass.</li> <li>Claude N. Lambert, M.D., Chicago, 111.</li> <li>Robert E. Tooms, M.D., Memphis, Tenn.</li> </ul> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_006/ArtificialLimbs-Autumn1971-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Children's Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource Hector W. Kay *