16 20 371 https://staging.drfop.org/files/original/80c2672becb304a755607958b8b3c960.pdf f647e29523f0bb254a98b3e47c5cfca4 https://staging.drfop.org/files/original/f95345137c719c2af67d3301523b3afb.jpg d6fcf2d9d9b48a1a4abf9da786e34eaa https://staging.drfop.org/files/original/752ebfc3ea102a5175fc0fb02e645908.jpg 5350192b793bb2e68a1dbc04c7211858 https://staging.drfop.org/files/original/9c6d7cf4e0c09122676c79d5d6d61204.jpg 902056a0233b4f2c12423310fba95867 https://staging.drfop.org/files/original/fec489d1be2e1025db85614faa8ae709.jpg 0a36603eee31a4a2a19d429958545543 https://staging.drfop.org/files/original/cec2ebadd71bf2d6eaca13a56f774b7c.jpg 0c0ee61bafc622396bcac40f430d3bff DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_028.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 28 - 44 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Turntable Lock for Elbow Units</h2> <h5>Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>In the conventional elbow unit (Hosmer E 400) for above elbow and shoulder dis articulation amputees, manual control of humeral rotation is permitted by virtue of cork and teflon gaskets providing mechanical friction between the top of the main portion of the elbow unit and the turntable to which the upper arm shell or socket is fastened.<a></a> The amount of friction is determined by the tension maintained by the stud and attaching nut. Since humeral rotation great as to rule out easy adjustment. At the same time there must be enough resistance to rotation to accomplish most activities. </p> <p> There are times when a rigid arm is desirable; for example, when climbing ladders, using a shovel for long periods, carrying an object balanced on the forearm, or carrying an object held away from the body. To provide rigidity for such demanding tasks, the North Western University Prosthetics Research Center has developed a manually controlled lock which can be mounted on the area provided for a forearm lift assist on the Hosmer E 400 elbow unit. A spring forcefully engages the locking pin in one of three holes drilled through the turntable for this purpose. Since the turntable possesses enough friction for most activities, the locking pin need only be used to overcome the tendency of the forearm to rotate gradually when shoveling, to provide the extra margin of safety when climbing vertical ladders, or to supply the rigidity needed in certain other tasks. The amputee returns the locking pin to the disengaged position when the task is completed. </p> <p> Installation of the lock requires: first, drilling the indexing holes in the turntable; second, revising the plastic cap on the elbow unit and mounting the locking device; third, cutting a notch in the cork and teflon gasket to make room for the locking pin and regluing the gasket to the elbow unit. </p> <p><b>Fig. 1</b> and <b>Fig. 2</b> are views of the locking device, and <b>Fig. 3</b>, <b>Fig. 4</b>, and <b>Fig. 5</b> show details of its installation. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Installation of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. View of modification showing indexing holes in turntable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Drawing of base of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Drawing of lock components. A, Pin; B, Cap; C, Spring </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Drawings of modified turntable. The radius of the indexing holes may be determined by using a 1/8-in. diameter scriber in the lock base mounted on the elbow and scribing directly on the turntable. The amputee can best select the locking positions after completion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The first prototype (not shown) of the lock was fitted to DM, a 38 year old farmer who is a left above elbow amputee. The lock was mounted on the posterior rim of the elbow frame. A 3/16 in. locking pin was used and has proved to be very durable. The lever which latches and unlatches the lock has been replaced because of breakage. A disadvantage was the requirement for modification of the elbow frame and extensive modification of the cork and teflon gasket. Another disadvantage was the location of the lock lever at the back of the elbow rather than at the side. The device has been worn continuously for 20 months with no malfunction in the locking pin. One unit of the second prototype (as shown in the illustrations for this article) of the lock was fitted to EA, a 38 year old farmer and bulldozer operator who is a right above elbow amputee. The device has functioned well for a period of more than 16 months, and the amputee reports that he uses il several times daily. He is able to lock and unlock the device without removing winter clothing. </p> <p> Another unit of the second prototype of the lock was fitted to IS, a 40 year old farmer who is a right above elbow amputee. The device malfunctioned after six months when the elbow became free moving without the usual amount of friction. This caused excessive strain on the locking pin, which bent under the load. The pin was replaced, friction was restored, and the device has worked for 10 additional months. The amputee reports using the lock when holding materials to be butt welded, when climbing ladders, and in other situations where a static arm is required. </p> <p><b>References:</b></p> <ol> <li>Aitken, George T., T. J. Bushey, Edward R. Ford, and Fred Leonard, <i>Upper-extremily components</i>, Chap. 2 in <i>Orthopaedic Appliances Atlas</i>,Vol. 2, Edwards, Ann Arbor, Mich., 1960.</li> <li>Sammons, Fred, <i>Elbow rotation lock</i>, Northwestern University Prosthetics Research Center, July 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., T. J. Bushey, Edward R. Ford, and Fred Leonard, Upper-extremily components, Chap. 2 in Orthopaedic Appliances Atlas,Vol. 2, Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall"> Research Associate, Northwestern University Prosthetics Research Center, 401 E. Ohio St., Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-41.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-45.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 Turntable Lock for Elbow Units Creator An entity primarily responsible for making the resource Fred Sammons, B.A. * https://staging.drfop.org/files/original/c8a6de84d03266c8bc9f6d6fbbd73688.pdf d1910921582f687b0864172e72031731 https://staging.drfop.org/files/original/1485e4d578f1b428ab1272868a562fc9.jpg 7f8190e7460853fcb6038029386ab1b8 https://staging.drfop.org/files/original/50626bc64a6c233af5c84abb7e6df06f.jpg cc5e165fe7160341865c6791ffbdf829 https://staging.drfop.org/files/original/a164e3f6134e5ced2d7e9cbcdad0579e.jpg 5901261c3142163ed97b63077e119af1 https://staging.drfop.org/files/original/3eb28fac21b5adb765e964436bd2f075.jpg aa6fff355b3e7a00e8413bfd9665f54c https://staging.drfop.org/files/original/f0969d5ad22c3d7d3386e1840992de54.jpg 40d2b29106fe4f7b4648d916a305851e https://staging.drfop.org/files/original/b8a15397236070a1928f734b01eb7ada.jpg aa0f0ea19415d3b62b627c9f367e717a https://staging.drfop.org/files/original/cb45f9034e87770a17262895139a95e2.jpg 0a2949048e4a5d562595657a3d9747e4 https://staging.drfop.org/files/original/ddfff8a45792bdbaff35b784cf009351.jpg ba30758487795821efba0587640fe3a8 https://staging.drfop.org/files/original/07ffd06b6d225ed567e2848bba985e83.jpg e3b152af1db7fd6c4894d6db133288ad https://staging.drfop.org/files/original/97f84bc7e3ced60be18d3ffe0df9cdca.jpg 2040d3bd5e41d0d2959bed152fa4c1cc https://staging.drfop.org/files/original/e57ff3235c3552832ed937f2e20f0f02.jpg 866160e477f752c327061c13dc0be413 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_004.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 4 - 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/1965_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria</h2> <h5>James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p><i>At a recent meeting of the Workshop Panel on Lower-Extremity Fitting <a></a>, which is sponsored by the Subcommittee on Design and Development of the Committee on Prosthetics Research and Development, there was prolonged discussion of below-knee prostheses. Questions were raised concerning the adequacy of the PTB design for many patients, especially patients who were longtime users of the joint-corset, below-knee limb. The view was expressed that the expenditures of time and money in achieving a successful PTB fit did not justify the selection of the PTB prosthesis or a conversion to it, and that the use of a joint-corset prosthesis initially would shorten the prosthetic restoration process for most patients.</i></p> <p><i>It was recognized that the private practitioner is often forced to elect the simplest and least expensive procedure for his patient. Institutional facilities, on the other hand, can take more of the patient's time, without having the often-required succession of visits reflected in direct cost to the patient or to the sponsor. Yet, the panel was of the opinion that some prosthetists probably are still committing errors in fitting PTB prostheses, resulting in deterioration of the stump, excessive shrinkage, or edema. Moreover, criteria for use of the joint-corset prosthesis are still misunderstood.</i></p> <p><i>Fortunately, the Workshop Panel on Lower-Extremity Fitting had the benefit of the counsel of James Foort, formerly of the University of California (Berkeley) but now of the Prosthetics-Orthotics Research and Development Unit at Manitoba Rehabilitation Hospital, Winnipeg, Canada Mr. Fool spoke at length on the PTB design and then agreed to put his comments in writing for the benefit of clinicians the world over. Presented below is his helpful review of the subject.</i></p> <p><i>We are indeed indebted to Mr. Foort for his contribution. The clear expression of certain axioms will, hopefully, solve some of the problems experienced in the fitting of this very important prosthetic appliance.</i></p> <p><i>Anthony Staros <a style="text-decoration:none;">*</a> - Chairman, Workshop Panel on Lower-Extremity Fitting</i></p> <p>The patellar-tendon-bearing (PTB) prosthesis has been in use for more than five years. It was fully discussed in the June 1962 issue of <i>Artificial Limbs <a></a>. </i>Although experience suggests that approximately 90 per cent of all below-knee amputees can benefit from the use of the PTB prosthesis, a substantial number of prosthetists continue to fit joint-corset prostheses to a large proportion of their patients. Apparently, these prosthetists and their clients have found that maintenance and replacement costs outweighed the fabrication and functional advantages of PTB prostheses. Difficulties developing from the use of the PTB prosthesis are said to be edema, stump breakdown, and stump shrinkage. With these difficulties in mind, the purpose of this review is to examine the fitting technique for PTB's, emphasizing factors to be considered in avoiding or overcoming the difficulties and outlining criteria for use of joint-corset prostheses.</p> <h3>PTB Fitting Technique</h3> <p>The most common error made with a PTB socket is an excessively tight fit in the popliteal area of the stump. Too large a bulge in the popliteal area can be constrictive, affecting circulation, causing edema, and in turn leading to deterioration of the stump end. <i>Posterior pressure needed to balance the posteriorly directed force against the patellar tendon by the weight-bearing bar of the socket must be provided by the posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures, as well as by the popliteal area of the stump. (First factor.)</i></p> <p>Emphasis on the patellar tendon as a weight-bearing structure has contributed to constriction of the stump in the popliteal area. <i>The posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures are important weight-bearing surfaces of the stump. (Second factor.)</i></p> <p>In order to make the area for pressure against the popliteal surface of the stump larger, many prosthetists have extended the back of the socket up into the space between the hamstring tendons, cutting grooves to relieve the tendons during knee flexion. This design can contribute to constriction of circulation in the popliteal area when the amputee stands or sits. <i>The back brim of the socket should be formed into a broad, flared surface against which the hamstring tendons can rest when the amputee sits. (Third factor.) </i>So shaped, the back brim of the socket can be made sufficiently high to provide the large support area needed to minimize pressure while holding the patellar tendon in position on the weight-bearing bar and still ensure sitting comfort (<b>Fig. 1</b>). When the back brim is made higher, as for a short stump, the flare also lifts the stump out of the socket and supports it when the amputee sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two views of a temporary plastic PTB socket showing the flared posterior brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edema is also caused by constriction at the mid-stump level, and such constriction can result from the cumulative effects of modifying the plaster stump model. The least desirable modification is that made in the lateral fibula area. This modification is meant to help stabilize the stump mediolaterally in the socket, but the fibula is a poor structure against which to stabilize. <i>To achieve mediolateral stability of the stump in the socket, the socket should fit securely against either side of the tibial crest and against the medial and lateral surfaces of the knee joint. (Fourth factor.) </i>Mediolateral stability is a problem only if the foot is set in or out too far. <i>The socket should be placed over the foot so that there is little tendency for the prosthesis to tilt medially or laterally on the slump as the amputee walks. (Fifth factor)</i></p> <p>Although breakdown at the end of the stump is sometimes attributed to pressure on the end, a more likely cause is constriction at the mid-stump level. Tightness around the middle third of the stump gives the amputee the feeling that the end is contacting the bottom of the socket or that the tissues are being pulled up against the end of the bone. There are, however, circumstances in which end pressure is damaging and painful. <i>The socket should support distal tissues with sufficient pressure to aid venous and lymphatic return without pressing against the bone ends. (Sixth factor.) </i>If the stump has been amputated through cancellous bone, however, the bone end may be an important weight-bearing surface (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A very short stump which is capable of bearing considerable weight on the end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently, the anterodistal tibia area is painful because of the thin cutaneous covering; it is also vulnerable to excessive pressure because of poor circulation. Hollowing out the socket in this region usually does not give the expected relief. Foot alignment, as viewed from the side, and a stiff heel action can be the causes of difficulty. <i>The foot should be pliant and aligned to give a smooth rolling action as the amputee walks, as though the foot were a segment of a wheel run. (Seventh factor.) </i>If, so to speak, the "hub of the wheel" is too far back, the end of the stump is forced forward painfully against the socket as the amputee attempts to control the prosthesis at heel contact by active extension of the knee. This problem is especially pronounced with recent amputees who have not become skilled at regulating the forces against the stump by appropriate coordination of knee and body actions. A softer heel wedge, increased plantar-flexion of the foot (or extension of the socket), or moving the foot forward (least likely) can reduce discomfort at the anterodistal end of the stump resulting from these causes.</p> <p>General tightness is sometimes considered a source of trouble-and may be initially. But a socket should fit snugly, especially for a recent amputee or one who has not worn a PTB prosthesis before. The newly fitted amputee may have to remove the insert from the socket shell, put it on the stump, powder it, and force it back into the socket shell, even when he is wearing only a cast sock over the stump. One should be sure, however, that the socket bears weight evenly on the main support areas and that it also supports the distal tissues. If the socket does provide proper support, the imprint of the stump sock on the skin will be even in appearance, with the important support areas on the stump somewhat reddened. During the early phases of walking, the amputee should not use the prosthesis excessively. Soon his stump will become accommodated, and then he will be able to use a wool sock. <i>Tissues which are snugly pressed in a socket will shrink until pressures are reduced to suitable levels. (Eighth factor.) </i>Sometimes when the stump is fitted snugly, a vacuum develops during the swing phase and has a tendency to produce edema. To correct this problem, holes -sufficiently large to prevent hissing noises- may be drilled into the prosthesis, or the suspension system should be made more effective.</p> <p>All these factors must be kept in mind when an impression is made over the stump and the plaster model of the stump is shaped for use as a socket mold.</p> <h4>Taking The Plaster Impression</h4> <p>It is not easy to outline a specific procedure for taking a plaster cast of an amputee's stump. Stumps vary in the amount and resiliency of tissue covering the skeletal frame to be fitted. Moreover, the size, strength, and shape of prosthetists' hands and their sense of pressure-all unique to the individual-vary considerably. But if the impression is made tightly over the weight-bearing areas of the stump, these areas will be better defined than if the cast is made looser, regardless of these other differences.</p> <ol> <li>The impression should be started at the knee. The plaster-of-Paris bandage is wrapped tight, starting at the superior edge of the patella. As each pass is made around the knee, the plaster is formed up higher on either side of the knee by guiding it upward with the fingers of the left hand (<b>Fig. 3</b>). At the back, the cast should cover the knee crease by about two finger widths. Wrapping continues in this manner down to the level of the tibial tubercle.</li><li>Next, an effort must be made to obtain an accurate imprint of the medial flare of the tibia (<b>Fig. 4</b>). The plaster-of-Paris bandage is pulled up against the medial flare with even tension, and each turn is anchored to the lateral surface of the knee. Thus tissue tension is prevented from driving the plaster away from this important support area.</li><li>The rest of the stump is wrapped with less tension.</li><li>The plaster is smoothed over the entire stump and worked around the bony areas. As the plaster is worked, the stump is palpated to determine how it should be held for shaping.</li><li>Just before the plaster begins to set, the thumbtips are positioned on either side of the patellar tendon, close to its edges, so that the plaster-of-Paris bandage is pulled in against the tendon as pressure is applied. This position of the thumbs precludes intrusion into the spaces under the edge of the patella medially and laterally. The fingers are placed around the media] flare of the tibia and held flat against the back of the stump. It is important <i>not </i>to push into the popliteal space with the fingertips. Where the fingers encircle the lateral side of the stump, they are not in contact, Across the back of the stump, they are straight and exert pressure against the posterior aspects of the lateral tibial condyle and the popliteal area. Very little force should be used. The cast has been wrapped tight at the top to obtain an imprint of the stump close to the required shape, and the cast is held to ensure that the required support areas will be well defined when it sets (<b>Fig. 5</b>).</li><li>When the plaster impression can hold its shape, the thumbs are used to obtain a clear imprint of the anterior crest of the tibia by moderately caving in the semi-set plaster along a 3/4-in. strip on each side of the tibia to within an inch of the end (<b>Fig. 6</b>). The impression will now be wedge-shaped in front. Just before the plaster sets firmly, the hands are returned to the holding position, and the cast is held until it can be taken from the stump. This holding-squeezing action flattens the back and ensures retention of the required anteroposterior width.</li></ol> <p><b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Starting the plaster impression and guiding the plaster upward along the sides of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pulling the plaster-of-Paris bandage against the medial flare of the tibia to obtain an accurate impression of this important support area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Holding the cast with moderate pressure and with the fingers flat across the back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Caving in the plaster on either side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Modifying The Model</h4> <p>It is desirable to modify the plaster stump model as soon as possible after the impression is taken, while the recollection of details is still strong.</p> <ol> <li>A groove is carved in the patellar-tendon ridge with a 1/2-in. self-cleaning rasp to a depth of about 1/2 in. The groove is made halfway between the inferior edge of the patella and the tibial tubercle. The groove should be about 3/4-in. wide between the upper and lower edge, and the edges should be smoothly curved toward the patella and toward the tibial tubercle (see <b>Fig. 7</b>).</li><li>Modifications on either side of the crest of the tibia are made in the usual way. <a></a></li><li>The medial flare area is smoothed first with a curved self-cleaning rasp to make the flare blend in with lower sections of the model and then with wire screening, which should be swept around the natural contours of the flare extending into the posterior area and even over the hamstring tendons (see <b>Fig. 8</b>).</li><li>The back of the model is flattened and smoothed over the popliteal area; care must be taken <i>not </i>to indent this area.</li><li>The flattened surface at the back of the model is extended downward and blended in with the more distal parts of the model by shaving off small amounts of plaster.</li><li>The model is smoothed on either side of the knee. If necessary, material is carved away to reduce the model to the measured width of the knee. This area is important, because it contributes to stabilization of the stump in the socket. The lateral side of the socket stabilizes the medial flare of the tibia against its weight-bearing surface in the socket. Sometimes a very slender amputee will find that when he sits, the wide part of his femoral condyles binds against the socket at the top. To correct this, the socket should be heated in that area and forced outward to give relief.</li><li>Plaster is added to the model in bony areas such as the head of the fibula, the crest of the tibia (especially toward the distal end), and the ends of the fibula and tibia. If the crests of the tibial condyles are prominent, extra space should be provided for them in the socket. They and the tibial tubercle seldom present problems if the patellar-tendon shelf has the proper dimensions, because then the socket is forced away from those prominences.</li><li>Before constructing the posterior flare on the plaster model, it is necessary to mark the socket trim lines on the model. First, a line is drawn circumscribing the model at the mid-patellar-tendon level and perpendicular to the long axis of the model. This line defines the back brim for the average type of stump. <i>A </i>shorter stump will be fitted higher at the back, depending on how short it is. Next, a line drawn through the middle of the patella and upward on either side gives the shape of the medial and lateral extensions of the socket. On the lateral side, the line will pass straight down through the posterolateral corner of the model to cross the posterior reference line. The corner can be rounded so that the lines join with a 1/2-in. radius. On the medial side, the trim line should be further in from the side so that the posteromedial curve is retained in the socket to help provide posterior support to the stump. This is possible because the medial hamstring tendons are toward the midline of the stump. After the model has been secured in a vise with the popliteal area up and the long axis of the model horizontal, plaster is poured above the trim line at the back (<b>Fig. 9</b>). When the plaster has set slightly, a 3/4-in. flare is formed by smoothing the plaster with wet fingers and thumb. It is seldom necessary to adjust the fit of the flare for relief of the low-set medial hamstring tendons, even though the socket curves around to the back on that side, because the flare allows the tendons to support considerable pressure comfortably. (For a medial view of the modified model, see <b>Fig. 10</b>.)</li></ol> <p><b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>, <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The patellar-tenclon groove. A, Carving the groove in the patellar-tendon ridge on the plaster model; B, the finished form of the groove. </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 finished form of the medial flare area on the plaster model. A, An anterior view; B, a posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marking and forming the posterior flare on the plaster model, which has been secured in a vise with the popliteal area up. Top, the line circumscribing the model at mid-patellar-tendon level defines the level of the back brim of the socket. Center, plaster is poured onto the model above the trim line and allowed to set slightly. Bottom, wet fingers and thumb are used to form the posterior flare. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Medial view of the modified model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Shrinkage</h4> <p>Even the seasoned stump can shrink. To the prosthetist this is a problem of economic significance, because his guarantee provides for repair or replacement. The worst of it is that when the socket of a PTB prosthesis is no longer satisfactory and must be replaced, there is little the prosthetist can do but rebuild the prosthesis completely. The least that can be done is to lay in material between the socket shell and the insert or to cast RTV Silastic resin under the stump. This sometimes affects alignment, which then must be adjusted. If the weight-bearing area can be modified easily, it is good practice to take a new cast of the stump, prepare a new model, and make a new insert over it. The new insert will support the stump distally, while the modified brim area gives satisfactory weight support and stabilization.</p> <p>Actually, what is needed is a different approach to the provision of prostheses. The recent amputee should be provided with a well-fitted limb to which a series of sockets can be easily attached until the stump has become stable. Then a final fitting can be made. At present, the permanent limb is often fitted as soon as the shrinker bandage treatment has been completed. The forces imposed on the stump by the prosthesis are much greater than can be developed by the shrinker bandage. Also, the socket forces are different in location. In addition to the loss of control and harmful forces that develop between the stump and the prosthesis, the reduced bulk of distal tissues leaves them unsupported and prone to edema.</p> <p>When the stump is fitted tightly, as recommended here, the initial discomfort will diminish as the stump shrinks and molds into shape. Finally, the amputee will be able to don his prosthesis while wearing a wool stump sock.</p> <h4>Perspiration and Maceration of the Stump</h4> <p>There have always been amputees who have suffered maceration of the stump end as a result of accumulation of perspiration in their sockets. Contributing to the heat in a PTB prosthesis are the rubber-leather insert, the thick plastic shell and surrounding materials, the closed end of the socket, and the tightness of fit. Ventilation is poor, even when holes are drilled through the walls of the socket. Use of a valve system, such as that designed at the Navy Prosthetics Research Laboratory, which allows air to enter slowly and forces it to escape up through the sock, could be helpful provided noise is avoided; and porous plastic laminates, such as have been developed at the Army Medical Biomechanical Research Laboratory, may be of some use as a solution to the problem. The most likely immediate solution is to make the socket thin, somewhat pliable, perforated, and without an insert. Such a socket must be titled with care, since there is no soft insert to provide a margin for error and to permit easy modification of the socket. A socket constructed of four to six layers of stockinet laminated with two turns of glass-cloth covering from the top to the tibial tubercle will serve. The socket, supported in a plastic receptacle (<b>Fig. 11</b>), can easily be replaced without seriously affecting the entire prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Temporary plastic socket and the receptacle into which it fits. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Use of Joint-Corset Prostheses</h3> <p>Under ideal conditions, the percentage of amputees who use joint-corset prostheses might be as low as 10 per cent. There is no doubt that the joint-corset system can make up for deficiencies in the fit of the socket and thereby serve as a safety factor when the proper lit of a PTB prosthesis is not achieved or maintained. Hut there are definite criteria which can be used for the prescription of a joint-corset prosthesis.</p> <p>Sometimes the amputee's occupatjon requires him to use his prosthesis under heavy-duty conditions; he may be required to pry up or lift heavy objects. <i>When the amputee must place a force on his prosthesis which is considerably greater than the weight of his body, a joint-corset prosthesis aids him by permitting part of the weight to be borne on the thigh. (First criterion </i>) The joint-corset system is especially effective when the knee is slightly flexed so that forces are borne by the back of the thigh and are transmitted to the shank through the side joints. When the thrust on the prosthesis is along its axis, the amputee can prepare for it by temporarily tightening his thigh corset.</p> <p>Many amputees kneel, climb ladders, or climb stairs frequently. Such activities may be especially difficult or troublesome to the bilateral amputee because of rotation of the PTB prosthesis on the stump. <i>The joint-corset system prevents the prosthesis from rotating about the amputated leg when the joints are flexed. (Second criterion.)</i></p> <p>There is the rare amputee whose knee is unstable, or whose musculature is so weak that the joint-corset system is required. <i>The joint-corset system can stabilize an unstable knee against extreme mediolateral motions; against dislocations; and, when a back-check is used, against hyperextension of the knee. (Third criterion.)</i></p> <p>For the amputee with a stable knee, however, the corset is functionally limited as a mediolateral stabilizer because of the thinness of the joints, the fleshy nature of the thigh, and the pliability of the leather corset. Only if the amputee also bears weight on the corset", or has an extremely atrophied thigh against which he laces the corset tightly, or the corset extends to the peroneal level with cross braces between the side joints, will the corset be of much value as a mediolateral stabilizer.</p> <p>Also rare are amputees who cannot bear weight effectively either on the stump or through the femur. <i>An amputee who cannot bear weight on the stump should be fitted with a quadrilateral ischial-gluteal weight-bearing support and have straps connecting the thigh to the side joints above the knee for control of flexion and extension and for suspension of the prosthesis. (Fourth criterion.)</i></p> <p>Sometimes an amputee is mentally retarded or senile. In such an event, especially if there are no qualified helpers to ensure that the prosthesis is donned correctly, the joint-corset system should be used. <i>The joint-corset system is an aid in ensuring that a prosthesis is correctly placed on the amputated limb when the amputee's judgment is questionable. (Fifth criterion.)</i></p> <p>A problem often faced by the prosthetist fitting a PTB prosthesis to an experienced wearer of a joint-corset prosthesis is that the amputee is not prepared to make the change, either because he doubts that he can do so successfully or easily, or because he has a definite bias toward the joint-corset prosthesis. <i>The joint-corset system should be used when there are definite psychological pressures favoring it. (Sixth criterion.)</i></p> <h3>Conclusions</h3> <p>Probably many prosthetists who fit the PTB prosthesis successfully have discovered for themselves, or have learned from previous experience with other prostheses, how to deviate from established procedures. For those who have difficulties, this review may be of assistance. But it may be necessary to have those who are successful demonstrate to those who are not. Short-term or immediate success should not mislead those who are trying to establish improvements. Often it is only after a year or so that results can be judged. Meanwhile, encouragement should be given to those who seek to develop devices and techniques which will eliminate as many as possible of the craft-oriented tasks needed to fit amputees, thereby increasing reliability and uniformity.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, <i>Report of third workshop panel on lower-extremity fitting, November 4-6, 1964.</i></li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis, </i>Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, Report of third workshop panel on lower-extremity fitting, November 4-6, 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>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria Creator An entity primarily responsible for making the resource James Foort, M.A.Sc. * https://staging.drfop.org/files/original/4762f350fbaca4d7dceedcfd3c7d363e.pdf 7281217b29c631bcd7ebf10f4c376c5e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_001.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Score</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The past twenty years of the Artificial Limb Program comprise predominantly a series of wins, a few losses, and some ties awaiting replays. Participants, coaches, and managers in this prolonged struggle against nature and ignorance have enjoyed some spectacular seasons, but they also have endured grueling practice and frustrating defeats. </p> <p>Wide interest in artificial limbs accompanies major wars. Ancient armorers made cleverly articulated limbs. The Napoleonic and Crimean Wars stimulated active development in Europe. The American Civil War led to numerous private inventions of prostheses. During World War I vigorous and systematic programs were conducted on both sides. These ended soon after the war, partly because of inflation and other disturbances, and partly because of confidence that limbs had been substantially improved. Everywhere there was a return to "normalcy," but the general impression that amputations are infrequent in peacetime is erroneous. Dr. Glattly's recent survey <i>(Artificial Limbs, </i>Spring 1963) corroborates the claim that for a variety of reasons very substantial numbers of civilians face this major operation in peacetime. </p> <p>In World War II both the Army and the Navy of the United States set up large amputation centers to provide definitive surgery, artificial limbs, and other rehabilitation. Both Services introduced some new materials and mechanisms. To combat severe shortages they used prefabricated, standardized parts and division of labor for fitting and assembling instead of the slow, painstaking custom craftsmanship in very small shops typical of the American limb industry. Dramatic successes occurred. Nevertheless, Service Centers, amputees, commercial limb shops, and, increasingly, the general public were made conscious of the severe limitations of even the best prostheses. </p> <p>The Surgeon General of the Army, therefore, called a conference in January 1945 which was supposed to agree upon the best available prosthetic components. The principal conclusion was that <i>none </i>of the available limbs was really adequate, so research was needed. </p> <p>The Surgeon General then asked the National Research Council to set up a committee to conduct a research and development program. The resulting committee and its descendants have had a variety of designations, membership, organizational structures, and sponsors. Originally the work was supported by the wartime Office of Scientific Research and Development, then by the Army. The Veterans Administration, for many years the sole sponsor of contractual research in prosthetics, still continues important support, but in recent years various agencies within the Department of Health, Education, and Welfare have assumed major financial responsibility. </p> <p>When the original Committee on Prosthetic Devices asked its surgeons to appraise the artificial limbs available in the summer of 1945, the two chief demands to its engineers were for development of a functional artificial hand that looked normal and for stance-phase stability for above-knee artificial legs, presumably from a lock released during swing phase. Patent files and technical literature were littered with descriptions of inadequate attempts by several generations of inventors. </p> <p>The surgeons' demands reflected a primary conception of the Committee's role to concentrate on <i>devices, </i>susceptible to engineering design. In an era when many orthopaedists still were active in military amputation centers and physical medicine was only emerging, the surgeons were not yet concerned with development of new surgical techniques or with prosthetics education. </p> <p>Neither were the surgeons primarily concerned with fitting, though its importance was realized. The second subcontract of the Committee, to develop further a saucer socket for the hip-disarticulation case, was with the Research Institute Foundation, a tiny laboratory which had been set up by the Artificial Limb Manufacturers Association. (This project incidentally initiated a number of ideas which later and independently were developed vigorously at larger laboratories.) Both Committee and limb industry a score of years ago considered the fitting of limbs to be a handicraft, often a sculpture-like art, learned by long experience but scarcely susceptible to systematic research. </p> <p>German studies of alignment principles in World War I had relatively little immediate impact on American practices. Alignment of the above-knee prosthesis in 1945 typically placed the artificial foot far out under the head of the femur "so the amputee would not fall over to the amputated side" and made the axis of the socket bore vertical "so as not to give in to flexion contracture." Thus, while standing on the prosthesis, the amputee leaned against his pelvic band and mechanical hip joint, stressing them severely, in an effort to shift his center of gravity nearer to the foot. Likewise, after exhausting the possibilities of lordosis and unsymmetrical gait in an effort to control a free knee joint after maximum hyperextension of a slightly flexed stump in a straight socket, the recent amputee demanded a mechanical knee lock; a stiff heel bumper or a "long" prosthetic step (caused by inadequate knee friction) only increased instability at heel contact and made the demand for a knee lock more insistent. </p> <p>The early years of the Artificial Limb Program were dramatic, in some senses wasteful, yet in others very fruitful. Some efforts were lost, but unquestionably the whole field of upper-extremity prosthetics was changed for the better by fundamental studies, development, and improved management of the individual amputee. Some unilateral amputees found the APRL hand adequately functional, and careful testing proved its cosmetic glove passed unrecognized in a wide variety of social situations. Thus one complaint was at least marginally resolved. </p> <p>Vigorous study of locomotion proceeded concurrently with numerous development projects. Reintroduction of the suction socket, almost a side activity, forced attention to principles of fitting and alignment, to fostering of cooperation among doctor, limb fitter, therapist, and amputee, and to prosthetics education. Improved alignment as well as added gait training reduced the clamor for knee locks for stance control, and attention shifted toward the swing phase. Several swing-phase mechanisms are now widely used. The Henschke-Mauch Model "A" hydraulic stance-plus-swing-control mechanism has finally been recommended after prolonged development and evaluation. If clinical application studies of the Henschke-Mauch Model "A," including application to recent amputees, prove as encouraging as now seems likely, this device will answer at last the second complaint of the surgeons back in 1945. </p> <p>But many problems remain. The Program has gradually spread its field of vision beyond the mere development of mechanical components. Fundamental research has provided data on locomotion, biomechanics, muscle action, pain, and other problems. Clinical studies have been made of amputation surgery, cineplasty, myoplasty, and early postsurgical fitting, though further studies of surgery and wound healing are needed. Fitting and alignment now can profit from better anatomical and biomechanical principles, new shop tools, improved materials, clearer analysis of defects, and greater insight into causes. The necessary skill and artistry of the increasingly professional prosthetist can be used more effectively. The team principle has become widely practiced, to the reassurance of all concerned. </p> <p>Continuing soul-searching has steadily spurred the participants in this battle against ignorance. The best artificial limbs are still crude. Very little has yet been done about orthotics, deliberately kept in abeyance because braces are worn for such a wide variety of conditions that analysis is difficult. The Subcommittee on Sensory Aids, resuming the tasks of the wartime Committee on Sensory Devices, is only beginning its task of reviewing the present VA projects on aids for the blind. CPRD is studying its possibilities and responsibilities in the broad field of bioengineering. </p> <p>The past score of years has given the Committee an intensive series of encounters, sometimes bruising-but often exhilarating-with problems of mechanisms, their human users, the man-machine interfaces, and the idio-syncracies of the professions concerned. </p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Member, Editorial Board, Artificial Limbs; Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Score Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/300fec58bb900f1c7824dd89bd4bbaae.pdf 76815d70cedf1bca701b131c7ff7e1e3 https://staging.drfop.org/files/original/900377a01eea06be7f175e196b90925d.jpg f2357efa66a29ce5c62e4d968a6ccfa9 https://staging.drfop.org/files/original/9f83d9cea044e7f3c97f76b921831c78.jpg 7eebd4fbeda2d03e63a1e5aa08d4ee8c https://staging.drfop.org/files/original/210a566f2d7906636a17a4da061ba64f.jpg a9a6af01b0842bab00a8484934d9b946 https://staging.drfop.org/files/original/1576a7cdca5985ca39b8dfd73643a26d.jpg cd929d3b6f4cf06461d5d6085b38b978 https://staging.drfop.org/files/original/7f40b03606f628d72d01f42ac743588c.jpg 7d7945a45ce4611bc7826c5b4eb56bac https://staging.drfop.org/files/original/60fd60e81e861bcade3d43e96948c6ed.jpg 616e1eafc83246f42671d97fe4d7cb35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_014.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 14 - 22 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_014.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Experiences with the PTB Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The original patellar-tendon-bearing (PTB) prosthesis was constructed at the Biomechanics Laboratory of the University of California. For details regarding the anatomical and physiological considerations<a></a>, the biomechanics<a></a>, and the construction<a></a>, the reader is referred to the June 1962 issue of <i>Artificial Limbs.</i></p> <p>In Finland about 1,000 PTB prostheses have been manufactured since 1959. Although the name of these prostheses and the main principle of their construction imply that weight is borne on the lower patellar ligament (<b>Fig. 1</b>), this is not the only weight-bearing area. Both tibial condyles and, to some extent, the distal end of the stump share the weight. The distribution of weight in these areas necessitates truly individual fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Vertical cross section of anterior portion of PTB socket. The supporting force, as shown by the arrow, acts on the lower patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For technical details of fabrication of PTB prostheses, the reader is referred to the issue of <i>Artificial Limbs </i>which has been cited. Here it is sufficient to say that a plaster cast of the stump is taken first. Then an intimately fitting, distally closed socket of hard plastic and a socket insert of sponge rubber are made. Distally, the socket is joined to a wooden shank, to which a SACH foot is attached (see <b>Fig. 2</b> for views of a finished prosthesis). It is not essential that the socket be made of plastic, but at present this seems to be the best material available. It is relatively easy to laminate a plastic shell from a plaster model. The plastic socket withstands moisture and is, therefore, relatively resistant to perspiration, and it is readily cleaned. The drawbacks are the airtightness of the material, the risk of its causing allergic reactions, and, perhaps, the poorer heat insulation in cold weather compared with materials previously used. These points will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with PTB prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. After three weeks the patients and their prostheses are examined at the Department of the State Supervisor, where either the prostheses are approved, or some modification, correction, or repair is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their PTB prostheses a questionnaire is sent to them. At the Department of the State Supervisor, record cards are kept for all amputees, on which are entered notations concerning modifications and repairs. Thus it is easy to check on what happens to the various prostheses.</p> <p>This article is based on the examinations of the amputees and their prostheses three weeks after the initial issue, data obtained from the questionnaires distributed to the amputees when they have worn their prostheses for six months, and data obtained from the record cards.</p> <p>The study covers 228 amputees fitted with PTB prostheses. Prostheses from different workshops differ somewhat from each other, since standardization of the products is a problem in Finland, as it is elsewhere, perhaps. Therefore, only genuine PTB prostheses have been included in this study.</p> <p><b>Fig. 3</b> shows the ages of the amputees, disclosing that the age group of 40-54 years is the largest. The youngest patient was 20, while the oldest was 75. Ex-servicemen account for 94.3 per cent of the series. The remainder are insured civilians. Only one of the cases in the series was a recent amputee whose initial fitting was with a PTB prosthesis. This does not imply that recent amputees are fitted for theoretical reasons with so-called "conventional" prostheses. On the contrary, it should be an advantage to be fitted from the outset with a PTB prosthesis, although it goes without saying that recent amputees offer special problems because of the longer duration of stump changes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Ages of the amputees when they were fitted with PTB prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. From the standpoint of prescription, it is of major interest to ascertain whether the PTB prosthesis can be worn while performing heavy labor, considering the absence of a thigh corset and the greater stress on the knee joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> discloses that the series includes 59 farmers or smallholders, 21 industrial workers, two lumbermen, and 7 painters. It stands to reason that amputees, whenever possible, choose labor that is not very heavy. Many farmers admitted that they had abandoned the heaviest tasks. However, others in the series mentioned lumbering as a part-time occupation. It was learned that some amputees had worn the PTB prosthesis without a thigh corset while walking on soft, uneven ground and on snow; in other cases, a short above-knee corset had been added almost immediately or when the PTB prosthesis had been worn for some time. It is apparent that stump length and the stability of the knee are important factors.</p> <p><b>Fig. 4</b> shows the lengths of the stumps in the series. In general, cases with a stump length of less than 12 cm. required a thigh corset, the length of which was about one-half or one-third the length of the thigh corset of a conventional prosthesis. The shortest stump in the series measured 6 cm., and the longest 35 cm. The series includes nine bilateral amputees (3.9 per cent).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn it? </i>According to the replies, 210 amputees (92.1 per cent) had worn their prostheses regularly from the outset.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>When the replies were compared with the record cards, it appeared that 18 (7.9 per cent) had not been able to wear their prostheses regularly. In three cases the cause could not be elicited. In 15 cases the causes were as follows:</li></ol> <ul> <li>The skin became irritated in three cases, and in one case an allergy set in.</li> <li>In two cases the socket became too loose.</li> <li>The stump did not tolerate the pressure; it became tender.</li> <li>There was pressure on the stump when the patient drove his car.</li> <li>Ulceration of the stump occurred in three cases.</li> <li>The prosthesis was cold in the winter, and it slipped off when the patient walked in the snow.</li> <li>The stump swelled when the patient was riding a bicycle.</li> <li>Stairs were a problem.</li> <li>The closed socket caused excessive perspiration of the stump.</li> </ul> <p>3. <i>Have you worn your prosthesis </i>(a) <i>when working indoors, (b) when working outdoors, (c) when working outdoors in very cold weather? </i>A total of 223 (97.8 per cent) had worn their prostheses while working indoors; 208 (91.2 per cent), while working outdoors; and 140 (61.4 per cent), while working outdoors in very cold weather.</p> <p>4. <i>Have you worn your prosthesis in some additional</i>- <i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only 21 replies were obtained on this point. One patient was a chauffeur, two were building their own houses, one was building a summer cottage, two fished, five were doing agricultural work, three did lumbering, six did gardening, and one was a night watchman.</p> <p>5. <i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>The majority had used conventional prostheses of wood or leather. Only a few had worn prostheses of light metal. Some amputees had had prostheses of all three materials in the course of years.</p> <p>6. <i>Have you been satisfied with your prosthesis? </i>There were 206 (90.4 per cent) satisfied wearers. Only 22 (9.6 per cent) complained.</p> <p>7. <i>Do you think this prosthesis is {a) better than, (b) just as good as, (c) not as good as your previous limb? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   207 ( 90.8 per cent)</p> </td> </tr> <tr> <td> <p>Just as good as previous prostheses</p> </td> <td> <p>   8 ( 3.5 per cent)</p> </td> </tr> <tr> <td> <p>Not as good as previous prostheses</p> </td> <td> <p>   12 ( 5.3 per cent)</p> </td> </tr> <tr> <td> <p>First prosthesis (recent amputee)</p> </td> <td> <p>   1 ( 0.4 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>The great majority were satisfied with the PTB prosthesis. What appealed to them most was its lightness and the freedom from a thigh corset. This enabled the development of the thigh muscles in a short time. However, not all the amputees were able to manage without a thigh corset.</p> <p>8. <i>What defects or drawbacks have you observed in your PTB prosthesis? </i>Listed below are the complaints of 26 amputees (12.3 per cent). In eight cases the complaints apply mainly to the stump, and in 18 to the prosthesis, but it is not always possible to distinguish sharply between the two.</p> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p><b>Prosthesis</b></p> </td> </tr> <tr> <td> <p>Allergic reaction</p> </td> <td> <p>Cold in the winter (two cases)</p> </td> </tr> <tr> <td> <p>Circulatory disturbance</p> </td> <td> <p>Socket closed and too warm (three cases)</p> </td> </tr> <tr> <td> <p>Ulceration</p> </td> <td> <p>Socket became too loose (two cases)</p> </td> </tr> <tr> <td> <p>Itching</p> </td> <td> <p>Socket pressed on the stump</p> </td> </tr> <tr> <td> <p>Stump shrinkage</p> </td> <td> <p>Flexion of the knee during work impossible because socket extends above knee</p> </td> </tr> <tr> <td> <p>Perspiration</p> </td> <td> <p>Unstable on slippery ground and without a thigh corset</p> </td> </tr> <tr> <td> <p>Edema</p> </td> <td> <p>Unstable in soft snow</p> </td> </tr> <tr> <td> <p>Fatigue</p> </td> <td> <p>Unstable on soft ground </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Excessive strain on the knee without a thigh corset</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Insert wears out too rapidly </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Heel of the SACH foot is too soft</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe of the SACH foot gradually bends upward</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe wears out too rapidly</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Difficult to ski</p> </td> </tr> </tbody></table> <p>9. <i>Has perspiration in the amputation stump constituted a problem? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Perspiration a problem</p> </td> <td> <p>   161 (70.6 per cent)</p> </td> </tr> <tr> <td> <p>Perspiration not a problem</p> </td> <td> <p>   39 (17.1 per cent)</p> </td> </tr> <tr> <td> <p>Initially excessive perspiration, later not</p> </td> <td> <p>   19 (8.3 percent)</p> </td> </tr> <tr> <td> <p>Less perspiration than with other prostheses</p> </td> <td> <p>   9 (4.0 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>Owing to the closed, air-tight socket, perspiration was a major problem, particularly in the summer. It should be borne in mind, however, that this problem also occurs with conventional prostheses, although perhaps not to the same degree. The possibilities for reducing the perspiration problem are discussed later.</p> <p><i>10. Has the skin on the stump tolerated the prosthesis? </i>The skin tolerated the prosthesis well in <b>190 </b>cases (83.9 per cent), better than with other types of prostheses in 14 cases (6.5 per cent), and not so well as with others in 24 cases (9.2 per cent).</p> <p><i>11. Have reddening of the skin and eczema occurred? </i>A total of 75 amputees complained of reddening and eczema, while 153 had no such symptoms.</p> <p><i>12. Did reddening, eczema, or ulceration of the stump occur before you started using a PTB prosthesis, and, if so, for how long? </i>In 157 cases (68.9 per cent) such symptoms had arisen from the use of conventional prostheses of wood, leather, or light metal.</p> <p><i>13. What are your experiences with the new prosthesis outdoors in cold weather? </i>A total of 142 amputees had worn their prostheses outdoors during the winter, and temperatures of -20 to -40 deg. C had caused no problem. Many had skied as much as 30 km. Only five (3.5 per cent) had found the new prosthesis too cold. Replies were as follows:</p> <table> <tbody><tr> <td> <p>No complaints</p> </td> <td> <p>   111 ( 78.2 per cent)</p> </td> </tr> <tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p>Somewhat colder than previous prostheses</p> </td> <td> <p>   21 (14.8 per cent)</p> </td> </tr> <tr> <td> <p>Very cold</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p><b>   142 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>It developed from the replies that the vast majority of the patients had been able to wear their PTB prostheses regularly from the outset. Eighteen amputees had experienced discomfort of various kinds. In many cases there were only minor complaints, and the source of the trouble was readily dealt with. Sometimes the complaints related to phenomena always associated with the manufacture and fitting of prostheses.</p> <p>It is noteworthy, too, that the patients wore their prostheses while performing hard labor.</p> <p>The vast majority of the patients were satisfied. The dissatisfied wearers numbered 22 (9.6 per cent). The causes for complaint are specified in <b>Table 2</b>. The ages and stump lengths of these patients are indicated in the tabulation to permit evaluation of their possible influence. Data regarding all the modifications needed to make the prostheses fit for use, even the smallest repairs, were obtainable from the amputee cards.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is a characteristic feature of the PTB prosthesis that it immediately starts remodeling the stump, because of the intimate fit of the socket. During the first few weeks the stump shrinks, so that the socket becomes too loose. It can be seen in <b>Table 2</b> that this occurred in 11 cases, or 50 per cent of the dissatisfied wearers. These patients were fitted with a new socket insert, and occasionally also with a new socket shell, which implies that a large part of the prosthesis had to be rebuilt. In many cases the insert had to be modified several times. These possibilities must be reckoned with when this type of prosthesis is prescribed.</p> <p>The regeneration of the thigh muscles in those who managed without a thigh corset has already been mentioned. This phenomenon results from the greater muscular activity required to control the movements and the stability of the knee with the PTB prosthesis. After three weeks none of the wearers was able to use his old prosthesis with a thigh corset, because the corset had become too tight.</p> <p>The genuine PTB prosthesis is furnished with only a narrow strap fixing it above the knee. In six cases it was necessary later to provide a thigh corset with sidebars, but the length of the corset was one-third to one-half of what is usual for conventional prostheses. These amputees had stumps which measured 12,13,15,19, 22, and 25 cm., respectively. Only half of these can be said to be particularly short. Obviously, the need for a thigh corset depends not only upon the length and shape of the stump, but also upon the stability of the knee. In three of the cases the knee had been strained. In one case the PTB prosthesis, even after being furnished with a thigh corset and sidebars, had to be replaced with a conventional prosthesis, but this was an exceptional case.</p> <p>Excessive perspiration in the stump, particularly during the summer, constituted a major problem. The closed socket insert and the airtight material are its main causes, but the muscular atrophy because of inactivity and the resultant poor circulation contribute. A gradual decrease in perspiration might be expected to occur, considering the development of the musculature and improved circulation resulting in all amputees who manage without a thigh corset, and considering also the pump effect exerted on the stump by the tight-fitting socket. A similar effect has been observed as a result of placing a sponge-rubber pad at the bottom of conventional prostheses of patients with chronic eczema and ulceration of the stump (<i>1</i>). In the present series, however, a later decrease of perspiration was observed in only 8.3 per cent of the cases. In addition, four per cent reported that perspiration has all the time been less of a problem with the new prostheses.</p> <p>When perspiration of the stump is excessive, skin complications-eczema and ulceration- are likely to occur. Data on skin symptoms in the present series were compared with corresponding data relating to the use of conventional prostheses. The comparison is hampered by the fact that the observation time is shorter for the PTB prostheses than for the older types. Results of the comparison were as follows:</p> <table> <tbody><tr> <th><p></p> </th> <th><p>PTB</p> </th> <th><p>Conventional Prostheses</p> </th> </tr> <tr> <td> <p>Reddening, eczema, ulceration</p> </td> <td> <p>   75 (32.9 percent)</p> </td> <td> <p>   157 (68.9 percent)</p> </td> </tr> <tr> <td> <p>No complications</p> </td> <td> <p>   153 (67.1 per cent)</p> </td> <td> <p>   71 (31.1 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   228 (100.0 per cent)</p> </td> <td> <p>   228 (100.0 per cent)</p> </td> </tr> </tbody></table> <p>It appears that with the PTB prosthesis skin complications were about half as common as with conventional prostheses.</p> <p>In cold winter weather, the PTB prosthesis is somewhat colder than prostheses made of leather or wood, but nonetheless satisfactory and fit for use.</p> <p>In general, the difficulties arising in the present series were due mainly to reduction in the volume of the amputation stump, instability of the knee, and, in some cases, shortness of the stump, which necessitated the construction of a thigh corset. Also, skin complications sometimes occurred as a result of the excessive perspiration caused by the closed-socket insert. The first-mentioned circumstances were easy to cope with, while the skin changes constituted a real problem. In some cases, an opening was made in the distal end of the socket insert, or a number of small holes were drilled in the socket. In certain cases, a sponge-rubber pad was utilized, partly to exert a continuous light pressure on the stump and partly to absorb the moisture accumulating in the bottom of the socket insert.</p> <p>When the PTB prosthesis was first introduced into Finland, we hesitated to prescribe it to amputees who move about much outdoors on soft ground; for instance, on fields and meadows, in the forest, and on snow. This group of persons consists mainly of farmers and lumbermen and the population of northernmost Finland. Our apprehensions have been confirmed only in occasional cases, and the general impression of the PTB prosthesis is favorable. The advantages far outweigh the drawbacks. In particular, the lightness of this prosthesis, the hygienic properties of the plastic material, and the regeneration of the thigh muscles should be emphasized.</p> <p>Reference to the literature shows that others have encountered the same problems that are described here. Frank A. Witteck <a></a>, writing in the June 1962 issue of <i>Artificial Limbs, </i>warned against prescribing the PTB prosthesis in cases with instability of the knee, to very heavy amputees, and in bilateral cases. However, if the stumps have been satisfactory, we have even fitted bilateral cases with PTB prostheses, and no special problems have occurred.</p> <p>In our experience, the PTB prosthesis is con-traindicated only in cases with instability of the knee and with very short stumps or with stumps of unsatisfactory shape.</p> <p>Because numerous, careful fittings are required in these cases, it is desirable that a prosthetist's shop be within easy reach. The PTB prosthesis makes heavy demands on the skill of the manufacturer.</p> <h3>Summary</h3> <p>This study was carried out on 228 amputees fitted with PTB prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans comprise 94.3 per cent of the series, the remainder being insured civilians. In some cases the prostheses were worn by amputees engaged in heavy labor under difficult conditions. Of the amputees, 92.1 per cent were able to wear their prostheses regularly from the outset, and 90.4 per cent were very satisfied. In particular, they emphasized the lightness of the prostheses and the absence of tight thigh corsets, resulting in a sense of ease and freedom.</p> <p>In some cases, complications were caused by a decrease in stump volume, a result of the intimate fit of the socket. This necessitated a change of socket insert, which is readily accomplished, and sometimes of the socket shell as well, which in effect amounts to making a new prosthesis. In certain cases, instability of the knee, the shape of the stump, and a stump length less than the optimum gave rise to symptoms which could be alleviated only by giving the amputee a thigh corset. The series includes four such cases (1.8 per cent).</p> <p>PTB prostheses were also prescribed in bilateral cases, of which there were nine (3.9 per cent).</p> <p>The study shows that the PTB prosthesis has been successfully worn in cold winter weather, although it is somewhat colder than prostheses made of wood or leather.</p> <p>In all the amputees the thigh muscles developed enormously within a few weeks.</p> <p>Excessive perspiration in the stump was a problem in many cases. This phenomenon is due to the intimate fit of the plastic socket. A gradual decrease of the perspiration was noted in 8.3 per cent. However, four per cent stated that, from the outset, perspiration had been less of a problem than with their previous prostheses. It should be borne in mind that during the warm season perspiration tends to be a problem with all prostheses.</p> <p>The PTB prosthesis without a thigh corset is contraindicated in cases with instability of the knee and in cases with a very short stump or with a stump of unsatisfactory shape. Furthermore, caution is indicated in the prescription of this prosthesis to farmers, lumbermen, and others who move on soft and slippery ground.</p> <p>The PTB prosthesis requires very careful fitting, and extreme care must be exercised in its manufacture. In cases where there is a long distance between the place of residence and the prosthetics facility, this is not perhaps the most appropriate type of prosthesis.</p> <p><b>References:</b></p> <ol> <li>Bakalim, Georg, Sponge rubber pad in the prosthesis in cases of chronic dermatitis and ulceration in the stump, Acta orthop. scandinav., 1:117, 1964.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</li> <li>Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</li> <li>Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-16.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-17.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experiences with the PTB Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/88bef5d62a14398fc3a18bca7131f8d8.pdf 86d59bbde4b62c325ee0ebad480c4e5f https://staging.drfop.org/files/original/a84e8ce4eb14a01f0ef2b2853a788184.jpg 0a6c5befd14aa80990442ce44b52ab3b https://staging.drfop.org/files/original/086c58dc00817fa00adcb9085b4887ee.jpg 3c6699b65e4f90cf65ce688efeef8135 https://staging.drfop.org/files/original/9b7bcc17ba2e80fbdba893a929d85938.jpg 9ed6bb7ee61966d89d7987f935e7b034 https://staging.drfop.org/files/original/16080d78a84c16864ec113cd9ecacdf5.jpg b392c89f1756f04fe19a3ad6250113e2 https://staging.drfop.org/files/original/29997ac6960eedc1a118bddad0b95f7c.jpg 6c9a31a9af5ba3831ccdbeb8f4936c57 https://staging.drfop.org/files/original/5786b706e7e673ea58f74136b2873bd9.jpg 0cd440682c88a020c34584737b244d7d https://staging.drfop.org/files/original/9619f95ba15af83f199f79659e870183.jpg b4c873ee734251f9760a68756ee81e23 https://staging.drfop.org/files/original/98848e3c786b553e83ab938453172bb8.jpg 0c8c38b091e2db04fca212e6d969202b https://staging.drfop.org/files/original/156b8585b39aa6c343505e1dbb2319eb.jpg 473d661cc1700725a11f2a0801e2f0b4 https://staging.drfop.org/files/original/180831d52019c33f425c4abef213436c.jpg cb53f48a3e0b0aadd418c3f302efb8c8 https://staging.drfop.org/files/original/00d9d63023a6fe1b224f4e65f8f427d8.jpg d19eb70180882f9be9283cfe7c9fad7c https://staging.drfop.org/files/original/92cc21d0b179a43c17c8e2601b36face.jpg ef09bcbd71c9a5ab1946affdd2d3a1fb https://staging.drfop.org/files/original/84ed9b79ed6c37a2442937152385a670.jpg 96cc057c0c3752fe06400aaef020bf31 https://staging.drfop.org/files/original/02800ee7d2bcaf59054a58fa1a76f5f9.jpg bcd50bad74ee70aedc0c9fdd43ae2b78 https://staging.drfop.org/files/original/e83e8ff373a7a2161bce8c4e4b469c59.jpg e0815425b9120a70904cb54f6db154c4 https://staging.drfop.org/files/original/13e717b3a2917a1f960b337b564c1a2c.jpg 95b5a4e637a9579f4f7f1262bd8f9f93 https://staging.drfop.org/files/original/c7761c10dee8f20eb5989c636532dd48.jpg 16a76ccbb32f47d32cc0636dfe8b849c https://staging.drfop.org/files/original/de8c25414b9f0dc535a4ece8c2a3bc3c.jpg e42c82f4b353b2d82db9be8e58647298 https://staging.drfop.org/files/original/aae1935446e932da0d197817ff316667.jpg cdfce01bb2a2f3d62f09803a4399a4cd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_004.pdf Year 1965 Volume 9 Issue 2 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/1965_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_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 Munster-Type Below-Elbow Socket, a Fabrication Technique</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Kevin A. Cody, M.A. <a style="text-decoration:none;">*</a><br />George Hartmann, C.P.O. <a style="text-decoration:none;">*</a><br />Dominick E. Casella <a style="text-decoration:none;">*</a><br /></h5> <p>The introduction of the Munster technique into the United States in 1958 generated considerable interest in the prosthetics profession, particularly for the management of amputees with short and very short below-elbow stumps. However, in spite of the enthusiasm for this technique, its application has met with varying success in this country. The dearth of precise instructional material has undoubtedly contributed to the lack of consistent results. Each prosthetist has improvised from the limited information available, sometimes successfully, sometimes unsuccessfully.</p> <p>The purpose of this article and the manual upon which it is based<a></a> is to present a detailed description of the Munster technique based upon the procedures utilized in the successful fittings performed in the New York University evaluations of 1963-1964.<a></a> But there can be no substitute for formal instruction and demonstration in the technique. This point is stressed because at least one critical procedure in the fabrication technique, that of cast taking, is quite difficult to learn by the written word and pictures alone.</p> <p>The procedures presented do not conform in every respect to those promulgated by the developers, Drs. Oskar Hepp and G. G. Kuhn.<a></a> However, it is believed they are a close approximation. For this reason the technique is referred to as the "Munster-type" fabrication technique. In choosing this title, it is intended to give appropriate credit to Drs. Hepp and Kuhn for the original development of the technique, without implying identity with their procedures.</p> <p>Short below-elbow stumps have always presented fitting problems for the obvious reasons of small attachment area, poor leverage, and a decreased range of useful motion. Split sockets and step-up hinges have commonly been used to provide a full range of elbow flexion (135 deg.) to amputees having very short below-elbow stumps. However, this system is characterized by several features which tend to reduce its over-all acceptability. Step-up hinges decrease the lifting power available to the amputee, increase the bulk of the prosthesis at the elbow and proximal forearm, and historically have lacked durability. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior-oblique and posterior-oblique views of the Munster-type prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the middle 1950's, Drs. Hepp and Kuhn of Munster, Germany, formulated a new approach to the prosthetic management of short upper-extremity stumps. They developed a technique for fabricating sockets for below-elbow and above-elbow amputations which provides a more intimate encapsulation of short slumps.<a></a> </p> <h3>Evaluation of Munster Fabrication Technique</h3> <p>New York University Adult Prosthetic Studies became interested in the Munster technique for amputees having short and very short be-low-elbow stumps, following the favorable experiences reported by amputee clinics in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children.<a></a> Under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development, New York University conducted an evaluation of what was considered the Munster technique in applications to adult amputees.<a></a> The general characteristics of the below-elbow sockets fabricated in this study were:</p> <ol> <li>The forearm was set in a position of initial flexion (average 35 deg.) in relation to the humerus. Because of the reduced range of useful motion, the socket was flexed to position the terminal device in the most generally useful area.</li><li>The anterior trim line extended to the level of the antecubital fold, with a channel provided for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket enclosed the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket. The trim line was just above the level of the epicondyles.</li></ol> <p>Because of the high anterior and posterior walls of the sockets, the range of motion for the average amputee was limited to approximately 70 deg. (from 35 deg. to 105 deg. flexion). The limited range of motion characteristic of Munster-type sockets bears emphasis (<b>Fig. 2</b> and <b>Fig. 3</b>). In current practice, the acceptable checkout standard for maximum elbow flexion with the prosthesis is that it should be within 10 deg. of stump flexion without the prosthesis. This standard is not applicable to the Munster-type prosthesis. Nevertheless, the decreased range of motion available has been found acceptable by unilateral amputees who typically use their prostheses as assistive devices and perform very few activities at the extremes of the flexion-extension range.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Maximum extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Maximum flexion, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results of the New York University study of Munster-type fittings cited earlier indicated that:</p> <ol> <li>Amputees reacted positively to the comfort and security of the socket.</li><li>The decrease in flexion range had no appreciable effect on the prosthetic functions of unilateral amputees. However, for bilateral subjects, modification of the anterior trim line and the provision of a wrist-flexion device were necessary for the performance of tasks close to the body.</li><li>Lifting and holding forces available to the amputee were generally superior.</li></ol> <p>(<b>Fig. 4</b> and <b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Live lift"-resisting vertical downward force while maintaining the elbow flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Axial load"-resisting vertical downward force with the elbow extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following the favorable results obtained in fitting adult amputees, New York University Child Prosthetic Studies initiated a study of the applicability of these procedures to children with very short, short, and long below-elbow deficiencies. As of March 1965, ten successfully fitted children ranging in age from 20 months to 10 years had worn their prostheses for periods ranging from 4 to 14 months.</p> <p>Although the study of the children's fittings had not been completed at this writing, the indications are that fabrication procedures for adults, as described in this article, would be equally applicable to children.</p> <h3>Prescription Considerations</h3> <p><i>A priori, </i>this method of socket fabrication would appear to be of greatest potential benefit to amputees with stumps of the short and very short types. These are patients who, under current practice, would typically be fitted with metal elbow hinges-step-up, polycentric, or, at the longer limits of the range, single-pivot or flexible hinges. Prime beneficiaries might be amputees who normally would be fitted with split sockets and step-up hinges because of the inherent disadvantages in this type of fitting.</p> <p>In general, this hypothesis has been verified by fitting experience to date. In the NYU evaluations approximately 90 per cent of the stumps fitted fell into the short and very short below-elbow categories. Specifically, nine adults (including one bilateral amputee) with stump lengths ranging from l-1/2 in. to 5-1/2 in. (18 to 52 per cent) and eight children with stumps 2 in. to 3 in. long (25 to 40 per cent) were successfully fitted with Munster-type prostheses.</p> <p>The precise limits of applicability of the Munster-type prosthesis (that is, the minimum and maximum stump lengths) must be determined individually for each patient. However, based upon a somewhat limited investigation of these considerations, the following guidelines are offered:</p> <p><i>Minimum length: </i>Very short stumps virtually disappear at 90 deg. of elbow flexion. Hence, the maximum prosthetic flexion angle obtainable with stumps in this category is limited accordingly. The shortest stump fitted at NYU was 1-1/2 in. (18 per cent) in length. The maximum flexion angle obtained (with prosthesis) was 80 deg.</p> <p>Thus, fitting of Munster-type sockets to stumps as short as 1-1/2 in. depends upon the acceptability of a very limited amount of elbow flexion (usually less than 90 deg.).</p> <p><i>Maximum length: </i>With regard to maximum stump length, two limiting factors must be considered:</p> <ol> <li>Depending on the extent of the anatomical deficiency, stumps of mid-length and longer usually have some degree of residual pronation-supination which may be harnessed in a conventional below-elbow socket with flexible hinges. This active pronation-supination of the prosthesis is eliminated with the Munster-type fitting. The question to be decided is whether other advantages of the Munster-type prosthesis adequately compensate for the loss of rotation in a given case.</li><li>The configuration of the Munster-type socket (proximal opening at an angle to the socket) presents progressively increasing difficulty in donning and doffing the prosthesis as stump length increases. Absolute stump length rather than proportion of sound side remaining appears to be the prime determinant. The difficulties can be reduced by socket modifications, such as a looser fit or lowered trim line. Such modifications, however, progressively reduce control and retention of the prosthesis.</li></ol> <p>NYU has fitted several adult and juvenile amputees whose stumps fell into the long classification; that is, 55 per cent of sound side or longer. One adult at the borderline of the long classification (5-1/2 in.-56 per cent) and a child well within this category (4 in.-66 per cent) were not affected by the considerations mentioned above. In both cases residual pronation and supination were minimal, and no difficulty was experienced in putting on and taking off the prosthesis.</p> <p>However, an adult with a 7-in. stump (66 per cent) required considerable modifications to the proximal brim before the prosthesis could be delivered successfully. The anterior trim line was reduced approximately 1/2 in. below the cubital fold to facilitate passage of the stump. The subject had about 55 per cent of residual stump rotation; but, since this rotation had not been utilized in the previous prosthesis, no deprivation was imposed by the Munster-type arm.</p> <p>One child with a 6-in. (92 per cent) stump was also successfully fitted with two different modifications of the Munster-type prosthesis. In the initial prosthesis, the posterior trim line was reduced to just above the olecranon for manageable donning and doffing. In a second fitting, the standard trim lines were maintained, but the socket was made somewhat looser than usual. Both modifications produced sockets with slightly reduced but still very acceptable retention.</p> <p>Thus, the Munster-type prostheses can apparently be fitted without difficulty to stumps up to the limit of the short below-elbow classification (55 per cent). The fitting of longer stumps involves consideration on an individual basis of the factors discussed.</p> <h3>Bilateral Fittings</h3> <p>The question of fitting Munster-type prostheses bilaterally is not fully resolved. Two problems are inherent in such fittings:</p> <ol> <li>The difficulty in donning two closely fitting prostheses without assistance.</li><li>The limitation imposed by restricted elbow flexion, particularly on the dominant side.</li></ol> <p>NYU has had no experience in fitting children bilaterally but has successfully fitted one bilateral adult amputee (4-in. and 5-1/2-in. stumps). The inherent problems were resolved by:</p> <ol> <li>Fitting the sockets less snugly than usual to facilitate donning.</li><li>Lowering the anterior trim line and providing a wrist-flexion unit on the dominant side for activities close to the body.</li></ol> <p>It is probable that selected juvenile bilateral amputees might be successfully fitted with similar modifications.</p> <h3>Procedures</h3> <h4>Stump Eexamination and Measurements</h4> <p>Materials required for stump examination and measurements are:</p> <ul> <li>Measuring tape</li> <li>Ruler</li> <li>Goniometer</li> <li>Measurement form (<b>Fig. 6</b>)</li> </ul> <p>A thorough stump examination is an important prerequisite to any prosthetic fitting procedure. In the Munster-type fitting, a stump examination is even more critical than usual because of the intimate socket encapsulation of the stump. Skin irritations, painful scars, abrasions, and sensitive areas must be identified so that necessary socket reliefs maybe anticipated and provided.</p> <p>Consistent with sound prosthetics practice, it is advisable to follow the conventional measurement procedures described in the<i>Manual of Upper Extremity Prosthetics</i><a></a> so that a comprehensive record will be available for future reference. The appropriate below-elbow measurements are recorded on the modified Upper-Extremity Measurement Chart shown as <b>Fig. 6</b>. However, it should be noted that, since the plaster-wrap casts are used as check sockets in this technique and stump molds made from the wrap casts are not corrected to measurements, the only measure essential for fabrication is the length of the normal forearm to wrist and thumb tip.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Measurement form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should also be noted that stump and sound forearm lengths are pleasured from the olecranon rather than from the epicondvles, since the olecranon is more convenient to use as a reference point on the cast and socket. These measurements are described below.</p> <p><i>Stump length: </i>The stump length is measured from the posterior aspect of the olecranon (<b>Fig. 7</b>). If distal redundant tissue is present, the measurement should include the redundancy.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Measuring stump length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Forearm length: </i>With the patient's sound forearm flexed at approximately 90 deg., and held midway between pronation and supination, measurements are made from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid, and from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Measuring forearm length. A, Measuring from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid; B, measuring from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Wrap Cast</h4> <p>Materials required to take the wrap cast are:</p> <ul> <li>Cotton stockinette (appropriate size for stump)</li> <li>Dacron tape for temporary harness</li> <li>Yates clamps</li> <li>Indelible marking pencil</li> <li>Three rolls of plaster-of-Paris bandage (6 or 8 cm. elastic-type preferred)</li> <li>Pail of water</li> </ul> <p>A snug, form-fitting cotton stockinette is placed over the stump to insulate the skin and hair from plaster. The assistance of the amputee or a temporary figure-eight harness may be used to keep the stockinette free from wrinkles. The harness method is generally preferable for children.</p> <p>Application of the proper molding grip is essential to the success of the wrap cast and hence to the final outcome of the fitting. It is important, therefore, that the prosthetist practice this procedure on each amputee prior to the application of the cast. He will thus become familiar with the individual characteristics of each amputee's stump, and the possibility of erroneous molding once the stump is wrapped will consequently be reduced. Furthermore, the amputee will know what to expect during the casting procedure and be better able to cooperate.</p> <p>It is important to note that the prosthetist will be able to apply the molding grip more conveniently when his arms and those of the amputee are at the same level. It is suggested, therefore, that child amputees sit on a table or stand on a raised platform.</p> <p>In this article, the specific steps to be followed are described for a right below-elbow amputee (the hand positions are reversed for a left amputee). Because of the fundamental importance of the correct molding grip, this aspect of the fabrication procedure is illustrated with both photographs and drawings.</p> <p>With the amputee's stump flexed to 90 deg., the index and middle fingers of the pros-thetist's right hand are placed on the anterior surface of the stump. The prosthetist's right wrist should be in a neutral or slightly extended position. The two fingers should rest on either side of the biceps tendon and along the anterior surface of the slump. Moderate pressure is exerted (to the point of firm resistance) simultaneously into the cubital fold and downward on the anterior surface of the stump, but am concentration of pressure distally is avoided (<b>Fig. 9</b> and <b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Practicing the molding grip. The prosthetist exerts moderate pressure on either side of the biceps tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Another view of the prosthetist exerting pressure on either side of the biceps tendon, simultaneously into the cubital fold and downward on the anterior surface of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The dorsal aspect of the proximal ulna is distinctly wedge-shaped. The prosthetist's left hand is shaped so that the thenar and hypo-thenar eminences form a channel into which this wedge will fit (<b>Fig. 11</b>). The grooved hand is then positioned against the underside of the stump to provide stability and support without distortion. The metacarpal joints of the prosthetist's left hand should be located just below the amputee's olecranon (<b>Fig. 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Practicing the molding grip. A, The wedge-shaped ulna as viewed from the rear; B, channel formed in the prosthetist's hand; C, the ulna fitted into the channel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Practicing the molding grip; positioning the grooved left hand of the prosthetist against the underside of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The index, middle, and ring fingers of the prosthetist's left hand are cupped and positioned on the distal posterior surface of the humerus just above the level of the epicondyles (<b>Fig. 13</b>). Gentle downward pressure is applied with the pads of the fingers. Care must be taken to avoid pressure between the palm of the hand and the olecranon. Thus relief is automatically provided for the olecranon. The little finger and the thumb may be curled to make contact with the medial and lateral epicondyles, respectively. However, these digits should <i>not </i>exert any pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Practicing the molding grip; gentle downward pressure being applied by the pads of the index. middle, and ring fingers of the prosthetist's left hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In view of the intimate fit which characterizes the Munster-type socket, tender areas and bony prominences such as the olecranon and the epicondyles must be clearly defined for the provision of the necessary reliefs. While the stump is flexed at 90 deg., these areas are marked with an indelible pencil so that thev may be easilv identified on the wrap cast (<b>Fig. 14</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Marking tender areas and bony prominences </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A preliminary trim line is marked on the cast sock by drawing a line posteriorly connecting two points 1 in. superior to the medial and the lateral epicondyle, respectively; and the line is continued anteriorly so that it passes through a point 1/2 in. above the mid-cubital space (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Marking the preliminary trim line on the cast sock. A, A line is drawn posteriorly connecting two points 1 in. superior to the medial and the lateral condyles; B, the line is continued to pass anteriorly 1/2 in. above the mid-cubital space. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The critical relationship between the stump and the Munster-type socket cannot be overemphasized. Every effort should be made, therefore, to obtain a properly fitting cast. To this end, it is recommended that at least two, and preferably three, casts be taken so that the prosthetist and the patient together may choose the best of the series. Elastic or non-elastic plaster-of-Paris bandages may be used, but the elastic is preferable since it results in a more accurate configuration.</p> <p>While the stump is flexed at 90 deg. and the humerus is held midway between internal and external rotation, the wrap is commenced with two circular turns above the elbow joint (over the olecranon and the cubital fold). Only very slight tension should be applied to the plaster-of-Paris bandage (either elastic or nonelastic) in the process (<b>Fig. 16</b><i>A</i>). The wrapping proceeds to the distal end of the stump in a figure-eight or a spiral pattern (<b>Fig. 16</b><i>B). </i>The wrap is continued at least 1/4 in. above the reference marks made earlier.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Wrapping the stump. A, The wrap is begun with two circular turns around the elbow joint-over the olecranon and the cubital fold; B, the distal end of the stump is included in either a figure-eight or a spiral pattern; C, the wrap is continued at least 34 in. above the reference marks made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the wrapping has been completed, the molding grip practiced earlier is applied (<b>Fig. 17</b>). Finger pressure should be sufficient to displace all loose tissue (to the point where firm resistance is reached). Pressure is maintained until the plaster has set.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Application of the molding grip to the wrap cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened, the proximal end of the wrap cast is reinforced with several turns of nonelastic plaster-of-Paris bandage in order to minimize distortion. Then the stockinette is pulled down over the cast (<b>Fig. 18</b><i>A</i>). As the cast is gently worked off the stump, upward pressure is applied to the arm to increase skin tension at the proximal end of the cast in order to break the vacuum seal (<b>Fig. 18</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Removal of wrap cast. A, Pulling the stockinette down over the cast; B, applying upward pressure on the arm as the cast is gently worked off the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The stockinette is removed from the cast, and the indelible markings which have been transferred from the stockinette to the inner wall of the cast are accentuated (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Accentuating the indelible markings transferred from the stockinette to the inner wall of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These procedures should be repeated until a minimum of two, and preferably three, casts have been taken.</p> <h4>The Check Socket</h4> <p>Materials required to prepare the check socket are:</p> <ul> <li>Knife</li> <li>Scissors</li> <li>Fresh plaster</li> <li>Water</li> </ul> <p>All of the wrap casts taken should be prepared in accordance with the procedures described below and used as check sockets. The one agreed upon by both the prosthetist and the patient as providing the most comfortable fit and the greatest range of motion and maximum security is selected for use in the preparation of the positive plaster model.</p> <p>A hole is cut in the cast, just large enough to allow the passage of a stump pulling sock and as close to the distal end as possible so that shortening of the cast is minimized (<b>Fig. 20</b><i>A</i>). The final trim lines for every socket must be determined individually for each amputee. However, as an initial step, the proximal end of the cast is trimmed to the level of the reference line made earlier (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Trimming the cast. A, The hole cut in the distal end should be just large enough to permit passage of a stump pulling sock; B, trimming the proximal end at the level of the reference line made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is then moistened, and the inside of the cast is smoothed with fresh plaster to remove all gauze marks, except in the area of the epicondyles and the olecranon (<b>Fig. 21</b>). <i>No </i>plaster should be added in these critical areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Smoothing the inside of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting The Check Socket</h4> <p>Materials required for fitting the check socket are:</p> <ul> <li>Cotton stockinette (stump pulling sock)</li> <li>Indelible marking pencil</li> </ul> <p>A length of stockinette is placed on the amputee's stump, and the distal end of the stockinette is drawn through the hole in the check socket. The stump is pulled into the socket, care being taken that all flesh is drawn inside the cast (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pulling the stump into the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the check socket on the amputee, the usual tests are made for adequacy of fit, comfort, and range of motion by having the amputee exert force against resistance in elbow flexion, extension, and rotation (<b>Fig. 23</b>). Although the stump cannot rotate the socket, there may be some undesirable rotation of the stump within the socket. If the fit of the check socket is not satisfactory, the socket should be rejected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Determining the adequacy of the fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the check socket causes any pain or discomfort, the appropriate area should be marked on the outside of the socket so that relief can be provided (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Marking an area which requires relief. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The same procedures are repeated with the other check sockets and the best socket is selected for use in completion of the prosthesis.</p> <h4>Establishing The Range of Motion in Check Sockets</h4> <p>The maximum forearm flexion and extension positions attainable with the Munster-type prosthesis will be significantly less than those achieved in conventional prostheses. Experience has shown that the maximum flexion range for the typical short below-elbow stump fitted with a Munster-type socket is approximately 70 deg. (from 35 deg. initial flexion to 105 deg. maximum flexion).<a></a> A range of motion of this magnitude is not always achievable but should be the initial goal of the fitting.</p> <p>The principal factors limiting the range of motion are:</p> <ol> <li>Restriction in the maximum flexion angle obtained attributable to one or more of the following conditions: <ul> <li>Insufficient relief for the olecranon</li> <li>Too small a channel for the biceps tendon</li> <li>Too high an anterior wall</li> </ul> </li><li>Restriction in extension attributable to too high a posterior trim line.</li></ol> <p>However, it must be emphasized that lowered trim lines or loose fit will adversely affect the retention of the socket on the stump. Hence, the initial trim lines need to be closely maintained in order to provide maximum socket retention. They should be reduced only when absolutely necessary to provide greater comfort or increased range of motion, or both.</p> <p>Materials required in establishing the range of motion are:</p> <ul> <li>Indelible pencil</li> <li>Scissors or knife</li> <li>Goniometer</li> <li>Ruler</li> </ul> <p>A line is drawn on the lateral side of the check socket coincident with its long axis (from the lateral epicondyle to the mid-distal end) to serve as a guide in measuring flexion and extension (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Drawing a line on the check socket coincident with its long axis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The center of the goniometer is placed on the lateral epicondyle. The lower arm of the goniometer is placed on the long axis line, and the upper arm of the goniometer is lined up with the acromion (<b>Fig. 26</b>). Maximum flexion and extension angles are measured from these points of reference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Placement of goniometer to measure maximum flexion and extension angles </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If motion is restricted, the specific cause for the restriction should be determined and corrective action should be taken (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Trimming the check socket to provide increased range of motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee cannot achieve the proposed 35 deg. of initial flexion in the check socket, the discrepancy is compensated for in the alignment of the forearm shell. Therefore, while the stump is maintained in an actively extended position, a second line is drawn on the check socket at an angle of 35 deg. between the humerus and the stump (<b>Fig. 28</b>). This line will serve as a guide in aligning the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Drawing a second line at a 35-deg. angle between the humerus and the stump to serve as a guide in aligning the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The adequacy of the proposed initial flexion angle is tested by placing a ruler along the <i>35 </i>deg. line drawn on the check socket (<b>Fig. 29</b>). The ruler is placed to correspond to the intended length of the finished prosthesis; that is, the olecranon-to-thumb-tip measurement recorded on the Upper-Extremity Measurement Form (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Placing a ruler along the 35-deg. line to test the adequacy of the proposed angle of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee should flex and extend this improvised forearm composed of the check socket and the ruler (<b>Fig. 30</b>). Maximum flexion should be about 105 deg., except for very-short stumps, where it probably may not exceed 90 deg. Because of the inherent limitation of motion associated with the Munster-type prosthesis, the usual test of having the amputee bring his terminal device to his mouth is not applicable. The goal is to provide the maximum flexion angle possible compatible with a cosmetically acceptable initial flexion position and socket retention.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Checking the flexion and extension of the improvised forearm composed of check socket and ruler. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the maximum flexion angle obtained with 35 deg. of initial flexion is not acceptable, the angle of the ruler is adjusted to provide greater initial flexion. Initial flexion angles to a maximum of 45 deg. have been used, but at the expense of decreased cosmesis (<b>Fig. 31</b>). If less than 35 deg. of initial flexion is desired for cosmetic or other reasons, the angle is decreased accordingly. Such reduction also decreases the maximum flexion angle obtainable. The selected angle of initial flexion is indicated on the check socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Alternative angles of initial flexion: 30 deg., increased extension, decreased flexion; 40 deg., increased flexion, decreased extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Preparation of the Positive Model</h4> <p>Materials required for the preparation of the positive model are:</p> <ul> <li>Plaster-of-Paris bandage</li> <li>Talcum powder</li> <li>Hollow pipe (approximately 12 in. in length and 1/2 in. in diameter)</li> <li>Awl</li> <li>Two roundhead screws</li> <li>Fresh plaster</li> <li>Water</li> <li>Sanding screen</li> <li>Indelible marking pencil</li> <li>Vaseline or other parting agent</li> </ul> <p>The distal end of the check socket is closed with plaster-of-Paris bandage or with masking tape (<b>Fig. 32</b>) and a small extension (approximately 1 in.) is constructed at the proximal end of the check socket (<b>Fig. 33</b>), again with plaster-of-Paris bandage or with masking tape. This extension will provide the prosthetist with a margin of safety in smoothing the positive stump model without disturbing the desired trim line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Closing the distal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Construction of extension at proximal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the inner surface of the check socket has been sprinkled with talcum powder, the check socket is filled with liquid plaster of Paris (<b>Fig. 34</b>). Before the plaster hardens, a hollow pipe is inserted into the plaster. A recess approximately 1 in. to 1-1/2 in. deep is made in the plaster at the proximal end of the mold. A small hole, approximately 1/4in. in diameter, should be drilled in the pipe toward the bottom of the recess to facilitate vacuum lamination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Check socket filled with liquid plaster of Paris and a hollow pipe inserted into the plaster. The small hole drilled in the pipe will facilitate vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the positive model has hardened, the check socket is punctured with an awl at the proximal and distal ends of the forearm-extension reference line (<b>Fig. 35</b>). The punctures should penetrate into the positive stump model. An indelible pencil is inserted into the holes to mark the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Puncturing the check socket with an awl in order to mark on the positive model the proximal and distal ends of the forearm extension reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster wrap (check socket) is removed, and major irregularities, for example, superfluous plaster, are trimmed from the positive model (<b>Fig. 36</b>). All reference marks should be accentuated on the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trimming irregularities from the positive stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The junction between the positive model of the stump and the mold extension is faired with liquid plaster of Paris to provide a smoothly curved radius (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Fairing the juncture between the positive model and the mold extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The olecranon area on the positive stump model is built up approximately 1/16 in. with liquid plaster of Paris (<b>Fig. 38</b>). This build-up will provide additional relief for this bony prominence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Building up the olecranon area on the positive model to provide relief for this bony prominence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal end of the positive stump model is built approximately 1/2 in. with liquid plaster of Paris. This build-up will increase the length of the socket slightly and provide space for the hole through which the stump sock is pulled (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Building up the distal end of the positive model to increase the length of the socket slightly and to provide space for the hole through which the stump sock is pulled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The positive model is sanded smooth, and roundhead screws are inserted into the two reference holes made on the lateral side of the model. These screws will produce projections on the laminated socket through which a line will be drawn to align the forearm extension cone.</p> <h4>Lamination</h4> <p>Materials required for lamination are:</p> <ul> <li>Drill with 1/8-in. bit</li> <li>PVA sheets</li> <li>Dacron blanketing</li> <li>Nylon stockinette</li> <li>Polyester resin</li> <li>Promoter</li> <li>Masking tape</li> <li>Vacuum pump</li> <li>Wrist unit</li> <li>Manila paper</li> </ul> <p>The socket and forearm shell are laminated in accordance with standard procedures.<a></a> Vacuum lamination<a></a> is recommended to provide a truer reproduction of the model.</p> <p>Holes 1/8 in. in diameter, are drilled through the undercut areas at the proximal end of the positive model in order to draw the PVA bag into those areas during vacuum lamination (<b>Fig. 40</b>). The holes should exit in the vicinity of the previously mentioned hole in the pipe.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Drilling 1/8-in. holes through undercut areas at proximal end of the positive model to draw in PVA bag during vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the stump model has been lubricated, the inner PVA bag, dacron blanketing (for a smoother inner surface), the nylon stockinette, and the outer PVA bag are applied in the usual manner<a></a>, under a vacuum pressure of 12 in. of mercury (<b>Fig. 41</b>). (This is equivalent to 5.9 psi.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Inner PVA bag, dacron blanketing, nylon stockinette, and outer PVA bag ready for lamination on lubricated stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Polyester resin is applied in the standard manner.<a></a> Special attention should be paid to working the resin into the undercut areas (<b>Fig. 42</b>). The layup is oven-cured as usual.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Working resin into undercut areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has cured, an opening is cut in the extreme distal end of the socket (<b>Fig. 43</b>). The hole should be of sufficient diameter to allow the passage of the stump pulling sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Cutting an opening in the distal end of the socket to allow passage of the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A reference line is drawn on the outer wall of the socket by connecting the two screwhead projections. A forearm extension cone is applied in the usual manner, with the long axis of the cone coincident with the reference line (<b>Fig. 44</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Forearm extension cone aligned with reference line established by screwheads on socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lamination procedure for the forearm is the same as for the socket, except that dacron blanketing is not used (<b>Fig. 45</b>). The forearm extension may be laminated as a separate section or directly over the socket, using a wax melt-out. Both procedures work satisfactorily. After the forearm laminate has been cured, the prosthesis is cut along the proximal socket brim and the mold is broken out.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Forearm extension laminated over socket and cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting of the Prosthesis</h4> <p>A 1-in. hole is drilled through the medial wall of the forearm shell close to the distal end of the inner socket to permit passage of the stump pulling sock. The edges of the hole are polished with a grinding cone (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Polishing the edges of the hole tor the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Wearing a length of stockinette (approximately 8 to 10 in.) as a stump sock, the amputee inserts his stump into the socket and pulls the distal end of the sock through the hole (<b>Fig. 47</b>). The application of tension on the stump sock facilitates the complete insertion of the stump into the socket. The sock is left on the stump and the end of the sock is tucked into the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Application of tension on the stump sock facilitates the complete insertion of the stump into the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is checked for the adequacy of its fit. Reliefs are provided and trim lines are modified (<b>Fig. 48</b>) where necessary for comfort and range of motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Checking the adequacy of socket fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnessing</h4> <p>Three different harness arrangements have been used successfully at New York University with the Munster-type sockets.</p> <p>Initially, the arms were fitted with a conventional figure-eight harness with triceps pad, flexible hinges, and inverted Y-strap. However, the intimate stump encapsulation, flexion attitude, and high trim lines of the Munster sockets provide excellent retention and security, and in most cases obviate the need for suspensory apparatus to maintain the socket on the stump. Without harness, the majority of subjects in the Xew York University stud}' with adult amputees were able to resist high axial loads (in the order of 50 lb.) with negligible socket displacement. In the fitting of child amputees, the same results obtained with axial loads up to one-third of body weight. Hence, the two simplified axilla-loop harness systems which will be described have proved adequate for most patients.</p> <p>The conventional harness is fabricated according to standard prosthetics practice.<a></a> However, because of the integral security of the socket, the size of the triceps pad may be reduced.</p> <p>In the New York University fittings a triangular triceps pad constructed of light-gauge aluminum covered with leather was used exclusively (<b>Fig. 49</b>). The general pattern of the templates used as a guide in shaping this pad is shown in <b>Fig. 50</b>. The exact size of the template for each subject is determined as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. View of conventional harness showing triceps pad fabricated of light-gauge aluminum covered with leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Pattern of template for triceps pad (not actual size). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The width is equal to one-half the circumference of the arm measured just above the epicondyles.</li><li>The length is three-quarters of the width.</li></ol> <p>There is no significant functional difference in the two simplified axilla-loop harness systems. In one system the reaction point is located at the proximal socket, while in the other it is located over the triceps. The choice between the two systems depends upon the amputees' preferences regarding the position of their control cables.</p> <p>To locate the reaction point on the proximal socket, a standard housing crossbar assembly is riveted to the <i>midline </i>of the posterior wall of the socket approximately 1/2 to 3/4 in. distal to the proximal brim (<b>Fig. 51</b>). The crossbar portion of the loop is directed upward.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Simplified axilla-loop harness with reaction point on proximal socket. Upper, standard housing crossbar assembly riveted to the midline of the posterior wall of the socket. Lower, harness completed with an axilla-loop arrangement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal retainer base plate is located on the lateral side of the forearm in the usual manner so that it produces as direct a line of pull as possible between the crossbar and the terminal device.</p> <p>The cable-housing assembly is attached in the usual manner. The cable should be maintained as short as possible without interfering with function in order to reduce the incidence of the cable rubbing on the flesh or clothing.</p> <p>The harness is completed with an axilla-loop arrangement (<b>Fig. 51</b>). An additional suspensory strap (that is, a front-support strap) or flexible hinges are not needed.</p> <p>The simplified axilla-loop system is appropriate for most patients. But some patients will object to the low position of the control cable, which may interfere with the sleeves of shirts or blouses. To meet such objection, the reaction point may be located on a small leather triceps pad (3 in. x 3 in.)(<b>Fig. 52</b>). A small strap, preferably Velcro, is sewn across the middle of the posterior surface of the triceps pad to provide a means of securing the pad to the arm. A standard housing crossbar assembly is attached over the strap and centered on the triceps pad. The distal retainer base plate is placed on the forearm in the same manner as described in the previous system. The cable housing assembly is attached in the usual manner. The harness is complete with an axilla-loop arrangement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Reaction point on small triceps pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Checkout Procedures</h4> <p>Standard below-elbow checkout procedures<a></a> are applied to the Munster-type prosthesis and the usual requirements should be met except for the following:</p> <ol> <li>Since prosthetic forearm rotation is eliminated, the pronation-supination measure is not applicable.</li><li>Since a decreased flexion range is an integral feature of the socket, the checkout standard of a 10-deg. loss of flexion with prosthesis does not apply. Maximum flexion for most amputees will range between 100 deg. and 115 deg., which may be approximately 30 deg. less than stump flexion with the prosthesis off.</li><li>Because of the decreased elbow flexion, the requirement for opening of the terminal device at the mouth may not apply. However, full opening of the terminal device should be available at maximum flexion of the elbow.</li></ol> <p>In following the checkout procedures, particular attention should be paid to the unique features of these sockets; namely, the critical importance of the fit of the socket around the epicondyles and olecranon and the built-in suspension of the sockets. The application of compression and torque forces (particularly a vertical downward force at the terminal device with the elbow flexed at 90 deg.) should indicate the presence of any pressure areas around the elbow. Additionally the axial-load test<a></a> -application of a vertical downward force at the terminal device with the elbow fully extended-should reveal any deficiencies in the suspension feature of the sockets.</p> <p>It must be recognized, however, that, because of the close fit of the socket over the epicondyles and olecranon, some adults will not be able to tolerate the accepted axial-load standard of 50 lb. (or, for children, one-third of the body weight). Special caution to avoid injury to the amputee should be taken when applying the axial-load force. Failure to meet the 50-lb. standard should not in itself be sufficient cause to reject the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</li> <li>Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The "Muenster" type fabrication technique for below-elbow prostheses, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the "Muenster-type" below-elbow prosthesis, April 1965.</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</li> <li>University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 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">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 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>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 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>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster-type' below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Dominick E. Casella </b></td></tr><tr><td class="clsTextSmall">Research Administrative Assistant, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>George Hartmann, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Kevin A. Cody, M.A. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N. W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_004/autum65-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_004/autum65-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_004/autum65-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_004/autum65-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_004/autum65-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_004/autum65-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_004/autum65-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_004/autum65-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_004/autum65-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_004/autum65-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_004/autum65-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_004/autum65-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_004/autum65-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_004/autum65-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_004/autum65-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_004/autum65-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_004/autum65-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1965_02_004/autum65-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1965_02_004/autum65-19.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 Munster-Type Below-Elbow Socket, a Fabrication Technique Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Kevin A. Cody, M.A. * George Hartmann, C.P.O. * Dominick E. Casella * https://staging.drfop.org/files/original/1bcf24533393a270e599124c79df627d.pdf 60d27e744f0e910fb5a36973e948eeb2 https://staging.drfop.org/files/original/f3330c73f6253b5091be2b01f531b140.jpg dc38c24c7179bb4effb3aae915ea79b5 https://staging.drfop.org/files/original/3bfbe6e6b7b7ca08a21d8a48c3f7aa45.jpg c78a26b9dc50869149e455dbeeb47f7a https://staging.drfop.org/files/original/65d4cca945fc77e2edf91de00c4620ee.jpg 059f9b70cc153445dd52ad38f1197c7a https://staging.drfop.org/files/original/6d57408b37f4a7b475d3206c69df9017.jpg 5054831ea0e4ec721daa3a4edd6360df https://staging.drfop.org/files/original/a0c55a5151b7c247a981368ea9bb74e3.jpg 56e078026c6bd5e04cc4d7a4a7644338 https://staging.drfop.org/files/original/d82cddd653af422dee248f52593085c6.jpg a9098af669adf8d1ac1861e371694404 https://staging.drfop.org/files/original/0d4a99f5d93c2bbb9b5ad821b8208825.jpg 67a7d08af08aa01f3f67a3ba4b200d7b https://staging.drfop.org/files/original/ab25a84fa2da308c0909dc1329c9f9a4.jpg eaf49a7130edc6d667abd9ce0349e04e https://staging.drfop.org/files/original/3ada30036b5b486eab3687d8874e56c2.jpg c89eb22bef8bad2e22f39b8d41c49a39 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_023.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 23 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_023.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_023.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>Inverted V-Strap Suspension for PTB Prosthesis</h2> <h5>Jack L Caldwell, C. P. <a style="text-decoration:none;">*</a><br /></h5> <p>The leather cuff-suspension strap described in <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis <a></a> </i> and in the June 1962 issue of <i>Artificial Limbs </i>has been found satisfactory in the majority of cases (<b>Fig. 1</b>). However, in certain cases with short stumps suspension problems have arisen. One particular case (<b>Fig. 2</b>), a patient having a very short stump (2 3/4 in.), presented such a critical suspension problem that other means of achieving suspension were attempted. The first approach was a figure-eight dacron strap with Velcro for adjustment (<b>Fig. 3</b>). A continuous strap encircling the thigh was crossed over the patella. The ends of the strap were attached to the socket. Socket retention was improved, but some disadvantages were noted. When tightened sufficiently to provide good suspension, the strap caused a circumferential constriction above the knee impairing stump circulation (<b>Fig. 4</b>). Furthermore, this type of suspension did not provide an adequate extension stop for the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior and posterior views of typical cuff-suspension system for PTB prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Very short below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Continuous-strap suspension arranged in a figure-eight with Velcro for adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Effect of circumferential constriction above the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Continued experimentation led to the use of the present suspension system using two straps looped through a ring for socket suspension (<b>Fig. 5</b>). The suspension system consists of two straps 1 in. wide and approximately 16 in. in length. When looped through a stainless steel ring, these straps form two inverted V's with the apex of each inverted V passing through the ring. The ends of the V-straps are attached to the socket. Each strap has one end anteriorly and one end posteriorly attached to the proximal socket, thereby providing a four-point suspension. The ring joins both straps and is attached to a flexible waist belt by an elastic thigh strap. No circumferential strap is used about the thigh; a waist belt and a thigh suspension strap, plus the free-sliding characteristics of the two V-straps through the ring, provide firm suspension in all positions of knee extension or flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The strap attachments to the socket should be placed so as to prevent knee hyperextension. The proper sites for strap attachment to the socket are related to the length of the stump. Usually, the shorter the stump the more anterior and proximal are the sites for attachment of the anterior suspension strap. The average short stump of 3 to 4 in. requires that the anterior attachments be located approximately 1 in. above the patellar-tendon contour of the socket and at each side of the patella, with sufficient space for the patella to pass between the straps as the knee is flexed. The posterior socket attachments may be located in the popliteal section of the posterior socket as shown in Figure 6. If the socket wall is thick, the posterior straps should be permitted to pass between the stump and the inner socket walls as illustrated in <b>Fig. 5</b>, <b>Fig. 6</b>, <b>Fig. 7</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Posterior view showing a common attachment point for the posterior straps. The attachment points may be either together or separate, and the straps may be attached either inside the socket or outside. Care must be taken to prevent the strap from rubbing against the (iliotibial) tendons on the lateral side of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Top view of the V-straps with the knee extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The V-straps must be sufficiently short to hold the ring down firmly against the superior margin of the patella. The elastic thigh strap may be adjusted for proper tension above the knee to prevent the ring from slipping down upon the patella.</p> <p>The ring must be sufficiently large to permit two 1-in. dacron webbing straps to slide through it without overlapping one another (<b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>). The ring shown in the illustrations accompanying this article is the Northwestern University upper-extremity harness ring described in the June 1962 issue of <i>Artificial Limbs. </i>It is an O-ring. If a D-ring is used, the flat side should be turned upward. A quick-disconnect snap fastener as illustrated may be used to connect the elastic thigh strap to the ring.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Top view of the V-straps with the knee flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Posterior-oblique view showing retention of the prosthesis to the slump while the knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As the knee is flexed, the suspension straps remain comfortable, and strap tension does not change regardless of knee position. <b>Fig. 8</b> and <b>Fig. 9</b> show a knee in full flexion. The dark areas on the V-straps demonstrate the amount of their excursion through the ring as the knee is flexed. When the knee is extended, the ring will slip forward over the shadowed areas, returning to the position shown in <b>Fig. 5</b> and <b>Fig. 7</b>.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-hearing below-knee prosthesis, </i>University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-hearing below-knee prosthesis, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jack L Caldwell, C. P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_023/spring65-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_023/spring65-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_023/spring65-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_023/spring65-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_023/spring65-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_023/spring65-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_023/spring65-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_023/spring65-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_023/spring65-9.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 Inverted V-Strap Suspension for PTB Prosthesis Creator An entity primarily responsible for making the resource Jack L Caldwell, C. P. * https://staging.drfop.org/files/original/ade32438fe78cc76b9983a4b8b03a966.pdf 24729f77c1e834d976420985feac692f https://staging.drfop.org/files/original/d92a7eff2668b5c4ae4ad1304d095fa8.jpg 835435b1ece19459b1ac8d1a17c66508 https://staging.drfop.org/files/original/b5aae5c48c7c5d7cb3451ea33d46ca35.jpg 7f2c8261672b992d5e23edec9c77f155 https://staging.drfop.org/files/original/c23813c8338bfd0e458ded21a75e5f4e.jpg 0f0b8b3e72dd2046648a7cd419c0d7a3 https://staging.drfop.org/files/original/05f26b792282c85b48f580e1eae102ec.jpg 99d0cf43ee5a531ada3afac54450494f https://staging.drfop.org/files/original/ce9fd6c6b75b551158c3744e94f094b7.jpg 73c12aa3dbf0a65f1f4fa64ac9dd6213 https://staging.drfop.org/files/original/07ee80f09471576171407de72fa75dd5.jpg 4f76e5e9d6715c10b86b5cb853ec87a4 https://staging.drfop.org/files/original/97a5dc6f83c442defa0fe8ace990f196.jpg e8575a35f4234f2cacbfae587bae4e43 https://staging.drfop.org/files/original/97b8c915a4b3c287a6f6d8da7f49a69a.jpg cbc601a2e8329c86d4569281990ed01c https://staging.drfop.org/files/original/06006f97bc193b21a924aebb7cc5e327.jpg 90544b8e8968a5c9e75adc9c7dca2a85 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_027.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 27 - 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/1965_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Orthopaedic Shoes for Bilateral Partial Foot Amputations</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Most physicians and competent orthotists recommend the use of orthopaedic shoes in cases requiring shoe modifications or braces. However, in practice, the term "orthopaedic" is loosely applied to a variety of shoes of widely different cost, construction, function, durability, and appearance. Orthopaedic shoes are distinguished from stock or nonorthopaedic shoes by a steel shank, a long, high, reinforced counter and internal corrections; prescribed modifications are incorporated as elements of the shoe construction rather than added externally. These are clear differences, and the superiority of orthopaedic shoes is generally recognized.</p> <p>Although related, there are two vastly different types of shoes labeled "orthopaedic." One is the kind of shoe described above, which is usually referred to as the <i>custom </i>orthopaedic shoe; the other is the <i>stock </i>orthopaedic shoe. The latter usually contains a steel shank, and in certain instances it also includes a long medial counter and Thomas heel. At this point, however, the similarity to custom orthopaedic shoes ends. Additional corrections which are prescribed must be added externally. They do not include the reinforcement required to prevent "breaking" of the sole at undesirable points and to prevent lateral bulging of the uppers.</p> <p>Despite these disadvantages, stock orthopaedic shoes are frequently prescribed or selected by patients. Cost is probably a significant if not decisive factor since typical costs for stock orthopaedic shoes average half or less than half the cost of custom orthopaedic shoes. On analysis, however, cost differences tend to narrow, as the useful life of custom orthopaedic shoes is longer. In our opinion, the functional and cosmetic advantages of custom orthopaedic shoes far outweigh the cost differential.</p> <p>Apart from considerations of cost, stock orthopaedic shoes may be selected because the appearance to the untutored eye of a new pair seems adequate, and because the patient may seem initially to walk in much the same manner when wearing equally new custom orthopaedic and stock orthopaedic shoes. Not immediately apparent are the quick deterioration and shorter life of the stock orthopaedic shoe and the functional value of the custom orthopaedic shoe. Because of adaptive measures employed by the patient to overcome deficiencies in the stock shoe and to present a normal appearing gait, the external appearance of the gait pattern with the custom shoe may not always be superior. Adjustments made by the patient to adapt himself to the shoes are revealed in the interaction of forces between the foot and the ground during the stance phase of walking. It is primarily to these forces that the wearer of custom shoes reacts when expressing a preference for the function of one shoe over another, even though improvements by a reduction in gait deviations may go undetected during visual observation.</p> <p>A recent experience illustrates these points. A young man with congenital deformities of the feet, for whom orthopaedic shoes had been prescribed, was tested in our laboratory. (He also had congenital deformities of the hands.)</p> <p>He was considered an excellent subject for this type of analysis because of the remarkable adaptations he had made to his deformities. Despite their severity, he was an extremely adept walker with a nearly normal gait whether he wore shoes or not. We believed that his high adaptability would tend to mask, to an unusual extent, any gross differences in his gait and that, therefore, detectable differences could be attributed to the function offered by the shoe.</p> <h3>The Subject</h3> <p>The subject for this study was a 19-year-old congenital amputee with partial hands and feet (<b>Fig. 1</b>). At the initial examination he was wearing previously prescribed stock orthopaedic shoes with steel shanks as the only special feature. Added externally were sole and heel extensions (<b>Fig. 2</b>). After approximately 12 months of wear a severe break in the tarsal region of the right shoe and another, though less severe, of the left shoe were exhibited. The lateral walls of both shoes bulged excessively, resulting in permanent deformation and reduction of support. The short steel shank protruded through the sole at a point corresponding to the break, and the wear of the soles revealed a pattern of little or no support anterior to the shank which terminated at a point corresponding to the tarsometatarsal joint line (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Congenital bilateral amputations with absence of tarsals in the right foot and presence of tarsals in the left. A, Lateral view; B, frontal view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stock shoes showing deformation after 12 months' wear. A, B, Externally added heel and sole extensions can be seen. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stock shoes showing: A, break in tarsal region; B, uncosmetic external corrections; C, protruding short steel shank and a wear pattern indicative of lack of support in the metatarsal and toe areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He was fitted at a commercial establishment with a prescription for custom orthopaedic shoes recommended by the Veterans Administration Prosthetics Center (<b>Fig. 4</b>). These shoes were specially reinforced with long, flat steel springs and steel shanks installed between inner and outer soles to increase the resistance to dorsiflexion after mid-stance and to shift the "toe break" further forward. They also featured stiff, high, long counters and a wider heel base with a reversed Thomas heel on the right shoe to increase lateral support. An inside cork extension was prescribed to accommodate leg shortening. After four months of use the wear pattern of the soles indicated that the patient was receiving support; that is, resistance to dorsiflexion or "shoe break" extended all the way out to the toe (Fig. <i>4B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Custom shoes after four months' wear showing: A, cosmetic advantage; B, reversed Thomas heel and an even wear pattern indicative of support provided over entire surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <p>To record the gait performance of the patient as completely as possible, several methods were employed. Thirty-five mm. motion pictures were taken in both the anteroposterior and the mediolateral planes as the patient walked with his old shoes and with his new shoes. Similarly, cyclographic recordings were made of angular and linear displacements at the hip, knee, and ankle. Force plates were used to record the ground reaction forces during stance phase. Finally the patient's opinions were recorded.</p> <h3>Results</h3> <p>A motion-picture analysis showed that the subject walked very well with both stock and custom orthopaedic shoes. He was able to make small but significant compensations in his body alignment and in the timing of his movements with the result that the total body center of gravity maintained a smooth translatory path.</p> <p>In general, the more detailed cyclographic recordings clearly demonstrated a remarkable ability on the part of the patient to maintain a reasonably normal gait pattern despite differences in functional losses between right and left leg and substantial differences in the height and functional character of the shoes.</p> <p>As shown in <b>Fig. 5</b> and <b>Fig. 6</b>, displacement patterns-that is, the motions of the hip, knee, and ankle in space-were essentially similar with both stock and custom shoes. The consistently higher elevation of each of the major joints with the custom shoe was due simply to differences in the elevation of the shoes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Horizontal displacement of targeted points on the subject's right lower extremity during ambulation, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Horizontal displacement of targeted points on the subject's left lower extremity during ambulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although knee-flexion patterns with custom and stock orthopaedic shoes were generally similar, flexion of the left knee during the early stance phase was reduced substantially with the custom shoes (<b>Fig. 7</b>). This was attributed to the increased support provided by the custom shoes in the tarsometatarsal region with a consequent reduction of the "drop off" on the right leg during late stance. As a result of the excessive "drop off" due to the "break" of the stock orthopaedic shoes, the hip remained at a lower elevation than it would otherwise have attained. The lower hip elevation necessitated additional compensatory flexion of the left knee by the patient in order to walk in a reasonably symmetrical manner. Reducing the "drop off" maintained the hip at a higher elevation and made this additional knee flexion unnecessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A computation of the actual forces applied to the ground was made by resolving both vertical and horizontal force components. Indicated in the following tabulation are the peak forces applied to the ground during the period of heel contact to foot flat and between the instant of heel off and push off in two trial runs with the stock shoes and in two trial runs with the custom shoes. (<b>Table 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As the patient weighed 196 lb., it may be seen that the differences between the first and second peaks were substantially lowered on the right foot and somewhat less diminished on the left foot when the custom shoes were worn, demonstrating a more nearly equal application of forces to the ground. These differences were due primarily to his ability to maintain higher fractions of his body weight on the supporting foot after heel off.</p> <p><b>Fig. 8</b> graphically illustrates, for comparative purposes, the average peak magnitudes of the axial load during heel contact to foot flat, and during heel off to push off. The most significant effect on gait of the custom shoes was to diminish the magnitude of the force with which the heel was initially applied to the ground and to increase the force applied to the ground during the portion of stance corresponding to the period between heel off and push off. Although the absolute values of these changes are small, they had highly significant effects in reducing the patient's adaptive efforts and in reducing shoe wear. As might be expected in the complete absence of plantar-flexion in the right foot, the effects were greater on the right side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Subject's Opinion</h3> <p>The subject stated unequivocally that the custom orthopaedic shoes were far superior to the stock shoes that he had previously worn.</p> <p>They were more comfortable, they provided better support, and the inside buildup was more cosmetically desirable. The subject wore the custom shoes home and refused to take the stock shoes with him, discarding them on the spot.</p> <h3>Summary</h3> <p>There is very little question in our minds of the superiority of custom orthopaedic shoes over stock orthopaedic shoes. Even in the case described in this article when, at first glance, the need might be considered minimal, clear advantages were provided. On this functional basis alone preference should go to custom orthopaedic shoes. Further study of the life expectancy of custom and stock orthopaedic shoes should serve to clarify objectively where real economy in this matter lies.</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>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_027/spring65-27.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_027/spring65-28.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_027/spring65-29.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_027/spring65-30.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_027/spring65-31.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_027/spring65-32.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_027/spring65-33.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_027/spring65-99.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_027/spring65-34.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 Orthopaedic Shoes for Bilateral Partial Foot Amputations Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/6d21fba44b4c02b4c004bf63e1f63831.pdf cfe971bc146b39e11e97c79118b1a01c https://staging.drfop.org/files/original/b6e1c2c759ed57d301d37d5ab4b5dac1.jpg 1c533dccdbe487d7d7d5d410dad1110b https://staging.drfop.org/files/original/c4a8c9195afad4e3ca03898f003dee7a.jpg daa3d984879549cbfc42159eb222089a https://staging.drfop.org/files/original/9f6daaddd1106d9cbe983c2033775d25.jpg becab7587312a262eb82597586a55b32 https://staging.drfop.org/files/original/362bb85952cc606295a9d63a6b958884.jpg bc9f5510398c4a397e38835cfa659c6b https://staging.drfop.org/files/original/3df3d00f10722335a631d5d506bce3e9.jpg 1438d406cb4650e0b21cc5cd159ab4d4 https://staging.drfop.org/files/original/3c515a6e746ee9da332077965f79f130.jpg eeaa58e7d94c89adda2a30a56fce67e6 https://staging.drfop.org/files/original/c14f2585925462148b4dc438c9c27a32.jpg d44e67466a5e9abea7791e13cea64868 https://staging.drfop.org/files/original/f76954679dfd8b87f5df527a3c7d892b.jpg 7ac7d32a7aec4d1aec8fd653c346fbc1 https://staging.drfop.org/files/original/1993fdd6c16310f6c51fb0a4ac52babe.jpg 3404b478edcf7b6daea295ec18b64db0 https://staging.drfop.org/files/original/5699bab2e0bc22f0d0c338f1fe253c49.jpg dd7be1022a55d231aecf0c0506683d10 https://staging.drfop.org/files/original/7edc77d5b01a38b55dc8a930df01f1a9.jpg d1de7bf09a288dccc2a1dbaa6f857c5e https://staging.drfop.org/files/original/19b07e847745ca927903c374fcdd08b3.jpg 329601d54d376428eddccdf1c99743e2 https://staging.drfop.org/files/original/35cb88c8107f12d1e13e4f66aeb734d0.jpg 50819e7dac33551723a15d6e26c1d066 https://staging.drfop.org/files/original/1cb6915c5fcaae6c2d352544442ba21e.jpg 0bcc34a21662a964b18d6bcb72c0e2ed https://staging.drfop.org/files/original/4ac29010338a64c8712eb4fcef376384.jpg ae72774766d287aff0fe5353562f75a3 https://staging.drfop.org/files/original/e7e2686a60c6518befb80b03771e5f80.jpg 9f8d304788a8729cacce1bfeb40979a6 https://staging.drfop.org/files/original/affd9f9bd75a9a20f20ca57f8be4e3c3.jpg 4a1273b17bd7fa3518107c0cfa7fe4de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_026.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 26 - 33 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_026.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee</h2> <h5>Liesl Friedmann, O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Considerable information is available concerning the treatment philosophy, prosthetic prescription, and training of the child with a unilateral upper-limb deficiency<a></a>. However, there are few published data on adapted equipment for the child with a bilateral upper-extremity deficit. To help remedy this lack, this article presents a brief discussion of the current treatment philosophy at the Institute of Physical Medicine and Rehabilitation in the New York University Medical Center and describes some of the adapted equipment and training procedures that have been found useful for children with congenital bilateral upper-limb deficiencies.</p> <p>The presentation is essentially confined to children fitted with conventional prostheses. Experience with unilateral and a few bilateral amelic children at the Institute of Physical Medicine and Rehabilitation has led to the conclusion that these patients obtain inadequate benefit from conventional fitting and might do better with externally powered prostheses. However, these prostheses pose their own unique training problems which are not considered here.</p> <p>Bilateral Fitting Recommended The child is fitted as soon as he sits independently. If there are lower-limb deficiencies or other conditions which delay the achievement of sitting balance, assistive devices and training programs are used to facilitate this accomplishment.</p> <p>It is believed that all children with bilateral upper-limb deficiencies should be fitted bilaterally at the outset for the following reasons:</p> <ol> <li>To encourage the performance of bimanual activities and, hopefully, to assist in the development of an appropriate body concept by providing bilateral extremities of equal length.</li><li>To aid balance and prevent scoliosis.</li><li>To increase prosthetic tolerance.</li><li>To prepare for later bilateral prehensile function.</li><li>To promote eye-hand control of the prostheses.</li></ol> <p>The considerations listed above outweigh the disadvantages of lack of sensory input from the covered stumps. Since the prostheses are not worn full time by any of these children, ample sensory stimulation of the deficient limbs can be achieved.</p> <h3>Training Considerations</h3> <p>In the training program, the longer stump is developed as the dominant member unless the child shows a strong preference for the shorter limb. If both sides are equal in length, the child's preference is determined by observation.</p> <p>If the child has lower extremities which can assist in the performance of activities of daily living, use of the feet is encouraged, with loafer-type shoes recommended for easy removal.<a></a> However, exclusive use of the feet should be discouraged. Pedal skills should be used to assist prosthetic function or in emergencies when the prostheses are not available. Thus, the feet should be used primarily for activities that cannot be performed with prostheses, although strict rules cannot be applied. The degree to which the lower extremities are used must be a matter of judgment based on the individual case. It should be remembered, however, that if the child becomes too dependent on his lower extremities he will have to learn to reduce foot usage when he reaches the age of social consciousness.</p> <h3>Fitting Modifications</h3> <p>In general, the same standard fitting procedures are used for the bilateral limb-deficient child as are used for the unilateral patient with the following modifications:</p> <ol> <li>A 12P hook is fitted immediately but is not activated . Passive mitts are not used.</li><li>During the passive phase of training (inactive terminal device), a figure-eight harness is used, with a chest strap connecting the two axilla loops added for retention. To prevent the harness from riding up in the back, a vertical strap from the cross of the figure-eight is attached to a waist belt.</li><li>The usual developmental sequence in a child's perception of the prehensile function of a hook is well known<a></a>. In bilateral amputees, the developmental sequence is the same, but is sometimes extended over a longer period. The therapist will usually be able to detect the child's readiness for cable attachment and active use by noting the typical signs of frustration arising from inability to function independently; for example, a sudden, sustained increase in crying, temper tantrums, refusal to wear the prostheses, and similar otherwise unexplainable manifestations. Occasionally, the child will verbalize the desire to do things independently without the prostheses. A reasonable attention span is an imperative requisite.</li><li>When the child reaches the age of four or five years, bilateral wrist-flexion units are provided.</li><li>For the very young above-elbow amputee, friction-lock elbow units, which have recently become available, are useful.</li></ol> <h3>Training Procedures</h3> <p>Patients with bilateral limb deficiencies below the mid-humeral level present less of a fitting and training problem than bilateral amelic patients. Nevertheless, they still require specialized training. It is recommended that they be taught the use of one hook at a time and learn pre-positioning of the terminal device by use of the opposite hook, the knee, elbow, chin, or any available hard surface. Training in changing the position of wrist-flexion units by pushing against a hard surface or the opposite prosthesis needs to be given. These patients must also learn to don and remove their prostheses <a></a> and perform the activities of daily living.</p> <h3>Assistive Devices</h3> <p>The pattern of the training program in the New York University Medical Center follows the developmental scale of the normal child as far as possible.<a></a> However, it must be remembered that the "child amputee" will eventually become a teen-ager and then an adult. Thus both the physical and psychological aspects of growth should be taken into account in special training programs.</p> <p>Most of the special training devices used by adults for independence in activities of daily living can also be used by the young teenager. However, since training must start at a very early age if independence is to be obtained, devices specifically designed for the very young child must be used initially. The items described in this article are some that have been developed for the patients at the Institute of Physical Medicine and Rehabilitation.</p> <h3>Self-Feeding Aids</h3> <p>The first level of activity training is self-feeding. A swivel spoon<a style="text-decoration:none;">*</a> possibly with a flat, built-up handle to prevent slipping (<b>Fig. 1</b>) is useful. Initially, the therapist places the spoon into the hook. Later, the child learns to pick up the spoon from the rim of the plate or from the table without assistance. Usually, the child can push the food against the rim of a bowl or against a plateguard. At about four years of age, the child is introduced to the use of a "pusher," a utensil (<b>Fig. 2</b>) commonly used by normal children in Europe. The pusher has been found to be a good pre-knife-and-fork feeding aid. The pusher, which can be made from a flattened and re-shaped teaspoon, is placed behind the "thumb" of the hook on the nondominant side by the therapist. At this stage it is also likely that the child will be able to use a regular teaspoon with a flat handle, bent at an angle which is a compromise between that needed for scooping and the angle needed to get the food to the mouth without spilling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Straight spoons. The one on the right illustrates a method of building up the handle to prevent slipping when grasped by a prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Top, metal pusher formed from flattened spoon. Bottom, spoon flattened to make pusher. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At six to seven years of age, knife-and-fork usage can be started (<b>Fig. 3</b> and <b>Fig. 4</b>). At first, both utensils are placed behind the "thumbs" by the therapist, but with practice the child learns to do this independently. Bilateral wrist-flexion units are very useful for proper positioning of the utensils as they are maneuvered for insertion into the terminal devices and then for cutting. To prevent plate movement, it is frequenth" helpful at this stage to use a damp, flat foam-rubber sponge, wet paper towel, or adhesive foam rubber attached to the bottom of the plate. Correct table height is important in reducing shoulder abduction during eating. With the prostheses in complete abduction, the elbows should barely touch the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of knife and fork for cutting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Use of knife and fork for peas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When teaching drinking with a cup, a plastic, flat-handled cup<a style="text-decoration:none;">*</a> should be used initially. If necessary to prevent spilling when the cup is placed on the table, a lid (<b>Fig. 5</b>) may be provided. At this stage, the child can grasp and release actively but has not yet learned to pre-position the hook. This must be done by the therapist. When the child is able to preposition the hook (three to four years of age), a regular plastic or paper cup can be introduced. Such cups must be held by the upper rim from above (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cup equipped with cover to avoid spilling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Plastic cup held at rim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the public schools of New York City, children are provided soup and a sandwich for lunch. These items are most difficult to handle with a prosthesis. Soup should be sipped from the cup or through a straw, but the child cannot control his prosthesis well enough to prevent mutilation of a sandwich. At the Institute of Physical Medicine and Rehabilitation, a sandwich holder has been devised which is used successfully by some children. The teacher or a parent must insert the sandwich, but the child can then eat it from the holder (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Sandwich holder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Dressing Aids and Adapted Clothing</h4> <p>The amount and type of dressing activities performed by the bilateral upper-extremity amputee vary greatly from one child to the next. For these patients the combined use of feet and teeth may be required.</p> <p>To don his prostheses the child must first put on his stump socks and then maintain them in position as he maneuvers his stumps into the sockets. This feat is not very difficult for the bilateral below-elbow amputee, but if one or both of the limbs are deficient above the elbows, the socks tend to fall off. Others<a></a> have described a bilateral stump sock which is useful. At the Institute of Physical Medicine and Rehabilitation, a connecting piece has been added to this bilateral stump sock to protect the back and axillary skin from irritation (<b>Fig. 8</b>). There is no commercial source for this item at present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Bilateral stump socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Adolescent girls frequently find a front-opening brassiere useful. The standard item can be easily converted into a front-opening type by sewing up the back, opening the front and fastening it with a long Velcro strap and D-ring (<b>Fig. 9</b>). To close the top, a supplementary smaller strap with Velcro or a large hook on an elastic strap may be used. Sleeveless dresses split below the waist and with an open back are helpful.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Front-opening brassiere. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major training problem is toileting, which is particularly difficult for females. If a female child does not have normal lower extremities or at least toes able to function sufficiently in grasping clothing or toilet paper at the proper body level, life-long dependency in this function may have to be accepted. In using bilateral upper-extremity prostheses for assistance in toileting, it is a problem to get the prostheses close enough to the body to adjust the underpants while wearing a dress, even with elbow turntables and bilateral wrist-flexion units.</p> <p>Some children have successfully used modified underpants which do not have to be removed. The crotch of the undergarment is split and refinished with binding (<b>Fig. 10</b>). The opening should close when the child is in the erect position. When the patient sits on the toilet seat, with the trunk flexed on the thighs and the lower limbs abducted, the opening is sufficiently wide to prevent soiling of the garment. With practice, the use of toilet paper can usually be mastered without special devices. Sometimes, however, the solution of this problem requires the development of special reaching devices which are highly individualized. Female patients usually find tampons much superior to sanitary napkins.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Modified underpants. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Schoolwork Aids</h3> <p>For the bilateral amputee to function effectively in school, adaptation of equipment is required in many activities. For example, cutting with scissors is an impossible task with the standard item. <b>Fig. 11</b> illustrates a simple and very satisfactory adaptation in which one handle of the child's scissors is embedded in a small piece of wood 1-1/2 in. X 1 in. X 1/2). The lower handle of the scissors is placed in a groove made with an X-acto knife and held in place with plastic wood. When the scissors are positioned in the wood block, the tip should touch the table. The axis of the two blades should not be tight and the blades should fall open with ease. The child holds the upper handle of the scissors with the hook tines pointing downward. As the handle of the scissors is pulled up and down, the block of wood rides flat on the table surface. In learning to use the adapted scissors, the child should start with straight lines on paper and then include gentle curves and corners and, finally, complex figures. Such scissors are effective only with paper; cloth cutting requires the use of electric scissors (<b>Fig. 12</b>). For cutting thread on a sewing project, a seam ripper is verv useful (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Scissors with one handle embedded in wood. Plastic wood holds the handle in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Electric scissors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Seam ripper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Writing can be facilitated by the use of a clipboard or attaching the paper to the table with masking tape, rather than letting the child struggle to hold the paper steady with his non-dominant prosthesis. Chalk holders which prevent the chalk from breaking and improve blackboard writing efficiency are available commercially<a></a>. A pencil holder has also been described<a></a>. A simpler crayon-holding device has been used for very young patients at the Institute of Physical Medicine and Rehabilitation (<b>Fig. 14</b>). This holder consists of a wood block (6 in. X 2 in. X 2 in.) with a series of holes drilled at angles to enable the child to withdraw and reinsert the cravon without having to pre-position the crayon. Unless the child presses down very hard, the crayon will not slip from the hook. If a thin layer of foam rubber is glued to the bottom of the wood block, it will not slip on the table. Some older children cannot use their other hook to insert a pencil behind the ''thumb" for stability. When clamped to the edge of the table, a simple block of wood with a single deep hole (<b>Fig. 15</b>) is effective in holding the pencil so that it may be properly grasped. In time, the child learns to pick up and position the pencil without special devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Crayon holder fashioned from wooden block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pencil holder clamped to edge of tray. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sewing and Knitting Aids</h3> <p>It is possible for a bilateral upper-extremity amputee to learn knitting and sewing. One needle with the knitting on it can be inserted in a vise (<b>Fig. 16</b>), while the other needle is held behind the "thumb" in the dominant prosthesis. The wool is laced around the needle by the nondominant hook. Thick needles and wool should be used. Sewing can be made easier by use of a frame mounted on a pivot with ball bearings (<b>Fig. 17</b>). Many four- and five-year-old children enjoy sewing cards or doing simple cross-stitch work. This is an excellent activity for training the child to achieve minimal opening of one hook at a time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Small vise used to hold knitting needle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Frame to hold sewing card, mounted on ball bearings to swing freely on pivot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Constant Modification Necessary It is hoped that other therapists will find these suggestions useful and that they will report special devices that they have used successfully. Finally, it should be emphasized that, although a variety of assistive devices, including the feet, are used by young children with bilateral upper-extremity deficiencies in performing the activities of daily living, the problem changes as the child grows older. The physical growth and social consciousness characteristic of the teen-ager may preclude the use of techniques that were acceptable in the younger child. Constant alertness to the need for modification of techniques is required to meet the changing physical and psychosocial needs of the developing child.</p> <p><b>References:</b></p> <ol> <li>Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</li> <li>Deutsche Vereinigung fur die Rehabilitation Behinderter (Heidelberg-Schlierbach), Information on measures for rehabilitation of children with dysmelia, 1962.</li> <li>Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bulletin, April 1965, pp. 7-16.</li> <li>Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</li> <li>Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</li> <li>University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Baby Cup, KT5, with flat double handle and lock lid (50 cents); Kayware Corp., 2731 North Crawford Ave., Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sta-Lcvel Baby Training Spoon ($1.00); Price Industries, Ltd., 815 East Talmadge Ave., Akron, Ohio.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Liesl Friedmann, O.T.R. </b></td></tr><tr><td class="clsTextSmall">Therapist-in-Charge, Children's Division, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 400 East 34th St., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_026/autum65-53.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_026/autum65-54.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_026/autum65-55.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_026/autum65-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_026/autum65-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_026/autum65-58.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_026/autum65-59.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_026/autum65-60.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_026/autum65-61.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_026/autum65-62.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_026/autum65-63.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_026/autum65-64.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_026/autum65-65.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_026/autum65-66.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_026/autum65-67.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_026/autum65-68.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_026/autum65-69.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee Creator An entity primarily responsible for making the resource Liesl Friedmann, O.T.R. * https://staging.drfop.org/files/original/a6215b76e14080dd6c7ca38556f64bd7.pdf 4e4651dcdc97cadd4a5eb1206df0da68 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_001.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_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>An Evolution in the Care of the Child Amputee</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past twenty years the child amputee has emerged as a clinical entity requiring specialized medical and paramedical services. Prior to World War II, no precise methods of management existed. Common practice in fitting a child amputee with a prosthesis involved procrastination. </p> <p>The extent of the change that has occurred is well illustrated by two articles appearing in this issue of <i>Artificial Limbs: Recent Concepts in the Treatment of the Limb-Deficient Child</i>, by Cameron B. Hall, M.D., and the report of the Consultants to the Subcommittee on Child Prosthetics Problems on <i>Nomenclature for Congenital Skeletal Limb Deficiencies</i>. Dr. Hall's article presents an overview of current thinking on the subject, while the nomenclature focuses attention on the precise identification of congenital limb malformations. Many events have contributed to this evolution in thinking and practice. </p> <p>In September 1946, under the aegis of the Michigan Crippled Children Commission, an amputee training center was inaugurated at the Mary Free Bed Guild Children's Hospital and Orthopaedic Center in Grand Rapids, Mich. This project was inspired by the late Carleton Dean, M.D., who was then Director of the Michigan Crippled Children Commission. In the early 1940's, Dr. Dean had recognized that something was amiss in the habilitation of child amputees. He was vitally interested in the amputee program that had been developed by the Armed Services and the Veterans Administration. The science of prosthetics was advancing at a phenomenal pace. New mechanical components were being developed and were proving to be superior to anything heretofore available. Plastic protheses were supplanting the old conventional wooden limbs. Dr. Dean argued that there was no reason why these advances could not be used for child amputees. </p> <p>Little (if any) literature on the management of the child amputee was available, although Dr. Atha Thomas, of Denver, had written a very interesting and instructive chapter entitled "Prostheses for Children" in his book, <i>Amputation Prosthesis</i> <a></a>. In this chapter he advocated amputation in tibial hemimelia, foot removal in proximal femoral focal deficiency, and in pseudoarthrosis of the tibia. Dr. Thomas discussed overgrowth of the fibula as a complication of the child amputee and advocated osteoplastic procedures as described by Nikitin<a></a> and Barber.<a></a> Of singular significance is the fact that Thomas advocated "early fitting." </p> <p>Four years after the opening of the child amputee center in Grand Rapids, the professional personnel presented a formal paper on <i>The Juvenile Amputee</i> at the annual meeting of the American Academy of Orthopaedic Surgeons in February 1950. One hundred ninety-two cases were analyzed in detail. In addition to this presentation, a 28-minute motion picture depicted the problems of the child amputee and demonstrated fitting and training techniques. A scientific exhibit outlining the methods utilized in the care of the child amputee through the team approach was also displayed. Thus, for the first time, the child amputee was identified as an entity to the medical community. Five principles of treatment were stressed: </p> <ol> <li>Physical examination and stump evaluation. </li><li>Utilization of physical and occupational therapeutic methods. </li><li>Detailed coordination of prosthetic fabrication and fitting. </li><li>Inpatient prosthetic training. </li><li>Regularly scheduled outpatient follow-up in an organized child amputee clinic. </li></ol> <p>In January 1954 a workshop was held in Grand Rapids to review the total child amputee problem. Representatives of the Children's Bureau of the Department of Health, Education, and Welfare, the University of California at Los Angeles, New York University, and the Army Prosthetics Research Laboratory (now the Army Medical Biomechanical Research Laboratory) attended. The individual members of the conference enthusiastically endorsed the proposition that an organized program of treatment for child amputees in the United States was definitely indicated. An attempt was made to define the child amputee as compared to the adult amputee. It was agreed that the child amputee could be described as a growing, immature, dependent individual whose long bone epiphyses were still "open." </p> <p>In December 1955, in formal session, the Prosthetics Research Board appointed an <i>ad hoc</i> committee of seven members charged with developing recommendations relative to child amputees in the United States. The outcome of this effort was the formation of the Subcommittee on Child Prosthetics Problems. Its mission was to develop information, and to advise the Prosthetics Research Board on all aspects of the child amputee situation in the United States. </p> <p>During March 1956 the Subcommittee on Child Prosthetics Problems mailed questionnaires to 84 prosthetists and 25 orthopaedic clinics throughout the United States. The response was prompt and enlightening. Analysis of the returns indicated universal interest in child amputee treatment procedures. Shop practices were sharply individualized, and no precise criteria for training existed. At this time there appeared to be only four specialized juvenile amputee clinics in the United States.<a style="text-decoration:none;">*</a></p> <p>With this background of information, the Subcommittee proceeded to encourage the development of child-sized prosthetic components. This endeavor involved not only the miniaturization of adult-sized components but also the introduction of specially designed features so that the devices could be operated by young children. With the assistance of the Army Prosthetics Research Laboratory under the direction of Colonel M. J. Fletcher, the Child Amputee Prosthetics Project at UCLA under the direction of Drs. Craig Taylor and Milo Brooks, and the sound evaluation services of New York University under the direction of Dr. Sidney Fishman, components were gradually developed, fitted, and evaluated relative to their efficiency on child amputees. </p> <p>Stimulated by Dr. Arthur J. Lesser of the Children's Bureau (who was then a member of the Subcommittee on Child Prosthetics Problems), significant steps were taken to encourage the formation of specialized child amputee clinics as a means of standardizing practices in the management of juvenile amputees throughout the country. With the ultimate goal of having a clinic within reach of every child amputee in the nation, definite criteria outlining the requirements for the operation of a satisfactory amputee clinic were formulated. As qualified clinics were established, the cooperative investigation of difficult clinical problems was undertaken. Since these clinics were devoting their efforts exclusively to the child amputee, techniques, appliances, and practices could be introduced and critically evaluated through New York University. Over the years the findings of these studies, which have been analyzed and published, have resulted in the evolution of standards of management never before attained. The fruitfulness of these endeavors is well illustrated by the fact that the Committee for Care of the Handicapped Child of the American Academy of Orthopaedic Surgeons, in conjunction with the Children's Bureau, recently published a document entitled <i>Standards for the Care of the Juvenile Amputee</i>. These standards, which have had nationwide distribution, are essentially the same as those that have evolved through the cooperative research program. </p> <p>The growth in the number of child amputee clinics has been most gratifying. As of January 1966 they numbered twenty in the United States and two in the Dominion of Canada. </p> <p>During the early years of the child amputee program, clinical statistics indicated a ratio of two post-traumatic or postsurgical amputees to one congenital amputee. However, in a period of eight to ten years, a dramatic change has occurred: First, because of the publicity given to the treatment program, children began to appear in clinics at a much younger age than previously. At this very young age, the majority of patients have limb deficiencies that are congenital in nature. <i>Second</i>, the logical consequence was a tipping of the scales of etiological incidence to the congenital type. At present, the majority of clinics report a ratio of five congenital types of deficiencies to two acquired types. </p> <p>Thus the meaning of the term "juvenile amputee" has broadened to encompass post-traumatic amputees, postsurgical amputees, and congenital limb deficiencies and malformations. </p> <p>In 1961 another significant step was taken by the Subcommittee on Child Prosthetics Problems. In that year it initiated publication of the <i>Inter-Clinic Information Bulletin</i>. The first issue was published in October 1961, and the <i>Bulletin</i> has appeared monthly ever since with articles written by the clinic chiefs pertinent to the child amputee. The success of this project is attested by the figures of March 1966 when 1,700 copies were printed and 1,565 were distributed; 351 individuals and institutions received 630 copies. In addition 400 copies were sent to the World Rehabilitation Fund for distribution to its members and 535 to the American Orthotics and Prosthetics Association for distribution to its membership. </p> <p>The impact of the thalidomide tragedy in Europe (West Germany and England) in 1959-1962 focused attention again on the need to improve prostheses, especially when malformed limbs or the complete absence thereof made it difficult to fit conventional suspension and power and cable systems. </p> <p>Heidelberg University had worked with pneumatic power and applied its principles very successfully to these children. Since then there has been a concerted effort in the United States to exploit external power, utilizing compressed carbon dioxide and electricity as power sources. At the present time, a significant number of children throughout the country are wearing externally powered prostheses on an experimental basis. </p> <p>Laboratories are continuing to develop devices in an effort to decrease weight, provide easier application, and improve power sources. There is good reason to believe that as time goes on these endeavors will bear fruit in improved, practical prosthetic function. Interest in child amputees is growing steadily in all parts of the world. These children—many of them multihandicapped—now have a much greater hope for better appliances and services than they ever had in the past. </p> <p>In retrospect, it is evident that much has been achieved by the Subcommittee on Child Prosthetics Problems during the past ten years, but also that much remains to be done. Hopefully, the foundations have been laid for further advances. </p> <p><b>References:</b></p> <ol> <li>Barber, G. C. P., <i>Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia</i>, J. Bone and Joint Surg., 13:68, 1939.</li> <li>Nikitin, A. A., <i>Comparative evaluation of late results of various amputations of lower extremities in children</i>, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B. Lippincott, Philadelphia, 1945.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich., George T. Aitken, M.D., and Charles H. Frantz, M.D. (1946); Kessler Institute for Rehabilitation, West Orange, N.J., Henry H. Kessler, M.D. (1949); University of Illinois Amputee Clinic, Chicago, Ill., Claude N. Lambert, M.D. (1952); Child Amputee Prosthetics Project, University of California, Los Angeles, Calif., Milo B. Brooks, M.D. (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barber, G. C. P., Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia, J. Bone and Joint Surg., 13:68, 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>2.</b> </td><td class="clsTextSmall">Nikitin, A. A., Comparative evaluation of late results of various amputations of lower extremities in children, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, J. B. Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Subcommittee on Child Prosthetics Problems, December 5, 1955-June 30, 1966. When the Subcommittee was formed in 1955 it was a part of the Prosthetics Research Board, the predecessor of the present Committee on Prosthetics Research and Development. The Subcommittee became a standing subcommittee of CPRD when CPRD was formed in 1959. Dr. Frantz, an orthopaedic surgeon in Grand Rapids, Mich., is Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission. On July 1, 1966, Dr. George T. Aitken, who also is an orthopaedic surgeon in Grand Rapids and Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission, became Chairman of the Subcommittee on Child Prosthetics Problems.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Evolution in the Care of the Child Amputee Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/64eb48831c842d569b969a8c4023b43a.pdf 23a3264fbd43cb19735d1394ea4628b9 https://staging.drfop.org/files/original/457d0569478cb47d506c23642463165c.jpg 45eb3dbafd54e0d668f2f3bfc95c21f2 https://staging.drfop.org/files/original/f273ddd8f2d9ddf2bcefdc00fecea5cd.jpg 32d7ead140275fb07cd1b5fb68f0d23c https://staging.drfop.org/files/original/926a3decfb9da45446674f936ec89f91.jpg a5f732da60ea27eaccc3b5f8030bb28a https://staging.drfop.org/files/original/1ed3a83ad57a832a54252e4a0737039f.jpg 74e042f3b878ccf644a029e6c7863bd2 https://staging.drfop.org/files/original/e646eb1d8492cc5ba623391e15c6cad5.jpg dcd12710088de3f157db636bb403595c https://staging.drfop.org/files/original/826147443b433df462696387b01d80a1.jpg a3dd7046d03c6312c1783e053e286e89 https://staging.drfop.org/files/original/6db35e73e1a625e17d758c9c372e668b.jpg 3d9d018b29c5258b24e6459783cdfe87 https://staging.drfop.org/files/original/2b3975ce6719b0edcd6b0152b38e1452.jpg 87afc6aa558904540e7d54714b7c124c https://staging.drfop.org/files/original/6f94b060664d6dee12584cfafd9dfb42.jpg e8c575c8db2e62e393094a9bf8f896e4 https://staging.drfop.org/files/original/6a71bd9c057c8ce272a912840c6bdcdb.jpg 27624130c2456841ffa292e8b25b333c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_005.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 5 - 9 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Evolution of the Georgia Warm Springs Foundation Feeder</h2> <h5>Robert L. Bennett, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Thirty years ago (March 1936) a young lady rom Crawfordsville, Ga., was fitted at the Georgia Warm Springs Foundation with what was referred to in her medical record as "an ingenious device" (<b>Fig. 1</b>). This apparatus was later called a "foot-operated feeder" because it required voluntary extension of her foot against a movable footboard on her wheelchair to bring about tilting of the seesaw cradle supporting her forearm. In this manner, she was able to feed herself. She used this device for twenty years and then returned to Warm Springs and was fitted with a far more efficient type with the imposing name "balanced forearm orthesis."<a style="text-decoration:none;">*</a> <!--Page 6--> The "ingenious device" just mentioned appears to have been the first feeder ever used at Warm Springs, and perhaps the first ever used anywhere.<a style="text-decoration:none;">*</a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "An ingenious device" supplied in 1936 to a patient at Georgia Warm Springs Foundation; also known as a "foot-operated feeder." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1936 is found what appears to be the first feeder used at Warm Springs that required shoulder depression to bring the hands toward the head, and perhaps this feeder should be thought of as the true ancestor of our present-day device. As can be seen in <b>Fig. 2</b>, the 1936 device consisted of a metal yoke bolted to the lapboard of a wheelchair but free to revolve horizontally. A metal forearm cradle fastened to the yoke by a wooden block moved vertically in a seesaw fashion. This was called a "Barker feeder," since Edward H. Barker was the first patient to use the device. Over the next few years, at least three patients were fitted with this type of feeder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the "Barker feeder" of June 1936. Perhaps the true ancestor of the present-day device, it required shoulder depression to bring the hand toward the head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Reviewing the literature to determine the first feeder and then tracing the development of the feeder at Warm Springs has been an unexpectedly difficult and time-consuming job. It has been most difficult to separate mobile supportive devices used in the treatment of the paralyzed upper extremity from the functional seesaw devices used to assist the patient with a paralyzed biceps to flex his elbow.</p> <p>Looking back over the years, one is rather amazed to find that it took so long to develop the <!--Page 7--> present-day balanced forearm orthesis. The excuse must be that the development of truly efficient orthetic devices comes only with persistent patient demands and long usage. Extensive patient demand for this type of apparatus did not come until the mid-1940's. Records indicate that perhaps as few as 20 feeders were made at Warm Springs between 1936 and 1946. It should be remembered that prior to the occurrence of large epidemics of poliomyelitis in the early 1940's there were really very few patients who survived the acute attack of poliomyelitis with massive involvement of upper extremities. As the incidence of acute poliomyelitis increased, the medical profession learned how to keep these patients alive. Rather suddenly, in the mid-1940's, Warm Springs was faced for the first time with the problem of large numbers of patients who had such weakness in their upper extremities that they could not bring their hands toward their head.</p> <p>In May 1943 the bulky base of the "Barker feeder" was replaced by a simple rod and collar, the rod passing through a hole in the lapboard of the wheelchair and held in position by a simple collar (<b>Fig. 3</b>). Several holes were placed in <!--Page 8--> the lapboard to determine the proper position for attaching the feeder. In March 1945 the feeder was placed on a simple aluminum base (<b>Fig. 4</b>). This allowed the patient to move the feeder horizontally across the lap-board by body movements for best position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The feeder of May 1943. The base of the "Barker feeder" has been replaced by a simple rod and collar. Several holes placed in the lapboard helped to determine the proper position for attaching the feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The stand feeder of March 1945. The aluminum base permitted the patient to move the feeder horizontally across the lapboard by body movements for best position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first real change in the design of feeders occurred in April 1946. The feeder was suspended from the upright of an overhead sling! Originally, it was called a "bird-cage feeder," simply because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages (<b>Fig. 5</b>). At this time, the Warm Springs treatment program dictated that no patient with severe upper-extremity involvement should use a feeder until late in the convalescent phase of care. Hence there was a natural transition from the use of overhead slings to protect the weakened shoulder girdle to the suspension feeder to develop functional capacity in the upper extremity. For the next ten years, there is record of 326 suspension feeders being fitted to a total of 197 patients. Only seven of this type were used after 1956, and none after 1961.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The "bird-cage feeder" of April 1946-so called because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was not until December 1949 that segmented feeder arms were used (<b>Fig. 6</b>). These arms were attached directly to the vertical tubing of the back of the wheelchair. Insofar as can be determined, hinged-spring control of the proximal link-seen in <b>Fig. 6</b>-was used in this instance only, and no further use of the mobile arms was made until October 1952.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Segmented-arm feeder used in December 1949. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The light and mobile C-clamp feeder that could be easily attached to the edge of a table, to the lapboard, or to a wheelchair arm rest was developed in the spring of 1950 (<b>Fig. 7</b>). Between 1950 and 1960, 61 were used on 45 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. C-clamp feeder developed in May 1950. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In October 1952 the segmented-arm feeder was again used but without the spring hinge at the attachment of the proximal link to the back of the wheelchair. The proximal link was rigidly clamped to the upright (<b>Fig. 8</b>), allowing horizontal motion only. This feeder was followed in 1953 (<b>Fig. 9</b>) by one to which ball bearings had been added to the base and to the moving joints of the arms. The base could also be <!--Page 9--> tilted to assist movement of the proximal link. This was really the first of the present-day Georgia Warm Springs Foundation feeders. Between 1952 and 1964, 786 of these feeders were applied to 427 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Segmented-arm feeder of October 1952. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Present-day Georgia Warm Springs Foundation feeder, the balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In September 1953 it was found that many patients with severe upper-extremity weakness had good musculature in the lower extremities and trunk; therefore, while they needed a feeder, they did not require a wheelchair. It was at this time that feeders were fitted directly to the trunk of the patient, either attached to a corset (<b>Fig. 10</b>) or to a belt. Between 1953 and 1961, 100 such feeders were fitted to a total of 53 individual patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Two views of a patient fitted with a corset-based feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the years 1946 through 1964, for which the record is quite detailed and complete, a total of 1,334 feeders were applied to 773 patients. Some patients had several different kinds of feeders, and so the latter number does not indicate that there were 773 different patients. In 1961 questionnaires were sent to 488 patients who had been fitted with feeders and who had returned to their homes with feeders. Two hundred nine replies were received; of this number, 139 (66.5 per cent) were still using their feeders.</p> <p>The feeder, or balanced forearm orthesis, was developed primarily for patients with paralyzed upper extremities following acute anterior poliomyelitis; however, it is being used for many neuromuscular problems that result in lack of sufficient voluntary strength to bring the hand toward the head. More recently it has been used in conjunction with externally powered orthetic devices that activate elbow, forearm, and hand.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1966_01_005/sp66-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_005/sp66-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_005/sp66-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_005/sp66-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_005/sp66-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_01_005/sp66-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_01_005/sp66-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_01_005/sp66-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_01_005/sp66-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_01_005/sp66-010.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 Georgia Warm Springs Foundation Feeder Creator An entity primarily responsible for making the resource Robert L. Bennett, M.D. * https://staging.drfop.org/files/original/a962e11e32431a447a3ce708cbc2efbd.pdf e6d793879e49c2715fac7901c9ab48ab DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_034.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 34 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_034.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_034.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>Review of Visual Aids for Prosthetics and Orthotics</h2> <h5></h5> <h4>Prosthetics (General)</h4> <p><i><strong>"A Day in the Life of the Amputee," Hosmer-Dorrance, 1955, 26 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents a bilateral upper-extremity amputee as he performs a number of activities related to self-care, work, and recreation. These include fishing, bowling, gardening, dressing, eating, playing pool, driving a car, and lighting a cigarette.</p> <p><i>Evaluation: </i>A technically well-executed film of a man who has acquired unusual skill in the use of the prostheses. It is recommended for upper-extremity amputees and for professional groups who wish to become familiar with the potential accomplishments of this type of amputee. Essentially, its purpose appears to be to encourage upper-extremity amputees to use prostheses and to develop maximal skill in their use.</p> <p><i>Distributor: </i>A. J. Hosmer Corporation, P. O. Box 37, Campbell, Calif. 95008.</p> <p><i><strong>"A Triple Amputee Steps Out," U.S. Veterans Administration, 1964, 25 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Shows the rehabilitation of a male adult with an above-knee amputation on one side, a below-knee amputation on the other, and a unilateral above-elbow amputation. The patient also suffers from heart and kidney complications that add to the difficulty of rehabilitation. Preprosthetic exercises and balancing activities are followed by ambulation with stubbies and, finally, with permanent prostheses and crutches.</p> <p><i>Evaluation: </i>The level of rehabilitation for this severely involved patient appears unrealistic; and, although he finally ambulates, the gait is labored and unsteady. Use of the upper-extremity prosthesis, which would seem a more useful activity for this patient, is not discussed. This film has little place in paramedical teaching and would be of interest only to note the accomplishments of this unusual and highly motivated amputee.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Diary of a Sergeant," U.S. War Department, 1945, 22 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>The story of a soldier (Harold Russell) who, having lost both arms during World War II, wages a determined and successful fight to achieve success in the use of artificial limbs and to establish himself as a useful member of society.</p> <p><i>Evaluation: </i>An excellent film for its era. It has lost much of its value, however, through the passage of time and today is primarily of historical interest. It deals with the emotional trauma involved in loss of arms and portrays the courage required by an amputee to achieve his rehabilitation goals. For these reasons, the film may still serve a purpose when used to motivate discouraged upper-extremity amputees or when shown to groups concerned with the emotional impact caused by crippling disease or injury.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Dynamic Exercises for Lower-Extremity Amputees," U.S. Veterans Administration, 1959, 10 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Reviews normal gait and the relationships of body segments during walking. Following the physician's examination of the above-knee stump, the amputee patient demonstrates a series of dynamic exercises to develop balance, coordination, and strength. These exercises are part of a physical-therapy program that prepares the amputee to meet daily functional demands. Several amputee gaits are demonstrated.</p> <p><i>Evaluation: </i>This is a large order for a ten-minute film, particularly since it goes beyond the scope of the title. The exercises <i>per se </i>are excellent, but the rate at which they are presented limits the use of the film as a teaching device. A patient-to-patient type of teaching contributes to some worthwhile scenes. The film is considered useful for those who are previously oriented in the techniques of dynamic exercises and who are experienced in working with amputees.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Gait Analysis," Northwestern University Medical School, 1961, 27 min., color, sound, 16 mm.</strong></i> <a style="text-decoration:none;">*</a></p> <p><i>Summary: </i>Demonstrates the most common gait defects that may be seen in an above-knee amputee, including circumduction, abduction, vaulting, medial and lateral whips, instability of the knee, long prosthetic step, and others. The defects are shown on a subject wearing an adjustable above-knee prosthesis and are described in detail, then discussed as to possible causes, considering the amputee, the stump, and the prosthesis. Demonstrates a normal gait so that comparison between normal and abnormal gait can be made. The narration is conducted by a physician, a prosthetist, and a physical therapist, all faculty members of the Prosthetic-Orthotic Education Program at Northwestern University Medical School. A pocket-size folder that summarizes the material presented has been prepared for use as a handout at showings.</p> <p><i>Evaluation: </i>This is a valuable teaching film. Ample time is allowed for the viewer to observe each gait deviation, making it possible for him to correlate the movie sequence with the material presented in the booklet that accompanies the film. Recommended for all medical groups concerned with the management of the lower-extremity amputee, including physicians, physical and occupational therapists, nurses, and prosthetists, at both the student and the graduate levels. The amputee patient would also benefit from seeing this film.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00.</p> <p><i><strong>"New Geriatric Prostheses Adaptable to Bilateral Amputees," Waterbury Hospital, Waterbury, Conn., 1964, 10 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes an above-knee prosthesis designed for use by the geriatric patient and points out the advantages of certain modifications over the more conventional "temporary" prosthesis. Demonstrates the use of these prostheses as fitted to a bilateral amputee, a 64-year-old woman.</p> <p><i>Evaluation: </i>This film would be of interest only to those who are dealing with the problems of prescribing, designing, or fabricating prostheses for the geriatric patient. The graphic description of the prosthesis is well presented.</p> <p><i>Distributor: </i>Dr. Sung J. Liao, Director, Department of Physical Medicine and Rehabilitation, Waterbury Hospital, Waterbury, Conn.</p> <p><i><strong>"New Legs," National Council for Care of Cripples, South Africa, 1960, 18 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the case history of a young railway plate-layer who suffered an accident that ultimately resulted in a bilateral hip disarticulation. He is fitted with a pair of prostheses that incorporate double-action hip joints. Following a training program, he is shown walking with prostheses and crutches and participating in many physical activities with and without the prostheses.</p> <p><i>Evaluation: </i>The purpose of this film is to encourage people living in South Africa to support rehabilitation through the purchase of Easter Seal stamps. Perhaps this accounts for the optimistic tone of this technically excellent picture. The amputee is unusually cheerful, physically agile, and well motivated, and his well-planned rehabilitation program is highly successful. This film might be of interest to the patient and family. For paramedical groups it is of interest only to show the potential achievement of one amputee with a bilateral hip disarticulation.</p> <p><i>Distributor: </i>Film Library, International Society for Rehabilitation of the Disabled, 219 East 44th St., New York, N. Y. 10017.</p> <p><i>Rental Fee: </i>$10.00. (No rental fee for members in good standing with the International Society.)</p> <p><i><strong>"Normal Human Locomotion," University of California at Los Angeles, 1965, 3 hr., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>This seven-reel film reproduces a classroom lecture as presented by Cameron B. Hall, M.D., in the UCLA courses in lower-extremity prosthetics. In his presentation, Dr. Hall graphically describes the normal pattern of human locomotion and explains it in terms of pertinent basic principles, including determinants of gait and mechanical forces. The film is printed at a contrast level that permits it to be shown in a partially lighted room, thereby allowing viewers to write on the illustrated lesson sheets provided with the film.</p> <p><i>Evaluation: </i>The film is of special value. It encompasses a difficult subject on the basis of research from voluminous literature, and it is organized in a clear, concise, and understandable manner.</p> <p>No attempt is made to achieve a technically perfect film; it comes "as is" from the classroom. Dr. Hall's teaching methods, which include skillful execution of illustrations, a keen sense of timing, and--most important-a sequential, organized presentation of materials, combine to make this film an excellent teaching device for both students and instructors.</p> <p>The film is highly recommended for any professional person engaged in gait training or concerned with any aspect of human locomotion. Its use in undergraduate programs will vary according to the teaching talents of the faculty members and the curriculum content. If the length precludes showing it in one session, it can be shown in two or three sessions. It is recommended that instructors review the film in order to strengthen their own teaching methods and to determine in what way it can supplement or reinforce instruction in their own particular situation.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00. (The film may be retained by the borrower for a maximum time of two weeks. Requests for the film should indicate the number of lesson sheets desired.)</p> <p><i><strong>"One Step at a Time," Rehabilitation Institute of Montreal, 1963, 15 min., black and white. sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Portrays a unilateral above-knee amputee who is first seen walking with crutches but without an artificial limb. After considerable introspection, this young male decides to be prosthetically fitted. As the story unfolds, it depicts his reaction to the various steps in the rehabilitation program. The three key people responsible for the program-the physician, the physical therapist, and the prosthetist-are presented, and their roles are briefly explained. The prosthetist plays the major role in this film.</p> <p><i>Evaluation: </i>The close-ups, the music, and the general tone of this picture are designed to show the emotional impact on the amputee of the various situations that evolve during the rehabilitation process. The movie is photographically artistic and technically good. Its use to professional people is limited, however, because of the superficial manner in which the material is handled. It appears to be directed toward the layman and especially toward the unfitted amputee.</p> <p><i>Distributor: </i>National Film Board of Canada, 690 Fifth Ave., New York, N. Y. 10019.</p> <p><i>Purchase Cost: </i>$75.00. (Available for review if viewer is interested in purchasing the film.)</p> <p><i><strong>"Physical Therapy Management of a Bilateral Lower-Extremity Amputee," U.S. Army, (PMF 5382), 1964, 32 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Illustrates the progression of physical-therapy procedures in the management of the amputee, following the program from the day preprosthetic stump exercises are initiated until the time skillful use of the prostheses is achieved and the amputee-a military officer-is returned to duty as an instructor. The various procedures include bandaging of the above-knee and below-knee stump, joint measurement, stump exercises, stump hygiene, care of the suction socket, body-strengthening and balancing exercises, gait training and analysis, and advanced functional activities. Also, briefly presented are the principles involved in fitting two types of prostheses, the suction socket and the patellar-tendon-bearing socket.</p> <p><i>Evaluation: </i>The film is technically superior and professionally sound. Of particular interest and worthy of mention are the well-presented progression of exercises, the clear graphic descriptions, the inclusion of training with the patellar-tendon-bearing prosthesis, and the portrayal of the exacting self-discipline required by the patient.</p> <p>Although the rehabilitation team is acknowledged, the film is presented entirely from the physical therapist's point of view. Because of the extensive amount of material in this film, its primary value lies in an orientation to a good physical-therapy program rather than its use in teaching skills. It is recommended for viewing by physical therapists and students, and also by any of the allied medical professions who have an interest in the management of the amputee. New amputees would also appreciate this preview of the treatment program.</p> <p><i>Distributor: </i>Requests for Army Medical Service motion pictures should be directed to the Commanding General, Attn.: Audio-Visual Communication Center, of the Army Area in which the requesting individual or institution is located, as follows: First U.S. Army, Governors Island, N. Y. (includes Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont); Second U.S. Army, Fort George Meade, Md. (includes Delaware, Kentucky, Maryland, Ohio, Pennsylvania, Virginia, and West Virginia); Third U.S. Army, Atlanta, Ga. (includes Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, and Tennessee); Fourth U.S. Army, Fort Sam Houston, Tex. (includes Arkansas, Louisiana, New Mexico, Oklahoma, and Texas); Fifth U.S. Army, 1660 East Hyde Park Blvd., Chicago, Ill. (includes Colorado, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming); Sixth U.S. Army, Presidio of San Francisco, Calif. (includes Arizona, California, Idaho, Montana, Nevada, Oregon, Utah, and Washington).</p> <p><i><strong>"Some Biomechanical Methods for Evaluating Activities," VA Prosthetics Center, 1956, 18 min., color, magnetic sound {requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Shows some of the biomechanical methods used in the laboratory to measure the effectiveness with which both normal and handicapped people can perform various activities. Various photographic, mechanical, and electrical techniques are demonstrated.</p> <p><i>Evaluation: </i>This interesting film deals with research methodology and is, therefore, of interest primarily to individuals engaged or interested in research.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <p><i><strong>"Suction Socket Artificial Limb," U. S. Veterans Administration, 1951, 24 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes the suction-socket prosthesis in terms of the anatomical principles involved in its fabrication and fitting. Presents the indications and contraindications for its prescription, emphasizing the importance of the emotional maturity of the patient. Demonstrates briefly gait abnormalities and training. Also illustrates check-out procedures.</p> <p><i>Evaluation: </i>Although made in 1951, this excellent film is valuable in its presentation of a type of above-knee prosthesis that continues to be widely used. This film is of greatest value to physicians, prosthetists, and physical therapists, both staff and students. As background information, it could be useful for anyone concerned with the management of the above-knee amputee.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <p><i><strong>"The Urban Maes Amputation for Peripheral Vascular Disease," U. S. Veterans Administration, 1956, 14 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates the Urban Maes operative technique of below-knee amputation in a patient with disease of compromised circulations. Shows the healed stump and joint range of motion some weeks later. Also presented are several other patients whose treatment management is similar. Several views of stumps are shown, and the patients are seen ambulating on a temporary pylon as well as on the permanent prosthesis.</p> <p><i>Evaluation: </i>Primarily of value to physicians. Because of its relative simplicity, however, the film would be a good selection to illustrate a well-defined surgical procedure to individuals who have not observed actual surgery.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Total Rehabilitation of a Bilateral High Upper-Extremity Amputee" U. S. Veterans Administration, 1959, 30 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Stresses the roles of all members of the rehabilitation team in the management of this amputee. Illustrates the team approach in establishment of the program-examination and supervision by the physician; preprosthetic preparation of the stump and an exercise program by the physical therapist; prosthetic training by the occupational therapist; and vocational guidance by the counselor. Most of the time in this film is devoted to occupational therapy, and the amputee is shown in several learning situations involving functional activities.</p> <p><i>Evaluation: </i>The scenes that show how the patient encounters difficulty in performing normally simple chores and how the patient and the therapist work together to find an efficient method of performance are well presented. Although the film does not attempt to present a step-by-step prosthetic training program, the omission of any reference to solving toilet problems, a real concern with this type of amputee, is unfortunate. The team approach is somewhat overemphasized in the film, particularly insofar as the meetings are concerned. This film has teaching value for occupational therapy students and for occupational therapists who have had limited experience in working with patients with upper-extremity amputations. It may also be useful as an orientation for any paramedical group whose members are concerned with the management of the high upper-extremity amputee.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C, 20420.</p> <p><i><strong>"Upper-Extremity Prosthetics," U. S. Veterans Administration, 1952, 23 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents two veterans, both of whom are upper-extremity amputees. One wears his prosthesis successfully; the other keeps his device in his desk. The film explains the dynamics leading to this difference. The successful patient is portrayed as the recipient of services offered in a well-planned amputee management program. The absence of such a program, together with other deterrent factors, is presented as the cause for the second patient's rejection of his original prosthesis. A program designed to correct his reluctance to wear the prosthesis is outlined.</p> <p><i>Evaluation: </i>This film succeeds in achieving its objectives, as it clearly demonstrates the importance of good technical and psychological management of the amputee patient. It is not recommended as a teaching film, for it is lacking in its portrayal of the ideal training program. It is recommended as a general type film for paramedical groups and for patients who might be resistant to the intensive effort needed to obtain maximal use of the prosthesis.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C. 20420.</p> <p><i><strong>"Upper-Extremity Prosthetic Principles," U. S. Veterans Administration, 1955, 29 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates several interesting activities that were part of a research program aimed at improving upper-extremity prosthetic devices. Of special interest are the demonstration of normal movements of the human hand in a variety of grasping and gripping activities, an analysis of lost movements at various levels of upper-extremity amputation, and the types of upper-extremity prostheses appropriate for specific levels of amputation.</p> <p><i>Evaluation: </i>As far as paramedical groups are concerned, this film is of interest to those who would like to be better informed about the development of prosthetic devices. It could be used to illustrate components of prostheses when these are not available, although it should be remembered that only those prosthetic devices in use prior to 1955 are included.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C. 20420.</p> <h3>Child Prosthetics</h3> <p><i><strong>"Adaptation of Children to Prosthetic Limbs," Michigan Crippled Children Commission, 1960, 20 min., color, optical and magnetic sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents five children, including upper- and lower-extremity amputees, each of whom demonstrates a wide range of physical activities while wearing his prosthesis. The disability of the child and the indicated prosthetic fitting are also presented.</p> <p><i>Evaluation: </i>This film demonstrates well how the artificial limb becomes an integral part of the body image at an early age. The remarkable skill and agility with which these children perform various physical activities are impressive. Some scenes are unnecessarily prolonged and repetitious. The technical quality of the film is not good, and prosthetically it is primarily of historical interest. Of possible interest to parents in demonstrating potential achievement.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Child Upper-Extremity Amputee," University of Michigan Medical Center, 1964, 19 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents ten child amputees and portrays their accomplishments in use of an upper-extremity prosthesis at specified ages, covering a span of several years in some instances. The x-rays of the involved extremities are shown, and a pictorial description of the amputation or limb deficiency is given. In cases of congenital amputees, diagnoses are given in terms of roentgenographical appearance. The type of prosthesis prescribed for each child and the changes necessitated by his growth and development are shown.</p> <p><i>Evaluation: </i>A well-presented, informative film that graphically portrays the accomplishments that may be expected of the child amputee who has the advantage of an early treatment program. It points out clearly the disadvantage to the child when prosthetic fitting is delayed. An orientation film of a specialized nature, it should be of interest to any professional person involved in the care of the child amputee. Parents of child amputees could also benefit by seeing this film. It is recommended for public health nurses who are in a position to refer the young amputee to the amputee clinic.</p> <p><i>Distributor: </i>Audio-Visual Education Center, University of Michigan, Frieze Building, 720 East Huron St., Ann Arbor, Mich. 48104.</p> <p><i><strong>"Child Prosthetics Project: A Report," University of California at Los A ngeles, 1958, 22 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Explains the role of each member of a large prosthetics team, which includes the family physician, pediatrician, orthopaedic surgeon, social worker, psychologist, engineer, prosthetist, physical therapist, occupational therapist, and project administrator. Portrays proceedings of a prosthetics conference, during which the patient and parent are presented. The contributions of the social worker, the psychologist, and the engineer are emphasized. At the conclusion of the film, it is explained that one of the principal purposes of the team is to collect research data with a view toward improving training and prosthetic devices and procedures.</p> <p><i>Evaluation: </i>At the time the film was made, it undoubtedly served the purpose of showing the UCLA program as well as presenting the concepts of the prosthetics team and the early fitting of the child amputee. Although it might be of some value in demonstrating a research approach, its outdated quality relegates it, for the most part, to the category of "historical interest."</p> <p><i>Distributor: </i>Paul L. Brand and Son, 2153 K St., N.W., Washington, D. C. 20001.</p> <p><i>Rental Fee: </i>S7.60 plus shipping charges.</p> <p><i><strong>"Early Development of Ambulation-Unilateral Below-Knee Amputee," University of California at Los Angeles, 1965, 18 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Depicts the progress of the child amputee from the time he attempts to stand until he walks independently with the prosthesis, which has become an integral part of his body image. Shown are the changing patterns of rhythm, the gradual narrowing of the base of support, and the increasing stability as motor-kinesthetic development takes place and the child participates in increasingly complex skills and play activities.</p> <p><i>Evaluation: </i>Presents well the concept of early fitting, as the child is shown wearing and using the prothesis as effectively as a normal leg. The film should be shown in conjunction with <i>Infant to School-Age Child - Unilateral Below-Elbow Amputee.</i></p> <p><i>Distributors: </i>Child Amputee Prosthetics Project, UCLA Rehabilitation Center, 1000 Veteran Ave., Los Angeles, Calif. 90024. Also available for loan from the crippled children's services in all 50 states and in the District of Columbia, the Virgin Islands, Puerto Rico, and Guam through funds supplied by the Children's Bureau, Department of Health, Education, and Welfare.</p> <p><i><strong>"Infant to School-Age Child - Unilateral Below-Elbow Amputee," University of California at Los Angeles, 1964, 10 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the various stages in the motor-kinesthetic development of the child and relates them to the specific times at which the child amputee is ready for initial prosthetic fitting as well as for increasingly complex devices. As skills and physical activities develop in response to demands of daily living, devices are provided that are appropriate to the level of function. The cooperation of the parents in the teaching process is stressed.</p> <p><i>Evaluation: </i>The concept of fitting the child amputee with the appropriate device at a specific time in his motor-kinesthetic development is well presented. The film has value, not only in demonstrating the progress of the child amputee, but also in teaching the basic principles of growth and development in the young child. Although the film is specialized in nature, it is recommended for undergraduate students in paramedical fields to present the principles of growth and development. It is highly recommended for professional groups working with child amputees. It should be shown in conjunction with the film <i>Early Development of Ambulation</i>-<i>Unilateral Below-Knee Amputee.</i></p> <p><i>Distributor: </i>Child Amputee Prosthetics Project, UCLA Rehabilitation Center, 1000</p> <p>Veteran Ave., Los Angeles, Calif. 90024. Also available for loan from the crippled children's services in all 50 states and in the District of Columbia, the Virgin Islands, Puerto Rico, and Guam through funds supplied by the Children's Bureau, Department of Health, Education, and Welfare.</p> <p><i><strong>"Juvenile Amputee with Congenital Skeletal Limb Deficiencies," Tulane University School of Medicine, 1964, 20 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents ten patients treated at a child-amputee clinic. As each case is presented, the limb deficiency is described on the screen in the terminology of the recently developed roentgenographic classification. The deficiency is further described by x-ray plates and by pictures of the child before surgical procedures. Scenes filmed at a later date show the patient wearing and using a prosthesis fitted to the surgically revised limb. The history of the child is outlined rather fully and, in some instances, the history is pictorially depicted at intervals over a number of years.</p> <p><i>Evaluation: </i>This film would be helpful in reinforcing use of the classification of limb deficiencies as developed by O'Rahilly and Frantz. The results obtained in fitting severely involved children are impressive. The information presented is too extensive for the time allotted, making it difficult to stay with the narrator and detracting from the technical quality of the film. This film is recommended for professional groups interested in orientation to this particular type of patient and program. It could also benefit parents of the congenital child amputee.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>S3.00.</p> <p><i><strong>"Lower-Extremity Amputees - Toddlers," Michigan Crippled Children Commission, 1957, 22 min., color, magnetic sound {requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Presents briefly the motor development of the child as it relates to the upright position and ambulatory progress. Describes anomalies and stumps, both pictorially and roentgenographically. Discusses the prosthetic fitting and the child's ambulatory program. Changes in gait patterns over a number of years are demonstrated.</p> <p><i>Evaluation: </i>The development of the gait pattern over the years is especially interesting. Because of advances in design, fabrication, and the fitting of prostheses since the film was made, it has outlived its period of optimal value.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Prosthetic Training of the Very Young Child Amputee - Upper Extremity,'" Michigan Crippled Children Commission, 1959, 20 min., color, optical and magnetic sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates the training technique used in teaching three upper-extremity child amputees to use their prostheses. It shows a child-sized APRL hand that was in the experimental stage at that time.</p> <p><i>Evaluation: </i>This film shows good beginning training technique, outlining three different areas of training-basic body-control motions, development of prosthetic control, and functional prosthetic use. The training situations shift abruptly, causing the film to lose continuity. Technically, it is not a high-quality film. Occupational therapists might find this film of value because some of the techniques of training are still acceptable, although the prostheses are outdated.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Upper-Extremity Amputees - Toddlers," Michigan Crippled Children Commission, 1956, 22 min., color, magnetic sound (requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Presents type, diagnosis, and prosthetic fitting of several upper-extremity child amputees. Demonstrates the performance of skills and activities while wearing the prosthesis.</p> <p><i>Evaluation: </i>This film, made at the Mary Free Bed Guild Children's Hospital in Grand</p> <p>Rapids during the earlier years of the child-amputee program, serves to demonstrate how readily children adapt to early prosthetic fitting. Advancements in the prosthetic field, however, cause the film to be outdated. It should be noted that the sound, which is magnetic, is cut off for about the last ten minutes.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <h3>Orthotics</h3> <p><i><strong>"Assistive Devices for the Physically Handicapped," National Foundation for Infantile Paralysis, 1951, 12 min., sound, color, 16 mm.</strong></i></p> <p><i>Summary: </i>Illustrates many assistive devices and their use by postpoliomyelitis patients. The devices include mouth sticks, overhead slings, feeders of various types, automatic page turners, hydraulic lifts, and several others.</p> <p><i>Evaluation: </i>This very comprehensive film is useful to show the kinds of devices used to increase the functional capacity of the post-poliomyelitis patient with severe residual paralysis. Credit is due those whose ingenuity resulted in the improvised equipment demonstrated here. While the film is photographically excellent, its content in terms of emphasis on certain devices, such as the mouth stick, is questionable. The film, made prior to the poliomyelitis vaccines, is necessarily outdated in some aspects, but the devices shown would still be of interest to personnel working with the severely disabled.</p> <p><i>Distributor: </i>Film Library, International Society for Rehabilitation of the Disabled, 219 East 44th St., New York, N. Y. 10017.</p> <p><i>Rental Fee: </i>$10.00. (No rental fee for members in good standing with the International Society.)</p> <p><i><strong>"Kinetics and Orthotics for Function," Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 1963, 25 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the basic principles in the selection and the use of orthotic devices to achieve as normal function as possible in the presence of upper-extremity weaknesses. The basic normal motions of the upper extremity in the performance of several everyday activities are carefully depicted. The subject, a quadriplegic patient, is introduced as he is undergoing a manual muscle test. The test, which reveals severe weakness in the musculature of the upper extremities, also serves as a basis for determining the degree and nature of the mechanical assistance required to supplement the existing strength. Periodic evaluations are made; and, as strength increases, the appliances are adjusted or replaced. Finally, the amount of assistance is reduced to the minimum required by the patient, who is shown performing a number of activities. Before discharge from the hospital, the patient is equipped with a flexor-hinge hand and is planning to return to his former occupation.</p> <p><i>Evaluation: </i>An excellent analytical presentation of the prescription and use of orthotic devices for severely involved upper-extremity patients. Outstanding in this picture is its adherence to the practice of sound teaching principles. As each new step is presented, the principle underlying the selection of orthotic devices is applied and illustrated. The analysis of normal motion serves as a basic approach to the problem. The film gives a feeling for the long time involved and is realistically hopeful in terms of patient accomplishment. This film is highly recommended for all paramedical groups; for occupational therapists it is of value in teaching specific techniques of training.</p> <p><i>Distributor: </i>Film Library, New York University Medical Center, 342 East 26th St., New York, N. Y. 10016.</p> <p><i>Rental Fee: </i>$5.00.</p> <p><i><strong>"Spinal Cord Injury" Rancho Los Amigos Hospital, 1961, 25 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Depicts eight levels of spinal-cord injury and demonstrates the degree of independence that the average patient can attain after injury. Independence is accomplished through a program of maximum strengthening of the remaining active muscles, combined with appropriate assistive devices, such as short leg braces, long leg braces, overhead slings, artificial muscles, special splints, crutches, hydraulic lifts, etc., and training.</p> <p><i>Evaluation: </i>This well-organized film discusses clearly and precisely each level of injury in terms of specific pertinent information, such as key muscle groups involved, functional loss, and orthotic devices. It points out that the prognosis of the patient is not constant with the level of injury, but is based on demonstrable muscle function. Limitations are carefully noted, and goals are realistic. The film is highly recommended for any professional person working with the paraplegic or quadriplegic patient and for inclusion in the undergraduate curriculum for therapists and nurses. Patient and family would benefit from seeing this film, provided they have accepted a realistic attitude toward rehabilitation.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00.</p> <p><i><strong>"The Heather Hand," U. S. Veterans Administration, 1960, 10 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes a light-weight, wrist-extension, hydraulic orthosis. Shows the patient putting it on himself and performing several activities.</p> <p><i>Evaluation: </i>Although this film illustrates the device very well and graphically demonstrates its function, it is of practically no value for paramedical groups because it is not accompanied by any explanation, either written or auditory.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <h3>Amputation Surgery and Fabrication of Prostheses</h3> <p>The compilers of this review did not consider themselves qualified to evaluate films on amputation surgery or the fabrication of prostheses.</p> <p>Titles of films on surgery may be found in the <i>Film Reference Guide for Medicine and Allied Sciences, </i>U. S. Department of Health, Education, and Welfare, Public Health Service, Communicable Disease Center, Atlanta, Ga. 30333.</p> <p>For those interested, the following films on the fabrication of prostheses are listed.</p> <p>Available from the Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001: <i>Above-Knee Prosthetics</i>-<i>Stump Casting with the Use of a Casting Stand; Below-Knee Prosthetics</i>-<i>Stump Casting with the Use of a Casting Stand; Fabrication Technique for Medial Opening, Polyester Nylon, Syme Prosthesis; Plastic Finishing of an Above-Knee Socket; The Total-Contact, Soft-End, Plastic Laminate Above-Knee Socket.</i></p> <p>Available from Hydra-Cadence, Inc., 623 South Central Ave., P. O. Box 110, Glendale, Calif.: <i>Hydra-Cadence, Reel 1; Hydra-Cadence, Reel 2.</i></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>Footnote</b></td></tr><tr><td class="clsTextSmall">Enhancing the value of this film and intended to be used in conjunction with it are 16 loop films, each of which depicts one gait deviation. These loops are 7 ft. in length and can be rerun an indefinite number of times on standard projectors. The set may be purchased for $25.00. When the film is ordered, a check in this amount should be made payable to the distributor: Ideal Picture Co., 417 North State St., Chicago, Ill. 60610.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Review of Visual Aids for Prosthetics and Orthotics https://staging.drfop.org/files/original/09ae6273b7efa1eca6cc0322ff308dd3.pdf c37e010a6efb7da15ebc3041aebdd09c https://staging.drfop.org/files/original/0e3e1220253af6aa4b191462f1226ca4.jpg b0082ad957d997d1c0132891b476d3b6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_044.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 44 - 45 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>L'Attelle Monotubulaire, a Review</h2> <h5>Ralph Lusskin, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>L'Attelle Monotubulaire is the second fascicle, or increment, of the Atlas d'Appareillage Prothetique et Orthopedique (Atlas of Prosthetic and Orthopaedic Appliances) being published under the direction of Professor Louis Pierquin of the Faculty of Medicine of Nancy {Artificial Limbs, Spring 1964). L'Attelle Monotubulaire describes a lower-extremity brace of novel design and function-the monotubular brace. This interesting departure in French orthotics utilizes a single straight tubular upright to provide lightness and strength. The conventional medial upright is eliminated.</p> <p>Additional departures include a round caliper shoe attachment placed anterior to the ankle joint as well as below it. Geometry is accommodated during ankle movement and spring action is added to the joint by the use of a telescoping lower leg piece which inserts into an upper tube below the calf band. Stops and additional springs can be attached to the stirrup piece.</p> <p>Thus there has been developed a brace that uses a straight upright anterior to the axis of the leg, which has a moderate posterior offset of the knee joint, which varies in length with ankle motion and is easily adjusted to the torsional alignment of the leg. Patellar-tendonbearing-type leg bands and quadrilateral sockets can be utilized in place of narrow leg and thigh bands. Wide, contoured plastic bands are attached by metal bands soldered to the brace.</p> <p>To evaluate such a novel device, one must determine whether construction would present significant problems, whether fitting and alignment procedures can be standardized, and whether utilization corroborates the claimed attributes. Unfortunately, the publication does not provide sufficiently detailed information to answer these questions. This work is presented in broad terms for the general information of the physician-therapist-orthotist team. It does introduce the device but does not describe the metals used or the fabrication methods. Alignment procedures are not discussed, although two errors-improper depth of the thigh and leg bands and improper rotational alignment due to faulty positioning of the shoe piece-are demonstrated. No analysis of failure rates or comparison of the effectiveness of this brace versus that of standard braces is given. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "When viewed laterally, the monotubular brace is traight; it does not show even the slightest curve at the level of the knee. It rests on a forward pin; that is, on a pin located in front of the axis of the limb." From L'Attelle Monotubulaire </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable thought and work have obviously been expended to bring this device to its present state. Thus it is unfortunate that one can only speculate concerning possible limitations or advantages that might be inherent in its design.</p> <h4>Possible Limitations</h4> <p>Difficulties in using this brace might be encountered if deformities of the knee in the frontal plane, for example, genu valgum or genu varum, are present. In addition, the management of any flexion contracture of the knee would apparently be most difficult.</p> <p>Ankle instability would not be controlled by this device. While drop foot could be managed, varus and valgus deformities, both fixed and functional, might exceed the capacities of the brace. It is not apparent whether or not a calcaneal deformity could be adequately stabilized.</p> <p>The report notes the critical nature of the depth of the leg band, indicating that proper alignment and fit are vital factors in the application of this orthosis and that careful supervision by the physician would be required.</p> <h4>Possible Advantages</h4> <p>Certain advantages of the monotubular brace are apparent. The simplicity of the single-bar fabrication, the lightness of the device, and its potential for control of bilateral disorder without clearance problems are all positive values.</p> <h4>Conclusions</h4> <p>Since the monotubular brace appears to have potential value and its limitations can be only assumed, the device should be the subject of a controlled evaluation to identify problem areas and to demonstrate the usefulness of the device. This evaluation should include the training of others in fabrication, alignment, and fitting of the brace, and its utilization by a representative group of patients under controlled conditions.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ralph Lusskin, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Clinical Professor of Orthopaedic Surgery, School of Medicine and Post-Graduate Medical School, New York University, 550 First Ave., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_044/1965_02_044.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource L'Attelle Monotubulaire, a Review Creator An entity primarily responsible for making the resource Ralph Lusskin, M.D. * https://staging.drfop.org/files/original/f73009e86594dcca75541df0a12e99d0.pdf 1889f60a10577651577742fa073f3c95 https://staging.drfop.org/files/original/290830ff921d3225c71b7da047de3c91.jpg 604673b43d699b8dd0e4e40b2ebc2915 https://staging.drfop.org/files/original/a35ba394e727d7f97890d44e3b4bc8f8.jpg d1d8235db6501bdc2e847d0aa6325edc https://staging.drfop.org/files/original/64c3f030f117136789588247cc666446.jpg 4f2e2336c57ccb9972606fa34fc39784 https://staging.drfop.org/files/original/80a7da92cda87b5b46d4629f021c8c94.jpg dbe15132b2e8b0856e434023c45cafd3 https://staging.drfop.org/files/original/5c1001c8613c3cdbbbeaec4168327017.jpg a0568a7d77d908e3e116118e815c1508 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_010.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 10 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_010.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_010.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Preliminary Design Analysis of Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Nancy V. Appoldt, B.A. <a style="text-decoration:none;">*</a><br /></h5> <!-- <sup Note="1">*Based upon a report entitled <i>Preliminary Design Analysis of Linkage Feeders, </i>published by Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, New York, N. Y., in May 1965. The report was prepared under the general supervision of Sidney Fishman, Ph.D., Project Director, Prosthetic and Orthotic Studies, New York University. The study reported upon was supported by funds from the Vocational Rehabilitation Administration, Department of Health, Education, and Welfare.</sup> --> <p>In 1962 the Committee on Prosthetics Research and Development authorized a survey of current orthotics research and development in a number of selected centers as an initial step in a proposed orthotics evaluation program. A prime purpose of the survey was the identification of orthotic devices and procedures as suitable subject matter for the evaluation program.</p> <p>One of the devices selected as meeting the requirements for inclusion in the evaluation process was the linkage feeder designed at the University of Michigan. However, it was apparent that this device, plus a number of others, was essentially a variant of the ballbearing feeder designed and developed two decades ago by the Georgia Warm Springs Foundation. Hence, a review of existing feeder designs was undertaken as a prelude to any formal evaluation program.</p> <p>The systems involved were those currently in use at the Georgia Warm Springs Foundation, Rancho Los Amigos Hospital, the University of Michigan, the Texas Rehabilitation Center, and the Texas Institute for Rehabilitation and Research. Two prefabricated units that were available commercially were also reviewed, but these units resemble the Rancho Los Amigos Hospital feeder so closely that separate consideration is not warranted.</p> <p>Ideally, a feeder supports the weight of the arm and permits the patient with severely weakened or paralyzed upper extremities to position the hand with a minimum of muscular effort. The extent of a patient's performance with a feeder and his method of performance are, of course, contingent on the nature and extent of his disability.</p> <p>The feeders considered in this article have numerous structural features and operational principles in common. An aluminum forearm trough and two stainless-steel swivel arms that rotate on ball or needle bearings support the weight of the upper extremity and provide useful motion when activated by a slight residual motor power in the head, neck, trunk, or arms. The joint cylinders may be rotated to bring the feeder assembly into an inclined plane which provides gravity assistance to the horizontal motions of the extremity. The trough pivot may be positioned to give a bias to both vertical motions of the forearm, namely, raising the hand to the head or lowering it to the table top.</p> <p>A number of accessory components may be attached to a feeder to adapt the equipment to individual requirements without modifying the basic design. Among these are metal clips, straps, and foam-rubber liners to prevent slippage <!--Page 11--> of the forearm; horizontal and vertical stops to restrict feeder motions to a controllable range; elastic-band and supinator assists to aid motion; and double T-bars to support the hand and provide attachments for self-help devices.</p> <p>The basic principles of the various feeders being the same, a matter of interest is the significance of the points on which they differ. In Appendix A the distinctive features of each of these systems are identified and illustrated in detail. The Georgia Warm Springs Foundation model is presented as the basic design, with its apparent advantages and disadvantages. The other four designs are then compared with the Georgia Warm Springs Foundation item.</p> <h3>SUMMARY AND CONCLUSIONS</h3> <p>Linkage feeders were received from the Georgia Warm Springs Foundation, the University of Michigan, Texas Rehabilitation Center, the Texas Institute for Rehabilitation and Research, and Rancho Los Amigos Hospital. With the Georgia Warm Springs Foundation balanced forearm orthesis as the frame of reference, the design and operational features of each feeder were subjected to critical examination. In summarizing the findings of the examination, two points must be emphasized:</p> <ol> <li>All feeders are in current and apparently successful use at the centers from which they were obtained.</li><li>The feeders were not applied to <i>bona fide </i>patients, but were analyzed in relation to use by a normal adult.</li></ol> <p>Thus the validity of the advantages and disadvantages cited in this report might require further verification.</p> <p>It is of value, however, to identify the <i>apparent </i>strengths and weaknesses of each feeder in relation to the Georgia Warm Springs Foundation balanced forearm orthesis. This feeder was the first of its kind, and its basic design served as a model for the subsequent feeders. The question that this review attempts to answer is: In what respects do the features of the other feeders appear to be superior or inferior to those of the Georgia Warm Springs Foundation Feeder?</p> <h3>UNIVERSITY OF MICHIGAN</h3> <p>The multiple adjustment features of the University of Michigan feeder appear to make it the most versatile of those reviewed. Moreover, this adjustment capability is maintained throughout the life of the feeder, in contrast to the reduced adjustability of the "permanent" feeder which is the end product in some of the other designs.</p> <p>The significant additional adjustment involves the rocker-arm assembly and allows the trough, and consequently the forearm, to be raised or lowered with respect to the trough pivot. The fore-and-aft adjustment found in other feeders is also available. Thus the forearm may be balanced against gravity in two dimensions, permitting maximum control of the forces acting about the trough pivot in horizontal, vertical, and intermediate positions of the forearm. The use of ball bearings in the distal link and trough pivot, as well as in the first and second joints, minimizes frictional forces in the system. The screw-adjustment system permits precise adjustment without the use of tools. The lateral location of the rocker-arm assembly, combined with the use of a triceps strap, permits a closer relationship between table top and trough, while the lateral space required for feeder operation is reduced by the use of a relatively short proximal link.</p> <p>The prime limitations of the University of Michigan feeder are:</p> <ol> <li>It is bulky and has a nonaesthetic appearance.</li><li>The nondetachable proximal link imposes the necessity for removing the entire feeder from the wheelchair when it is to be collapsed, transported, or stored.</li><li>The triceps strap may bind, reducing or eliminating elbow support.</li></ol> <h3>TEXAS REHABILITATION CENTER</h3> <p>The outstanding characteristic of the Texas Rehabilitation Center feeder is its simplicity. The adjustability of link lengths should also be useful for applications to children during the growth years.</p> <p>The absence of ball bearings in the proximal joint makes this feeder more difficult to maneuver in horizontal motions. The short swivel arms and stationary elbow dial restrict extension of the arm and thereby limit function to a reduced zone of motion. Contact of the elbow dial with the distal link obstructs lateral trough motion, while the rocker-arm assembly restricts the upward tilt of the trough. Because the trough is offset from the distal link vertically, <!--Page 12--> placement with relation to a table top is more distant than with the Georgia Warm Springs Foundation, University of Michigan, or the Rancho Los Amigos Hospital system, each of which has horizontally offset troughs. In order to change tilts at the first and second joints, the device must be returned to the orthotics shop.</p> <h3>TEXAS INSTITUTE FOR REHABILITATION AND RESEARCH</h3> <p>The Texas Institute for Rehabilitation and Research model is notably streamlined in appearance. Frictional resistance is minimized in horizontal feeder motions by the use of needle bearings at the end of the distal link.</p> <p>As with the Texas Rehabilitation Center feeder, an orthotist must make any tilt adjustments. This lack of ready adjustment might tend to hinder a patient's performance if his wheelchair were on uneven terrain. It might also delay accommodation to improvement or regression of his disability. The trough's vertical offset from the distal link and relatively long vertical rod limit the closeness of trough placement to the table top. Moreover, to bring the trough as close as possible to the table top, clearance of the distal link is minimized (1/2 to 1 in.) and the link may strike objects on the table.</p> <h3>RANCHO LOS AMIGOS HOSPITAL</h3> <p>In the Rancho Los Amigos Hospital feeder a unique tilt adjustment is provided at the distal end of the proximal link. Adjustment of the second joint, therefore, is easier and more precise. The rocker-arm assemblies permit greater ranges of motion at the trough pivot than those of the Georgia Warm Springs Foundation model. The outside rocker-arm assembly, which has a ball-bearing unit at the trough pivot similar to that of the University of Michigan feeder, minimizes friction in vertical motions and permits two-dimensional adjustment of the pivot relative to the forearm. A ball-bearing unit may also be added to the joint at the end of the distal link to minimize friction in horizontal feeder motions.</p> <p>Each of the feeders, when compared with the Georgia Warm Springs Foundation system, appears to have both positive and negative features. On the basis of the available data, resolution of the various pros and cons as to which feeder is the best is not feasible. Certainly the thought that the most advantageous characteristics of the five feeders might be combined in one superior system has appeal.</p> <p>However, selection of the optimal feeder for a particular patient depends primarily on the purpose for which the device is prescribed. Purposes may range from support of the arms in a comfortable position for the most severely disabled to increased functional independence and participation in vocational activities for others. Thus a single feeder, even one incorporating the best elements of the various designs, may not serve the needs of all patients.</p> <p>Nevertheless, the similarities and differences of the five feeders identified in this review, and particularly the significance of the differences, are worthy of further study. If patients' needs in relation to the functions offered by the various components could be precisely defined, an individual's requirements might best be met by using selected components from one or more of the available feeders.</p> <!--Page 13--> <h3>Appendix A</h3> <h3><i>A Detailed Comparison of Five Feeders</i></h3> <h4>GWSF Balanced Forearm Orthesis</h4> <p><b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Georgia Warm Springs Foundation (GWSF) balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>attaches to the chair upright <i>2. </i>Two screws <i>3 and 4 </i>extend from the clamp to provide attachment for, and anteroposterior angular adjustment of, a ball-bearing tube 5.</p> <p><i>Advantages - </i>The proximal joint may be independently tilted anteroposteriorly and rotated mediolaterally to provide a gravity assist or to compensate for an inclined chair upright or for slopes. There is minimal joint friction.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable swivel arm 6 terminates distally in a ball-bearing tube <i>7. </i>Length of proximal link is adjustable during fitting, nonadjustable in the finished unit. The proximal link is either a drop-type <i>6 </i>or straight (not shown). Accessory collars (not shown) may be used to raise the proximal link. The distal link 8, curved approximately 90 deg., terminates in a vertical tube or post <i>9, </i>the height of which may be increased by height extenders (not shown).</p> <p><i>Advantages - </i>The feeder may be removed from the chair upright without disturbing the base assembly. Minimal friction is present between proximal and distal links. Drop-type proximal link is useful in obtaining proper feeder height for short patients (without clamp adjustment). The straight proximal link may be used with collars to provide elevation of the feeder for taller patients. The curved distal link reduces interference between elbow and distal link. Height extenders are useful for gaining additional trough height and increasing elbow-distal link clearance.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A drop <i>10 </i>or straight (not shown) offset rod inserted in the tube permits rotation of the trough. Accessory collars <i>11 </i>increase rod height. The distal end of the rod fits into two sleeves <i>12 </i>which rotate on the rod. The sleeves are brazed to a 1-in. flat bar with threaded holes for attachment to the underside of the trough <i>13. </i>An L-shaped bar <i>14 </i>soldered to the rod between the sleeves holds the movable sleeve unit on the rod.</p> <p><i>Advantages - </i>The offset rod provides additional trough-link clearance. Additional height adjustment is useful in accommodating tall patients.</p> <p><i>Disadvantages - </i>The L-shaped bar imposes a "down" stop on trough motion.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>15 </i>has prepunched holes interiorly for anteroposterior adjustment on the sleeve bar. The elbow dial is stationary (not shown) or hinged <i>16 </i>to the stem of the cradle and connected to the rocker-arm assembly by a linkage rod <i>17.</i></p> <p><i>Advantages - </i>The hinged dial permits full elbow extension.</p> <p><i>Disadvantages - </i>The stationary dial restricts elbow extension.</p> <!--Page 14--> <h4>The University of Michigan feeder.</h4> <p><b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The University of Michigan (U of M) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>similar to the GWSF item attaches to the chair upright <i>2. </i>An adjustment assembly connects the clamp with a ball-bearing cylinder <i>3 </i>and allows positioning anteroposteriorly by screw <i>4 </i>and mediolaterally by screw 5. Feeder height may be regulated by an adjusting nut <i>6 </i>incorporated into the ball-bearing tube.</p> <p><i>Advantages - </i>Greater precision in mediolateral, anteroposterior,and height adjustments than the GWSF feeder. No tools are required for adjustments. Minimal joint friction.</p> <p><i>Disadvantages - </i>Bulky, conspicuous. Weight of unit must be supported when attaching clamp to wheelchair.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The vertical portion <i>7 </i>of a straight swivel arm is threaded to accommodate the height-adjusting nut. The proximal link, which terminates distally in a ball-bearing tube <i>8, </i>is relatively shorter than the GWSF item. The distal link is angled distally 90 deg. and has a ball-bearing tube <i>10 </i>attached. The distal link is proportionally longer than the GWSF item.</p> <p><i>Advantages - </i>Short proximal link decreases space required (laterally) for feeder excursion. Minimal friction present at second ballbearing joint. Angled distal link provides trough-link clearance. Minimal friction present between distal link and rocker-arm assembly.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint. Linkage is not readily detachable from the wheelchair assembly.</p> <!--Page 15--> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A short vertical rod fits into the ball-bearing tube to permit horizontal rotation of the trough. Affixed to the superior end of the rod is a U-shaped housing <i>11 </i>which supports a ballbearing unit <i>12. </i>Extending from this unit is a threaded shaft which is mounted by a grooved block and adjusting screw <i>13. </i>Affixed to the block is a curved supporting arm <i>14 </i>which extends under the trough and attaches to another grooved block and screw assembly on the inferior lateral aspect of the trough <i>15.</i></p> <p><i>Advantages - </i>Minimal friction present in vertical motions of the trough. Screw-type adjustments permit finer control of elbow-hand balance. Balance of the feeder may be adjusted in two planes, vertical as well as anteroposterior. No tools are required for adjustments.</p> <p><i>Disadvantages - </i>Conspicuous, crude appearance.</p> <p><b>Trough</b></p> <p><i>Description - </i>A triceps strap <i>16 </i>has hinged attachments to two outriggers <i>17 </i>and <i>18 </i>which are riveted to the inferior and lateral aspects of the forearm cradle <i>19.</i></p> <p><i>Advantages - </i>Triceps strap permits full elbow extension. Posterior protrusion of elbow is less with triceps strap than with elbow dial.</p> <p><i>Disadvantages - </i>Triceps strap may be displaced from support position with repetitive motion.</p> <!--Page 16--> <h4>The TRC Feeder</h4> <p><b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Texas Rehabilitation Center (TRC) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly One arm of a U-shaped rod <i>1 </i>inserts into the round clamp <i>2. </i>The other end is brazed to a vertical tube <i>3 </i>so that bending of the U-rod tilts the tube anteroposte-riorly. Rotating the rod within the clamp tilts the joint mediolaterally.</p> <p><i>Advantages - </i>Simple and inconspicuous. The effect of increased friction from absence of ball bearings in the proximal joint is uncertain. Some friction at this point may be advantageous, for example, to lend stability at the shoulder so that motion imparted to the feeder will occur at the elbow first. It may, however, be disadvantageous if the impedence cannot be readily overcome, particularly in the zone of hand motions about the head.</p> <p><i>Disadvantages - </i>Benders must be used to obtain anteroposterior tilt adjustments.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>A detachable straight swivel arm <i>4 </i>is adjustable in length from 4 3/4 to 8 in. and terminates in a ballbearing tube 5. The distal link <i>6 </i>is a straight swivel arm, adjustable in length from 4 3/4 to 8 in., and terminates in a vertical tube <i>7.</i></p> <p><i>Advantages - </i>Feeder can be removed from chair without disturbing the base assembly. Ball bearings reduce joint friction. Short proximal link reduces lateral space required for feeder excursion.</p> <p><i>Disadvantages - </i>Short linkage lengths limit reach and permit joint toggle. As with the GWSF unit, benders must be used on the proximal link to obtain tilts at the second joint without affecting the plane of motion of the first joint. When the forearm is inclined vertically, the distal link interferes with horizontal excursion of the dial.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A rod, Y-shaped distally <i>8, </i>swivels within the tube and articulates with pre-drilled holes in the trough fenders <i>9 </i>to form the trough pivot.</p> <p><i>Advantages - </i>Pivot joints are easily adjusted on the trough without tools. The location of the trough pivot, being higher with respect to the trough than that of the GWSF feeder, more closely approximates the center of gravity of the forearm.</p> <p><i>Disadvantages - </i>Y-shaped rod imposes "up" stop on trough.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>10 </i>has anteroposterior adjustment on pre-drilled holes. Forearm cradle as stationary dial <i>11.</i></p> <p><i>Disadvantages - </i>As with the GWSF stationary dial assembly, elbow extension is limited.</p> <!--Page 17--> <h4>The TIRR Feeder</h4> <p><b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The Texas Institute for Rehabilitation and Research (TIRR) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly A round clamp <i>1 </i>is attached to the chair upright. An offset plate <i>2 </i>affixed to the clamp provides the mounting for the needle-bearing tube <i>3, </i>which is adjustable anter-oposteriorly in the trial feeder, nonadjustable in the permanent model (not shown). The tube is tilted mediolaterally by rotation of the round clamp.</p> <p><i>Advantages - </i>Smaller tube with needle bearings reduces bulk of unit and provides an unobtrusive appearance. Minimal joint friction.</p> <p><i>Disadvantages - </i>In the permanent feeder, mediolateral adjustments cannot be made without affecting anteroposterior tilt which has been established.</p> <!--Page 18--> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The proximal and distal links are straight and terminate in needle-bearing tubes 5 and <i>6. </i>The proximal link is detachable and the length of the links is adjustable in the trial model, nonadjustable in the permanent model.</p> <p><i>Advantages - </i>Feeder may be removed from the chair without disturbing the base assembly. Minimal joint friction.</p> <p><i>Disadvantages - </i>As in the GWSF unit, benders must be used to effect tilts at the second joint without altering the base assembly.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A relatively long vertical rod <i>7 </i>terminates superiorly in a clevis hinge <i>8. </i>A rectangular bar <i>9 </i>bearing two threaded holes for trough attachment is brazed to the movable portion of the hinge.</p> <p><i>Disadvantages - </i>The length of the vertical rod is not sufficient to prevent interference of the distal link with the lateral excursion of the elbow dial when the trough is in the "up" position. This means of offsetting the trough from the distal link positions the terminal end of the link approximately 1/2 in. above the table top. The path of feeder motion is obstructed by objects on the table.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>10 </i>and hinged elbow dial <i>11 </i>are similar to the GWSF unit's trough. The linkage rod <i>12, </i>which is adjustable for fitting purposes, is nonadjustable in the permanent feeder (not shown).</p> <p><i>Advantages - </i>Permits full elbow extension.</p> <!--Page 19--> <h4>The RLAH Feeder</h4> <p><b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The Rancho Los Amigos Hospital (RLAH) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>As in the GWSF unit, a round clamp <i>1 </i>attaches to the chair upright. An L-shaped bracket <i>2 </i>extends from the clamp to provide attachment for and anteroposterior angulation of an adjusting plate <i>3. </i>A ball-bearing tube <i>4 </i>is soldered to the posterior lateral aspect of the plate.</p> <p><i>Advantages - </i>As with the GWSF unit, the proximal joint may be tilted mediolaterally by rotating the wheelchair clamp and anteroposte-riorly by a separate adjustment. The plate simplifies anteroposterior adjustment.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable drop swivel proximal link 5 is similar to the GWSF item and terminates distally in an adjustable ball-bearing tube <i>6. </i>A small hinge unit <i>7 </i>permits anteroposterior tilting of the tube. The selected tilt position is maintained by set screws <i>8. </i>The distal link, similar to the GWSF item, is curved 90 deg. and terminates in a vertical tube <i>9. </i>An alternate unit (not shown) for patients with limited motion in the horizontal plane replaces the vertical tube with a ball-bearing unit. Post height extenders, like those of the GWSF system, may be fitted into the vertical tube to elevate the trough.</p> <p><i>Advantages - </i>The tilt adjustment for the second joint permits greater ease and precision in providing assistance to horizontal motions of the forearm. As with the GWSF distal link, the curved offset permits adequate horizontal rotation of the rocker-arm assembly when the trough is in the "up" position. Ball bearings used at the end of the distal link reduce friction between the distal link and the rocker-arm assembly. Additional feeder height may be desirable for tall patients or for specific activities (for example, combing the hair).</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>The standard assembly consists of a vertical rod which swivels within the tube and is surmounted by a U-shaped hinge unit <i>10. </i>Fixed to the movable portion of the hinge is a 1-in. rectangular bar <i>11. </i>Threaded holes in the bar can be aligned with drill holes in the underside of the trough for attachment and anteroposterior adjustment. The outside rocker-arm assembly incorporates a height-adjusting collar <i>12 </i>on a longer vertical rod and a ball-bearing trough pivot <i>13. </i>A clamp anchored to the hinge axis medially, attaches to an offset rod <i>14 </i>to permit vertical adjustment of the trough with respect to the hinge.</p> <p><i>Advantages - </i>The outside rocker-arm assembly reduces friction in vertical motions and permits greater control of elbow-hand balance by means of placing the trough pivot closer to the center of gravity of the forearm.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>15 </i>and dial <i>16 </i>are similar to but not identical with the GWSF forearm cradle and stationary dial.</p> <p><i>Disadvantages - </i>Stationary dial restricts elbow extension.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Nancy V. Appoldt, B.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-005.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Preliminary Design Analysis of Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Nancy V. Appoldt, B.A. * https://staging.drfop.org/files/original/8697a8f963d8891708f7146a8800f1fa.pdf 49a4a04ffbca3021f555d7b987e35685 https://staging.drfop.org/files/original/4caa47c2d021f88d058ca6724b453a4c.jpg 87d9e4145cc6305c442954af03851d1a https://staging.drfop.org/files/original/db019b84f1068a9dd8b7a17c9f3c82f5.jpg 4b54d9acd0a32a50d47ca3a3315312b8 https://staging.drfop.org/files/original/daf8c596c8eb7e9d49656325de183a55.jpg abe05f2d30dae891020dbda823205d85 https://staging.drfop.org/files/original/2cf7234b28f3f375fd1f6ba2eb438cba.jpg 5007228a1cc68268e5171f413d39e00f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_001.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Aging and Amputation</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a part of a lower extremity due to peripheral vascular disease (PVD) incident to the effects of arteriosclerosis with or without the presence of diabetes is today the predominant type of amputation that is being performed in peacetime in the Western World; <i>i.e., </i>the United States and Europe. These ischemic amputations begin to make their appearance in the late forties of life and their incidence increases rapidly in succeeding decades. Lower-extremity PVD cases constituted 85 per cent of all amputations performed at the Massachusetts General Hospital during the period 1962-1964 and the average age of these patients was 70 years.</p> <p>This predominance of PVD lower-extremity cases in the field of amputation surgery is a development of quite recent origin. A survey of lower-extremity amputations by Doctor Jan Hansson in Sweden for the period 1947-1962 documents this fact. During this period, the incidence of lower-extremity amputations in individuals under 60 years of age remained constant at an annual rate of 4 to 5 per 100,000 population. In males over 60, the rate rose from 34 per 100,000 in 1947 to 129 in 1962. In females over 60 years of age, the amputation rate increased from 24 to 62 per 100,000 during this period. Doctor Hansson expressed the opinion that these rates would continue to rise over the coming years.</p> <p>One cannot but surmise that these rapidly increasing rates of lower-extremity amputations in individuals over 60 years of age are but a reflection of the change in the character of our older aged population that has occurred over the past four decades as a result of the dramatic advances that have been made in the prevention, care, and management of disease. Before the advent of insulin, it is doubtful that many diabetics lived long enough to develop gangrene of a lower extremity. Countless numbers of people are now reaching the age of 65 or older with medical conditions which, forty years ago, would have been fatal at a much earlier age.</p> <p>Ischemic amputations of the lower extremity formed an insignificant part of the workload of prosthetic facilities forty years ago. This is borne out by Doctor Hansson's Swedish study. In 1926, only 2 per cent of fitted lower-extremity cases were due to PVD amputations, whereas by 1955, they had increased to 57 per cent. Older prosthetists in the United States, whose professional experience dates back to the 1920's, have unanimously stated that this Swedish study accurately reflects their own experience in that forty years ago they rarely fitted a PVD amputee, whereas today these cases form the major part of their workload. The incidence of ischemic amputations was relatively low in 1926 and at that time the mortality rate for these operations was extremely high in view of the fact that no means were available to control infection. Furthermore, it appears that forty years ago very few of these cases were considered as candidates for prosthetic rehabilitation.</p> <p>Potentially, the Medicare Act for the Aged which became effective in July 1966 can relieve a serious national inequity that in the past has involved the older aged amputees in this country. Over the years federal and state programs have been available to provide financial assistance for needy amputees from birth until they reached the 60 to 65 year age period. The Children's Bureau and the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare have conducted these assistance programs through their support of corresponding state agencies. Until the Medicare Act, amputees and other handicapped individuals over 65 years of age who needed assistance, except for beneficiaries of the Veterans Administration, have been dependent upon local welfare programs that varied widely in their character throughout the country. The 1964 annual VRA report revealed that only 1.7 per cent of their rehabilitated cases for that year were over 65 years of age. Yet this older aged segment of our population is characterized by multiple disabilities and, as a group, does not have the financial resources to take advantage of the rehabilitation opportunities that are available in most sections of this country. A bulletin of the National Health Survey of the Public Health Service, Series 10, Number 32, reports that 50 per cent of citizens 65 years or older have incomes of less than $3,000 per year and that 50 per cent have disabilities that limit materially their daily activities.</p> <p><b>Table 1</b> compares, in terms of their ages, a study of 12,000 new, fitted amputees that were collected during the two-year period 1961-1963 in the United States with all new cases that were furnished prostheses in Great Britain in 1962. No unfitted or old amputee cases provided with a new replacement device are included in these two groups of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The basis for this wide disparity between Great Britain and the United States with respect to the fitting of older aged amputees is economic. Any amputee in Great Britain, regardless of his age, can receive a prosthesis at government expense if he demonstrates that he has some useful prosthetic rehabilitation potential.</p> <p><b>Table 2</b> presents the sources of payment for prostheses of the 12,000 new, fitted cases cited in <b>Table 1</b> above. Cases assisted by welfare agencies are almost exclusively geriatric since the state programs subsidized by the Children's Bureau and VRA are available to younger amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data presented in <b>Table 2</b> apply to the United States as a whole and vary widely between individual states. This is illustrated by <b>Table 3</b> that compares the percentage of new, fitted cases over 65 years of age in two states that have, roughly, the same numerical population. The relatively higher economic status of state A and its well-developed welfare programs, as compared with state B, form the basis for the very wide disparity in the fitting of older aged amputees in these two states. The Medicare Act is now available to provide the geriatric amputees in state B with the prosthetic rehabilitation services that have been denied them in the past.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Individuals with peripheral vascular disease of their lower extremities of a severity requiring amputation have, as a group, multiple disabilities that can abridge and even reduce to zero their prosthetic rehabilitation potential. The prosthetic evaluation of these cases, therefore, is critical. They have widely varying rehabilitation goals. Recent studies of these geriatric amputees indicate that, under present management concepts, only about 30 per cent will ever be able to obtain any use of their prostheses. This percentage could be significantly increased if the surgical community would adopt a conservative philosophy in its management of PVD amputations with respect to the original level of amputation and the indications for reamputation in cases of delayed wound healing.</p> <p>The study of PVD amputations at the Massachusetts General Hospital, referred to above, documents the fact that the preservation of the knee joint is all important in determining the rehabilitation potentials of these cases. Percentage-wise, twice as many below-knee cases will be able to use effectively a replacement device as those with above-knee amputations. That there are today widely divergent views concerning the level of amputation in PVD cases is indicated by the fact that, in one large metropolitan area, two-thirds of these cases were amputated above the knee and, in another large city, two-thirds were amputated below the knee. A study of all ischemic amputations performed in 1964 at 14 Veterans Administration hospitals reveals this same disparity in surgical philosophy as regards the level of amputation. The two extremes among these hospitals is shown in <b>Table 4</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The study of 12,000 new, fitted cases cited earlier reveals that the reamputation rate in successfully fitted, below-knee cases is almost zero. The reamputation of a BK is nearly always due to wound complications at the time of amputation. Pedersen and others have shown that a high percentage of these cases of delayed wound healing following amputation below the knee will successfully respond to conservative management and, because of the preservation of the knee joint, will become effective users of prostheses.</p> <p>The percentage of geriatric amputees that can achieve some useful degree of prosthetic rehabilitation would be increased by early fitting and ambulation. There is today an undue time lag between amputation and the fitting of these cases. A recent spot check revealed that this interval averages seven and one-half months. During this period, many of these older amputees will have developed contractures that may preclude prosthetic restoration, or they may become wedded to a wheelchair existence.</p> <p>It is hoped that orthopedic surgeons who are knowledgeable in the field of amputee rehabilitation will endeavor to inform the general surgeons in their respective communities with regard to modern concepts in the care and management of this form of disability.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-04.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Aging and Amputation Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/854528621eb80bd8a9b4f7349f5d48a6.pdf e7ecf8eb166fd1de014a65d9a4e19c54 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_020.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 20 - 23 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Conclusions of a Conference on Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>Following the preparation of the <i>Preliminary Design Analysis of Linkage Feeders </i>by Prosthetic and Orthotic Studies of New York University,<a></a> it seemed desirable to explore the significance of the design similarities and differences identified in the NYU report.</p> <p>Accordingly, a Workshop on Linkage Feeders was organized and conducted under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development. Participants in the workshop conference, which was held at the University of Michigan, Ann Arbor, Mich., July 26-27, 1965, included representatives from the five centers whose feeder designs were discussed in the NYU analysis, plus unattached engineering and other consultants.<a style="text-decoration:none;">*</a></p> <p>At the conference, the design and applications of linkage feeders were discussed in considerable detail, both with respect to the major components (chair-attachment assemblies, proximal and distal links, rocker-arm assemblies, and troughs) and the device as a whole. In the following presentation of major points emerging from the discussions, it will be noted that while there were areas of disagreement, a community of agreement on many considerations was evident.</p> <h4>Adjustment</h4> <h4><i>Availability to the Patient</i></h4> <p>A characteristic of the University of Michigan and the Rancho Los Amigos Hospital systems is that provisions for adjustment are retained throughout the life of the orthoses. At the other centers, apparently, a temporary feeder is used initially, with adjustments made during the course of training by physician, therapist, or orthotist. Before the patient leaves the center, the optimal adjustments are frozen, so to speak, in a permanent unit.</p> <p>A basic difference in philosophy is evident here. The belief at the University of Michigan is that the patient's family can be taught to adjust the feeder and should have the privilege of doing so; for example, to accommodate changes in the status of the patient's muscular torques with time. The belief at the other centers is that the optimal feeder geometry established during training may be lost with patient-family manipulation.</p> <p>Since proponents of both approaches are apparently satisfied with the results achieved, no categorical rule would appear to apply. To the impartial observer, retention of adjustability would seem desirable with, perhaps, provision for locking the adjustment features, if this restriction were found necessary.</p> <h4><i>Precision</i></h4> <p>Theoretically-and perhaps actually-the threaded-screw adjustments of the University of <!--Page 21--> Michigan model provide the means for securing more precise adjustments than any of the other units.</p> <p>There appears to be no question that the provision of an efficient system of balances and biases is critical to the patient's performance and increases in importance with the extent of disability.</p> <p>There is, however, considerable question concerning the degree of precision achieved or required in these units. Since motion of the forearm in the trough shifts the center of gravity of the forearm in relation to its axis of rotation, as do objects of different weights held in the hand, optimal adjustment would seem to be dynamic rather than static. Moreover, desired adjustments are in relation to a particular configuration of trough and rocker-arm assembly, for example, and this configuration itself may not represent the optimal design. It is noteworthy, though, that all the systems reviewed appeared to be very useful devices, despite these lacks.</p> <h4>Extent of Use</h4> <p>Texas Rehabilitation Center apparently applies linkage feeders primarily or solely for use with lapboards. Most of the other institutions plan more extensive use, particularly that involving activities at tables or desks, with a strong bias toward vocational rehabilitation or an approximation of normalcy. This difference in approach obviously influences feeder design and application, particularly with respect to the "reach" provided and provisions for securing adequate trough height to avoid disturbing objects on the table or desk. Total linkage length, the use of drop rather than straight swivel arms, and curved rather than straight distal links, may all be affected by these considerations.</p> <p>On this question of limited <i>vs. </i>extended feeder usage, the latter approach (maximum function and use) seems preferable unless the goals are unrealizable.</p> <h4>Link Lengths and Ratios</h4> <p>In mechanical terms, the maximum feeder reach is the sum of the lengths of the proximal and distal links, while the minimum reach is the difference between the two lengths. Kinematically, the two links should be of equal length.</p> <p>A considerable variety of link lengths and ratios was evident in the five feeders reviewed, each apparently representing a compromise between kinematic and practical considerations, that is, the need to reduce the length of the proximal links to permit passage through doorways without interference by the projecting joint between the proximal and distal link. All compromises apparently worked satisfactorily. However, the maximum length for the proximal link commensurate with noninterference would appear desirable to reduce the stress on bearings.</p> <h4>Bearings and Friction</h4> <p>Four of the feeders reviewed incorporated ball bearings to reduce joint friction while only one (Texas Institute for Rehabilitation and Research) used needle bearings. However, since these latter were said to be strong and durable and result in smaller joints, they may well be the bearings of choice.</p> <p>There was some difference of opinion concerning the need for antifriction bearings at the rocker-arm assembly (for trough function). Some conferees deemed a small amount of friction (for dampening) desirable here (for some patients); others disagreed. An obvious solution to meet both contingencies would be the incorporation of antifriction bearings, with nylon washers available for insertion if friction were desired.</p> <h4>Distal Links</h4> <p>Straight, angled, and curved distal links were represented in the feeders reviewed. Functionally (reduced interference between distal link and trough) and aesthetically, the curved links appeared to be superior.</p> <h4>Trough Pivots and Forearm Position</h4> <p>Despite the variety of rocker-arm assembly designs and trough-pivot positions (offset, below the trough, and forked to each side of the trough), the function of all designs appeared to be reasonably satisfactory. Independent engineering opinion tended to favor a forked pivot supporting the trough halfway through the thickness of the forearm rather than below it.</p> <!--Page 22--> <p>Forearm motion (sliding) within the trough was considered. The value of the typical elbow disk (dial) in stabilizing the forearm was questioned by the engineering consultants at the workshop. A strap that pivots on an axis passing through the anatomical axis of the elbow (as in the University of Michigan design) was considered to be more satisfactory. Velcro was suggested as a possible means for retaining the forearm in the trough.</p> <h4>Cosmesis</h4> <p>Feeders are rather conspicuous, mechanical, utilitarian devices. Hence the stress placed on cosmetic considerations by the conferees was all the more noteworthy. Two factors are apparently involved: <i>first, </i>the appearance of the feeder itself, that is, graceful lines, lack of obtrusiveness, etc.; <i>second, </i>the simulation of normalcy in use, for example, sitting at the table to eat a meal rather than using a lap-board.</p> <h4>An Appropriate Name</h4> <p>So-called linkage or ball-bearing feeders are obviously more than this name connotes. A less awkward term that would more appropriately define the characteristics and function of the device would be very desirable. Numerous suggestions were made by the conferees, including the term "balanced forearm orthesis" developed by Dr. Robert L. Bennett at the Georgia Warm Springs Foundation. However, none of the suggestions aroused any enthusiasm.</p> <h4>Potential Users</h4> <p>An attempt was made by the workshop participants to estimate the number of persons who would derive benefit from the use of a feeder.</p> <p>It was mentioned that a large but unspecified number of postpoliomyelitis patients would require such devices for the remainder of their lives.</p> <p>As far as new cases were concerned, the five centers represented at the workshop fitted a total of approximately 150 cases per year. It was estimated that an equal number of patients who might benefit from feeders were not being fitted because of lack of publicity concerning their value or lack of knowledge concerning applications. The conferees were also of the opinion that although new poliomyelitis patients are rare, survivors of automobile, diving, trampoline, and other accidents resulting in high spinal-cord injuries are increasing. In general, these patients require more sophisticated feeders than those developed originally for victims of poliomyelitis.</p> <h4>Need for Further Research</h4> <p>All the feeders reviewed appeared to be of fairly adequate design, and all appeared to be fairly useful devices. Presumably, each device could be improved by incorporating features in other designs, or by taking cognizance of suggestions advanced during the workshop. However, further research to develop a new design-a "super feeder"-does not seem indicated at the present time.</p> <h4>Need for Education</h4> <p>If, as postulated at the workshop, numerous patients with high spinal-cord injuries (who could benefit from the use of a feeder) are not being provided with the device, an obvious educational need exists. To meet this need, two elements are involved: <i>first, </i>information concerning the existence and usefulness of linkage feeders should be brought to the attention of physicians and institutions treating appropriate patients; <i>second, </i>hospital and rehabilitation personnel should be trained in the application and adjustment of the device.</p> <p>To these ends, it was considered that:</p> <ol> <li>Publicity might profitably be given to the NYU review and to the deliberations of the workshop conference.</li><li>Announcement should be made that commercially made feeders closely resembling the Rancho Los Amigos Hospital model described in the NYU report are available.<a style="text-decoration:none;">*</a> </li><li>Announcement should be made that instructional material dealing with the application and adjustment of feeders has been prepared by the Georgia Warm Springs Foundation<a></a> and Rancho Los Amigos Hospital<a></a>, and that reports on design principles have been published by the University of Michigan.<a></a></li><li>Based on available experience, information concerning feeder design principles and applications might well be included in one or more courses offered by the Prosthetics and Orthotics Education Program.</li></ol> <p><b>References:</b></p> <ol> <li>Georgia Warm Springs Foundation, <i>Instructions forbalanced forearm orthesis and research kit.</i></li> <li>Georgia Warm Springs Foundation, <i>Instructions foruse of balanced forearm orthesis kit.</i></li> <li>New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, <i>Preliminary design analysis of linkage feeders, </i>May 1965.</li> <li>Rancho Los Amigo Hospital, <i>How to fit and adjust aball bearing feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>How to fit and adjust asuspension feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>Uses and limitationsof mobile arm supports.</i></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Theory of"feeder" mechanics, </i>Am. J. Phys. Med., <b>42:3, June </b>1963, pp. <b>113-139.</b></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Designrefinement of the linkage feeder, </i>Arch. Phys. Med., 44, November 1963, pp. 609-615.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Theory of'feeder' mechanics, Am. J. Phys. Med., 42:3, June 1963, pp. 113-139.</td></tr><tr><td class="clsTextSmall"><b> 8.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Designrefinement of the linkage feeder, Arch. Phys. Med., 44, November 1963, pp. 609-615.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Rancho Los Amigo Hospital, How to fit and adjust aball bearing feeder.</td></tr><tr><td class="clsTextSmall"><b> 5.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, How to fit and adjust asuspension feeder.</td></tr><tr><td class="clsTextSmall"><b> 6.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, Uses and limitationsof mobile arm supports.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Georgia Warm Springs Foundation, Instructions forbalanced forearm orthesis and research kit.</td></tr><tr><td class="clsTextSmall"><b> 2.</b> </td><td class="clsTextSmall">Georgia Warm Springs Foundation, Instructions foruse of balanced forearm orthesis kit.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Jaeco Orthopedic Specialties, Box 616 M-R5, Hot Springs, Ark. 71919; J. A. Preston Corp., 71 5th Ave., New York, N.Y.; Orthopaedic Supplies Co., Inc., 9126 East Firestone Blvd., Bldg. R, Downey, Calif.; Rehabilitation Equipment, Inc., 175 E. 83rd St., New York, N. Y. 10028.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Persons attending the workshop were: Herbert Elftman, Sidney Fishman, as co-chairmen; Edward Haak, James Poulson, of the Georgia Warm Springs Foundation; Robert C. Juvinall, James W. Rae, Jr., Edwin M. Smith, of the University of Michigan; G. Hartmann, Nancy Verdon (Appoldt), of New York University; Alice Garrett, Patrick Marer, Betty Yerxa, of Rancho Los Amigos Hospital; Thorkild Engen, of Texas Institute of Rehabilitation and Research; Linda Parker, Randolph Witt, of Texas Rehabilitation Center; Hans A. Mauch, Colin A. McLaurin, Eugene F. Murphy, as engineering consultants; Hector W. Kay, James R. Kingham, A. Bennett Wilson, Jr., of the staff of the Committee on Prosthetics Research and Development. (Mr. Wilson also served as an engineering consultant.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, Preliminary design analysis of linkage feeders, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Conclusions of a Conference on Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/4dd6d94c1daa2cb68cd4f392331932db.pdf 259046e83e06f18b250ccc9220f4934a https://staging.drfop.org/files/original/2d3c637c51e5be4ea4a9b4f22c646846.jpg 11fee075823dd0fa5b865a8e747525dc https://staging.drfop.org/files/original/71f334ea18c694ea04b3d9b1f08a2253.jpg f7ec0a39eb5bbe47b310aa1f57a3d155 https://staging.drfop.org/files/original/6a0443994001a210b073e6923907b80a.jpg f8dcbc9d4224aa5e9cbb3f44145131fb https://staging.drfop.org/files/original/9263685d4481876c0d4e9272dd4ebeea.jpg d0d533d69cdfefbd4d631caee28aa13c https://staging.drfop.org/files/original/98f2d20450ad3768fbb296aef6b3bf20.jpg 74771fdcfdd89388647e71b2b29d843c https://staging.drfop.org/files/original/c55b28bda436388da75e3eee453c6c75.jpg 722fd6cb26bbb613bcdda96faad136a5 https://staging.drfop.org/files/original/46575d89fa490b67fd583a23dbb0eba1.jpg 1d6a709393590127cca18e095b03d7c1 https://staging.drfop.org/files/original/03efb5bd9a7aa0a4e0c7536b11d81944.jpg b8ab156ee418e2e7f14c6f781ad91ddc https://staging.drfop.org/files/original/9b3dd80c9f94cac1f8d03173ac09fa29.jpg 2cc8730d37d1046df4e01ae577b08e1a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_024.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 24 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_024.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_024.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Nomenclature for Congenital Skeletal Limb Deficiencies, a Revision of the Frantz and O'Rahilly Classification</h2> <h5></h5> <!--Page 24--><!--====NEW ARTICLE====--> <p><i>Report of the Consultants to the Subcommittee on Child Prosthetics - Problems of the Committee on Prosthetics Research and Development:</i></p> <p><i>Cameron B. Hall, M.D., Los Angeles, Calif.<br /> Claude N. Lambert, M.D., Chicago, Ill.<br /> Ronan O'Rahilly, M.D., St. Louis, Mo.<br /> Chester A. Swinyard, M.D., Ph.D., New York, N.Y.</i></p> <p><i>Prepared by Robert L. Burtch, M.A.,<a style="text-decoration:none;">*</a> Research Scientist, Prosthetic and Orthotic Studies, New York University Post-Graduate Medical School, under the supervision of Sidney Fishman, Ph.D., Project Director, and Hector W. Kay, M.Ed.,<a style="text-decoration:none;">*</a> Associate Project Director, Prosthetic and Orthotic Studies, New York University Post-Graduate Medical School.</i></p> <p>At the request of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, Child Prosthetic Studies, New York University, initiated a study of congenital skeletal limb deficiencies during March 1963<a></a>. The primary purpose of this initial effort was to determine the adequacy of the classification nomenclature for congenital skeletal limb deficiencies proposed by Drs. Charles H. Frantz and Ronan O'Rahilly<a></a> and of a description-classification form developed by NYU Child Prosthetic Studies. The results of the evaluation<a></a> indicated that 471 of 577 limbs (85 per cent) were classifiable within the framework of the Frantz-O'Rahilly system.</p> <p>In the light of these generally favorable results, the Subcommittee on Child Prosthetics Problems appointed a group of consultants (Drs. Cameron B. Hall, Claude N. Lambert, Ronan O'Rahilly, and Chester A. Swinyard) to consider possible ways and means by which the Frantz-O'Rahilly plan might be modified to provide an even more comprehensive system for classifying limb deficiencies.</p> <p>In the course of several joint meetings of the consultants and the NYU staff, a revised system was developed. The revised system generally follows the basic principles proposed by Drs. Frantz and O'Rahilly, in that: <i>first</i>, it is based on a description of <i>absent </i>skeletal parts; <i>second, </i>deficiencies are classified under the two basic headings, Terminal and Intercalary, with subgroups of Transverse and Longitudinal under each of these headings. However, the use of anatomical terms has been extended significantly and is included in the classification of all deficiencies. Thus the use of such clinical descriptive terms as hemimelia, peromelia, ectromelia, phocomelia, dysmelia, etc., has been eliminated. Only two basic descriptive <!--Page 25--> terms are now proposed: Amelia, or <i>complete </i>absence of a free limb, and meromelia, or <i>partial </i>absence of a free limb. The latter term is a derivative of the Greek <i>meros </i>(part or partial) and <i>melos </i>(limb).</p> <p>The use of the revised nomenclature adheres to procedures set forth in the <i>Standard Nomenclature of Diseases and Operations </i><a></a>. The classification of a given deficiency, therefore, proceeds from the general to the specific, citing absent skeletal elements for definitive identification. For example, Meromelia: Terminal Longitudinal; Metacarpal: I, II, III describes a terminal longitudinal deficiency of the hand involving absence of digital rays I, II, and III. To provide a basis for possible international consideration, the anatomical terminology utilized in this system is consistent with <i>Nomina Anatomica.</i><a></a> Since x-rays and the resulting classification may be expected to change depending on the degree of maturation (for example, tarsals and carpals), cases where ossification is continuing must be reclassified periodically.</p> <p>The material related to the revised classification system is presented in five parts:</p> <blockquote> <ol> <li>A definition of the terms and symbols employed.</li><li>Two charts (II. a. and II. b.) adapted from articles by Dr. Hall <i>et al. </i><a></a> and Dr. O'Rahilly<a></a> to facilitate understanding of the basic principles involved.</li><li>A detailed, illustrated description of the classification plan.</li><li>A description-classification form used for recording purposes.</li><li>Instructions for use of the description-classification form.</li></ol> </blockquote> <ol> <li>TERMS AND SYMBOLS <ul> <li>TERMS <ul> <li>Amelia - <i>Complete </i>absence of a free limb (exclusive of girdle).</li> <li>Meromelia - <i>Partial </i>absence of a free limb (exclu- sive of girdle).</li> <li>Terminal - Absence of all skeletal elements distal Deficiency to the proximal limit of the defi- ciency, along the designated axis (longitudinal or transverse).</li> <li>Intercalary Deficiency - Absence of middle part(s) lying between a proximal-distal series of limb components; elements proximal to and distal to the absent part(s) are present.</li> <li>Transverse - Absence extending across the width of the limb.</li> <li>Longitudinal - Absence extending parallel with the long axis of the limb (forearm and/or hand, or leg and/or foot), either pre-axial, postaxial, or (as in the hand or foot) central in nature.</li> <li>Pre-axial Absence of the portion of the fore- arm and/or hand, or leg and/or foot on the thumb or the great-toe side of the limb (radial or tibial portion).</li> <li>Postaxial - Absence of the portion of the fore- arm and/or hand, or leg and/or foot on the side of the limb opposite the thumb or the great toe (ulnar or fibular portion).</li> <li>Central - Absence of one or more of the intermediate digital rays (for example, Ray III).</li> <li>Rudimentary - A remnant of an osseous element. If the remnant is identifiable (for example, the humerus), the term "rudimentary humerus" would be applicable. If the remnant cannot be identified, the symbol "X" (unknown) would be cited (for example, "rudimentary X").</li> <li>Ray - A digit.</li> </ul></li> <li>SYMBOLS <ul> <li>I - Intercalary.</li> <li>T - Terminal.</li> <li>- - Transverse.</li> <li>/ - Longitudinal</li> <li>Pre - Pre-axial.</li> <li>Post - Postaxial.</li> <li>? - Questionable identity of element cited (for example, radius <b>?</b>).</li> <li>X - Unknown (unidentifiable).</li> <li>:I, II, III, IV, or V - Digital ray(s) involved, starting from pre-axial to postaxial side of limb.</li> </ul></li> <li>SKELETAL ELEMENTS<br />Capital letters are used to identify skeletal elements that are <i>completely </i>absent; small (lower case) letters are used to identify skeletal elements that are <i>partially </i>absent. If the word identifying the skeletal element is written out, the first letter of the word is capitalized when the element is completely absent (for example, Humeral), and in lower case when only partially absent (for example, humeral). <ul> <li>HU or hu - Humeral.</li> <li>U or u - Ulnar.</li> <li>R or r - Radial.</li> <li>CA or ca - Carpal.</li> <li>TI or ti - Tibial.</li> <li>FI or fi - Fibular.</li> <li>TA or ta - Tarsal.</li> <li>MT or mt - Metatarsal.</li> <!--Page 26--> <li>MC or mc - Metacarpal.</li> <li>PH or ph - Phalangeal.</li> <li>FE or fe - Femoral.</li> <li>PP or pp - Phalanx Proximal.</li> <li>PM or pm - Phalanx Middle.</li> <li>PD or pd - Phalanx Distal.</li> </ul></li> <li>SKELETAL SEGMENTS <ul> <li>P - Proximal third of element cited.</li> <li>M - Middle third of element cited.</li> <li>D - Distal third of element cited.</li> <li>The symbols P, M, and D are used to indicate thirds of the skeletal elements cited, which may be completely or partially absent. Utilization of the three symbols requires the following clarification:</li> </ul></li> <li>TERMINAL TRANSVERSE (T-) DEFICIENCIES <ul> <li>P - absence of <i>part </i>of the proximal third of the skeletal element cited <i>and everything distal to it.</i></li> <li>M - absence of <i>all or part </i>of the middle third of the skeletal element cited <i>and everything distal to it.</i></li> <li>D - absence of <i>all or part </i>of the distal third of the skeletal element cited <i>and everything distal to it.</i></li> </ul></li> <li>TERMINAL LONGITUDINAL (T/) DEFICIENCIES <ul> <li>P - absence of <i>part </i>of the proximal third of the skeletal element cited and everything distal to it <i>parallel with the same axis. </i></li> <li>M - absence of <i>all or part </i>of the middle third of the skeletal element cited and everything distal to it <i>parallel with the same axis. </i></li> <li>D - absence of <i>all or part </i>of the distal third of the skeletal element cited and everything distal to it <i>parallel with the same axis.</i></li> </ul></li> <li>INTERCALARY TRANSVERSE (I-) DEFICIENCIES AND LONGITUDINAL (I/) DEFICIENCIES <ul> <li>P - absence of <i>all or part </i>of the proximal third of the skeletal element cited.</li> <li>M - absence of <i>all or part </i>of the middle third of the skeletal element cited.</li> <li>D - absence of <i>all or part </i>of the distal third of the skeletal element cited.</li> </ul></li> </ul></li><li> <ol> <li>BASIC SCHEMA FOR CLASSIFICATION OF CONGENITAL SKELETAL LIMB DEFICIENCIES - <b>Fig. 1</b> presents a basic schema for the classification of congenital skeletal limb deficiencies which has been adapted from one originally presented by Dr. Cameron B. Hall <i>et al. </i>.<a></a></li><li>BASIC SCHEMA FOR CLASSIFICATION OF CONGENITAL SKELETAL LIMB DEFICIENCIES - <b>Fig. 2</b> presents a basic schema for the classification of congenital skeletal limb deficiencies which has been adapted from one originally presented by Dr. Ronan O'Rahilly.<a></a></li></ol> </li><li>CLASSIFICATION NOMENCLATURE <ol> <li>Terminal Transverse (T-) Deficiencies ( <b>Fig. 3</b> and <b>Fig. 4</b>)</li><li>Amelia - complete absence of a free limb (exclusive of girdle). (For example, Amelia: T-; Upper Right.)</li><li>Meromelia - partial absence of a free limb (exclusive of girdle). <ol> <li>Humeral or Femoral (P, M, or D) - Partial absence of the humerus or femur and all distal elements.(For example, Meromelia: T-; humeral D (distal third above-elbow-type stump).)</li><li>Radio-Ulnar or Tibio-Fibular <ol> <li>Complete absence of the Radius and Ulna or Tibia and Fibula, and all distal elements. (For example, Meromelia: T-; Radio-Ulnar (elbow-disarticulation-type stump).)</li><li>Partial absence of the radius and ulna or tibia and fibula, and all distal elements. Use P, M, or D, as appropriate.(For example, Meromelia: T-; radio-ulnar M (short below-elbow-type stump).)</li><li>Complete absence of <i>one </i>of the forearm or leg elements, and all distal elements. (For example, Meromelia: T-; Radius (wrist-disarticulation-type stump).)</li></ol> </li><li>Carpal or Tarsalol - Complete absence of all hand or foot elements. (For example, Meromelia: T-; Tarsal (ankle-disarticulation-type stump).)</li><li>Carpal or Tarsal, Distal - Absence of the distal row of carpals or tarsals, and all other hand or foot elements distal to this level.(For example, Meromelia: T-; carpal, Distal (mid-carpal-type stump).) <ol> <li>Carpal or tarsal, Pre- or Postaxial - Absence of either the pre- or postaxial carpal or tarsal bones, <i>and all other hand or foot elements. </i>(For example, Meromelia: T-; carpal, Pre-axial (carpal-metacarpal-type stump).)</li><li>Metacarpal or Metatarsal <ol> <li>Absence of all metacarpals or metatarsals and all hand or foot elements distal to this level. (For example, Meromelia: T-; Metatarsal (tarsal-metatarsal-type stump).)</li><li>Absence of a portion of metacarpals or metatarsals and all hand or foot elements distal to this level. Use P, M, or D to indicate absent segment(s) of each metacarpal or metatarsal. (For example, Meromelia: T-; metacarpal: I D, II D, III D, IV M, V M (trans-meta-carpal-type stump).)</li></ol> </li><li>Phalangeal <ol> <li>Absence of all phalanges from all five digits. (For example, Meromelia: T-; Phalangeal, Upper Right (metacarpo-phalangeal-type stump).)</li><li>Complete or partial absence of <i>one or more phalanges from all five digits </i>(but not all phalanges from all five digits).(For example, Meromelia: T-; phalangeal, Upper Right: I, II; III PM, IV PM, D; V PD (trans-phalangeal-type stump).)</li></ol> </li></ol> </li><li>Terminal Longitudinal (T/) Deficiencies (<b>Fig. 5</b>) <ol> <li>Major Long Bones <ol> <li>Complete absence of one of the forearm or leg elements and of the corresponding portion of the hand or foot. The skeleto-anatomical terms Radial (R), Ulnar (U), Tibial (TI), or Fibular (FI) are used to indicate the absent long bone. In order to provide greater precision, the identifying number of each absent ray is included in the nomenclature. (For example, Meromelia: T/; Radial: I, II.) If all but one unidentifiable ray or rudimentary <!--Page 28--> ray is absent, the symbol "X" (unknown) or term "rudimentary X" is used.</li><li>Partial absence of one of the forearm or leg elements and absence of the corresponding portion of the hand or foot. P, M, or D is used to indicate the absent segment (s) of the long bone. Lower case letters are used, and the absent ray(s) is cited. (For example, Meromelia: T/; fibular M: IV, V.)</li></ol> </li><li>Carpal or tarsal, Pre- or Postaxial - Absence of <i>either </i>the pre- or postaxial carpal or tarsal bones, <i>and </i>corresponding digital rays.(For example, Meromelia: T/; carpal, Pre-axial: I, II.)</li><li>Metacarpal or metatarsal (P, M, or D) <ol> <li>Absence of all phalanges of one to four digits <i>and </i>complete or partial absence of their respective metacarpals or metatarsals.(For example, Meromelia: T/; metacarpal: I, II, III, V.)</li><li>In the case of partial absence of a specific metacarpal or metatarsal, P, M, or D is used to indicate the absent segment (s).(For example, Meromelia: T/; metatarsal: I, II; III D; V M.)</li></ol> </li><li>Phalangeal Absence of all or part of one or more phalanges from one to four digits.(For example, Meromelia: T/; phalangeal, Upper Right: I, II, III.)</li></ol> </li><li>Intercalary Transverse (I-) Deficiencies (<b>Fig. 6</b> and <b>Fig. 7</b>)<br /> A minimum of at least two digital rays (two metacarpals or metatarsals and their associated phalanges) must be present to permit classification as an Intercalary Transverse (I-) deficiency of the major long bones. In such cases, the hand or foot deficiencies (if any) are classified separately. Where there are fewer than two complete digital rays, the deficiency is classified as Terminal Transverse (T-), with a description of the distal digital elements that are absent (for example, "all but one ray absent"). <ol> <li>Major Long Bones <ol> <li>Humeral, Radio-Ulnar; or Femoral, Tibio-Fibular - Complete absence of all three major long bones in the limb with hand or foot elements attached directly to the trunk. (For example, Meromelia: I-; Humeral, Radio-Ulnar.)Concomitant hand or foot deficiencies are classified independently of the major long bone deficit. (For example, Meromelia: I-; Humeral, Radio-Ulnar; plus T/; metacarpal: I, II, V.)</li><li>Humeral or Femoral - Complete or partial absence of the long bone cited. (For example, Meromelia: I-; Humeral.) <!--Page 30--> If a partial absence exists, P, M, or D is added to indicate the absent segment (s) of the bone cited.(For example, Meromelia: I-; humeral M, D.)</li><li>Radio-Ulnar or Tibio-Fibular - Complete or partial absence of the long bone cited.(For example, Meromelia: I-; Radio-Ulnar.)If a partial absence exists, P, M, or D is used to indicate the absent segment (s) of each bone.(For example, Meromelia: I-; tibio-fibular P, M.)</li><li>Humeral, radio-ulnar; or femoral, tibio-fibular - Partial absence of <i>all three major long bones </i>in the upper or lower limb. P, M, or D is used to indicate the absent segment (s) of each long bone.(For example, Meromelia: I-; humeral D; radio-ulnar M, D.)</li></ol> </li><li>Carpal or Tarsal - Complete absence of the carpal or tarsal bones, with proximal and distal skeletal elements present.(For example, Meromelia: I-; Carpal.)</li><li>Metacarpal or Metatarsal - Complete absence of the metacarpals or metatarsals, with proximal and distal skeletal elements present. (For example, Meromelia: I-; Metacarpal.)</li><li>Phalangeal - Absence of all or part of the proximal and/or middle phalanx from all <i>five </i>digits. (For example, Meromelia: I-; phalangeal, Lower Right: I PP; II PP; III PM; IV PM; V PP.)</li></ol> </li><li>Intercalary Longitudinal (I/) Deficiencies (<b>Fig. 8</b>) <ol> <li>Major Long Bones <ol> <li>Complete absence of one of the forearm (R or U) or leg (TI or FI) elements with hand or foot elements intact along the same axis as the deficient long bone. (For example, Meromelia: I/; Fibular.)</li><li>Similar to above except that <i>only part </i>of the long bone cited is absent. P, M, or D is used to indicate the absent segment(s).(For example, Meromelia: I/; radial P, M.)</li></ol> </li><li>Carpal or tarsal, Pre- or Postaxial - Absence of <i>either </i>the pre- or postaxial carpal or tarsal bones with all other hand or foot elements present. (For example, Meromelia: I/; tarsal, Pre-axial.)</li><li>Metacarpal or metatarsal - Absence of <i>all or part </i>of one to four metacarpals or metatarsals.(For example, Meromelia: I/; metatarsal: I, II.) If only part of a metacarpal or metatarsal is absent, P, M, or D is used to indicate the absent segment(s) of the involved ray.(For example, Meromelia: I/; metatarsal: I D; II M, D.)</li><li>Phalangeal - Absence of <i>all or part </i>of the proximal and/or middle phalanx of from one to four digits. (For example, Meromelia: I/; phalangeal, Upper Left: I PP; II PM; IV PP.)</li></ol> </li></ol> </li><li>DESCRIPTION-CLASSIFICATION FORM <b>Fig. 9</b> presents the description-classification form developed by NYU Child Prosthetic Studies for recording congenital skeletal limb deficiencies.</li><li>CLASSIFICATION OF CONGENITAL SKELETAL LIMB DEFICIENCIES The following instructions were developed by NYU Child Prosthetic Studies to accompany the description-classification form: <ol> <li>Fill in the identification items at the top of the page.</li><li>Indicate in the space provided the presence or history of congenital visceral, soft-tissue or skeletal anomalies other than those of the limbs; that is, cardiac, pulmonary, gastrointestinal (esophageal and/or duodenal atresia, imperforated anus, etc.); genito-urinary, for example, cryptorchidism; cleft palate, hare lip, congenital and/or structural scoliosis, spina bifida, etc.</li><li>Using a <i>black </i>pencil or pen, shade in all <i>absent </i>skeletal elements or parts of elements. If an anomaly has been converted to an amputation, describe and classify the <i>original </i>anomaly. Care should be taken to retain the approximate length and girth proportions when shading in partial elements. Using a <i>red </i>pencil or pen, also indicate on the appropriate limb the approximate <i>site </i>and <i>date </i>of the surgical conversion (s).</li><li>In cases where prosthetic restoration is appropriate, indicate the analogous functional level of amputation for prosthetic purposes (for example, short above-elbow, short below-elbow, long above-knee, etc.) in the space provided. Consult <i>Upper </i>and <i>Lower Extremity Manual(s) </i>for functional amputation levels.</li><li>Indicate next to the appropriate skeletal part on the diagram any of the following conditions that exist. Also, include any unlisted conditions present, as well as any additional information that will enhance the completeness of the description. <ul> <li>Synostosis - Contracture</li> <li>Hypoplasia - Pseudoarthrosis</li> <li>Bifurcation</li> <li>Valgus - Dislocation</li> <li>Varus - Subluxation</li> <li>Syndactylism - Supernumerary digit(s)</li> <li>Torsion - Soft-tissue nubbin(s)</li> </ul></li><li>After completing the description of each affected<!--Page 34-->limb, insert in the appropriate space the appropriate classification nomenclature.</li></ol> </li></ol> </li></ol> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Basic schema adapted from Dr. Cameron B. Hall <i>et al. </i>(5). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic schema adapted from Dr. Ronan O'Rahilly <i>(6). </i>The term "meromelia," denoting <i>partial </i>absence of a free limb, is applicable to all examples in the schema with the exception of the transverse deficiency of the <i>complete </i>limb which has been denoted as "amelia." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Terminal transverse (T-) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Terminal transverse (T-) deficiencies (continued). The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Terminal longitudinal (T/) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Intercalary transverse (I-) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Intercalary transverse (I-) deficiencies (continued). The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Intercalary longitudinal (I/) deficiencies. The shaded areas in the example sketches represent absent elements or parts thereof. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Description-classification form for recording congenital skeletal limb deficiencies. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Burtch, Robert L., <i>A study of congenital skeletal limbdeficiencies, </i>Inter-Clinic Information Bulletin, May 1963, pp. 1-6.</li> <li>Burtch, Robert L., <i>The classification of congenitallimb deficiencies: A preliminary report, </i>Inter-Clinic Information Bulletin, October 1963, pp. 4-9.</li> <li>Excerpta Medica Foundation (Amsterdam, London,ilan, New York), <i>Nomina anatomica, </i>2nd ed., 1961.</li> <li>Frantz, C. H., and Ronan O'Rahilly, <i>Congenitalskeletal limb deficiencies, </i>J. Bone &amp; Joint Surg., Boston, 43A:1202-1224, December 1961.</li> <li>Hall, C. B., M. B. Brooks, and J. F. Dennis, <i>Congenital skeletal deficiencies of the extremities, </i>J.A.M.A., Chicago, 181:590-599, August 1962.</li> <li>O'Rahilly, Ronan, <i>Morphological patterns in limbdeficiencies and duplications, </i>Am. J. Anat., Philadelphia, 89:155-187, September 1951.</li> <li>Thompson, Edward T., ed., <i>Standard nomenclatureof diseases and operations, </i>McGraw-Hill, New York, 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">O'Rahilly, Ronan, Morphological patterns in limbdeficiencies and duplications, Am. J. Anat., Philadelphia, 89:155-187, September 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and J. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., Chicago, 181:590-599, August 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">O'Rahilly, Ronan, Morphological patterns in limbdeficiencies and duplications, Am. J. Anat., Philadelphia, 89:155-187, September 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and J. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., Chicago, 181:590-599, August 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Excerpta Medica Foundation (Amsterdam, London,ilan, New York), Nomina anatomica, 2nd ed., 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Thompson, Edward T., ed., Standard nomenclatureof diseases and operations, McGraw-Hill, New York, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burtch, Robert L., The classification of congenitallimb deficiencies: A preliminary report, Inter-Clinic Information Bulletin, October 1963, pp. 4-9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Frantz, C. H., and Ronan O'Rahilly, Congenitalskeletal limb deficiencies, J. Bone &amp;Joint Surg., Boston, 43A:1202-1224, December 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Burtch, Robert L., A study of congenital skeletal limbdeficiencies, Inter-Clinic Information Bulletin, May 1963, pp. 1-6.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Since April 1, 1965, Mr. Kay has been serving as Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences—National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Since September 1, 1965, Mr. Burtch has been serving as Coordinator of the Physical Medicine and Rehabilitation Service, Maimonides Hospital—Coney Island Division, Ocean and Shore Parkways, Brooklyn, N.Y. 11235.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_01_024/sp66c-009.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Nomenclature for Congenital Skeletal Limb Deficiencies, a Revision of the Frantz and O'Rahilly Classification https://staging.drfop.org/files/original/bce63a5f984a2b7e266ad41c794457eb.pdf 3336381361b926e881b5e08b4d5a104f https://staging.drfop.org/files/original/8984ef005962175cd2cd9ca4c67dd953.jpg 27b4bfe13ac727d78e188ef5c0b67354 https://staging.drfop.org/files/original/abfa246572131fe9dd3cdcbd55538f20.jpg a393b0f058bc54700d9c3ab34b65c9f4 https://staging.drfop.org/files/original/b1236f8892840de73e07786a00477f27.jpg 17ad3bcf73e9cc611c2f726000e15585 https://staging.drfop.org/files/original/f423924d489cce78f8517b42ebf79aae.jpg da4e43f799a904dc23d6620dc6553989 https://staging.drfop.org/files/original/1605ed8928919d3ac2b4a9755e041d30.jpg 36995fceb11605d7162400a6c40443e0 https://staging.drfop.org/files/original/999e0f60cb6a02c2a0115145cf515482.jpg 1dad4baf20341bf6baeb1f03138e9898 https://staging.drfop.org/files/original/f6b705039b55b6defd8e13b6e9c13e02.jpg abe2f39e1bd4137970fc50bef98c633e https://staging.drfop.org/files/original/59c9f866e0c4115b40694ac727ab58e3.jpg 22142ed910fdea4adda64f3b92d3480d https://staging.drfop.org/files/original/c807f2e8e367587163feae6926ca1b81.jpg 5f9b6c07208aad1b7d1c8f17934ec314 https://staging.drfop.org/files/original/74e60652660a7f2fade6c3f7f604d916.jpg 4c8a84c66cf97e3b930c25c10fce434a https://staging.drfop.org/files/original/0422d5a84c721d8228bef8e3651da68e.jpg 4c29f85936b1ff8d7fde5e8a6c90e7a8 https://staging.drfop.org/files/original/9a2d677825dd94e876b15c4dd04e83bc.jpg e5ef2eba763449d1d7606f322f5ae139 https://staging.drfop.org/files/original/07ea344764325dbc83c30b93217adcb4.jpg a579c5f3e92ff8e9ead1a6975eb28f55 https://staging.drfop.org/files/original/a4abcb85f4dca41eb258db103a1b6758.jpg 33f7ded8889906f86c4011008830c2f7 https://staging.drfop.org/files/original/b37d8f6126d94e2d7899983c1a474c0f.jpg 1fe5f44a5993f642ec0619a7eab4ef46 https://staging.drfop.org/files/original/3af334d9f215fbfc19ea5de010c1cd7c.jpg f585c5ed5d6d36c905cf9769833bd923 https://staging.drfop.org/files/original/a4a20ebdca1ecd21eaae49d233d5ce56.jpg 63ada1bca5d0c342a0eb4a5ac485ec14 https://staging.drfop.org/files/original/766e46411ccd23ec701dab020f5f81ba.jpg 80998bfac3aa008d9f07c6c5a820fa6b https://staging.drfop.org/files/original/137b1d7a083dea7f124c935af402eed6.jpg 19c2b24e6295de60f62d98abb36ee83e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_005.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 5 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The suspension casting technique permits the casting of an amputee's lower-extremity stump while it is being held in an attitude simulating stance-phase weight-bearing in a prosthesis. This is accomplished through application of the principle of the Chinese finger trap; namely, when a cloth cylinder of suitable weave is stretched longitudinally, the circumference of the cylinder is decreased.</p> <h3>Suspension Casting of the Below-Knee Stump</h3> <p>In casting below-knee stumps, a cast sock clamped in a ring is the cloth cylinder. As the amputee bears weight on the suspended sock, the sock stretches longitudinally and constricts circumferentially, thereby firming the tissues of the stump during the application of the plaster wrap. The amputee is properly oriented in an upright position for casting and for producing accurate alignment lines on the cast. The tissues are firmly contained, edema is restricted, and bony prominences are emphasized. Distal redundancy is held firmly in the correct position by the suspension sock. While the stump is suspended, areas requiring relief can be definitively outlined and, if necessary, build-ups of appropriate thickness can be applied to the suspension sock prior to wrapping. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Equipment required includes:</p> <ol> <li>A ring, approximately 6 1/2-in. inside diameter.</li><li>A rubber gasket.</li><li>A hose clamp.</li><li>A VA or a Berkeley casting stand with vertical adjustment.</li><li>Bathroom scale and platform.</li></ol> <p><b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Data to be obtained and recorded are:</p> <ol> <li>The length of the normal leg from the medial tibial plateau to the floor, with the shoe off.</li><li>The shoe size.</li><li>The anteroposterior dimension of the stump, measured with a VA caliper while the stump is fully relaxed and supported by the prosthetist.</li><li>The mediolateral dimension of the stump just proximal to the tibial plateau, measured with a VA caliper.</li><li>The length of the stump, measured from the end of the stump to the level of the midpatellar tendon. A small square is used to obtain this measurement; the blade of the square should contact the crest of the tibia.</li></ol> <p><b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PREPARATION OF MEDIAL TEMPLATE.</b> Because the medial flare of the tibial condyle is a particularly good weight-bearing area, it is desirable to construct a medium-weight cardboard template of the medial aspect of the stump for use as a guide in checking and maintaining the contours of the positive model in this important area. A cast sock is pulled over the stump and held with moderate tension by the amputee. To prevent bulging of the gastrocnemius during the tracing, the weight of the stump is supported by the prosthetist. The pencil is held vertically and slight pressure is exerted against the stump as the outline is drawn. The outline should extend from the proximal border of the femoral condyle to the midline of the distal aspect of the stump. After the medial tibial plateau is marked on the outline as an important landmark, the template is cut out and checked against the stump. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PREPARATION OR RELIEF PATCHES.</b> Relief patches should be prepared prior to suspension of the amputee in the ring. Various materials may be used for the patches, such as 1/8-in. Kemblo rubber, 1/8-in. adhesive-backed felt, or any foam material 1/8-in. thick and of sufficient density for dimensional stability. Areas usually requiring relief are the tibial tubercle, the tibial crest, the distal end of the tibia, the leading edge of the lateral tibial condyle, and the head and distal end of the fibula.</p> <p>The patch for the head of the fibula should extend at least 1/4 in. beyond the bone area. If the head of the fibula is prominent, a double patch is sometimes indicated.</p> <p>The patch for the tibial crest should be 1-in. wide. This will allow 1/4 in. of plaster on each side for blending the edges of the positive stump model. The actual relief remaining is 1/2-in. wide, sufficient to cover the lateral edge of the tibial crest and blend into the medial tibial surface. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>SIZING THE CAST.</b> The dimensions of the negative cast produced are dependent upon the stump, the number and weight of the socks used, and the tension with which the plaster bandages are applied. One heavy cast sock is used to accommodate the fit of a stump wearing a three-ply wool sock in a hard socket. For a mature stump, two heavy cotton cast socks are used to accommodate a five-ply wool-sock fit in a hard socket. For a socket incorporating an insert, one light-weight cotton cast sock is used. Both socks and relief patches are removed from the negative cast before the plaster is poured to form the positive stump model. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>ASSEMBLY OF EQUIPMENT AND SUSPENSION OF AMPUTEE.</b> Preparatory to taking the negative cast of the stump, the distance from the end of the stump to a point 4 in. above the proximal edge of the patella is marked on a heavy cast sock, the ring is mounted horizontally on the vertical stand, and the cast sock is centered in the ring with the mark showing. The gasket is then applied over the sock and secured with the hose clamp.</p> <p>Next, the ring is lowered on the easting stand to facilitate entry of the stump into the sock. Then the ring is raised until one-half of the body weight is borne by the stump sock, as indicated by the scale. Under these conditions, the suspension sock should contain the thigh to a point 3 in. above the superior border of the patella. The height of the ring should be adjusted until the amputated side is slightly high,so that further stretching of the suspension sock will be accommodated during the wrapping process.</p> <p>The amputee should be positioned so as to obtain a correct base of support and so that his thigh is vertically centered in the ring. The knee should be flexed so that the stump is approximately 12 deg. from the vertical, measured along the crest of the tibia. Excessive flexion will result in loss of support or cause bridging of the sock along the posterior aspect of the stump. The stump is palpated, and areas requiring relief are outlined. The relief patches are glued to the appropriate areas. and the flexion angle of the knee is checked. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>WRAPPING THE STUMP.</b> Starting from a level just proximal to the top edge of the patella, four wraps of 4-in. plaster bandage are firmly applied. As noted previously, the medial flare of the tibial condyle is a good weight-bearing area. For emphasis, the plaster bandage is applied with firm tension diagonally upward in this area. The plaster bandage is then spiraled downward until the remainder of the stump is completely covered.</p> <p>Before the plaster begins to set, it is worked by hand to ensure an intimate contact between the wrap and the stump, to emphasize bony areas including the patella, to enhance the texture of the plaster, and to assist in obtaining a smooth inner surface in the cast.</p> <p>Several techniques and devices may be used when casting a below-knee stump to locate and define the patellar tendon and the support area posteriorly. Later in this article some of the variations will be presented.</p> <p>When the suspension casting technique was used initially, no attempt was made to deform the cast permanently at the patellar tendon or in the popliteal area. The patellar tendon was defined by a light massaging action on the cast, using the web of the hand between the thumb and index finger, and by applying a light counter-pressure posteriorly with the other hand. The hands were removed after the contouring, and the plaster was allowed to set. This method kept distortion of the tissues to a minimum and preserved the contours of the medial flare of the tibia.</p> <p>This technique has been modified to the extent that the hands are held in such a manner as to deform the cast permanently, producing a patellar-tendon bar anteriorly and a flattening of the popliteal area posteriorly. Any distortion of the contours of the medial flare of the tibia is corrected later by use of the template (previously discussed) when modifying the positive model of the stump. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>ALIGNMENT LINES.</b> After the plaster has set, two vertical alignment lines are scribed on the cast with the use of a plumb bob while the amputee is standing in a position simulating stance phase in a prosthesis. Half of his weight should be borne on the amputated side. The pelvis should be level and at right angles to the line of progression. One line, scribed on the anterior aspect of the cast, will be used as a reference for the correct adduction or abduction angle of the socket during bench alignment. The other line, scribed on the lateral aspect of the cast, will serve as a reference for the flexion angle of the socket.</p> <p>In order to remove the cast, the hose clamp is released to allow rotation of the ring in the stand. After the ring has been lowered sufficiently to permit the amputee to sit down, the hose clamp, gasket, and ring are removed. Care must be taken to avoid distortion of the cast during its removal.</p> <p>Before plaster is poured to form the positive model of the stump, the cast socks and relief patches are removed from the negative cast, and the cast is oriented with the reference lines vertical. Orientation can be accomplished by setting the distal end of the cast in plaster and using a square to obtain the correct alignment. A Milmo vertical transfer jig is a useful device for this procedure and also provides a means for holding the pipe vertically in the cast until the plaster hardens. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>MODIFICATION OF THE POSITIVE MODEL.</b> Modifications of the plaster model of the stump are made in accordance with the principles developed at the University of California Biomechanics Laboratory, Berkeley and San Francisco. <a></a></p> <p>An essential prerequisite to the modification of the plaster model is a complete examination and evaluation of the stump by the prosthetist. Variations in modification will necessarily be based upon this evaluation.</p> <p>An outline of the socket is drawn on the plaster model of the stump. This outline extends from the midpatellar level anteriorly to 2 1/2 in. to 3 in. above the midpatellar tendon level on the medial and lateral aspects of the model, down to a point 1/2 in. above the midpatellar-tendon level on the posterior aspect of the model.</p> <p>The anteroposterior dimension of the positive model will be determined by the type of socket to be fabricated. For a socket with a soft insert, the anteroposterior dimension of the model should be modified to that of the stump. For a hard socket, the anteroposterior dimension of the model should be 1/4 in. greater than the measured anteroposterior dimension of the stump; for example, if the anteroposterior dimension of the stump is 3 in., the anteroposterior dimension of the model should be 3 1/4 in.</p> <p>The following example is offered for guidance in determining the amount of plaster to be removed from the patellar-tendon area of the stump model as opposed to the amount to be removed from the popliteal area. Assuming that the anteroposterior dimension of the stump is 3 in. (to which 1/4 in. must be added for a hard socket) and that the anteroposterior dimension of the slump model is 4 in., it follows that 3/4 in. of plaster should be removed (that is, 4 in. less 3 1/4 in. equals 3/4 in.). Two-thirds of this amount, or 1/2 in., is removed from the patellar-tendon area (that is, 2/3 of 3/4 in. equals 1/2 in.). The remainder, or 1/4 in., is removed from the popliteal area (that is, 3/4 in. less 1/2 in. equals 1/4 in.).</p> <p>To prevent restriction of circulation in the stump, the plaster is removed posteriorly to produce a flattened surface rather than a bulge. The deepest removal of plaster is opposite from and just distal to the midpatellar-tendon level-thus creating the start of a radius proximally-and is continued downward to blend in toward the distal aspect of the stump model. <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>MODIFICATION OR THE POSITIVE MODEL.</b> Starting approximately 1/4 in. from the edge, plaster is removed from the reliefs to blend the edges into the contours of the stump model. Plaster is removed from the area of the medial shaft of the tibia to within 1 in. of the end. The angulation of the shaft must be maintained. The amount of plaster removed is dependent upon the amount of tissue covering the shaft. Approximately 1/8 in. to 1/4 in. of plaster is removed from the anterolateral aspect of the model, starting at the distal border of the relief for the leading edge of the flare of the lateral tibial condyle and continuing to within 1 in. of the end of the tibia. The template made from the stump is used as a guide in modifying the flare of the tibial condyle. The mediolateral dimension of the model should be reduced to within 1/8 in. to 3/16 in. of the measured mediolateral dimension of the stump. Usually, smoothing this area of the model with wire screening is all that is necessary.</p> <p>If warranted, 1/8 in. of plaster may be added to the relief of the anterodistal aspect of the tibia. The patella is smoothed by a wash of plaster rather than removal of plaster. Along the previously drawn posterior trim line of the socket, a build-up of plaster is applied to a height, of about 3/4 in. The build-up should be given a generous flare, and the distal border of the liare should be blended into the contours of the model, especially in the area of the hamstrings. Plaster should be added to eliminate any groove between the junction of the posterior plaster build-up and the medial or lateral side of the model. A piece of plastic screen or line sandpaper should be used to smooth the entire surface of the model. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>BUILD-UP FOR RTV PAD.</b> When a Silastic RTV pad is to be used in the socket of the finished prosthesis, an additional plaster build-up about 3/4 in. high is formed on the distal aspect of the model. A piece of cardboard is applied to the cast to serve as a form for the plaster to be added. The form is sloped away from the distal anterior aspect of the tibia to provide any additional relief required. If the pipe is held vertically when the plaster is poured, a flat distal surface incorporating the correct angular alignment will result. All edges should be feathered into the contours of the model, especially in the tibial area.</p> <h3>Variations in Suspension Casting of the Below-Knee Stump</h3> <p>Since the introduction of the suspension casting concept, many variations have evolved in its use. These variations are mainly in the wrapping, the forming of the patellar-tendon bar, the modification of the wrap cast, and the modification of the positive model of the stump. <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CALDWELL PROCEDURE.</b> In the procedure followed by Mr. Jack L. Caldwell,<a style="text-decoration:none;">*</a> gypsona plaster bandage is used in place of standard plaster bandage, a clamp (the Caldwell clamp) is used to measure the anteroposterior dimension of the stump and to contour the patellar-tendon bar and the popliteal area into the wrap cast, one heavy-cast sock is used during the wrapping procedure, the flare for the posterior proximal edge of the socket is formed in the wrap cast prior to pouring the plaster to form the positive model of the stump, and the distal portion of the stump is wrapped first for contouring purposes.</p> <p>In the Caldwell procedure, measurements are taken and recorded on a measurement chart before casting is begun. The patellar-tendon bar of the Caldwell clamp is pressed gently against the amputee's patellar tendon, and the reading made on the clamp scale is recorded. After the stump has been wrapped, the dimension should be approximately 1/8 in. greater than the measurement made on bare skin. Before the contouring clamp is applied to the gypsona-wrapped stump, the popliteal pad and the patellar-tendon bar should be greased with vaseline, since gypsona has an adhesive property not present in the ordinary plaster of Paris or elastic plaster. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CALDWELL PROCEDURE.</b> As soon as the wrap is completed, the clamp should be slipped onto the amputee's stump and the popliteal pad pressed into the proper area gently and correctly. With the contouring clamp in place, the wet plaster is worked into the medial tibial condylar shelf.</p> <p>A line is drawn circumscribing the wrap cast at the midpatellar-tendon level, also the socket trim line. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CALDWELL PROCEDURE.</b> After the cast has been trimmed along the proximal trim line, several longitudinal cuts about 1/2 in. in length are made downward from the trim line in the area above the popliteal fossa. The cut area is reinforced with small strips of wet gypsona plaster. The use of warm water will reduce the time required to handle the plaster. The inside of the cast where the cuts were made is smoothed with a paste of warm water and plaster-of-Paris powder. <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FOORT PROCEDURE.</b> In a procedure developed by Mr. James Foort,<a style="text-decoration:none;">*</a> one heavy cast sock is used routinely, no relief patches are applied to the suspension sock prior to wrapping, plaster is used to provide reliefs during modification of the positive model of the stump, the distance between the hamstrings is measured and used as a control for the posterior outline of the socket, the modification of the positive model under the flare of the medial tibial condyle is extended posteriorly to include the hamstring tendons, and the position of the posterior flare on the plaster model of the stump is located at the midpatellar-tendon level.</p> <p>A fixed ring holds the casting sock at the top, a clamp ring binds the sock against the fixed ring, a clamping screw is used to force the clamp ring out against the fixed ring, and a pin connects the ring assembly to the UCB stand.</p> <p>The distance between the outer edges of the tensed hamstring tendons is measured and recorded.</p> <p>After the plaster wrap has been applied to the stump, the patellar tendon is defined by pressing the thumb tips on either side of it. At the same time, light counterpres-sure is exerted with the fingers across the back of the stump. This procedure is similar to the technique described in <i>The Patellar-Tendon-Bearing Prosthesis </i><a></a> and subsequently modified as reported in <i>Air-Cushion Socket for Patellar-Tendon-Bearing Below-Knee Prosthesis. <a></a> - <b>Fig. 16</b></i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FOORT PROCEDURE.</b> When the plaster stump model has been cast, plaster is removed from the sloping surface of the medial flare with a curved l 1/2-in. rasp. The purpose here is to prepare the surfaces for supporting weight. Coupled with pressures from lateral surfaces, the medial flare helps to stabilize the stump mediolaterally in the socket. But very little adjustment of this surface is required. A 1/4-in. adjustment at the deepest part of the shelf, tapering off to nothing along the vertical portions, would be the greatest amount removed. If the model is of a seasoned stump, it is sufficient merely to work this area smooth with wire screening. The screening should be swept around the natural contours of the flare, into the posterior area, and over the hamstring tendons.</p> <p>Plaster is added to the stump model in bony areas to provide relief. In addition, a posterior flare is constructed on the model by means of a plaster build-up. This is done by pouring plaster over the posterior surface above the circumscribed mid-patellar-level line until the addition is 1-in. thick. The plaster is spread with a wet spatula, and the flare is formed with wet fingers and thumb. The back flare is not grooved for the hamstring tendons. Instead, a broad surface is provided against which the tendons can rest when the amputee is seated. The build-up for the posterior flare should be trimmed to about 3/4 in. with a flat rasp. <a></a> - <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>VARIATION USED AT NUPRC.</b> Another slightly different procedure sometimes used at the Northwestern University Prosthetics Research Center incorporates a patellar-tendon pad and a popliteal pad into the wrap during suspension casting. The pads used were developed at the Veterans Administration Prosthetics Center in conjunction with a pneumatic casting svstem. These pads define the patellar-tendon bar and the popliteal depression, and their use results in a positive stump model with an anteroposterior dimension that is within 1/16 in. of the measured anteroposterior dimension of the stump. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>VARIATION USED AT NUPRC.</b> Two wraps of standard plaster bandage are applied to the proximal aspect of the stump, covering the patellar-tendon area. The protuberance of the pad is positioned over the patellar tendon and covered with two additional wraps of bandage applied with firm tension to hold the pad in place.</p> <p>The popliteal area is then covered with two wraps of plaster bandage, and the pad is placed so that its top edge is approximately 1/2 in. above the top of the proximal border of the head of the fibula. The lateral edge of the pad should be placed 1/2 in. medial to the medial border of the head of the fibula. The pad is covered with two additional wraps of plaster bandage, and firm tension is applied during the wrapping. The wrap is then spiraled down to include the rest of the stump, and the plaster is worked by hand to emphasize bony areas.</p> <p>If the resulting stump model has a depression in the popliteal area, some plaster is removed from the medial and lateral border of the depression so as to prese nt a flatter posterior surface. A slight screening is usually all that is necessary to finish the patellar-tendon bar. The medial template should be used when modifying the cast to arrive at a true contour of the medial flare of the tibial condyle.</p> <h3>Suspension Casting of the Above-Knee Stump</h3> <p>Suspension casting of above-knee stumps may be used in conjunction with a UCB casting stand and brims. The technique permits the firming of stump tissues that are not in contact with the brim. It is also a means of controlling bulges at the distal end of the brim and the adduction angle of the femur. The technique results in a smooth interior to the negative cast of the stump. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE ABOVE-KNEE STUMP</b>. The major equipment required is a UCB stand, a set of brims, and a roll of 4-in. tubular gauze.</p> <p>Initially, the stump is correctly fitted into the brim, in accordance with the instructions contained in <i>Adjustable-Brim Fitting of the Total-Contact Socket</i>. <a></a> The brim is set in the stand horizontally. When all the necessary conditions-such as, the correct anteroposterior and mediolateral dimensions and the circumference of the brim-are satisfied, a piece of tubular gauze approximately 1-yd. long is applied to the brim. The tubular gauze is held to the outside of the brim with adhesive tape and is then draped down through the brim. A stump sock is then applied to the amputee's stump. The distal end of the stump sock is pulled down through the tubular gauze, and the stump sock is removed entirely while pulling the stump into the brim.</p> <p>Pulling the stump into the brim in this manner results in a bulging of the stump around the distal edge of the brim. To alleviate this situation, the amputee is instructed to flex his trunk over the brim as far as possible, thereby easing the gluteal muscles proximally. As the amputee straightens up in the brim, the tissues should be gently eased proximally in the anterior area of the brim. When the amputee bears weight on the brim, some of the bulging will have been eliminated. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE ABOVE-KNEE STUMP.</b> The tubular gauze distal to the brim is grasped and pulled downward, causing the tubular gauze to stretch longitudinally and reduce circumferentially, thereby compressing the stump tissues. With one hand, the prosthetist maintains tension on the distal end of the gauze as he grasps the gauze at the distal end of the stump with his other hand. The amputee is instructed to remove some weight-bearing from the brim, and the gauze is tied with string at the distal end of the stump. Weight-bearing should be reapplied to equal approximately one-half of the amputee's weight. A piece of 1-in. elastic webbing is tied to the distal end of the gauze and passed under the arch of the amputee's foot, usually from the lateral to the medial side. Sufficient force is applied to the elastic to maintain the correct adduction attitude of the femur. <b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE ABOVE-KNEE STUMP.</b> A firm, even wrap of standard plaster bandage is applied, enclosing the stump completely. While the plaster is still wet, the prosthetist palpates the stump to locate the distal end of the femur. He then applies gentle pressure approximately 1 in. above the end of the femur until the plaster sets.</p> <p>Before the plaster is poured to form the positive model of the stump, the tubular gauze is removed from the brim area down to its contact with the plaster wrap.</p> <h3>Suspension Casting for the Syme's Amputation</h3> <p>The suspension casting technique provides a means of wrapping a Syme's stump with plaster bandages under weight-bearing conditions. It is an excellent means of holding an unstable heel flap or supporting redundant tissue in the correct position during the casting procedure. It firms tissues, resulting in a smooth interior to the wrap cast, and it provides a means for checking the size of the medial opening prior to laminating the socket. <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> The equipment used is the same as that used for casting below-knee stumps; namely, an adjustable vertical stand, a ring, a gasket, a hose clamp, a cast sock, and a scale.</p> <p>A light-weight cast sock is used because it has more stretch than a heavy cast sock and can conform intimately to the contours of the stump. The sock should contact the thigh approximately 3 in. above the patella, with one-half of the amputee's weight borne by the sock.</p> <p>With the amputee supported in a level position, blocks are placed under the stump to contact its distal surface. Areas requiring relief are located by palpation and outlined. An outline of the medial opening is planned and drawn on the suspension sock, as described in <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening</i>. <a></a></p> <p>The largest circumference at the bulbous end of the stump is measured, and a horizontal line is drawn just proximal to this. The stump is then measured proxi-mally until the same circumference is obtained, and another horizontal line is drawn at this level. A line is drawn along the crest of the tibia. Just 3/4 in. medially from the tibial line another line is drawn parallel so as to intersect the two horizontal lines. The width of the cut-out is usually equal to 1/4 of the circumference measured. This remaining vertical line is drawn following the posterior contour of the stump to complete the medial opening. Relief patches 1/8-in<i>. </i>thick are prepared and applied to the areas previously outlined on the suspension sock. <b>Fig. 23</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> The blocks are slid from under the stump, and the amputee retains weight-bearing on the sock. Plaster bandages are contoured to the distal end of the stump, and the bulbous end is wrapped up to the distal horizontal line of the medial panel. The plaster bandage is applied vertically to cover the stump to the anteromedial and posteromedial vertical outlines of the panel, and horizontally to include the top edge of the patella down to the top line for the medial opening. After wetting his hands, the prosthetist works the plaster to ensure an intimate contact of the wrap, especially in the area just proximal to the bulbous end. If necessary, one wrap of plaster bandage can be applied in this area to prevent possible bridging.</p> <p>The wooden blocks are then slid back under the plaster wrap of the distal stump. Slight contact pressure is all that is required to provide a flattened surface to the distal end of the cast. If too much weight is borne on the blocks, the amputee should be raised slightly by vertical adjustment of the casting stand. <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> The plaster is worked along the stump and around the proximal aspect of the wrap. The prosthetist locates and defines the patellar tendon and flattens the wrap cast posteriorly just below the midpatellar-tendon level. After the plaster has set, the remaining area to be covered is evident. Vaseline is applied to the uncovered portion of the sock and 1 in. to 1 1/2 in. along the plaster cast bordering the area. A splint of plaster bandages is made, large enough to cover the opening but not so large as to extend beyond the lubricated areas of the wrap cast. The splint is applied to cover the medial opening and worked well by hand to obtain an intimate mating along all the edges. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>CASTING THE SYME'S STUMP.</b> After the panel covering the opening has set, alignment lines are drawn on the cast to be used later for bench alignment. The amputee is oriented so that his pelvis is level, with half of his weight borne on the amputated side. Using a plumb bob, the prosthetist draws a vertical line on the anterior aspect of the wrap cast to determine the adduction angle of the socket and another vertical line on the lateral aspect of the cast to determine the flexion angle of the socket. Before removing the panel, the prosthetist draws two horizontal lines on the panel extending onto the body of the cast for positioning purposes.</p> <p>The clamp on the casting stand is loosened to permit the amputee to be seated. The clamp and ring holding the cast sock are removed. The prosthetist slides a knife under the edges of the medial panel and exercises care to avoid distortion during removal. The exposed cast sock is cut, and the stump is withdrawn from the cast.</p> <p>The cast sock and relief patches are removed from the interior of the wrap cast, and the medial panel is replaced and held in position with additional strips of plaster bandage.</p> <p>The positive stump model is then poured into the wrap cast, with the wrap cast held so that the alignment lines are vertical. The holding pipe is inserted vertically and should be invested into the plaster to within 1/2 in. of the end of the cast.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</li> <li>Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</li> <li>Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</li> <li>Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Manager, J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla. 32806.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center, 401 East Ohio St., Chicago, Ill. 60611. The work of the Center is supported by U. S. Veterans Administration Research Contract V1005M-1079.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/4a1d647a65001ac401d87d1ff0a502dc.pdf be21d355bbb7726b48257560f38ffcc1 https://staging.drfop.org/files/original/ade75bbe682d095fafd8dc98e0bdeebc.jpg cb33bea6982578ca9f1ac897d024b8aa https://staging.drfop.org/files/original/f53916b68ed1a9091e5b7dfd3280019f.jpg e427877188e0e0d0e8f2b3055d5f8df4 https://staging.drfop.org/files/original/1dd8550b2936a7b9cdcc9b23c89e287c.jpg 04f2643b57c264bf37196de0ec256397 https://staging.drfop.org/files/original/e6dab0edff7c7c4249c3192ca924704f.jpg c979896054406fa7bbaa56c9b9bb2d45 https://staging.drfop.org/files/original/3e28fdce00199c50876c4dea728fcd3d.jpg 5fdcfa70023ebdf6bbe368c413721e11 https://staging.drfop.org/files/original/f43c68108152e6a1e1c805a301451b93.jpg 0d3fa2972071447fad21b77828e0dde6 https://staging.drfop.org/files/original/c1607df85b443b92c33b9062283f89f9.jpg ed20251e138d78199b81805f9b773f8e https://staging.drfop.org/files/original/7c2db4f48c70105bc7bf7a49a36f693d.jpg 69d9387960fd1c5c46cf6fd1945e043b https://staging.drfop.org/files/original/a1504fa035cb6baf568bc21f4e6032ae.jpg d2ee96370904fedccfdd586158fc8106 https://staging.drfop.org/files/original/a75b7b94908e32a9a415c6af0859c4d1.jpg 4777a991370a82177c1ba45d1885294f https://staging.drfop.org/files/original/5137c3276e634e3a7a07c361d89615f6.jpg fba588d37b02c32d343d6047401bbf78 https://staging.drfop.org/files/original/2b8e10f3ccd57901d0685024fa54fe16.jpg 4993250f15bf97bab4d79615df1bcda1 https://staging.drfop.org/files/original/0de013a315001679feaee2a5fb2512ec.jpg f62d2caa4a29bf71c555be9f20eeb071 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_027.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 27 - 38 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Fitting and Training Children with Swivel Walkers</h2> <h5>W. M. Motloch <a style="text-decoration:none;">*</a><br />Jane Elliott <a style="text-decoration:none;">*</a><br /></h5> <p><i>Mobility can be provided fairly successfully for the bilateral hip-disarticulation patient when his arms can be used in connection with crutches and canes, but when the patient cannot use crutches a most difficult problem is presented to the clinic team. The most effective means of treating patients who have complete or essentially complete absence of all four limbs has been to provide them with a socket encasing the pelvic region mounted on a three- or four-wheeled platform (<b>Fig. i</b>), or to provide them with motorized carts with special controls. The unpowered vehicles permit the patient to be upright but generally they must be moved from place to place by an attendant, and the motorized carts are expensive.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. i. Three-wheeled cart built by Child Amputee Prosthetics Project, University of California, Los Angeles, for patient with congenital bilateral above-elbow amputations and bilateral lower-extremity amelias. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experiments at the Child Amputee Prosthetics Project, University of California, Los Angeles, with pylons mounted on rockers, and hinged at a point anterior to the anatomical hip joint, proved to be very disappointing mainly because the effort required in their use exceeded the functional gain (<b>Fig. ii</b>) <a></a>.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. ii. Same child who appears in Figure i shown on pylons mounted on rockers and hinged at a point anterior to the anatomical hip joint. Although the child learned to ambulate with this device, her progress was slow and the energy expenditure extremely high. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>To overcome some of the deficiencies presented by previous approaches, Richard E. Spielrein, <a></a> Senior Engineer, Repatriation Department, Commonwealth of Australia, suggested a pylon arrangement to capitalize on side-to-side oscillations of the man-machine combination (<b>Fig. iii</b>) and built a prototype, based on mathematical computations, which was used successfully by a 16-year-old girl.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iii. Swivel walker developed by Richard E. Spielrein, Senior Engineer, Repatriation Department, Commonwealth of Australia. From Spielrein, R. E., A Simple Walking Aid for Legless People. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Ontario Crippled Children's Centre, Toronto, Canada, has successfully utilized the principles set forth by Spielrein and presents herewith instructions for fabrication and use of the so-called swivel walker (<b>Fig. iv</b>).</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iv. Swivel walker developed by the Ontario Crippled Children's Centre, Toronto, Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experience has been limited to young children, but the walker should prove successful with older persons. It has been suggested that the principle of the swivel walker might also be applied in the case of paraplegia.</i></p> <p><i>A. Bennett Wilson, Jr.</i><a style="text-decoration:none;">*</a></p> <p>The swivel walker in its simplest form (<b>Fig. 1</b>) consists of two pylons attached in a vertical position to a pelvic socket, and two foot pieces which are attached to the pylons so that each may rotate about the vertical axis of the appropriate pylon. Stops are provided to limit rotation of the feet in each direction, and a spring returns the feet to a neutral position when no force is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Principle of the swivel walker. The child can transfer his weight to one foot by leaning sideways and then swivel forward about this foot, using only the force of gravity. Stops are provided to limit forward or backward swing, with springs returning the foot to the neutral position when it has been returned to the floor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The soles of the feet are canted in relation to the floor, and the pylons are positioned with their center lines falling posterior to the center of gravity of the patient and prosthesis so that tilting of the body on one side will cause rotation of the socket about the long axis of the pylon on the tilting side. The contralateral pylon is raised initially and swings forward due to gravity until it strikes the floor ahead. Backward motion can be obtained by tilting sideways and leaning backward so that the center of gravity falls posterior to the center lines of the pylons. Of course, to manipulate the swivel walker, the patient must have a mobile trunk.</p> <p>The type of walker suggested for initial use is shown in <b>Fig. 2</b>. Later, a more cosmetic device can be used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic dimensions of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is essentially the same as that for a conventional bilateral hip-disarticulation prosthesis <a></a> and is mounted on a platform which, in turn, is mounted on two aluminum tubes. In the bottom end of each pylon is mounted an ankle joint, or rotation unit, which in turn is attached to a foot piece mounted so that the inner edge rests on the floor when the appliance is at rest (<b>Fig. 2</b>). The foot pieces should have rubber soles to prevent slipping.</p> <h3>Measurements</h3> <ul> <li>Measurements that need to be recorded (<b>Fig. 3</b>) are:</li> <li>Crown-rump length Waist width</li> <li>Crest of ilium to ischial tuberosities</li> <li>Distance between ischial tuberosities</li> <li>Maximum distance across pelvis</li> </ul> <p>The "normal" height of the child with pylons on can be estimated by multiplying the crown-rump length by two or a little less.</p> <h3>Taking the Cast</h3> <p>Taking the cast usually requires the services of two people. A length of large-diameter stockinette is sewn closed at one end, with openings for existing limbs if present. Straps or webbing are used to suspend the stockinette from an overhead hook. This arrangement ensures firm contours and supports the child. The lower trunk, excluding the limbs, is then wrapped with plaster bandages up to the rib cage.</p> <p>If the child is not toilet trained, the cast is made over the diapers. If diapers are not worn, the ischial tuberosity, pubic tubercle, crests and anterior spine of the ilium, and the rib cage are marked as shown in <b>Fig. 4</b>. For use in alignment, vertical lines indicating the lateral and sagittal planes are drawn on the cast before it is removed from the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fabrication</h3> <h4>Socket</h4> <p>The original socket is usually made so that it extends a little higher than the waist, both front and back, for early training. As ability to balance improves and proficiency increases, the height can be reduced to approximately waist level. It is important that forward, backward, and side-to-side motions of the torso are not restricted.</p> <p>The original socket fabricated for testing the first model of the swivel walker was heat-formed out of acrylic sheet, but all later models have been of polyester laminate. Two complete layers of Dacron felt, two partial layers of Dacron felt, and two partial layers of glass cloth are used, as shown in <b>Fig. 5</b>. The lay-up is completed with four layers of nylon stockinette before impregnation with a mixture of 70 per cent rigid and 30 per cent flexible polyester resin. The laminate should be formed under a vacuum in order to prevent unnecessary bulk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Recommended socket configuration. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing and removal from the plaster cast, the socket is trimmed approximately as shown in <b>Fig. 5</b> and all edges are rounded and smoothed. Ease of entry and exit is facilitated by an anterior hinge.</p> <p>A plastic hinge with the trade name of Polyhinge is satisfactory and may be fastened with flat-head wood screws. Either polyester or epoxy paste can be applied to the screw heads to prevent corrosion if necessary.</p> <p>Wooden blocks are screwed to the base of the socket to provide a level surface for mounting the socket on top of the pylon walker.</p> <p>The pylons are aluminum tubing, 2-in. outside diameter, 1/16-in. wall thickness. The top ends are fitted with wooden plugs; the bottom ends are fitted over the ankle joints.</p> <p>The dimensions of the pylon and its placement are based on the "normal" height of the child and are indicated in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Measurements required for fabrication of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An adequate method for fastening the pylons is to slit the ends and use hose clamps (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Assembly of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Ankle Joint</h4> <p>The ankle joint (<b>Fig. 7</b>), mounted between the pylon and the foot piece, permits rotation of the foot piece about a vertical axis to allow forward and backward swing. As can be seen in <b>Fig. 7</b>, the foot piece is returned to a neutral position by a spring-loaded roller. Built-in stops restrict rotation to approximately 39 deg. forward and 11 deg. backward. (It is planned that a simpler, less expensive version of the ankle joint will be available commercially in the near future.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Foot Pieces</h4> <p>The foot piece (<b>Fig. 2</b> and <b>Fig. 6</b>) consists of a block of wood, a platform sole, and a rubber undersole. The rubber is glued to the wooden platform, which is fastened to the block of wood with glue and screws. The block is bored to receive the lower part of the ankle unit, which is held in place with epoxy resin or paste.</p> <h3>Alignment</h3> <p>The main considerations in alignment are (<b>Fig. 2</b>):</p> <ul> <li>The center lines of the ankle joints should fall approximately 1 1/2 in. behind the center of gravity of the child's body.</li> <li>When the walker is at rest, the pylons should be vertical.</li> <li>The foot platform should tilt about 6 deg. and rest on the medial edge.</li> <li>When viewed from above, the foot pieces are rotated out about 10 deg. (This adjustment is made by reaching down inside the pylon with an extension wrench and slackening off the bolt. This releases a tapered shaft, enabling the foot piece and lower ankle housing to be rotated to the desired position.)</li> </ul> <h3>The Cosmetic Swivel Walker</h3> <p>To improve appearance and to permit the patient to assume a sitting position, the pylons can be replaced with articulated limbs (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Swivel walker equipped with articulated limbs to permit sitting, and fabricated to improve cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The knee joints and hip joints are those used in a Canadian-type hip-disarticulation prosthesis, and they are aligned in a similar manner. For purposes of stability, the hip joints are placed well forward and the knee joints well back. It is imperative that the alignment between the socket and the foot pieces be identical to that used with the pylon type.</p> <p>The lateral straps are 1-in. elastic webbing installed with sufficient tension to prevent hip or knee flexion when the limb is lifted clear of the floor. Each strap is attached to the socket and to the lower limb in such a manner that in the standing position the direction of pull is behind the hip joint and in front of the knee joint. In the sitting position, the straps pass in front of the hip joint and behind the knee joint.</p> <p>The foot is carved from solid wood, bored out to receive the lower housing of the ankle joint. Foot pieces, used for training, are at-</p> <p>tached by screws through the soles of the shoes into the wooden feet. When the child has progressed to a point where foot pieces can be removed, screws are used to secure the soles of the shoes to the wooden feet. The shoe soles should be flat, with the same 6 deg. tilt from the medial edge.</p> <p>The shank sections must be hollow so that a wrench may be inserted from the top to adjust the vertical shank bolt.</p> <h3>Training</h3> <p>It is recommended that training for young children be commenced by using a lateral rocker as shown in <b>Fig. 9</b> to enable the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. When the child feels secure in this arrangement, he is transferred to the swivel walker with short pylons and encouraged to go through the same rocking motion. At this point it is necessary to demonstrate to the child the forward swing by placing the hands on the trunk and guiding the child through the side-to-side motion coupled with a forward tilt. This support is gradually decreased until the child can manage unaided.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Device for training patient to use the swivel walker. The lateral rocker enables the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As proficiency in the use of the swivel walker increases, the height of the pylons is raised in 1-in. increments until a "normal" height is attained. The rate of increase will vary according to the child's capability. Experience at the Ontario Crippled Children's Centre has been that the height can be increased one inch about every two days.</p> <p>At low heights body sway above the waist is required to operate the walker. As the height is increased, the child's movement alters to a lateral displacement of the hips such that the body moves sideways while remaining vertical.</p> <p>When patients become proficient in the use of the walker, they do not swing the walker to the limits of the stops.</p> <p>The ability to walk backward is attained with little more difficulty than walking forward, but smaller steps are generally used. One child was able to walk very well in either direction within a period of two weeks. Walking backward is important because it permits the child to back out of corners or similar situations.</p> <p>Great care must be taken with the child during training, since it is possible that a few falls will occur until his sense of balance is perfected. Falls from being pushed by other children are likely to be far greater in number than those resulting from overbalancing. It is recommended that some form of protective head covering (such as an ice hockey head guard) be worn during this stage of training.</p> <p>One child was fitted with the swivel walker shown in <b>Fig. 8</b> after she became proficient with the pylon type. Initially, the foot pieces were larger than the shoes. As proficiency developed, they were gradually trimmed in size and finally removed, leaving the shoes tilted at the same angle.</p> <p>With both types of walker it was found that the children averaged approximately 120 steps per minute, each step being approximately three inches when walking forward.</p> <p>Each child had to be treated individually according to his own temperament. One child was extremely nervous and frightened, and so training had to be carried on more slowly than with another child who accepted alterations readily.</p> <p>From experience gained so far, it is suggested that a child who is nervous and cautious be given a period of at least one week to become used to major adjustments and alignment changes.</p> <p><b>References:</b></p> <ol> <li>Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</li> <li>McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</li> <li>Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jane Elliott </b></td></tr><tr><td class="clsTextSmall">Physiotherapist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-09.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Fitting and Training Children with Swivel Walkers Creator An entity primarily responsible for making the resource W. M. Motloch * Jane Elliott * https://staging.drfop.org/files/original/13483799eeef6de665c9bbb9af7b9faa.pdf c58980d044e592784ff92c261572cb70 https://staging.drfop.org/files/original/88328052220571e0fc20a864a6829964.jpg 66cafb6c0ae410559da88d3c6d548b21 https://staging.drfop.org/files/original/96e82ff7eea90594d484b9bd33e81c7e.jpg 1434282fa08d69ba185572ba4a1fcd1b https://staging.drfop.org/files/original/b6d5144215bb3dbbd723c4b8bb3a62a5.jpg e5382c2d9f7afecf74fe925fff7e28a5 https://staging.drfop.org/files/original/9cb7c3ebdffb95d6682116b73f94baa3.jpg 3208b240ca5b9271e98a68e4b09db6d0 https://staging.drfop.org/files/original/79695db2e584586503cc226686d16e5d.jpg 15434912daba69219d4e20745bd20a2a https://staging.drfop.org/files/original/32ad6c8f31a40cf8768910f1f71a1e86.jpg 9ad57bb3f90aece39e7c67bc4ef9a9e7 https://staging.drfop.org/files/original/2dd6ac18d6245c9d29236c6c620a12ad.jpg 6b452113afc75f8a732e203232711048 https://staging.drfop.org/files/original/5b0cbe7e09c8a178d30df13f69f31b97.jpg a90dab8ec34461f8015b8160e1c757a3 https://staging.drfop.org/files/original/aa411e9c0d94b09ee34d8dfe6cd61643.jpg fc2fc8ec437f8c653cbf5204e56de2b5 https://staging.drfop.org/files/original/edc114da52e28e0c0b6b7232ac00385e.jpg 724e3a1f505bb49024a7dfd947aeb382 https://staging.drfop.org/files/original/0c3ce7981d1ba2ffd57a31f9b99441cb.jpg 394e213d7b1c2193df215ac99c04fe37 https://staging.drfop.org/files/original/ad3b7233a6cabfff6c8399230b2a134d.jpg 4d44106fab8c1b1165d4b3fac0937598 https://staging.drfop.org/files/original/88fa3fd1d2928a71d8d8e0999736376b.jpg c2bea47e140174bc3875689af1a1b991 https://staging.drfop.org/files/original/ee51beb02fd85067cd1d579fac60ba28.jpg af3799f1f630e053b0fd5fe9480fb8bd https://staging.drfop.org/files/original/ac4030ee6c7df699fe7d75382c651bdf.jpg 7116e89a6c7eb72b5f55206c520ef96d https://staging.drfop.org/files/original/945bda9a12449fb3635d9974f819b027.jpg ba18513057ab53a915cf3129a30346a8 https://staging.drfop.org/files/original/739f04652820548143db4fa58b496a59.jpg 5030742e0bfdb6beb718ef64ecac8ea0 https://staging.drfop.org/files/original/1737d62016b57b8b2823cb05b2d0c4a0.jpg fd477e4cae07b389d7b5be19e0705ebc https://staging.drfop.org/files/original/3fd18dbb5eab5745097f327f368b2b8b.jpg 1f4f074ccae5fda0c472b769bf69f07a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_001.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 1 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limb Prosthetics-1967</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p><i>Because of the large demand for reprints of </i>"Limb Prosthetics Today" <i>which originally appeared in the Autumn 1963 issue of ARTIFICIAL LIMBS, the article has been revised to reflect the numerous advances that have been introduced into limb prosthetics since 1963. To distinguish this revision from the original we have chosen the title </i>"Limb Prosthetics-1967."</p> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>"History" </i>written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stib-bert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses. Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A., Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H., Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan <i>, </i><a></a> a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of The Surgeon General of the Army, initiated a research program in prosthetics.<a></a> The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made <i><a></a>. </i>Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Academy of Engineering.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roehampton, London, by the Ministry of Health, and a new program was initiated in West Germany by the government. Also, a program was started in Russia. The so-called "Thalidomide Tragedy" of 1959-1960 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480 the United States supports prosthetics research in India, Israel, Poland, and Yugoslavia.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and ortho-tists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 5,787 physicians, 3,962 therapists, and 2,000 prosthetists have been enrolled in these courses during the period 1953 through 1967.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In July 1965 the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled by use of antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>).<a></a> The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disar-ticulation case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump-Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p><i>A </i>true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the resuit is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many pros-thetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through The Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation At The Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disar-ticulation cases.</p> <p><i>Shoulder Disarticulation And Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare, the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963 it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted, limb as soon as the sutures were removed some two to three weeks after surgery. In 1963 Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day after.<a></a>Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Results with over 400 patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated, postsurgical pain is greatly alleviated, contractures are prevented from developing, phantom pain seems to be virtually nonexistent, less psychological problems seem to ensue, and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days during which ambulation is encouraged. At the end of this time the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematic cross section showing most of the elements of the application of a prosthesis to a below-knee amputee immediately after surgery. The suture line, silk dressing, and drain are not shown for the sake of clarity. View "A" is an enlarged schematic section of the cast socket, prosthetic unit attachment straps, stump sock, and fluffed gauze at the distal portion of the stump. The fluffed gauze does not extend beyond the area indicated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>Contractures</h4> <p>When immediate postsurgical fitting is employed there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily but it is most difficult, and sometimes impossible, to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.<a></a> </p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>). A number of devices have been introduced in recent years to aid the prosthetist in obtaining accurate casts rapidly <i><a></a>. </i>Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administraton Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>).<a></a> Not only is the need for the alignment jig eliminated but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses For Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed.</p> <p>Most Syme prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 25</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 26</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 27</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses For Below-Knee A mputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 28</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by-means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 29</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cutaway view of the patellar-tendon-bear-ing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 30</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Trial below -knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p>Several simplified adjustable shanks have been made available recently expressly for use in the immediate postsurgical fitting technique (<b>Fig. 31</b>). Straps are provided for lamination into the plaster cast-socket. Provisions are incorporated for adjustability in all planes. The shank and foot can be connected to and disconnected from the socket easily and quickly. Although these units were designed for temporary use, they are sturdy enough for use on a permanent basis. A natural appearance can be obtained by using plastic cosmetic covers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Prosthetic unit designed especially for fitting below-knee cases immediately after surgery. The stainless steel straps are laminated into the plaster socket. All parts below the top plate are easily removed without affecting alignment. A sach foot is normally used with this device. Although designed for temporary use, this device can form part of a "permanent" prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Knee-Disarticulation And Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 32</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists have installed commercially available piston-type hydraulic swing-phase control units, but this requires extreme care to achieve the proper result.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Model <i>"B" </i>(<b>Fig. 33</b>), and the Hydra-Knee. These units are all of the piston-cylinder-type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 34</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The Henschke-Mauch "HYDRAULIK" set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 35</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used. A promising stance-phase control unit currently being evaluated is the Henschke-Mauch Model "A" hydraulic unit. The Model "A" unit contains the same swing-phase control device as the Model "B" and provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The Model "A" and Model "B" units are interchangeable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 36</b>A) has generally been the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 36</b>B),a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 36</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 36</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket.<a></a></p> <p>(<b>Fig. 36</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischium area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs (<b>Fig. 37</b> and <b>Fig. 38</b>) are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. The same principles used in the below-knee device (Fig. 31.) are incorporated. In addition, mechanical friction about the "knee" axis and a mechanical "knee" lock are provided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. This is essentially the same unit shown in Fig. 37. except that hydraulic resistance instead of mechanical friction is provided about the knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Hip-Disarticulation And Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 39</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses<a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles has been developed in Russia for below-elbow amputees. Versions of the Russian design are available in England and Canada. Similar devices have also been developed in Austria and Italy. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore less in need of sophisticated devices. The devices are expensive and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for patients with amputations above the elbow and higher. Efforts to develop useful externally powered arms, both electrical and pneumatic, are being made in both the United States and abroad, especially in reference to severely handicapped children <a></a>.</p> <p><i>Hand Substitutes - Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanism have been developed for terminal-device operation-voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 40</b> and <b>Fig. 41</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dor-rance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-8, ring-type harness is most generally used. Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses For The Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses For The Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of prerlexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 44</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figureeight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 45</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Typical prosthesis for the above-elbow case. The figure-8 harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 46</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 47</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is begun usually on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and use of canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 49</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 50</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechan-ical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations For Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these, procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging The Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 52</b>, <b>Fig. 53</b>, and <b>Fig. 54</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees <a></a></h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 55</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects-and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases.</p> <p>It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 37-39 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty <a></a></h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis.</p> <p>Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h4>Agencies That Assist Amputees</h4> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, 828 Davis Street, Evanston, Ill. 60201.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, Autumn 1957.</li> <li>Artificial Limbs, April 1961.</li> <li>Artificial Limbs, June 1962.</li> <li>Bechtol, Charles O., and George T. Aitken, <i>Cineplasty</i>, Chap. 12 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Blakeslee, Berton, <i>The limb-deficient child</i>, University of California Press, 1963.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower-extremity amputees</i>, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs</i>, covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>, Chap. 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees</i>, a review of technique and criteria, Artificial Limbs, Spring 1965.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artificial Limbs, Autumn 1966.</li> <li>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council</i>, J. Bone and Joint Surg., 29: 538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation</i>, Publication 1352, 1966.</li> <li>Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, <i>A new surgical-prosthetic approach to Syme's amputation, a preliminary report</i>, Artificial Limbs, Spring 1966.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial limbs with the adjustable coupling</i>, Artificial Limbs, Spring 1963.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty</i>, Chap. 12 in <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. <i>Haddan, Amputa- tion prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees</i>, Chap. 7 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>The prosthesis on the operating table from the neurophysiological point of view</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bechtol, Charles O., and George T. Aitken, Cineplasty, Chap. 12 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton, The limb-deficient child, University of California Press, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Vultee, Frederick E., Physical treatment and training of amputees, Chap. 7 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chap. 12 in Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Artificial Limbs, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artificial Limbs, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial limbs with the adjustable coupling, Artificial Limbs, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artificial Limbs, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chap. 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiological point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, Autumn 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, A new surgical-prosthetic approach to Syme's amputation, a preliminary report, Artificial Limbs, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone and Joint Surg., 29: 538-540, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputa- tion prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-34.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-52.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-53.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-54.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-55.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-02.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-03.jpg Figure 12 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-04.jpg Figure 13 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-05.jpg Figure 14 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-06.jpg Figure 15 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-07.jpg Figure 16 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-08.jpg Figure 17 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-09.jpg Figure 18 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-10.jpg Figure 19 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limb Prosthetics-1967 Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/43d2e80bb7287060417ad2e656a4a222.pdf 1e835407f00822f0f13ceb8823bc60bb https://staging.drfop.org/files/original/4883a90da6034c4c1b32440d97b3755d.jpg 6be8ba96a52feee7928cfa58d70a9cb1 https://staging.drfop.org/files/original/30087b0ad704d400a5301996e194aa1b.jpg 03b421194ff589844bf70b4d3b6137c3 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_047.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 47 - 50 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>New Concepts in the Management of Lower-Extremity Amputees</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>For many years the acceptable practice in management of lower-extremity amputation after wound closure consisted of the application of a reinforced gauze dressing and the confinement of the patient to bed until the wound was healed. Fitting of a prosthesis was seldom attempted until edema was reduced to a more or less stable point by means of elastic bandages which had to be removed and reapplied at regular intervals during the day. Elaborate precautions had to be taken so that muscle contractures would not occur. With this method of treatment it was rare for a patient to be fitted less than six weeks after surgery, most patients requiring a much longer period.<a></a></p> <p>The reluctance to fit patients before the stump was "stabilized" was, in a large part, due to the need for one or more socket replacements shortly after the initial fitting. A number of physicians advocated the use of temporary prostheses usually consisting of a plaster-of-Paris socket and a peg leg to hasten stabilization of the stump, but this practice never became widespread, probably because no adequate documentation was made of the various series that were reported, and many physicians realized that it was extremely difficult to obtain adequate fit and alignment with the techniques existing then.</p> <p>The introduction of the patellar-tendon-bearing socket, total-contact sockets, new stump-casting techniques, adjustable legs, and plastic-laminate sockets led the Department of Orthopaedic Surgery, Duke University, to embark on a study to determine the earliest practical time for fitting. The project has demonstrated clearly that successful application of prostheses can be made as soon as it is safe to remove the sutures.</p> <p>In the late fifties Berlemont of France <a></a> began providing patients with leg prostheses immediately upon completion of surgery and initiating ambulation training the following day. Berlemont's technique was modified somewhat by Weiss of Poland <a></a>, who brought it to the attention of Americans in a lecture given at the Sixth International Prosthetics Course in Copenhagen in July 1963. A tour of the United States by Weiss later that year, sponsored by the Vocational Rehabilitation Administration and the Committee on Prosthetics Research and Development, stimulated sufficient interest at the University of California, San Francisco, and the U.S. Naval Hospital, Oakland, for these groups to experiment with the concepts reported by Weiss.</p> <p>Initial results led the Veterans Administration to support an experimental program proposed by the Prosthetics Research Study of Seattle, Washington. Other groups, notably Duke University, the University of Miami, Marquette University, and a group in New York City centered around the Hospital for Joint Diseases, became interested and embarked on modest experimental programs.</p> <p>Because there was not available any written or visual material covering European experience, each group approached the problem along somewhat different lines. From time to time through the efforts of the Committee on Prosthetics Research and Development and the University Council on Orthotic-Prosthetic Education, these groups were brought together for the purpose of exchanging ideas and coordinating the efforts of all involved. Meanwhile, the Vocational Rehabilitation Administration made it possible for a number of the research teams to visit Weiss. Experience with more than 400 cases has now been accumulated.</p> <p>At its meeting January 20, 1967, which was preceded by a conference of research teams involved in immediate postsurgical fitting, UCOPE decided to offer courses in the technique to qualified teams.</p> <p>The basic technique consists of the application of a nonadherent silk mesh dressing and fluffed gauze over the wound and a sterile stump sock and plaster-of-Paris cast (which is also the socket for the prosthesis) over the stump (<b>Fig. 1</b>). To the socket is attached an adjustable pylon-type prosthesis suitable for the level of amputation. Provisions are made for easy removal and reattachment of the prosthetic unit to prevent the prosthesis from being wrapped in the bedclothes and causing undue stresses on the stump. A drain is usually used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An example of immediate postsurgical fitting of prosthesis to a below-knee amputee. Note the waist-belt suspension, the cast-socket carried above the knee, the pylon, and the foot. See also Figure 18 in Limb Prosthetics-1967, the preceding article in this issue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is encouraged to stand <i>between parallel bars or with the aid of a "walker" </i>about 24 hours after surgery if there are no physical or medical contraindications. The amount of weight-bearing and ambulation is increased daily and the patient is graduated to crutches, to canes, and to unaided walking as his physical condition permits. The drain is removed 48 hours after surgery, and the cast-socket is kept in place until time for removal of the stitches- some 10 to 14 days after surgery.</p> <p>A new cast-socket is applied immediately, and the pylon-type prosthesis is replaced. The second cast is removed 8 to 10 days later when it is generally possible to make a cast for fabrication of a plastic socket.</p> <p>The advantages of treating patients in this manner are a reduction in the formation of edema, a reduction in the incidence of pain, elimination of the formation of contraction, decreased hospitalization time, and less time lost from work. The technique appears to permit improved wound healing, and a number of investigators feel that in cases of amputations because of vascular disorders many more knee joints may be preserved than when conventional methods of treatment are used. In one series of a hundred cases, the average time between surgery and delivery of the "permanent" prosthesis was 28 days. The shortest time was 17 days <a></a>. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Progress of 80-year-old patient whose leg was amputated because of vascular disease and diabetes. A, First day postoperative; B, seventh day postoperative; C, seventeenth day postoperative; D, twenty-sixth day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Patients of all types and all ages have been treated successfully by fitting prostheses immediately after surgery. However, success depends upon many factors, and the technique should not be undertaken unless the team has a thorough understanding of proven methods. For this reason, courses are being offered at Northwestern University, the University of California, Los Angeles, and New York University.</p> <p>In spite of the success achieved by the research teams and others that have been trained by them, it is not clear why certain of the advantages accrue, and to what degree the various factors that enter into success are critical. Continued research is expected to answer these questions.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., The principles of amputation surgery, Chap. 10 in Orthopaedic Appliances Atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Berlemont, M., Notre experience de l'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</li> <li>Berlemont, M., L'appareillage des amputes des membres inferieurs sur le table d''operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</li> <li>Weiss, Marian, The prosthesis on the operating table from the neurophysiologies point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiologies point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de l'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Berlemont, M., L'appareillage des amputes des membres inferieurs sur le table d''operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The principles of amputation surgery, Chap. 10 in Orthopaedic Appliances Atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development. National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_047/1967_01_047-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_047/1967_01_047-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New Concepts in the Management of Lower-Extremity Amputees Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. *