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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_118.pdf Text Any textual data included in the document <h2>The UCLA Total Surface Bearing Suction Below-Knee Prosthesis</h2> <h5>Timothy B. Staats, M.A., CP.&nbsp;<a style="text-decoration: none;">*</a><br />Judd Lundt, B.S., A.E.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>While there was clear evidence to support examination of suction as a suspension technique for below-knee prostheses<a></a> in the early 1950s, overwhelming activity was in a direction that led ultimately to the development of the PTB design.<a></a> What is truly remarkable is the almost blind obedience that the practitioners and educators have given to PTB theories, a recognition that has rendered them all but untouchable gospel. Introduction and widespread use of transparent check sockets has probably done more to cause the prosthetist to question the accuracy of his PTB fitting methods than any other development in the last decade. Inaccuracy in socket fit that this powerful tool has revealed has led to the obvious conclusion: more precise casting and modification methods are required. This is the intent of the technique described here.</p> <p>This paper presents a departure from PTB philosophy and technique. The methods described freely borrow from and recognize individuals who have developed alternative ideas, many of which have been integrated into the UCLA Total Surface Bearing Suction Below-Knee Prosthesis. The substance of this paper includes suction as the obvious mode of suspension. However, the essence of suction suspension, and of this article as well, is the critical anatomical accuracy of the socket fit. We refer to it as the total surface bearing or TSB technique. Without TSB, successful long-term suction suspension cannot be achieved. With TSB, the prosthetist can achieve suction if desired or may choose to fit with a sock and without suction if so indicated. Whatever the case, the final result will be improved fit and better patient comfort.</p> <h3>Suction Suspension</h3> <p>Suction below-knee prostheses are unique in that they do not require auxiliary suspension systems such as straps, cuffs, thigh lacers, or sleeves to maintain the socket on the residual limb. This is not to suggest that auxiliary suspension need not be employed as an extra measure of protection, particularly with a very active patient. However, in principle no other suspension should be required (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg"><b>Fig. 1</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg"><strong>Figure 1. UCLA Total Surface Bearing Suction Prostheses.</strong></a><br /> <p>Three variations of suction socket are discussed in this article. The first is the "tension suction" variation.<a></a> This socket is made vol-umetrically smaller than the residual limb. Suction is maintained in the same manner as with the rigid above-knee suction prosthesis. This is probably through tension placed on the skin, thereby enhancing the friction between the tissue and the socket. Normally, a valve is placed at the distal end to release air while the socket is being applied. The second classification is "atmospheric suspension," mentioned by Murphy<a></a> in 1950 and later by others.<a></a> In atmospheric suspension, a non-elastic, but flexible interface is used, which virtually collapses around the residual limb when the prosthesis is unweighted. The third type of suction will be called "active compression suction." In this case, the socket interface is made of an elastic or elastomeric material which must be stretched or rolled over the residual limb, thereby gripping the skin through compression as well as through friction created between the skin and the socket.<a></a></p> <h3>Fitting Variables</h3> <p>The primary concern of any prosthetist attempting to fit a suction below-knee prosthesis should be the general health of the residual limb tissues. The UCLA experience has been similar to studies by Holmgren<a></a> and Bedouin.<a></a></p> <p><i>Types of Patients</i></p> <p>The suction below-knee prosthesis, properly fitted, appears to stimulate circulation and can be used on vascular amputees as well as amputations due to other causes. The suction below-knee may actually help to more quickly stabilize tissue fluid volume. Ages of patients have ranged from five to 88 years.</p> <p><i>Skin Problems</i></p> <p>A suction below-knee prosthesis virtually eliminates skin problems caused by movement and friction created between the residual limb and the socket interface. Problems of skin irritation related to hygiene and allergic reaction are covered in a later section.</p> <p><i>Bony Prominences</i></p> <p>Grevsten,<a></a> using x-ray evaluation of suction below-knee fittings, found that the movement of skeletal anatomy inside the socket is less than one-half that inside ordinary PTB sockets. The UCLA experience, which employs a more intimate casting and cast modification technique (TSB), suggests an even greater reduction in skeletal movement. More importantly, few problems with bony prominence pain or discomfort were reported by patients in the over 150 fittings conducted at UCLA and other locations during the teaching of this technique.</p> <p><i>Length</i></p> <p>We have found no correlation between residual limb length and the ability to wear a suction below-knee prosthesis. Fittings and suction suspension have been successfully achieved with residual limb lengths as short as 3 1/2". However, these are not all long-term results.</p> <p><i>Volume</i></p> <p>More important was the finding that many residual limbs initially fit with suction would lose this effect within one or two hours of wear. There is an immediate fluid volume adjustment. Patients fit with suction over longer periods of weeks and months will continue to experience residual limb volume changes until a point of volume stability is achieved. This normally will occur within six weeks. Any loss of body weight will certainly contribute to loss of suction as well.</p> <p><i>Shape</i></p> <p>Generally, with enough effort almost any shape residual limb can be fit with suction. However, to achieve suction with conical shape residual limbs, whether bony or fleshy, can be difficult. With such cases, it is often necessary to enlarge the gastrocnemius muscle bulge area of the socket while tightening slightly proximal to this to maintain suction. Many prosthetists might question the long-term effect of this technique on the health of the residual limb. Short term effects have not been adverse and results look encouraging.</p> <p><i>Patient Cooperation</i></p> <p>Patients who intend to wear suction below-knee prostheses must be intelligent, cooperative and aware of the critical nature and accuracy required in this type of fitting. Numerous adjustments may be required during the first several months to maintain the intimacy of the fit. The patient must fully understand the function of the valve and the socket liner. It is imperative that any patient wearing a suction below-knee prosthesis, no matter how effectively fit, wear an auxiliary suspension as a back-up in case loss of suction does inadvertently occur.</p> <h3>Comparison of Theories</h3> <p>In the below-knee prosthesis, suction is a mode of suspension that can only be maintained through a precisely fit socket. A major aim of this article is to present a technique whereby such a fit can be achieved. Development of the total surface bearing (TSB) below-knee socket combines a staged precision casting method with a significantly different model modification to yield this result. In order to understand these differences, it is necessary to contrast the TSB and the more traditional PTB sockets.</p> <p>The basic philosophy of the patellar tendon bearing below-knee prosthesis can be stated as follows: Increase weight bearing on areas of the residual limb over pressure tolerant areas and relieve pressure over those areas which are pressure sensitive. With the total surface bearing below-knee prosthesis weight is distributed over the entire surface of the residual limb, including areas which have in the past been considered pressure sensitive. In TSB, the accuracy of fit and careful use of measurements has eliminated the need for relief buildups over bony areas of the residual limb during the plaster casting and model modification procedures. The resulting corrected model for a TSB socket is thus distinctly different from that developed in accordance with PTB modification techniques.</p> <h3>Evaluation and Measurement</h3> <p>Measurements include all standard below-knee prosthetics parameters. The following additional considerations are necessary.</p> <p><i>Circumferences</i></p> <p>Carefully located circumferential measurements are taken at one inch intervals. The intervals are laid out from a bony landmark which can be defined accurately during the plaster casting procedure. Normally, the apex of the head of the fibula or the distal anterior tip of the tibia are chosen, depending on which is more prominent. The tibial tubercle may also be used. However, it is necessary to measure at least one interval more proximal when this location is chosen. In very fleshy or redundant residual limbs, it is wise to select the fibular head as some elongation may occur during casting which will obscure the distal end.</p> <p><i>Length</i></p> <p>The length measurement must be accurately gauged from the distal end of the residual limb to both the medial tibial plateau and to the inferior edge of the patella while under forceful upward loading.</p> <p><i>Evaluation</i></p> <p>Patients with chronic skin problems or burn scar tissue may not be suitably fit in sockets where the skin is directly in contact with the socket liner, unless the interface surface is impervious to body fluids. Perspiration can cause maceration even in healthy skin and an appropriate interface must be selected in such cases.</p> <h3>Plaster Casting Technique</h3> <p>An essential element of a successful TSB socket is a precisely cast residual limb. The diagonal four stage casting technique which draws from work adapted from Fillauer,<a></a> Gleaves,<a></a> Tranhardt,<a></a> Morris,<a></a> Hayes,<a></a> Stokosa,<a></a> and Vinnecour<a></a> was developed to best achieve that end. Unusual elements of the technique include:</p> <ol> <li> <p>Sheer nylon stockings for an ultra-thin barrier between skin and plaster, resulting in a more accurate cast.</p> </li> <li> <p>A beveled anterior first stage splint which is very accurately tailored to encompass the head of the fibula, the shaft of the tibia, and the entire medial flare. This first stage (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg"><b>Fig. 2</b></a>) is carefully molded to all bony anatomical structures. If properly applied, it will establish the medio-lateral dimension within 1/8" of patient measurement in most situations and require little or no model modification of the anterior aspect of the medial flare of the tibia.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg"><strong>Figure 2. The entire medial tibial flare and all bony prominences are carefully molded.</strong></a></li> <li> <p>A second stage of elastic plaster bandage which is wrapped with about half the available stretch applied. This stage must not extend more proximal than about 1" to 1 1/2" below the crease of the skin in the popliteal fold. The anterior stage is maintained in position during this second procedure with firm proximal compression. As the second stage sets, the proximal posterior aspect is lightly compressed to help define the antero-posterior dimension of the cast. The medial lateral dimension is never sacrificed in any attempt to decrease the antero-posterior dimension.</p> </li> <li> <p>A third stage splint, which creates the posterior brim shape and completes the basic cast used when a non-supracondylar trim line, is desired. The salient point of the third stage is the hand molding of the plaster bandage in the hamstring tendon region. When properly applied, the posterior brim will appear premodified with a diagonal trim which accommodates the lower anatomical insertion of the medial hamstring muscle group. It is necessary to do four things simultaneously to create an acceptable third stage, and generally will take considerable practice before re-peatable accuracy and skill is achieved. It is necessary first to locate and create the shape of the tendons; secondly, compress the antero-posterior dimension of the cast both proximally and compression-ally; third, mold the medial and lateral posterior areas of the third stage to prevent looseness in the hamstring areas proximal to the medial tibial plateau region; and fourth, spread the fingers of both left and right hands to stretch the plaster bandage to prevent a ridge from forming in the posterior aspect between the second and third stages (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg"><strong>Figure 3. The posterior trim and hamstring muscle reliefs are created during the wrap casting procedure.</strong></a></li> <li> <p>A fourth stage splint is used when supracondylar suspension is planned. It is applied in a manner similar to that used in Fillauer's three stage casting technique.</p> </li> </ol> <h3>Alginate Pressure Fitting</h3> <p>The first step in the fitting process occurs immediately after the hardened cast is removed. Through application of dental alginate to the inside of the wrap and a refitting on the patient, a more intimate contour is achieved. Though somewhat of a messy procedure, this will minimize the need to remove plaster from the model during modification. When casting very obese patients or those with excessive redundant tissue, this step may not be successful and may result in distortions in the final model.</p> <p>The nylon stockings are carefully removed from the cast and a hole is cut in each of the distal, lateral, medial, and posterior aspects to permit air to escape when the alginate is applied. The holes should be approximately 1/4" in diameter and should be cut using a knife. (A hand drill or drill press will likely grab the fabric in the wrap and destroy it.) About eight to ten ounces of dental alginate are mixed to a thick, but creamy consistency and quickly applied to the entire inner surface. The cast is replaced on the residual limb and forced proximal with moderate pressure. Alginate should exude from all cut holes (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg"><strong>Figure 4. The wrap cast is alginated and pressure fitted.</strong></a><br /> <p>The instant the alginate stops flowing from the holes, they are covered with the hands or fingers to prevent further leakage. Any excess alginate can be smeared about the proximal brim to perfect the fit in this area (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg"><b>Fig. 5</b></a>). This procedure must be conducted quickly and precisely or air pockets will occur. If air pockets do occur, we have found that additional algination attempts have been unsuccessful.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg">Figure 5. The completed diagonal four stage wrap cast.</a><br /></strong><br /> <h3>Total Surface Bearing Model Modification</h3> <p>The antero-posterior and medial lateral are modified exactly to residual limb measurements. The anterior modification of the anteroposterior is markedly different from the PTB "Bar." The TSB modification follows the shape of the anatomy in this region as shown in the xeroradiograph of the below-knee amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg"><strong>Figure 6. Xeroradiographs lateral view of below-knee amputation. Notice the shape proximal to tibial tubercle.</strong></a><br /> <p>Notice that the shape of the tibia angles posteriorly immediately above the tibial tubercle. Plaster removal follows this shape. The inferior edge of the patellar area is modified as though the patella were being lifted proximally about 1/4". In other words, the true tibial plateau is below the inferior edge of the patella in most cases (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg"><b>Fig. 7</b></a>). The posterior aspect of the model normally requires only smoothing or only slight reduction to establish the correct AP.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg"><strong>Figure 7. Modification inferior to patella simulates shape of anatomy rather than "PTB" patellar bar.</strong></a><br /> <p>Plaster is removed from the posterior aspect of the medial flare of the tibia. This half moon shape sweeps into the medial hamstring area. Up to 3/8" of plaster may be removed in a very redundant residual limb. It is not unusual to see a medial hamstring 1/2 to 3/4" lower than the lateral side. Generally, the lateral side hamstring can be kept almost at tibial plateau level and is maintained at this level across the popliteal fossa.</p> <p>Absolutely no buildups are applied to the crest of the tibia, the head of the fibula, the anterior distal aspect of the tibia, or any other bony prominences. Reliefs are created by removal of plaster from around these areas to accentuate their shapes and to compress the tissues. Usually no more than 1/8" of plaster is carved away using a curved blade flexible knife (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg"><strong>Figure 8. No plaster buildups are added to master model. Plaster is carefully removed around bony prominences and over bony prominences.</strong></a><br /> <p>The model is next measured for circumferences using the previously established bony landmark as a guideline for accurately locating the measurement levels (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg"><strong>Figure 9. Circumference measurements of master model are reduced below patient measurements to achieve suction.</strong></a><br /> <p>It is generally found that the model at this point will be approximately at the residual limb measurement or somewhat larger, even if fairly liberal modifications have been performed. If the model were to be smoothed and a socket fabricated at these measurements (0" to +1/8") it will result in about a two-ply heavy cast sock fit or about one "Socket Liner Stump Sock."<a></a> However, this may not in itself achieve suction.</p> <p>In order to create a suction fit, the model must be carefully reduced in its circumferential measurements starting from a point approximately one inch above the tibial plateau and proceeding distally the entire length of the cast. As a beginning, a minimum of 1/2" of tension reduction less than the patient's measurements is applied at each measured level. Ultimately, in a new patient (any patient who has never worn a suction socket) the tensions may well reach 3/4" to 1" less than the original anatomical measurements. However, it is not a simple matter of initially bringing the tensions on the model to these values. This is inadvisable and potentially harmful for the patient. A gradual reduction process over time must be followed in order to achieve the results just stated.</p> <p>In pilot studies and in pilot courses conducted at UCLA in 1984, an attempt to empirically arrive at appropriate TSB suction tension values was made. Each prosthetist was asked to carefully record how much reduction in residual limb measurements was required to finally achieve suction suspension. The compiled results of these efforts suggest an initial tension value of 3/4" is necessary at each level to achieve suction. This value may vary depending on residual limb musculature, length, and tissue type.</p> <h3>Check Sockets</h3> <p>It is advisable, if not imperative, to use transparent check socket fittings to confirm the accuracy and precision of the wrap cast and subsequent model modifications. The UCLA technique involves two types of check sockets: flexible check sockets and more conventional rigid check sockets.</p> <p><i>The Flexible Check Socket</i></p> <p>A check socket is vacuum formed using 1/8" Surlyn® plastic. On a five to seven inch residual limb this will result in a very thin socket probably no thicker than 1/32". A valve is located distally to release air from the socket as it is donned (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg"><b>Fig. 10</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg"><strong>Figure 10. A flexible check socket is vacuum formed with small valve placed distally.</strong></a><br /> <p>Lotion or Vaseline® is used to lubricate the surface of the residual limb to aid in donning<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg"><b>Fig. 11</b></a>). Flexible socket fit can be confirmed by direct palpation of the anatomy from the outer surface. Any air spaces or otherwise loose areas are located and subsequently corrected on the model. It is not unusual for this flexible socket to hold suction even if inadequate tensions were applied to the model (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg"><strong>Figure 11. The flexible check socket is "wet" fit to the patient.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg"><strong>Figure 12. Suction, total contact, volumetric and anatomic accuracy of check socket are determined in the flexible check socket.</strong></a><br /> <p>Accordingly, if the socket is made rigid by an application of a roll of fiberglass casting tape to the outer surface, suction will invariably be lost almost immediately. This demonstrates one of the many problems facing anyone wishing to fit or wear a suction below-knee prosthesis. The flexible socket in this case is exhibiting atmospheric suction. The socket collapses around the residual limb as any attempt is made to remove it. Rendering the socket rigid transforms this flexible membrane into a rigid socket and as the socket wall cannot move, suspension is lost.</p> <p><i>The Rigid Check Socket</i></p> <p>A rigid check socket may be used after the model corrections, determined by the fit of the flexible check socket, have been performed. With the rigid fitting, it is common to find the need to increase tension values to an average of 5/8" to 3/4". It must be assumed that fluids rapidly leave the residual limb as a more rigid, accurate fitting socket is applied. It might also be speculated that the muscles flatten out somewhat as excess fluid leaves the residual limb. Examination of residual limbs in properly fit rigid transparent suction check sockets after several hours of wear reveal good color and lack of a distal discoloration which one might expect in a "tight" socket.</p> <h3>Socket Materials</h3> <p>A variety of materials and fabrication techniques have been examined for their application to the suction socket. Varying levels of success have been achieved; however, there are usually trade-offs involved. Suction may be achieved with a removable liner/insert alone that keys into the prosthesis much like a liner in a PTB socket. A prosthesis may also be constructed with a hard suction socket with no liner or with a soft liner that is permanently attached. In any case, some type of valve is usually necessary, installed either in the liner, in the socket, or at the end of a tube extending from the distal end of the socket to the outside finish lamination of the prosthesis. Valveless liners are also possible; they will be discussed later.</p> <p>In considering a method of constructing a suction socket, it is important to realize that there will be no sock to absorb moisture; the patient will likely require some type of powder, cream or lotion application to don the socket, and the skin will be in direct and intimate contact with the inner material. All of these factors dictate a non-porous, easily cleaned material that will minimize the growth of bacteria, yet provide the necessary cushioning and comfort for daily or specialized activities. Whichever approach is taken, the prospects of success are limited only to the ingenuity of the prosthetist and the materials employed.</p> <p><i>Hard Socket Variations</i></p> <p>This is perhaps the most difficult variation with which to achieve success since the demands of precision required for fit and comfort are the highest. Firm residual limbs of good muscle mass are the most likely candidates for this design.</p> <p>The hard socket is undoubtedly the easiest to fabricate, and for the patient is the easiest to keep clean. Even if accepted by the patient, these sockets will feel hard and, while suitable for walking, they are probably not appropriate for heavy activities such as running. However, hard sockets, with the addition of a single nylon sheath, have been very successful in the long-term with low activity level patients. Flexible acrylic and polyester laminates backed on the outer surface with soft foams such as PE-LITE™ or Aliplast™ have enjoyed about the same level of success as a hard socket. Patients report that these sockets feel hard despite the padding. Additionally, allergic skin reactions seem to be more common when flexible resins are used. Minute cracking in the interface may create a breeding ground for bacteria or lead to skin irritation through surface friction.</p> <p>A number of thermoplastic liners have been successfully fit (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg"><b>Fig. 13</b></a>). Some have been quite comfortable, notably the "total flexible brim" variation suggested by IPOS<a></a> and Sabolich.<a></a> Both are frame-supported polyethylene designs. Since thermoplastics may exhibit "cold flow" and may actually shrink, they are not ideal materials. An interesting characteristic of thin thermoplastic sockets is the enhanced capability of atmospheric suction. However, this advantage is basically negated by a lack of long-term durability. The suggested ease of refabrication and/or inexpensive nature of replacement does not hold up to criticism by patient used to no-nonsense prosthetic care. Another negative characteristic of thin thermoplastic liners such as Surlyn® and polyethylene is the inability to make adjustments after fabrication.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg"><strong>Figure 13. Surlyn® inner flexible socket with outer frame fitted in 1985 as a suction below-knee prosthesis.</strong></a><br /> <p>A major point of consideration in fitting any socket material that directly contacts the skin is the coefficient of friction at the interface. There are definite differences which are recognized empirically and clinically, but not objectively related to prosthetic fit in the below-knee as well as in above-knee suction sockets. For example, Surlyn® and Durr-Plex both seem to have a surface which adheres very well to slightly damp skin. When these surfaces are lightly sanded, they lose some of this gripping capability. This can be both a positive and a negative factor, depending on the skin tolerance of the patient involved.</p> <p>Generally, hard socket variations of suction below-knee prostheses, while feasible, are not very practical for most patients. Moreover, the instance of inadvertent loss of socket suction must be expected. This is not really considered a problem since we recommend that auxiliary suspension be worn even on the best suction below-knee fitting.</p> <p><i>Soft Socket Variations</i></p> <p>Early suction liners were made of leather backed with Neoprene™. Even when given a sealant coating, the leather will begin to deteriorate and develop offensive odors in a fairly short period. However, good comfort has been achieved as has adjustability. Replaceability is not really possible in this variation.</p> <p>PE-LITE™ and Surlyn®-backed PE-LITE™ have both been successfully used for soft suction liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg"><b>Fig. 14</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg"><b>Fig. 15</b></a>). It wears fairly well and can be cleaned with baking soda, vinegar, or rubbing alcohol to eliminate both odor and dirt. These liners will likely pack-out in time, and thus, normal prosthetic delivery should include a duplicate. Replacement duplication after wearout of thermoplastic foam liners is not really practical to the level of precision necessary to maintain suction.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg"><strong>Figure 14. Pelite™ liner with Plastozote distal end, distal valve and Surlyn® outer shell fitted as suction below-knee prosthesis in early suction below-knee courses at UCLA in 1985.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg"><strong>Figure 15. The TSB Suction below-knee can be fitted on almost any length below-knee residual limb. Auxiliary suspension is not shown in this diagram but is recommended for all suction below-knee wearers.</strong></a><br /> <p>Another major advantage of these materials is that they may be easily added to or otherwise adjusted. By use of selectively placed materials of varying durameters, comfort can be achieved in very bony patients and those with poor skin conditions. It is important to further note that some foams are not closed cell and will, therefore, permit moisture, dirt, and bacterial buildup which may not be easily removed. However, coatings have been developed which may solve the interface cleansing problem. Additional considerations in the use of a liner coating are potential allergic reactions, alteration of friction and shock absorption characteristics of the liner material, and adequacy of adherence.</p> <p>Foam liners, it must be remembered, provide comfort by absorbing load forces of axial, shear, and torque. The shock of impact is absorbed in the compression of the foam or in the compression of the gases within the individual cellular structure of the foam. Any buildup of heat within a liner could lead to problems for the patient in an intimate suction fit.</p> <p>In summary, soft foam liners are very practical from the point of view of comfort and the ability to adjust to maintain fit. Their major drawbacks are that they change shape with wear and they do get dirty and smell if not meticulously cleaned daily.</p> <p>Three known types of silicone liners are presently in use or in experimentation at this time. Koniuk<a></a> reported fabricating cast silicone liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg"><b>Fig. 16</b></a>) which can be later duplicated from the same mold. There have been some problems with tearing of these liners in early phases of development, but this is viewed as a materials problem only. Early liners were fairly thick and heavy which can be detrimental. Some problems of skin reaction to direct contact with silicone have been reported. Since silicones are relatively inert, skin irritation most likely may be attributed to friction between the skin and the liner. It may actually be holding the skin too well. Some patients may also be allergic to the catalysts used in the preparation of the silicone elastomer.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg"><strong>Figure 16. Silicone below-knee socket liner with expulsion valve installed.</strong></a><br /> <p>Experiments with very thin laminated sheath-like silicone liners have been attempted with some positive initial results. However, adjustments are not possible because of the inability to cement to the material, a characteristic of the entire silicone group. Bedouin has reported using fills between the socket liner and the outer lamination as a means of reestablishing lost suction.</p> <p>Kristinsson<a></a> has demonstrated a preformed silicone liner which either rolls on or is pulled on the residual limb. The effect is to create distension of the distal tissues. Some problems have been seen in initial demonstrations, among which are tearing of the liners during application, some discomfort by patients with a hairy limb, and heat build-up. It may be too early in the development of these direct-contact silicone liners to determine with fairness their ultimate practicality. It is certainly true that lack of adjustability will likely continue as a source of considerable concern.</p> <p>A relatively new system, the PM Liner, developed by Peyton Massey<a></a> has been used as a suction below-knee liner. While proprietary in nature, it appears to be a vinyl-like foam which may be heated and formed with ease directly over the below-knee model. It has the comfort and padding of silicone but is much easier to work with and does not migrate as is the tendency with some silicone materials. Massey has been adapting this liner for use with adhe-sives so as to make it possible to glue patches of similar material to the PM Liner.</p> <p>A new concept in liners under development, called the Socket Liner Stump Sock,<a></a> offers an additional variation for potential use with a suction below-knee prostheses. It is a neoprene sock that is fabric-backed on both sides. When properly fitted, it maintains suspension by compression. The problem with this variation at present is that the smooth surface of the cloth outer face of the liner against the smooth inner socket surface does not provide sufficient friction to hold suspension. A coating is under development to resolve this problem. This liner offers an excellent compromise for the patient wishing to have an intimate TSB fit without complete suction. There is reportedly very little or no motion between the liner and the residual limb.</p> <p><i>Suction Below-Knee Valves</i></p> <p>Several specialized valves have been developed for the suction below-knee prosthesis although any valve can probably be used. An important feature in a valve for suction below-knee application is air expulsion capability. With such a valve, the patient simply forces his residual limb into the socket to expel the air through the distal end. Problems experienced with all valves have been accessibility and leakage brought on by inability to securely bond the valve seat to the liner.</p> <h3>Auxiliary Suspension</h3> <p>As has been previously emphasized, auxiliary suspension is mandatory on all suction below-knee prostheses. Sleeve type suspension offers the best compromise of comfort, security, and maintenance of suction. Cuff suspension in all forms has been tried, but cannot assist in sealing the socket to the residual limb. Three types of sleeves should be considered.</p> <p><i>The Latex Sleeve</i></p> <p>This provides the best seal and the most positive suspension, but has the problem of skin irritation, durability, odor, discoloration, and loss of shape.</p> <p><i>The Neoprene Sleeves</i></p> <p>These offer an acceptable seal that, while not as positive as the Latex, are acceptable so long as the sleeve has been properly manufactured. Neoprene sleeves are similar to Latex sleeves with respect to skin rashes and durability. Daily cleansing with alcohol can greatly reduce the incidence to skin problems. Providing the patient with multiple sleeves and proper hygienic education will reduce the incidence of skin rashes.</p> <p><i>Cloth Lined Neoprene Sleeves</i></p> <p>While these sleeves do not work well for total suspension, they can afford a margin of back-up for good suction wearers.</p> <h3>Some Suggestions for Skin Problems</h3> <p>For any serious rashes or other skin conditions, the patient should always be directed to his physician. A number of techniques have been tried by patients to clear up simple rashes. One technique is to wear a "Baggie®" or a thin polyethylene sheet directly against the skin of the residual limb until the rash clears. Some patients wear this inner protection at all times as a method of preventing rashes which might be caused by friction. When used with sock fittings, this will keep moisture out of the sock, thereby helping to prevent skin maceration. Some athletic patients apply transparent surgical tape over areas that are known to be prone to skin breakdown during heavy sports activities. Some brands that have been successfully used include 2nd Skin™, Op-Site, and Bioclusive Pads®.</p> <h3>Conclusion</h3> <p>The suction below-knee prosthesis, while an excellent option for some patients, may for others be the triumph of valor over reason. Should the decision be made to proceed with suction, both the prosthetist and patient must be completely aware of the long and difficult route involved. There will be obvious changes in the residual limb following initial fit which will require socket adjustment and refabrication over an extended period. There will probably be the need for some experimentation with materials and fabrication methods to arrive at an optimum fit for the patient. However, once these factors have been resolved, the results of a well-fit suction socket will be a marked improvement in patient comfort, satisfaction, and in a prosthesis that the patient "feels" is more a part of his person.</p> <p>If, on the other hand, suction is not a goal, the Total Surface Bearing casting and modification techniques that support a suction fit are entirely valid for every below-knee fitting regardless of the socket interface or method of suspension. In the view of the authors, these improvements over more traditional methods of below-knee prosthetics have been long overdue. Clearly, the superiority of Total Surface Bearing has been established and undoubtedly is the most important dividend of the research and education on suction below-knee fittings.</p> <h3>Suggested Readings</h3> <ul> <li> <p>Roberts, Ruth, "Suction Socket Suspension for Below-Knee Amputees," <i>Archives Physical Medicine and Rehabilitation</i>, Vol. 67, March, 1986, pp. 196-199.</p> </li> <li><a href="poi/1978_01_003.asp"></a> <p><a href="poi/1978_01_003.asp">Grevsten, S., "Ideas on Suspension of Below-knee Prosthesis," <i>Prosthetics Orthotics International</i>, 2, 1978, pp. 3-7.</a></p> <a href="poi/1978_01_003.asp"></a></li> <li> <p>Grevsten, S., "Patellar Tendon Bearing Suction Prosthesis Clinical Experiences," (Uppsala) <i>J. Medical Science</i>, 82, 1977, pp. 209-220.</p> </li> <li> <p>Grevsten, S. and L. Marsh, "Suction-type Prosthesis for Below-Knee Amputees: Preliminary Report," <i>Artificial Limbs</i>, 15, Spring, 1971, pp. 78-80.</p> </li> <li> <p>Pearson, J.R., S. Grevsten, B. Almby, and L. Marsh, "Pressure Variation in Below-Knee, Patellar Tendon Bearing Suction Socket Prosthesis," <i>J. Biomechanics</i>, 7, 1974, pp. 487-496.</p> </li> <li><a href="cpo/1984_03_004.asp"></a> <p><a href="cpo/1984_03_004.asp">Murphy, E., "Sockets, Linings, and Interfaces," <i>Clinical Prosthetics and Orthotics</i>, Vol. 8, No. 3, Summer, 1984, pp. 4-10.</a></p> <a href="cpo/1984_03_004.asp"></a></li> <li> <p>Schuch, M. and A.B. Wilson, "The Use of Surlyn® and Polypropylene in Flexible Brim Socket Designs for Below-Knee Prostheses," <i>Clinical Prosthetics and Orthotics</i>, Vol. 10, No. 3, Summer, 1986, pp. 105-110.</p> </li> <li> <p>Kay, H. and J. Newman, "Report of Workshop on BK and AK Prostheses," Orthotics and Prosthetics, Vol. 27, No. 4, December, 1973. Abrahamson, M., et al., "Improved Techniques in Alginated Check Sockets," <i>Orthotics and Prosthetics</i>, Vol. 40, No. 4, Winter, 1987, pp. 63-67.</p> </li> <li> <p>Pritham, C, "Suspension of the Below-Knee Prosthesis: An Overview," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 2, June, 1979, pp 1-20.</p> </li> <li> <p>Holley, Teresa, "The Suction BK Prosthesis," UCLA Prosthetics Education Program term paper, 1984.</p> </li> </ul> <p><b>References:</b></p> <ol> <li>Murphy, E., "Lower Extremity Components," <i>Orthopaedic Appliance Atlas</i>, Vol. 2, J.W. Edwards, 1960.</li> <li>Radcliffe, C.W. and J. Foort, <i>The Patellar-Tendon-Bearing Below Knee Prosthesis</i>. University of California, Berkeley, Biomechanics Laboratory, 1961.</li> <li>Grevsten, S., <i>The Patellar Tendon Bearing Suction Prosthesis</i>. 1977 Functional Studies, Doctoral Thesis, University of Uppsala, Sweden.</li> <li>Bedouin, Leo, personal communication, Dan Muth Company San Francisco, California, 1981-March, 1987.</li> <li>Friestadt, Ake, "The Swedish Suction BK Prosthesis," presentation at UCLA Advanced below-knee Prosthetics Seminar, October, 1984. Contact Een Holmgren Co., Uppsala, Sweden.</li> <li>Murphy, E.F., "The Fitting of Below Knee Prostheses," Klopsteg PE, Wilson PD (eds), <i>Human Limbs and their Substitutes</i>, New York, McGraw Hill, 1954, pp. 693-735.</li> <li><a href="cpo/1986_02_093.asp">Sabolich, J. and T. Guth, "Below Knee Prosthesis with Total Flexible Socket: Preliminary Report," <i>Clinical Prosthetics and Orthotics</i>, Vol. 10. No. 2, Spring, 1986, pp. 93-99.</a></li> <li>Kristinsson, O., "The ICEROSS System," lecture at UCLA Advanced Below-knee Prosthetics Techniques Seminar, Fall, 1986. Contact: Ossur hf. Reykjavik, Iceland.</li> <li>Holmgren, G., "The Patellar Tendon-Bearing (PTB) Suction Prosthesis," <i>Disability</i>, Strathclyde Bioengineering Seminars, August, 1978, MacMillian Press, Chapter 47.</li> <li>Grevsten, S. and U. Eriksson, "Stump-Socket Contact and Skeletal Displacement in Suction Patellar Tendon Bearing Prosthesis," <i>J. Bone and Joint Surgery</i>, 56, 1974, pp. 1692-1696.</li> <li>Fillauer, C, "A P.T.B. Socket with a Detachable Medial Brim," <i>Orthotics and Prosthetics</i>, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> <li>Gleaves, J.A.E., <i>Moulds and Casts for Orthopedic and Prosthetic Appliances</i>, Charles C. Thomas Publishers, Springfield, Illinois, 1972.</li> <li>Tranhardt, T., "Trimlines for Prosthetics," lecture to California Association of Prosthetists and Orthotists, Lake Tahoe, California, Spring, 1978.</li> <li>McQuirk, A. and A. Morris, <i>Controlled Pressure Casting for PTB Sockets</i> (Teaching Manual), Hangers, Roehamptom Lane, London, England, 1982.</li> <li>Hayes, R., "A Below-Knee Weight Bearing, Pressure Formed Socket Technique," <i>Orthotics and Prosthetics</i>, Vol 29, No. 4, December, 1975, pp. 37-40.</li> <li>Stokosa, J., "Prosthetics for Lower Limb Amputees," in Haimovici, H., Vascular Surgery, Norwalk, Connecticut, Appleton Century-Crofts, 1984.</li> <li>Vinnecour, K., "Clinical Below Knee Prosthetics," lecture at UCLA Prosthetics Education Program Advanced below-knee Symposium, Fall, 1983.</li> <li>Cascade Orthopedics, Chester, California.</li> <li>Staats, Timothy, "Advanced Prosthetics Techniques for Below-Knee Amputations," <i>Orthopedics</i>, 8, 1985, pp. 249-258.</li> <li>IPOS Manual, "Below Knee Supracondylar Flexible Socket," IPOS-USA, Niagara Falls, New York, 1982.</li> <li>Koniuk, W., "A Pure Silicone Below-knee Socket Liner," lecture at American Academy of Orthotists and Prosthetists at San Francisco, California, Winter, 1986.</li> <li>Mr. Peyton Massey, New Life Laboratory, Santa Monica, California.</li> </ol> <em><b>*Judd Lundt, B.S., A.E. </b> Prosthetics-Orthotics Education &amp;Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024.</em><br /><br /><em><strong><b>*Timothy B. Staats, M.A., </b></strong>CP. Prosthetics-Orthotics Education &amp;Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024.<br /><br /><br /></em> Page Number(s) 118 - 130 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource The UCLA Total Surface Bearing Suction Below-Knee Prosthesis Creator An entity primarily responsible for making the resource Timothy B. Staats, M.A., CP. * Judd Lundt, B.S., A.E. * https://staging.drfop.org/files/original/d1e6d37381974afea447207e5e2dcbe4.pdf 098f55530355bceeb283da47fcc350e7 https://staging.drfop.org/files/original/0666e268b5cec1356b0b7c65cbfadb51.jpg 34526111ef1e2eb773fafce8d671b491 https://staging.drfop.org/files/original/cc9fd87e23971d5b30a0750aca41f5a3.jpg 63bf988ca05ee052c35c60bac08961ea https://staging.drfop.org/files/original/85d3b8a378a156a011e468adb5269da1.jpg 5bf92dc7bf504dcff53808541d517251 https://staging.drfop.org/files/original/227e6156213f99f0da1e50d223dee8a0.jpg 3db61f11e3ba6a4f7e34e896d5442696 https://staging.drfop.org/files/original/9a578284ee6908603aea1c033d17b00a.jpg e8da77889765cbddc376316eae272fe9 https://staging.drfop.org/files/original/2cdd2bdc87a91cc20b1bd2e2c8de8fdb.jpg bc32bfecba3ba120e95537d67188be8d https://staging.drfop.org/files/original/08887b5a399d3835a423a7465e92c363.jpg b49025384d7feb416227e5c087356179 https://staging.drfop.org/files/original/3bdc683c4fd3a3b01dd291dcc05442a7.jpg dc3f77f6a7dc6e8f10d15f57a79b4bd5 https://staging.drfop.org/files/original/baa8c678a811a389abfecf5c63ec394a.jpg fadb2fb86dfab8eae20656c2668c41bf https://staging.drfop.org/files/original/8af81fcc4e2a1200c4b3ebacefd7dcdc.jpg 71e21b708994bac32da23d1191b72f33 https://staging.drfop.org/files/original/df8f5de5f6e51604721fe6c8eac18d00.jpg daf7122151ce6dea1bd294319637ca83 https://staging.drfop.org/files/original/fc36c0b09aa6f3af1a634440b2895b0c.jpg 737f8f6f58dd6ce0aa0bafb5bc333f08 https://staging.drfop.org/files/original/f23de5b7227d292fd049b5c53370ad5e.jpg 322c5646d98f492326ba9b2ad1189f10 https://staging.drfop.org/files/original/12807becbc364793ce64139f3ed19ca0.jpg 76b2ffd63899936900e983217326addb https://staging.drfop.org/files/original/c7c004b4cacc9f9a708a3486dc137efa.jpg d1ecb9180a51ca39aec2e6a1a746c16d https://staging.drfop.org/files/original/0b96ee4588a2a50ba8ae866ee38bd212.jpg 9ce093f92ed02602e5a59abd344d72a8 https://staging.drfop.org/files/original/6dca045beee9acf9d8ca40d95e842f26.jpg 261149ab340dc088401ee1852c05995d https://staging.drfop.org/files/original/1dfabfd667493e59ce35c164c328039a.jpg d22c081e2b4704fdbf8a951a6c62136a https://staging.drfop.org/files/original/70bc99ba51deb9adc1649fc859b83790.jpg 1315b524e4b6252efd9c727af36bddc5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_015.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 15 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Upper-Extremity Prosthetics Armamentarium</h2> <h5>Maurice J. Fletcher, Lt. Col., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The word "armamentarium" is defined as "the equipment, instruments, apparatus, or paraphernalia used by the practitioner of medicine." As applied to artificial limbs, it refers to the array of components necessary for the prescription fitting of prostheses in relationship to the site of amputation.</p> <p>In the prosthetics armamentarium, it is desirable that a complete range of components be available in order to provide satisfactory prostheses for all sites of upper-extremity amputations. A few gaps still remain in the present armamentarium of devices, but such temporary inadequacies are in the area of special cases, such as in transcarpal and fore-quarter amputations and in children's prostheses. The few remaining gaps are being rapidly filled, and supplementary components for fortifying the present armamentarium, such as additional hand sizes, are under consideration at the present time. The fact that devices now exist in each category of necessary arm components does not necessarily mean that they are the ultimate. They might even be interim devices, but they do permit prescription fitting of arm prostheses to a degree of efficiency heretofore unattainable. As a device is made available for each category of the armamentarium, improve-ments are attempted in these individual devices to increase their efficiency and useful-ness to the amputee. New models and methods of operation are being exploited in the hope of providing, eventually, even more efficient restorative prostheses. It is the purpose here to provide brief descriptions of the functions provided by the basic units of the present upper-extremity armamentarium. For a more detailed treatment of the devices and the philosophy underlying their design, reference may be had to <i>Human Limbs and Their Substitutes</i> (McGraw-Hill, in press) and to the <i>Manual of Upper-Extremity Prosthetics</i> (University of California at Los Angeles, 1952).</p> <h3>Terminal Devices</h3> <h4>APRL Model 4c Voluntary-Closing Hand and Cosmetic Glove</h4> <p>As the name implies, in the APRL voluntary-closing hand (<b>Fig. 1</b>) prehension force is obtained voluntarily by the amputee. Tension applied to a control cable closes the index and middle fingers against the thumb in a three-jaw-chuck pattern. These one-piece, hollow, metal fingers move through a 1 1/2-in. range, but since the thumb tip can be set in either of two positions 1 1/2-in. apart, objects up to 3 in. wide can be grasped. Finger angles are such that a grasped object is forced inward toward the palm. Security of grasp is further increased by the use of felt pads on the inner surfaces of the fingers and thumb. Any degree of prehensile force up to about 35 lb. can be obtained. The ring and little fingers are of cast latex and are attached so that they roughly conform to the shape of the object being handled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. APRL model 4C voluntary-closing hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The actuating mechanism, shown in <b>Fig. 1</b>, consists of a cam-quadrant type of clutch which automatically locks the index finger and middle finger in place when tension in the control cable is released. Reapplication of tension automatically unlocks the mechanism, and a spring forces the fingers to the fully open position, at which point the mechanism is recocked and ready for another cycle. Backlash is eliminated in the lever system by incorporation of an auxiliary spring-and-lever system. In fact a certain amount of frontlash may be introduced into the system. The voluntary-closing type of mechanism permits fuller utilization of the potentialities of a cineplasty tunnel than any device heretofore available.</p> <p>The APRL hand is covered by a cast polyvinyl chloride glove of extremely natural appearance (<b>Fig. 2</b>). Developed especially for the APRL hand, it has been designed with particular regard to eliminating as much as possible the resistance to operation of the fingers. In order to reduce the necessarily high cost of coloring each glove on a custom basis, after careful experimentation six Caucasian and six Negroid shades have been provided. They satisfy the majority of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. APRL model 4C voluntary-closing hanc covered with APRL cosmetic glove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Voluntary-Closing Hook</h4> <p>The APRL voluntary-closing hook (<b>Fig. 3</b>) contains essentially the same mechanism employed in the APRL hand. One hook finger is closed against a stationary hook finger, the two designed to accommodate objects up to 3 in. in size. A control button permits the engagement of a stop to limit hook opening to 1 1/2-in. so that the hook finger does not have to move through its full range before recocking of the locking mechanism takes place. Moreover, locking action in the l 1/2-in. open position can be eliminated at the will of the amputee when this is desired for repetitive tasks. The rubber-lined, lyre-shaped, aluminum hook fingers are specially designed to provide maximum function. The smooth exterior surfaces present the least amount of friction to aid in entering pockets, while the rubber linings provide friction to aid in handling objects. Duckbill finger tips lend facility in handling small objects. By removing the fingers and reinstalling them 180 deg. from the original position, a right hook can quickly be converted to a left, or vice versa.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. APRL voluntary-closing hook in open and closed positions. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Northrop-Sierra Voluntary-Opening Two-Load Hook</h4> <p>In the Northrop-Sierra voluntary-opening two-load hook (<b>Fig. 4</b>), designed primarily for bilateral amputees, tension on the control cable causes one hook finger to open against a spring force, which in turn provides prehensile force between the hook fingers when there is no tension on the control cable. The spring force is provided by two identical coil-type springs. When both are engaged, a prehensile force of approximately 7 lb. is available at the ringer tips. When only one spring is engaged, 3 1/2 lb. of force are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Northrop-Sierra voluntary-opening two-load hook. Schematic diagram (above) shows arrangement of hook thumb and enclosed coil springs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lyre-shaped fingers are the same as nose used in the APRL hook.</p> <h4>Dorrance Voluntary-Opening Hook</h4> <p>Prehension in the Dorrance hooks is provided by rubber bands which force the hook fingers together. Adjustment of the prehension force is accomplished by adding or removing bands. Hook fingers are available in many different sizes and shapes of both steel and aluminum. Dorrance hooks offer the extreme in ruggedness and simplicity. The model known as Utility #5, shown in <b>Fig. 5</b>, is very popular.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Dorrance #5 utility hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Length Adapters and Fairings</h4> <p>To provide a constant effective prosthetic length when terminal devices of different lengths are interchanged, as in the case of the APRL hook and hand, length adapters and fairings (<b>Fig. 6</b>) have been made available. The length adapter is simply a stud with male threads at one end and female threads at the other so that it may be inserted between terminal device and wrist unit. Also available is a plastic fairing which covers the length adapter and provides a smooth transition between the oval end section of the APRL hand and the circular section of the wrist unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Wrist fairing and length adapter for APRL model 4C hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wrist Units</h3> <h4>Manual Friction-Type Wrist Units</h4> <p>Female threads receive the stud of the terminal device, the wrist-flexion unit, or the length adapter to permit attachment of these units to the arm. Compression of a rubber washer between the terminal device and the wrist unit provides sufficient friction to permit a certain amount of adjustment in the rotation of the terminal device without slippage under average operating conditions. SierraEngineering Company supplies the friction-type wrist unit in one size, 2 in. in diameter, suitable for the average adult male, while Hosmer supplies essentially the same unit in three sizes-2 in. in diameter for the average male, 1 3/4-in. in diameter for women and large children, and 1 3/8-in. in diameter for small children. All these units are designed to facilitate incorporation into plastic-laminate arms.</p> <h4>Manual Lock-Type Wrist Units</h4> <p><b>Hosmer F-M Wrist Unit</b></p> <p>Rapid interchange of terminal devices and positive locking of the terminal device in the pronation-supination plane are afforded by the Hosmer F-M (Fletcher-Motis) unit (<b>Fig. 7</b>). A serrated steel adapter with an annular groove is attached to the stud of the terminal device by threads. To connect the terminal device to the arm, the stud is forced into the wrist unit until a locking yoke and gear segment are engaged. To adjust the amount of rotation of the terminal device, the control button is depressed to the first detent, which releases the gear lock and permits rotation since the terminal device is retained by engagement of the locking yoke in the annular groove on the adapter. Further depression of the control button disengages the locking yoke and permits removal of the terminal device. A coiled compression spring attached to the end of the adapter facilitates operation of the F-M unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Hosmer F-M wrist unit, with exploded view showing arrangement of parts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Quick-Change Wrist Unit</b></p> <p>The Hosmer quick-change wrist unit provides essentially the same function as the F-M unit but is not quite as rugged and is more difficult to operate in some instances. The adapter and terminal device are released by rotating the forward portion of the wrist section, which disengages a detent-type lock. The quick-change unit is lighter in weight than the F-M unit and is used when weight is an important factor.</p> <h4>Northrop-Sierra Wrist-Flexion Device</h4> <p>The Northrop-Sierra Model B wrist-flexion device (<b>Fig. 8</b>), when used, is installed between the terminal device and the wrist unit. Consisting of a simple detent-type lock with three positions, it permits manual positioning and locking of the terminal device at 0, 25, and 50 deg. of flexion. Depression of a control button at the base of the unit disengages the lock to permit a change in the amount of wrist flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Northrop-Sierra model B wrist-flexion device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bilateral amputees find this device especially useful for working in areas close to the face and body, and some unilateral amputees have found it helpful in certain tasks necessary to their particular occupation.</p> <p>The APRL-Sierra below-elbow wrist-rotation unit (<b>Fig. 9</b>) has been developed to step up or multiply the residual pronation-supination of below-elbow amputees. A given rotation of the inner socket by the stump produces, through a planetary gear system, 2.3 times that amount of rotation in the terminal device. A locking mechanism, actuated by relative motion between the forearm and upper arm, and by which the unit is unlocked upon full extension of the forearm and locked upon flexion, is provided when desired.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. APRL-sierra wrist-rotation step-up unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Below-elbow amputees with little or no pronation-supination and nearly conical stumps have been fitted successfully with this unit, since rotation of the inner socket can be produced by rotating the humerus. In this case the lock must be provided so the stump may rotate relative to the socket upon flexion.</p> <h3>Below-Elbow Hinges</h3> <h4>Robin-Aids Flexible Hinges</h4> <p>Where no wrist-rotation step-up unit is used, the Robin-Aids flexible hinge (<b>Fig. 10</b>, bottom) is employed between the socket and arm cuff or triceps pad to impart axial stability to the entire prosthesis and yet to permit maximum use of the residual pronation-supination. The Robin-Aids hinge consists of a metal cable covered with a wrapped-wire housing and having flat terminal plates designed for firm anchoring in the plastic-laminate forearm and for fastening to the upper-arm cuff.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-elbow hinges. Top, Sierra insert hinge; center, Hosmer variable-ratio step-up hinge; bottom, Robin-Aids flexible hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Leather-Strap Hinges</h4> <p>Nylon-coated leather straps may be fabricated in the shop and used in lieu of the Robin-Aids flexible hinge.</p> <h4>Single-Axis Hinges</h4> <p>Metal single-axis hinges specially designed for plastic fabrication are available from several manufacturers. This type of hinge is used where maximum stability is required, such as in short below-elbow cases and in heavy-duty arms.</p> <h4>Polycentric Hinges</h4> <p>Polycentric hinges may be substituted for the single-axis hinges. They are preferred by many prosthetists because less care is required in location to give the same amount of comfort to the patient. Instead of a single axis, two hinge points are provided in this unit, thereby exerting less pressure on the stump through the socket when the forearm is flexed and when some slight misalignment exists.</p> <h4>Northrop-Sierra Insert Hinges</h4> <p>Insert-type hinges might be classified as semiflexible hinges, since they provide a degree of stability somewhere between that offered by the flexible Robin-Aids hinge or the leather strap and the solid steel hinges. They are generally used on medium below-elbow prostheses where sufficient stability cannot be obtained with the flexible hinge but where the stump is long enough to provide sufficient stability so that the metal-strap hinges are unnecessary. Insert hinges are installed in "ears" on the distal end of a leather arm cuff so that the cuff may be hinged about the proximal end of the forearm socket. The method of assembly is illustrated in <b>Fig. 10</b>, top.</p> <h4>Step-Up Hinges</h4> <p><b>Hosmer MA-100 Hinges</b></p> <p>The Hosmer MA-100 step-up hinge (<b>Fig. 11</b>) was developed to permit full flexion of the prosthetic forearm when flexion of the stump is limited to 90 deg. or more. Step-up action is provided through two gears so that flexion of the stump 90 deg. results in 135 deg. of forearm flexion. The multiplication in motion results in a corresponding decrease in torque about the prosthetic forearm, and often an assistive lift is required for forearm flexion. This is accomplished by employing one of the above-elbow harnessing systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer MA-100 step-up hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Variable-Ratio Step-Up Hinge</b></p> <p>The Hosmer variable-ratio hinge (<b>Fig. 10</b>, center) provides approximately the same function as the MA-100 hinge but is usually preferred because the changing ratio of stump action to forearm action provided by the sliding lever system results in easier operation. This ratio in the fully extended position is 1:1.8, increases to 1:1.3 when the forearm is flexed 90 deg., and decreases to 1:1.8 at the 135-deg. position. Furthermore, because of the sliding action of the hinge, the stump does not extend as far below the forearm in flexion as in the case of the MA-100 hinge, a fact which in many instances eliminates the necessity for enlarging the sleeve of the garment covering the artificial limb.</p> <h4>Robin-Aids Stump-Actuated Elbow Lock</h4> <p>The Robin-Aids elbow (<b>Fig. 12</b>) was designed for short below-elbow cases where flexion of the forearm is limited to less than 90 deg. or for those cases where the torque about the elbow is too weak to offer sufficient stability. Full extension of the stump forces a lever into a detent on a segment about the elbow axis, locking the forearm in flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Robin-Aids stump-actuated elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Units for Above-Elbow Cases</h3> <h4>Northrop Model C Elbow</h4> <p>An alternating-type control for the locking mechanism is the prominent feature of the Northrop Model C elbow (<b>Fig. 13</b>). The first pull on the control cable drops a lever into a detent on a sector, resulting in a positive locking action about the elbow axis. The next pull on the control cable removes the locking level from the detent, thereby making the forearm free to rotate about the elbow axis. Eleven locking positions are available. In the average above-elbow case, the control cable is generally actuated by humeral extension, leaving the other hand or prosthesis, as the case may be, free. The excursion required, about 3/8-in., is so slight that after some practice most amputees are able to operate the locking unit with a motion that goes unnoticed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Northrop model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attachment to the upper arm is afforded by a single bolt in a turntable arrangement which permits the amputee to select at will the plane of forearm flexion and extension. A specially designed saddle for lamination into plastic is used for attaching the unit to the forearm.</p> <p>The Northrop elbow is presently available in one size only, 3 in. in diameter.</p> <h4>Hosmer Elbow Unit</h4> <p>Locking action of the Hosmer elbow unit (<b>Fig. 14</b>) is accomplished by permitting two tightly wound coil springs to wrap themselves around a shaft. Such an arrangement permits an infinite number of locking positions. Attachment to the arm and forearm and operation by the amputee follows the same pattern as in the case of the Northrop Model C.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Hosmer elbow unit, without turntable or forearm saddle attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Hosmer unit is available in two sizes, approximately 2 and 3 in. in diameter. Recently Hosmer has added to its line a smaller elbow designed for children.</p> <h4>Elbow-Disarticulation Prostheses</h4> <p>The APRL-Sierra side-locking elbow hinge (<b>Fig. 15</b>) was developed expressly for elbow disarticulation and for very long above-elbow cases where insufficient room exists for the fully enclosed type of elbow unit. An alternating-type locking unit on the outside of the inner hinges permits locking and unlocking of the elbow by humeral extension, as in the case of the standard above-elbow amputee. This unit may also be used on short below-elbow cases where use of the Robin-Aids forearm-actuated lock is not feasible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. APRL-Sierra outside-locking elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Control Systems</h3> <p>For terminal-device operation and forearm control, Bowden-type controls, along with such parts as retainer and terminal fittings specially designed for use on artificial arms, are available from a number of sources for both the harness and cineplasty applications. This type of control system (<b>Fig. 16</b>), consisting of high-strength woven wire cable enclosed in a wrapped-wire housing, has proven infinitely more satisfactory than anything else used to date, mainly because of its resistance to stretching and its relatively high power-transmission efficiency.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bowden-type control cable and attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-Elbow Biceps Cineplasty Control Systems</h4> <p>Special control-system kits are available for below-elbow amputees with biceps cineplasty tunnels. The twin-cable system (<b>Fig. 17</b>), often referred to as the UCLA system, is available with either straight or ox-bow acrylic tunnel pins reinforced with a copper core. Provisions have been made for quickly attaching or removing the control cables with respect to the pin. Rapid selection of the initial tension on the muscle tunnel is made possible by the incorporation of a turnbuckle type of unit which controls the effective cable length. A single-cable system using a sheave-type equalizer and known as the APRL system is also available (<b>Fig. 18</b>). Cable-tension adjust-ment is provided by a single cable-length ad-juster installed between the sheave and the terminal device. Each of these systems is considered merely as a replacement for the shoulder-operated control system, since all other portions of the prosthesis are the same whether operated from the shoulder or from the muscle tunnel.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Twin-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. APRL single-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nudge Control</h4> <p>For the shoulder-disarticulation case, in which it is impossible to provide from shoulder movement force and excursion necessary to operate the Northrop Model C or Hosmer elbow, there is available the Nudge Control, which permits the elbow lock to be controlled by chin movement. The nudge control (<b>Fig. 19</b>) is especially useful for bilateral shoulder-disarticulation cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Nudge control for operation of elbow lock in shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusion</h3> <p>This, briefly, completes the basic items of the armamentarium of devices available for prescription fitting relative to sites of amputation. There are, however, many supplementary devices, available in the field and well known to the industry, which are used with the devices described.</p> <p>With the existence of the many devices now on the market, it is possible to custom-build prostheses to rare or irregular cases, and to increase the number of items in the armamentarium makes such custom-building more feasible. A number of improvements are constantly being made in the research establishments on existing devices, and these, of course, will be fed into the industry as they are developed to the point where they are considered commercially marketable and necessary items of the armamentarium.</p> <p>Needless to say, each existing armamentarium item is being accorded careful study by the various research groups in an effort to increase efficiency and utility. Many new devices are now in the research stage; some are approaching the transitional period; others are known to be necessary and steps have been taken to prove such devices and to production-engineer them to the point where they will be marketable from the standpoint of increased efficiency, decreased maintenance, and economics. To mention a few items, the goals sought include improved terminal devices, both hand and hook; the cosmetic glove; improved elbow-lock mechanisms and elbow mechanisms themselves; the cosmetic approach to the entire prosthesis, up to and including the shoulder; and improvement of the over-all control systems to make them more efficient and more durable than are those now available. Already existent items of the armamentarium, such as harnesses, harness materials, and fittings, have been passed by purposely in this discussion, since they are well known to the industry. The use of some of the new synthetic materials, such as nylon, orlon, and dacron webbing, is standard practice in most limbshops. These new webbings are perspiration-resistant and possess adequate strength to meet the requirements of modern prosthetic devices. New webbings of various types and structures are constantly under study and test. Steady improvement has been made in the process of weaving these materials to prevent stretching.</p> <p>It is hoped that, through the gradual improvement of all items of the armamentarium, the comfort and utility of upperextremity prostheses will be increased to the point where an amputee will continuously wear and use a prosthetic device and will no longer be considered by society as a handicapped person. It may then be realized that the amputee can perform his job as well as can the normal person. The prescription fitting of each individual case may become so precise and so efficient that there will no longer be a question as to the value of the prosthesis to the amputee in returning to his place in society. The continuous development of new items for the armamentarium, and improvement in items existing in the present armamentarium, will make available to the prosthetist a variety of components permitting the satisfactory fitting of each amputee in conformance to his own individual pattern of life and will permit the new amputee to resume many jobs without loss in efficiency.</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>Maurice J. Fletcher, Lt. Col., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Director, Army Prosthetics Research Laboratory, Walter Reed Army Hospital; member, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-019.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 Upper-Extremity Prosthetics Armamentarium Creator An entity primarily responsible for making the resource Maurice J. Fletcher, Lt. Col., USA (MSC) * https://staging.drfop.org/files/original/7a75c3d9c233cf93787c08c21ed693e3.pdf e5110d02dd384bb6a5f6f5a10d2586ba https://staging.drfop.org/files/original/dd9cefbe75906e9bba04a5826a47ec5f.jpg 7703fefe919d06bde880ad14c32d7f75 https://staging.drfop.org/files/original/1ec821d58a0459aef4c5528b6090c4c4.jpg bcb495632b7e2d3954e57ff157efed5e https://staging.drfop.org/files/original/1379cb8157b2580aa03fb6a64d890b95.jpg a581fb1c72db3af322da27e57eaa0f6e https://staging.drfop.org/files/original/5bdb4472cef92dc9646b1510876e7782.jpg 1591cb62ca55a5fe3e1780a2e5b6a80d https://staging.drfop.org/files/original/4fce8019d5930c0d95a39cb58a87c9c3.jpg 528c9b83635d9135a577534f3859d802 https://staging.drfop.org/files/original/657b4b73124d4aa6f38ae9451948f8ba.jpg 8b789aec8e717b99d01ede87115e9e6d https://staging.drfop.org/files/original/736753da520fdd6d08411546b891cd1a.jpg 69932579ec5c82657a8978acf7988bf4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_049.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 49 - 57 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/1970_02_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_049.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 Use of External Support in the Treatment of Low Back Pain</h2> <h5>Jacquelin Perry. M.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The origin of therapeutic procedures can generally be traced to local efforts directed toward resolving continuing disability of the patient. In the treatment of low back pain, this approach often included designing special supports by individual physicians and orthotists. Such independent activity in numerous locales resulted in a long list of brace designs, many of which carry impressive eponyms that tend to stress differences rather than elements of commonality. </p> <p> To compile the available information concerning bracing, the American Academy of Orthopaedic Surgeons published the <i>Orthopaedic Appliances Atlas</i><a></a> in 1953. Of the 30 types of spinal support described in that volume, 17 were specifically designed for the sacroiliac or lumbosacral areas. Ten years later, in 1962, a survey of orthopedic services in the United States by Nattress and Litt<a></a> identified 30 braces, of which 22 corresponded to the design customarily considered effective at the lumbosacral region. These two reports, along with the present study, described a total of 40 different devices designed for low back problems. </p> <p> Details of designs are readily available, but objective criteria to weigh the relative merits of the different devices are almost nonexistent. As a consequence, physicians generally make their selection either by adopting the customs observed during their training, or by accepting the preference of the local orthotist. Undoubtedly, some braces have withstood the test of time, while others have become items only of historical interest. Superimposed on this background, the more recent introduction of prefabricated parts for brace construction has probably influenced the frequency with which certain types of braces are prescribed.</p> <p> The extent to which these influences have altered the availability and prescription of brace designs today has not been reported. Also unknown is the nature of the relationship between the etiology of the low back pain and the type of support that clinicians have found to be effective. Identification of this type of information is pertinent because the subject of orthotics is now being presented in formally organized courses on a nationwide basis. </p> <p> This paper records the results of a three-phase study conducted in 1968-69 by the Subcommittee on Orthotics, Committee on Prosthetic-Orthotic Education (CPOE) of the National Research Council. Approval of the Executive Committee of the American Academy of Orthopaedic Surgeons was obtained. The purpose of the survey was to identify the current practices of orthopedic surgeons with respect to external supports for the management of low back pain. </p> <h4> Method</h4> <p><i> Pilot Study </i></p> <p> An unstructured pilot questionnaire was sent to 150 orthopedic surgeons selected because of their considerable experience in the management of low back pain. They were asked to list the types of support they prescribed, and to indicate the clinical conditions for which each support was chosen. The results of this pilot study formed the basis for the next phase of the investigation. </p> <p> The 90 physicians (60%) who responded were explicit in their choice of a device and the clinical indication for its use. Eighty-three reported frequent prescription of external support as part of their therapeutic program. (Two said they never used external supports, and five indicated they rarely prescribed such aids.) </p> <p> Within each class of support (brace, corset, cast), a similar pattern of practice was evident. Numerous designs were listed, but most were mentioned only occasionally. The majority of the respondents preferred one or two types of support. Within a total of 12 different braces reported, three-fourths of the physicians listed the Chairback (Knight) and Williams braces (<b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>). Six other designs were mentioned only once. Identification of corset preference was a bit clouded by the indiscriminate use of both generic and trade names. The generic term "lumbosacral" was specified by half of those responding. An additional one-fourth of the pilot-study participants used trade names such as Camp, Spencer, and Winchester. The next most frequently mentioned device was the sacroiliac belt (8%). Of the six casts identified, the flexion jacket was preferred by more than half of the pilot-study orthopedists; the second choice was the body jacket (19%). In designating the clinical conditions warranting external support, two response patterns developed in the pilot survey. Seven types of disability were mentioned frequently and in explicit terms, viz., postoperative fusion, spondylolisthesis, chronic backache, acute strain, disc syndrome, degenerative joint disease, and the postoperative disc. Several other conditions, identified by a wide variety of terminology, were mentioned with moderate to rare frequency. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Knight dorsolumbar brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical modification of the Knight brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Williams lumbosacral brace. (Illustrations from Orthotics for Physicians and Therapists, Prosthetic-Orthotic Education, Northwestern University Medical School, Chicago, HI.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>National Survey of AAOS</i></p> <p> The findings of the pilot survey were used to construct a questionnaire applicable for a comprehensive national study. This questionnaire was sent to the membership of the American Academy of Orthopaedic Surgeons (AAOS). The form (presented at the end of this article) was a check sheet on which physicians were asked to match the types of support they prescribed with the clinical conditions they treated in this manner. </p> <p> The following supports, all of which were more than rarely mentioned in the pilot study, were included. (The restriction on corset choice was the result of a decision to use generic rather than trade names in order to avoid repeating the confusion produced in the pilot study.) </p> <p><b><i>Braces</i></b></p> <ol> <li> Chairback (Knight) </li><li>Williams </li><li>Norton-Brown </li><li>Goldthwaite </li><li>Bennett </li></ol> <p> <i>Corsets</i> </p> <ol> <li>Lumbosacral </li><li>Sacroiliac </li></ol> <p> <i>Casts</i> </p> <ol> <li>Flexion </li><li>Body jacket </li><li>Cast with one leg </li></ol> <p> Eleven clinical conditions were selected for the national inquiry, based upon the </p> <p> returns of the pilot study and upon the clinical experience of the NRC committee. Provision was made throughout for physicians to indicate devices or clinical problems other than those listed on the form. The questionnaire was also designed to indicate the relative frequency ("usually" or "rarely") of the prescriptions. </p> <p><i> Survey of the Functions of Support</i></p> <p> Late in 1968, a second national survey was conducted among the AAOS membership to determine prevailing opinions about the functions of the various types of support. The purpose of this phase of the study was to attempt to relate the anticipated function of the external support to the different preferences in prescription. </p> <p> Profiting from the findings of part one of the national survey, the list of supports was again shortened. This time, the orthopedists were queried about two braces (Williams and Chairback [Knight]); "corset" was listed as a single category, as were the flexion casts. A miscellaneous category was added for other comments. (The questionnaire appears on page 57.) </p> <p> Six probable functions were selected for study. These included: immobilization of the spine, restriction of lumbosacral motion, unloading of the intervertebral disc, support of the abdomen, correction of posture, and psychological effect. As always, there was a provision for other choices. </p> <h4> Results </h4> <p> On the first national survey, 5,215 questionnaires were mailed. With the aid of one follow-up, 3,140 (60%) were returned completed. An additional 1% of the returns were incomplete because the physicians had retired or their practices did not include patients with low-back problems. </p> <p> In the second phase of the study, the same number of forms were sent out, with 2,192 (42%) being filled in and returned. No follow-up mailing was conducted, </p> <p> Annotated responses or explanatory letters accompanied 1,034 (33%) of the questionnaires. These consisted of: (<i>a</i>) identification of the type of device they preferred if it was not specifically mentioned on the form; <i>(b) </i>comments regarding precise fitting or construction characteristics considered to be important; (<i>c</i>) reasons for not prescribing external support; and (<i>d</i>) other modes of treatment which should accompany use of a support. </p> <p><i> Use of Supports for Low-Back Problems</i></p> <p> Most of the orthopedic surgeons indicated use of a judicious selection of braces, casts, and corsets; the average physician reported that he used three different devices in his practice. A small group stated that they used only one type of device: a brace (4%), a corset (4%), or a cast (1%). Only 14 respondents stated that they "never used support" for the patient with a low-back problem. </p> <p> Among the clinical indications, the inclusion of the term "fracture" caused considerable confusion in the information collected. Either all types of braces are used for fractures in the "low back," or the orthopedist's attention was directed to fractures of the spine in general. The latter seemed highly probable, as most indicated that a brace other than those listed was used. Typically, these were the Jewett, Taylor, and Baker types, commonly used for lesions in the thoracic and thoracolumbar areas. As the extent of this confusion could not be identified, all data referring to "fracture" were omitted from the analysis. </p> <p> Certain characteristics in the prescription of external support became evident. A majority of the profession used the same groups of devices. The nature of the disability dictated the frequency of prescription as well as the type of support preferred. </p> <p><i> Support Preference </i></p> <p> The lumbosacral corset is the most popularly used low-back support, followed by the Chairback (Knight) spinal brace. Utilization of the other types of support fell far behind these two leaders <b>Table 1</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The degree of dominance by the lumbosacral corset varied with the method of comparison; 28.5% of the physicians indicated use of the lumbosacral corset for at least one condition. When all clinical indications were considered, preference for the lumbosacral corset was 44.2%. The Chairback brace was used by 21% of the physicians for 22% of the clinical conditions listed. All other types of support were used less than 9% of the time. The Williams brace was third in popularity. A variety of casts preceded any other choice of brace or corset <b>Table 1</b>. </p> <p> As "lumbosacral corset" is a generic term that overlooks design differences between the Camp, Winchester, Spencer, and other specific corset styles, a comparison was made with the designated preferences for the total group of "low-back braces." The relative preference between the corset and the low-back brace again depended on the method of comparison. The use of a brace at some time was indicated by 40.2% of the physicians, in comparison to 32.4% for corsets. However, when all the clinical indications were totaled, the preference reversed, with the corsets dominating (46.7% in contrast to 39.0% for braces). </p> <p> Some geographic patterns for brace preference were found, especially for those used less frequently <b>Table 2</b>. The middle and southeastern sections of the United States were the only areas where the Williams brace was used widely; it was fourth in preference on the West coast. With the exception of New York, no mention of it was made in the eastern or New England states. The Bennett brace was second in popularity in Maryland and third in Ohio. Predominance of the Norton-Brown<a></a> brace was restricted to Massachusetts and Maine, a note consistent with the fact that the originators are from Boston. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Clinical Indications</i> </p> <p> The survey form asked the physician to check whether he rarely or usually used some type of support for each of ten clinical conditions listed <b>Table 3</b>). Three patterns of use were apparent. The responding physicians seldom used external support in the treatment of an acute strain (17%), for an obese person with pain (19%), or during the postoperative period following disc surgery (28%). When support was used for these conditions, it was generally a corset. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the other extreme, most physicians used support following spine fusion (84%), for treatment of spondylolisthesis (70%), and for pseudoarthrosis (66%). In these instances, the most common type of support was a brace. </p> <p> The orthopedists were evenly divided as to the advisability of prescribing any type of support in treating the degenerative back, the disc syndrome of chronic backache, or as a preoperative trial. A similar lack of agreement was indicated concerning the type of support preferred. As a preoperative trial, there was equal preference for a brace or cast. For the other disabilities, the preferred support was the lumbosacral corset. </p> <p> Comparison between the specific brace design and the clinical condition <b>Table 4</b> showed that the Chairback was the most frequently used brace in each situation, and the Williams brace ranked second in preference. Spondylolisthesis and the disc syndrome were the most common indications for the Williams brace. Spondylolisthesis was also the primary reason for using the Bennett brace. Otherwise, preference for the Norton-Brown, Goldthwaite, and Bennett braces paralleled the use of back support in general. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Function of External Supports</i> </p> <p> Three approaches to the data collected on functions of supports seemed pertinent: the general expectation for external supports, the types of support chosen for each of these functions, and the functions expected of each of the support designs. </p> <p> The function most commonly ascribed for external support was restriction of lumbosacral motion (30%); abdominal support was second (19%), followed by postural correction (15%) and immobilization of the spine (12%). </p> <p> To restrict lumbosacral motion, the Chairback (Knight) brace or a corset were equally preferred. The Williams brace was the third specific device indicated for this purpose, although a larger number of physicians indicated that they used some type of cast to restrict motion. </p> <p> Abdominal support was most often assigned to the corset. This dominated its next competitor, the Chairback (Knight) brace, by a ratio of two to one. Again, the Williams brace ranked third for the function of supporting abdominal muscles. </p> <p> Postural correction was almost equally divided between the corset and a Williams brace, although the use of casts was not uncommon. </p> <p> An interesting situation developed in the category of spinal immobilization. It was the only function identified for the flexion cast, yet this device was fourth in preference. The support most often indicated for spinal immobilization was the Chairback (Knight) brace, a finding which probably reflects its national popularity. </p> <p> While external supports are seldom used for psychological reasons, when the practice is followed the corset is the most popular device, followed by the Chairback brace. </p> <p> The concept of unloading the disc has obviously not been accepted by the majority of orthopedic surgeons, since only 8% indicated this as a function of external support. However, those who did think in these terms showed a strong preference for the Williams brace, with a cast as an alternate. </p> <p> Focus on the individual types of support showed that the prime functions of the corset were considered to be abdominal support and restriction of lumbosacral motion. The Chairback (Knight) brace was assigned the same functions, but with greater emphasis on restriction of motion. This function was also considered the main purpose of the Williams brace, with correction of posture as its second indication. Casts were generally used to restrict lumbosacral motion, although a surprisingly larger number were also assigned the function of correcting posture. Consistent with the belief that immobilization, as opposed to restriction of lumbosacral motion, is seldom accomplished with external support, even casts were assigned this as a third function. </p> <p> In addition to completing the survey form, a third of the respondents (1,034) added notes to further explain their preferences. These varied from a single listing of a specific brace to lengthy letters explaining their philosophies of low-back management. A majority of these replies were focused on either the fitting or construction characteristics of their support preferences. </p> <p> Sixty respondents emphasized the advantages of using exercise early in the treatment of low back pain. Two purposes were expressed: to avoid external support and to overcome the muscle weakening and contracture development that accompanies prolonged immobilization. One respondent summarized this philosophy very succinctly by stating he "never prescribed support without a plan to eliminate it." A smaller group (30) felt that the disadvantages were sufficient to preclude any prescription of external support. All who said they "never" or "rarely" used support emphasized instead their reliance on an organized program of exercise. Specific application of this philosophy was frequently mentioned in relationship to postoperative management of spine fusions. Many respondents also brought out the fact that the treatment of low back pain must be individualized to fit the particular patient's need. This fact must never be forgotten, of course, and the purpose of the survey was not to contradict the concept of individualized patient care, but merely to identify the spectrum of external support which physicians have found adequate to meet their multiple goals. </p> <h4> Discussion </h4> <p> The potential list of 40 external-support designs for low back pain has been severely pruned by the influences of prolonged clinical experience, greater intermingling of orthopedists through professional meetings, and the use of prefabricated parts. Notes by some of the respondents indicated that cost, emphasis on exercise, and early surgery are other important influences. </p> <p> The clinical indications for use or non-use of external support were rather sharply defined, but there is no comparable distinction between the accepted styles of support. The latter was indicated by the overlap between clinical entity and support design, as well as by the identification of the functions of the different devices. The mechanical characteristics and the limitations of these various designs which lead to such ambiguity have yet to be objectively identified. </p> <p> Investigators<a></a> have found that, unless the support is carefully designed, motion at the lumbosacral joint could be increased with the support rather than </p> <p> restricted. Personal experience indicates that this might also lead to increasing the patient's pain. </p> <p> A problem still not studied is identification of the characteristics of the patients which govern the choice of support. </p> <h4> Summary </h4> <p> The lumbosacral corset is the most commonly prescribed external support for low back pain. The Chairback (Knight) and Williams braces are next in preference, with a cast being used least frequently. There is a definite relationship between the etiology of the low back pain and the type of support chosen. The major indication for support prescription is to restrict lumbosacral motion. </p> <p><b>References:</b></p> <ol> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, </i>J. W. Edwards, Ann Arbor, Mich., 1952. </li> <li>Nattress, LeRoy Wm., Jr., and Bertram D. Litt, <i>Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, </i>American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </li> <li>Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, <i>J. Bone Joint Surg., </i>39A:111-139, January 1957. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Nattress, LeRoy Wm., Jr., and Bertram D. Litt, Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">American Academy of Orthopaedic Surgeons, Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, J. W. Edwards, Ann Arbor, Mich., 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jacquelin Perry. M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Kinesiology Service, Rancho Los Amigos Hospital, Downey, Calif.; Associate Clinical Professor of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Use of External Support in the Treatment of Low Back Pain Creator An entity primarily responsible for making the resource Jacquelin Perry. M.D. * https://staging.drfop.org/files/original/37c3fec692e2b57f47245df169887b35.pdf 4946ee134a3401f408e0f322622aa167 https://staging.drfop.org/files/original/cda236ac9cde9b85325e3b96250a8f34.jpg 26aeac3a42f4a49224918f719d96a7bf https://staging.drfop.org/files/original/61e5df6689a2f5df64d735ec336e8dd7.jpg 25e56e96ed63a1d92e654c1dfd5447c9 https://staging.drfop.org/files/original/fd0fd82498d9cf6124c858bd221e6da0.jpg ceb9e4d935e7a64a1a6b54d44300cd2f https://staging.drfop.org/files/original/d3c8b0e372904833805dd1044f5bb20f.jpg b836b034c8fba7dd52dcbf61c62f7557 https://staging.drfop.org/files/original/c807aa7a3fefd3330cb672958e4f9744.jpg cef35b057b604843a8fda814493e07bd https://staging.drfop.org/files/original/ef44f82ae71f82036a91bd66e369ab5f.jpg 0a8cf7b7df88f1f5875f99e02d60f2a1 https://staging.drfop.org/files/original/aae5019d6873ca6c365835a4c4706720.jpg ebaef7afe5ead98ddf0119032fb488da https://staging.drfop.org/files/original/00f96c383c511633e3f05f8c9f266f5b.jpg 17c8c67c8c1a64cd510eedfe1639eb79 https://staging.drfop.org/files/original/0b29948807ab4359f31ff27cd2112168.jpg 1cafb32b82c0b235dc700d48c8dcba50 https://staging.drfop.org/files/original/9500eb71d186ca76e567a337583202af.jpg e86c2a546d0bea141aba88885bd080ed https://staging.drfop.org/files/original/5644f8d878cf4491ab0b287029eb3741.jpg 0d76a9bdf9ccd33b508307f1bd262151 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_105.pdf Text Any textual data included in the document <h2>The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses</h2> <h5>C. Michael Schlich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The need for improved prosthetic socket designs to increase amputee comfort and function has long been recognized by prosthetists and other health care professionals involved in amputee rehabilitation. Reduction of the hardness and stiffness of wood and plastic laminate sockets has been addressed with various soft liners or inserts in an attempt to improve comfort and function. The subject is well covered in literature from Radcliffe's and Foort's initial description of leather and Kemblo® liners in 1961,<a></a> through Leon Bennett's work with gel liners in 1974,<a></a> to Tim Staats' description of multi-durometer liners in 1984.<a></a> Liners have no doubt been useful in below-knee prosthetics, but the proponents of soft liners seem to have overlooked the potentials offered by flexible brims.</p> <p>At least two engineers active in prosthetics research have for some time raised questions concerning socket brim stiffness as a negative factor with respect to socket comfort. Dr. Eugene Murphy first considered this theme as early as 1957<a></a> when he proposed, "minimize the stiffness gradient between the rigid socket wall and the flexible skin, i.e., taper flexibility of the socket brim." As Dr. Murphy<a></a> later relates:</p> <blockquote> <p>"This theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett. The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months."<a></a></p> </blockquote> <p>In the course of developing the ultralight weight below-knee prosthesis at Moss Rehabilitation Hospital,<a></a> A. Bennett Wilson, Jr. recognized the possibilities afforded by the use of thermoplastics to achieve flexible brims that would be sufficiently durable. During the past year, we have been funded by the Veterans Administration Rehabilitation Research and Development Service to carry this idea further.</p> <p>After reviewing the theories set forth previously and considering the properties of new materials and techniques now available, a set of criteria for socket design was established:</p> <ol> <li> <p>Flexible brim</p> </li> <li> <p>Tapering flexibility of the socket in the brim area</p> </li> <li> <p>Flexibility options in other areas of the socket</p> </li> <li> <p>Light weight, but durable</p> </li> <li> <p>Thermoplastic and modular (i.e. no lamination, no epoxy, no glue, etc.)</p> </li> <li> <p>Compatibility with existing modular component systems</p> </li> </ol> <p>The resulting socket design (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg"><b>Fig. 1</b></a>) consists of the following components: (1) a Surlyn® inner socket or liner; (2) a polypropylene frame for socket support and attachment; (3) silastic foam soft end pad for establishing total contact; (4) United States Manufacturing Company<a></a> adaptor hardware<a style="text-decoration: none;">*</a> for attachment to Otto Bock<a></a> modular systems; and (5) neoprene sleeve suspension.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg"><strong>Figure 1. Complete prosthesis, except for cos-mesis and suspension, incorporating a socket with flexible brims.</strong></a><br /> <p>Fabrication of this socket system is as follows:</p> <ol> <li> <p>The cast is modified for a PTB-supracon-dylar socket design, and the distal end of the model is extended approximately one inch to allow for a silastic foam end pad and the modular adaptor (U.S. Mgf. Co.) for connection of the pylon to the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg"><strong>Figure 2. The modi-fled plaster model of the stump is extended to allow for location and alignment of the U.S.M.C. adaptor connector plate for the pylon.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg"><strong>Figure 3. The modified plaster model complete with adaptor, ready for vacuum-forming of the Surlyn® inner socket.</strong></a></li> <li> <p>An inner liner of Surlyn® is vacuum formed using either 12" x 12" x 3/16" Surlyn® for light to regular duty sockets, or 12" x 12" x 1/4" Surlyn® for heavy duty sockets (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg"><strong>Figure 4. Vacuum-forming the Surlyn® inner socket.</strong></a></li> <li> <p>One layer of thick stockinette and a nylon stocking are applied over the vacuum-formed Surlyn® liner to facilitate separation of socket frame and liner (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg"><strong>Figure 5. Application of stockinette and nylon sock over Surlyn® inner socket to provide for separation of the polypropylene outer socket to be vacuum-formed over it.</strong></a></li> <li> <p>The socket frame is vacuum formed of polypropylene directly over the inner socket. A piece 12" x 12" x 3/8" is suitable for light duty while a piece 1/2" thick is usually adequate for heavy duty (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg"><b>Fig. 6</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg"><strong>Figure 6. The outer socket frame is vacuum-formed over the inner socket</strong></a></p> </li> <li> <p>After the final vacuum forming stage, the socket liner and socket frame are separated from each other and from the cast model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg"><strong>Figure 7. The inner socket and socket frame before trimming</strong></a></li> <li> <p>The Surlyn® liner is trimmed for a PTB-SC design and the polypropylene frame is trimmed for a PTB socket design and is fenestrated over the tibial crest anteriorly and the gastrocnemius area posteriorly (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg"><strong>Figure 8. The socket frame and inner socket after trimming</strong></a></li> <li> <p>The Surlyn® liner is now inserted into the polypropylene frame (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg"><strong>Figure 9. The socket frame and inner socket assembled.</strong></a></li> <li> <p>The U.S. Manufacturing Co.<a></a> adaptor hardware is used to attach the socket to the Otto Bock<a></a> titanium modular endo-skeletal components and an appropriate foot.</p> </li> <li> <p>During initial fitting, the distal end pad is foamed in place while the patient stands to provide total contact.</p> </li> </ol> <p>The Otto Bock modular system has sufficient range of adjustment to suffice for alignment of prostheses for most geriatric patients. However, the use of the Berkeley BK alignment device might be desirable for some of the more active patients (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg"><b>Fig. 10</b></a>). A special adaptor plate is made of 1/8" aluminum sheet so the Otto Bock 4R22 adaptor component can be used between the socket and the alignment device.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg"><strong>Figure 10. View showing adaptor needed when the UCB adjustable below-knee "leg" is used for alignment trials.</strong></a><br /> <p>Cosmetic finishing may make use of any of several foam cover systems available, such as the round styrofoam cover available from the U.S. Manufacturing Company (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg"><b>Fig. 11</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg"><strong>Figure 11. The completed prosthesis with cosmetic stocking pulled down to show the carved styrofoam cover.</strong></a><br /> <p>Below-knee patients fitted at the University of Virginia during the past two years, who voluntarily agree, are being refitted by their original prosthetist with the flexible brim thermoplastic system described here. Our initial conclusions are very positive. To date, eight flexible brim thermoplastic sockets have been fit on seven patients, with one patient having worn his for over one year. There have been six fittings since February, 1986. Only one socket failure has been noted, that of the Surlyn® inner flexible socket which split along the tibial crest on a patient weighing over 350 pounds. That particular socket lasted approximately four months. Though not indicated for use on someone of this weight, we were interested in determining its durability limits.</p> <p>Subjective evaluation includes patient questionnaires and comments, comparing their existing prosthesis with the new flexible brim thermoplastic socket system. Patient reaction, thus far, indicates enhancement of patient comfort and awareness of reduced prosthesis weight, especially with our geriatric subjects. Although not originally designed for geriatrics, this patient population has specific needs that can be met by this socket design, such as socket flexibility, less confining brim, reduced proximal shear forces, and extreme light weight. When used with Otto Bock titanium modular components and a "Lite" SACH foot, this system weighs between one and a half and two pounds.</p> <p>Current objective evaluation includes collecting heart rate and step count data in the patient's home environment, using a newly developed ambulatory physiological monitoring system. This includes physiological data with the patient's existing prosthesis in addition to that collected with the flexible brim thermoplastic socket system. This system of patient monitoring, or surveillance, electronically records heart beats (EKG), standing versus sitting posture, and step count, plotted against time up to 24 hours. The goal is to document any changes in activity level and energy expenditure that occur with use of new prostheses, such as the flexible brim thermoplastic socket system presented in this paper.</p> <p>In conclusion, a new socket design rationale and system utilizing existing thermoplastic materials has been presented. Patients fit with this system are currently being evaluated both subjectively and physiologically. Fittings and evaluations will continue until a significant number are completed and related data gathered. A follow up report will follow with final conclusions and statistical data presented.</p> <p><b>References:</b></p> <ol> <li>Bennett, Leon, "Gel liner effects," <i>Bulletin of Prosthetic Research</i>, BPR 10:21; Spring, 1974, pp. 23-53.</li> <li>Otto Bock Orthopedic Industries, Inc., 4130 Highway 55, Minneapolis, MN 55422.</li> <li><a href="cpo/1984_03_004.asp">Murphy, Eugene F., "Sockets, Linings, and Interfaces," <i>Clinical Prosthetics and Orthotics</i>, 8:3, Summer, 1984, pp. 4-10.</a></li> <li>Murphy, Eugene F., "Transferring Load to Flesh," <i>Bulletin of Prosthetic Research</i>, BPR 10:16; Fall, 1971, pp. 38-44.</li> <li>Radcliffe, C. W., and J. Foort, "The Patellar-Tendon-Bearing Below-knee Prosthesis," Biomechanics Laboratory, Dept. of Engineering, Univ. of Calif., Berkeley, and School of Medicine, Univ. of Calif., San Francisco, 1961.</li> <li>Staats, Timothy B., "Multiple Durometer Socket Liners for P.T.B. Prostheses," <i>Orthotics and Prosthetics</i>, 38:4, Winter, 1984, pp. 63-68.</li> <li>United States Manufacturing Co., 180 North San Gabriel Boulevard, Pasadena, Calif., 91107.</li> <li>Wilson, A. Bennett, Jr., "Ultralight Prostheses for Below-knee Amputees," <i>Orthotics and Prosthetics</i>, 30:1, March, 1976, pp. 43-48.</li> </ol> <div style="width: 400px;"><b>Footnote</b> USMC Part Nos. 41014, 42012, 43026, and 29316<br /><br /></div> <em><b>*A. Bennett Wilson, Jr. </b> The Department of Orthopedics and Rehabilitation at the University of Virginia.</em><br /><br /><em><b>*C. Michael Schlich, C.P.O. </b> The Department of Orthopedics and Rehabilitation at the University of Virginia.</em><br /> <div style="width: 400px;"><br /><br /></div> <div style="width: 400px;"></div> Page Number(s) 105 - 110 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 10 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/5fbec4052a52f2f96c332992054740bd.pdf 20e1c68a1e68c26c17ebe0dcbed427db https://staging.drfop.org/files/original/1aa501ac55eba1dc5a0b97d8b3391563.jpg 1c3a60d6625ab486da03f8e2fc2f4e77 https://staging.drfop.org/files/original/16e17501c3eb200567a45563f807c9bd.jpg a2e25a04633c58de9d3fe329ed8a47d6 https://staging.drfop.org/files/original/6dc1d516628f4acd9f6a74eea19e37e0.jpg d80207c27684f55a49e165cd49c6f76a https://staging.drfop.org/files/original/f8ee04e92547ecb0cde7b37fab8d661f.jpg ecad7b10960f167cd183869d747a981e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_024.pdf Text Any textual data included in the document <h2>The Use of the AFO and PTB Orthoses for Severe Pes Planus</h2> <h5>Gustav Rubin, M.D., F.A.C.S.&nbsp;<a style="text-decoration: none;">*</a><br />Malcolm Dixon, M.A., R.P.T.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>When the severely deformed pes planus foot is rigid, the deformity fixed, and the arch totally dropped, to provide the patient with a conventional molded arch "support" is an exercise in futility. Placement of a shoe insert under the non-existent long arch cannot prevent further dropping on weight-bearing if the talar head is already in contact with the floor and the intertarsal joints are immobile.</p> <p>It is the purpose of this paper to report the use of the Ankle Foot Orthosis and Patellar Tendon Bearing Orthosis for such a situation.</p> <p>Because it would not be feasible to attempt to raise the arch of a rigid foot with an orthosis, the authors decided to employ an orthosis to decrease stresses on the foot and ankle by transferring push-off forces to an AFO.<a></a> This was to be accomplished by fabricating the orthosis with a solid ankle and modifying the shoe to incorporate a long steel spring and a rocker bar. Since it was anticipated that this approach might not provide adequate relief, it was considered that the next procedure would be to introduce partial unweighting with a Patellar Tendon Bearing Orthosis.<a></a> This would also be fabricated with a solid ankle and include a shoe with a long steel spring and a rocker bar.</p> <h3>Case Report</h3> <p>B.L., age 62, was initially referred to the VA Prosthetic Center on June 14, 1982, with a history of painful feet since World War II, which had become worse in recent years. The patient stated that "my feet are going to collapse and I can hardly walk and barely make it when I stand and walk." He had a cerebral vascular accident on January 18, 1982, but had made an almost complete recovery. There was also a history of aortic valve insufficiency and gout. The patient was receiving Coumadin, in-deral, digoxin, and allopurinal for his medical problems. He had not had relief of his foot pain from arch supports in the past.</p> <p>On examination there was noted medial downward dislocation of the talar heads, abduction of the forefeet, absence of the long arches, marked restriction of joint motion, marked splaying of the forefeet and severe hallux valgus, bilaterally (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg"><b>Fig. 1</b></a>). The dorsalis pedis and posterior tibial arteries were palpable.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg">Figure 1.</a> The severe bilateral pes planus noted when patient was first seen at VAPC.</strong><br /> <p>X-Rays confirmed the clinical findings of severe pes planus and hallux valgus bilaterally. The patient's private orthopedic surgeon had fit him with short AFOs (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg"><b>Fig. 2</b></a>). These were a significant improvement over previous arch supports, but were bio-mechanically inefficient. Bilateral solid ankle AFOs and shoes with long steel springs and rocker bars were prescribed (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg"><b>Fig. 3</b>)</a>.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg">Figure 2.</a> Orthosis prescribed by patient's private orthopedic surgeon.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg">Figure 3.</a> Bilateral AFOs and shoe corrections prescribed at the VAPC.</strong><br /> <p>On July 16, 1982 the patient reported that he was much more comfortable.</p> <p>When re-evaluated on October 21, 1982 it was indicated that the left side was subjectively worse than the right. He was experiencing very painful weight-bearing directly on the talar head. The "comfort" that he had reported in the previous note was relative. A PTB orthosis was prescribed for the left side (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg"><b>Fig. 4</b></a>), in accordance with the originally outlined plan of procedure.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg">Figure 4.</a> The final prescription included an AFO on the less symptomatic right side and a PTB orthosis for the left side.</strong><br /> <p>On April 19, 1983 the patient stated that the PTB was an improvement over the AFO.</p> <p>On August 7, 1984 he returned for a new orthosis because of loss of fit. The patient had lost weight following cardiac surgery for aortic valve replacement and triple bypass in March, 1984.</p> <p>On October 4, 1984 he reported that the new orthoses were "comfortable, that he feels much better with them, and is able to ambulate." He and his wife both stated that he "would not be able to walk" without these orthoses.</p> <h3>Discussion</h3> <p>Severe pes planus of the type described in this report can only be helped to a limited degree by orthoses. However, if a maximally efficient approach is employed, the limited degree of relief can be significant and allow an almost non-ambulatory patient to achieve a useful degree of ambulation.</p> <p>A solid ankle AFO not only functions to stabilize the ankle and foot, but when combined with shoe corrections (rocker bar and long steel spring), it acts to diminish the stresses on the foot and ankle. The PTB provides, in addition, partial unweighting while retaining the features that permit transfer of forces to the orthosis.</p> <p>We have employed the AFO in other similar instances, but this was the first occasion in which we employed the PTB for severe pes planus.<br /><br /><em><b>*Malcolm Dixon, M.A., R.P.T. </b>Malcolm Dixon, M.A., R.P.T., is Chief of Clinical Services at the Veterans Administration Prosthetics Center.<br /><br /><b>*Gustav Rubin, M.D., F.A.C.S. </b>Gustav Rubin, M.D. F.A.C.S., is Chief of Special Clinics at the Veterans Administration Prosthetics Center, 252 7th Avenue, New York City, New York 10001.</em></p> <p><b>References:</b></p> <ol> <li>Rubin, Gustav; Dixon, Malcolm; and Danisi, Michael, "VAPC Prescription Procedures for Knee Orthoses," <i>Orthotics and Prosthetics</i>, 31:3: pp. 9-25, September, 1977.</li> <li>Rubin, Gustav, "Patellar-Tendon-Bearing (PTB) Orthosis," <i>The Bulletin of the Hospital for Joint Diseases</i>, XXXIII:2: pp. 155-172, October, 1972.</li> </ol> Page Number(s) 24 - 26 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Use of the AFO and PTB Orthoses for Severe Pes Planus Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., F.A.C.S. * Malcolm Dixon, M.A., R.P.T. * https://staging.drfop.org/files/original/bfcefefb32a201912fdc868f0f0cc04e.pdf 0148ecdd9b99d82897c6b1c95fb4d6cd Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_001.pdf Text Any textual data included in the document <h2>To Check Out Or Not To? That Is The Question</h2> <h5>Kurt Marschall, CP&nbsp;</h5> <p>It is now over twenty-five years since the introduction of intensive short-term courses in prosthetics and orthotics at New York University, Northwestern, and the University of California at Los Angeles. These condensed courses have benefitted every practitioner, not only in his practical approach to patient management, but also in his inter-relationship with his peers through a unified and common language that we call "nomenclature." In countless cases, these formal educational courses have served as a springboard to successful completion of the certification examination.</p> <p>It was the Veterans Administration which at that time took the primary responsibility of disseminating and funding prosthetic research programs. Their Clinic Team approach became very popular, leading to the simultaneous education of physicians, therapists and prosthetists/orthotists. Undoubtedly, this close relationship of the three disciplines, working together for one common goal, namely, the rehabilitation of the disabled, has narrowed a gap that formerly was all too visible. I feel it has also helped to lift the field of prosthetics and orthotics out of the dark age, out of its sole "craftsmanship concept" into the more comprehensive classification of "professionalism"—all in all, an appropriate tribute that was long overdue.</p> <p>Every prosthetist/orthotist, having successfully completed these short-term courses, came out a better person, a better clinician. The physician and therapist, by the same token, gained insight into our field as never before. Now all three disciplines in their deliberations at clinic meetings spoke at the same level through a unified language, and intelligent solutions were arrived at by understanding the underlying problems.</p> <p>A by-product of this progressive and noteworthy approach was the respect the prosthetic/orthotic practitioner gained from the medical and paramedical professions, once his continued striving for excellence in performance and elevation of standards was realized by them. This respect, however, was not attained very easily. In our quest for sharing the knowledge and insight into our field with the physician and therapist, we also committed a monumental mistake—making them experts in the fitting, alignment and fabrication of every prosthetic/orthotic device there is. Without realizing it at the time, we gave into their hands a powerful tool, even further, a most powerful weapon —<em>the check-out sheet!!!</em></p> <p>There, in black and white, we developed a questionnaire telling them exactly how to pick a device apart, piece by piece, making them the sole, omnipotent judge of whether to pass or fail it. By setting up this systematic method of examining our devices we have admitted that one cannot trust our professional judgment or technical expertise. I know of no other group in the health care profession that has so mindlessly relinquished its professional prerogatives and intricate understanding of a subject to another discipline, with certainly less knowledge of the particular subject, for its scrutiny. Even today, after 25 years of continuous upgrading, we sheepishly subject ourselves to this procedure. This permits even a therapist fresh out of school, but equipped with a check-out sheet, to suddenly become powerful and to be feared for his or her "judgment" when check-out day rolls around. Countless man-hours and precious components and materials have been wasted when physician and therapist could not see eye-to-eye with the prosthetist/orthotist on alignment, fitting and finishing procedures. A device often had to be altered, sometimes even done over entirely, for rather trivial reasons, not to mention the immense damage inflicted on the patient-prosthetist/orthotist relationship when these so-called "problems" were hashed out in the open, for everyone to hear, rather than in a more private setting.</p> <p>There is no doubt in my mind that the level of education and the competence of every prosthetist/orthotist has risen tremendously in the last two and one-half decades, especially for one who takes advantage of the continued education process. He is a better person than he was 25 years ago, and his knowledge of the subject, "Prosthetics and Orthotics," is vastly greater than that of a physician or therapist. He is a professional who will, without complaint, work his way around a poorly-amputated limb that may not be to his liking for fitting purposes and come up with a functional prosthetic device without asking the surgeon for a revision. He will produce an adequate prosthetic device despite flexion contractures and edema, due to insufficient exercise and lack of proper stump-wrapping.</p> <p>Nobody denies the need for a check-out after a prosthetic/orthotic device has been completed. But yesterday's check-out sheet should be scrapped in its entirety —the sooner the better—and replaced with one consisting of only three questions:</p> <ol> <li>Is the prosthesis/orthosis as prescribed?</li> <li>Is the patient comfortable?</li> <li>Is the prosthesis/orthosis functional?</li> </ol> <p>The above criteria should more than satisfy any physician or therapist.</p> <p>The decision as to pleasing cosmetic appearance, insofar as possible, should be left to the patient.</p> <p>The decision on whether or not accepted standards and principles have been met in the fitting, alignment and fabrication of the device, should be entirely that of the prosthetist/orthotist.</p> <p>The field of prosthetics and orthotics has come of age; so have its practitioners. The check-out sheet has not kept pace with changing times and should be abolished in its present form.</p> Page Number(s) 1 - 2 Year 1979 Volume 3 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource To Check Out Or Not To? That Is The Question Creator An entity primarily responsible for making the resource Kurt Marschall, CP  https://staging.drfop.org/files/original/9278e2810ea9f78e2de4c8bba8abbd72.pdf a774a49fa86c90712363d0801131e532 https://staging.drfop.org/files/original/08588a42be997361ba8f0142b7823983.jpg bee92071ff1c11bb2d2ceb61ca93b3df https://staging.drfop.org/files/original/9c17baf3b9691a8d9a37cdce7212e703.jpg feecd87d738ea94d1b39cc924df85985 https://staging.drfop.org/files/original/3d034d5f3443f358031dab6eba679d06.jpg 1f5e08192e9e7ef11a3299d1f9749209 https://staging.drfop.org/files/original/451f37e9c36d349733b74e0af0e323d3.jpg 232044070b13d5921ba696566e6e560e https://staging.drfop.org/files/original/efaaeec0404c6bfdb706ef31a7cc8773.jpg 31daf4bc27bde9e0a78a2d1ffc3a261f https://staging.drfop.org/files/original/11ccde34591e33f4bf94ae477a409147.jpg 32fd97e2284084e280a5a3c40bc68e12 https://staging.drfop.org/files/original/b9380eca06f68f68dc024f24e35ce0fa.jpg bf40832a2704e549a6292d2e59bc98bb https://staging.drfop.org/files/original/c7b17c455f05352581a7c7a67769c333.jpg 7c8cbab28c7a54a0495778bcbf11af86 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_036.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 36 - 41 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_036.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Toronto Orthosis for Legg-Perthes Disease</h2> <h5>W. P. Bobechko, M.D., F.R.C.S.(C.) <a style="text-decoration:none;">*</a><br />C. A. McLaurin, B.A.Sc, P.Eng <a style="text-decoration:none;">*</a><br />W. M. Motloch <a style="text-decoration:none;">*</a><br /></h5> <p>The treatment of Legg-Perthes disease has been given considerable attention at the Hospital for Sick Children in Toronto during the last few years. It is now known that certain types of Legg-Perthes disease have a good prognosis regardless of the type of treatment used, whereas other types tend to have a poor prognosis. Proper prescription of treatment must, therefore, recognize this difference in prognosis.</p> <p>Attempts have been made to assess the outcome of the disease on the basis of age at onset and the degree of involvement of the ossific nucleus of the femoral head.</p> <p>In children who develop Legg-Perthes disease prior to the age of five years, the prognosis tends to be better than in a child who develops the condition at an older age. This difference is probably related to the total mass of bone that has to be re-ossified, since it has been noted that in a smaller femoral head the time for re-ossification is often shorter, being in the vicinity of 12 to 18 months compared to several years for an older child.</p> <p>The degree of involvement also plays a most important part, and attempts have been made here to differentiate between cases where the entire femoral head is involved, with avascular necrosis of the entire ossific nucleus, and those where merely a portion is involved. The partial-head-type of Legg-Perthes disease carries a much better prognosis and is less liable to deformity, since a part of the femoral head remains uninvolved.</p> <p>If there is any tendency towards the formation of a metaphyseal cyst, the possibility of a poor long-term result is increased.</p> <p>The stage at which the patient is first seen is of the utmost importance. If the child is seen early in the course of the disease, before joint deformity has occurred, proper management, if instituted quickly, can often result in a congruous joint. If, however, there is already considerable flattening and subluxation when the child is first seen, then the result, of course, cannot be as good. If the entire process of reossification has already occurred by the time the child is first seen, the golden opportunity has passed, and at this stage only secondary reconstructive procedures can be carried out, with even less satisfactory results.</p> <p>Certain selected cases are suitable for innominate osteotomy, in which the femoral head is covered and seated just as if the hip were held in abduction and internal rotation. At present, innominate osteotomy is restricted to the child who carries an unusually bad prognosis; that is, a child over the age of six years with total involvement of the femoral head. In addition, an arthrogram must be made to be certain that a significant joint deformity is not already present. If a deformity is present, innominate osteotomy is contraindicated. In addition, prior to the use of an innominate osteotomy, full joint movement must be obtained, which sometimes will require traction or soft tissue release of contracted structures, such as the psoas tendon.</p> <p>In the very young child with only a part of the head of the femur involved, often no treatment is indicated, provided that no soft tissue contractures have occurred. If soft tissue contractures are present, then soft tissue release may suffice, with or without a short period of traction.</p> <p>This leaves a small group of children for whom bracing may be used to advantage. These children would typically be in the under-six age group, with partial or total head involvement and with free joint movement, before deformity has set in.</p> <p>In the past, ischial weight-bearing braces have been used in the treatment of Legg-Perthes disease with little regard for the various forms and severity of the disease process. Cineradiography has revealed that as the patient walks with an ischial-bearing brace the involved hip tends to move medially and laterally, a condition which may contribute to subluxation and further flattening in the form of a coxa plana; therefore, use of such braces has been discontinued at the Hospital for Sick Children.</p> <p>In 1957, Dr. William Craig<a style="text-decoration:none;">*</a> of Los Angeles first reported <a></a> the use of the abduction and internal rotation method of treatment of Legg-Perthes disease, a procedure which has been modified by Dr. Gordon Petrie<a style="text-decoration:none;">*</a> of Montreal. <a></a> When a child was allowed to bear weight on the legs in the abducted cast, it was found that a remodeled femoral head would, in fact, develop in a spherical fashion in its round and uninvolved acetabulum. This method has proved satisfactory in many instances, but there are certain disadvantages. Because the child's legs must be kept in abduction for a period of several years, cast changes must be made at 8-to 12-week intervals. Considerable stiffness develops about the knees and ankles and, in some instances, there has been a suggestion of flattening of the femoral condyles because of the continuous pressure that is applied to the knee as it is held in one position over a prolonged period of time. In addition, prolonged plaster immobilization encourages the development of osteoporosis, atrophy of muscle, pressure sores, and other problems.</p> <p>To eliminate some of the problems encountered with the use of abduction casts, a new type of articulated experimental brace has been designed. Known as the "Toronto Legg-Perthes Brace," it provides for 90-deg. abduction and slight internal rotation, yet allows hip and knee movements so that the child may ambulate and sit (<b>Fig. 1</b> and <b>Fig. 2</b>). With the brace, the child is encouraged to walk as much as possible, for it is the weight-bearing movement with the hips centered in a safe position that encourages successful remodeling of the femoral head during growth. The brace is removed easily, but the child, of course, must not be allowed to walk without the brace. It is emphasized that at present (1968) this brace has been used on an experimental basis for the past 18 months, and we do not yet have any indications as to whether any problems will develop, such as those that were produced by ischial weight-bearing braces which, in fact, produced a coxa plana and probably did more harm than good. Cineradiography on one patient has indicated that the femoral head does stay within the acetabulum during loading and unloading of the joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front and rear views of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Toronto brace for Legg-Perthes disease in use. <i>Left, </i>Three-quarter view in the standing position; <i>Right, </i>side view in the sitting position. Note that the thighs are maintained in the abducted position at all times. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sixteen patients are presently using the Toronto brace and, in our present state of knowledge, this new type of brace appears to fulfill all the criteria set forth.</p> <h3>Biomechanics</h3> <p>The Toronto brace holds the legs in 90-deg. abduction with respect to each other, with the feet rotated internally. The body weight, when the patient stands erect, is distributed axially through each leg to each foot. The shoes are fastened to blocks of wood with the plantar surface at an angle of 45 deg. to the floor. The foot blocks are tied together by rods which are rigidly attached to the blocks but articulated at the sagittal plane. The force diagram is shown in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Resolution of forces being applied to patient using the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each tie rod is connected by a ball joint to a rigid frame that supports the two thigh cuffs. The thigh cuffs take no load when the patient stands with knees extended, yet the hips are held in abduction as the knees are flexed. The geometry permits each knee to flex independently of the other (<b>Fig. 4</b>) and, because ball joints are used, accurate alignment is not necessary. The ball joints also allow dorsi-plantar flexion of the foot block (<b>Fig. 5</b>). Because the plantar surface of the shoe and foot is at 45 deg. to the floor, plantar flexion of the foot itself is accompanied by toe-in and dorsiflexion of the foot is accompanied by toe-out. Otherwise, toe-in and toe-out are securely held to the appropriate angle (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic view from the front of the Toronto brace for Legg-Perthes disease to show the geometry of the system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Location of the shoe with respect to the foot block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic view from the top of the Toronto brace, showing angular position of the sole of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fitting and Fabrication</h3> <p>The first step in fitting and fabrication of the Toronto orthosis is to make a tracing of the patient's legs and pelvis when he is supine with each leg abducted 45 deg. from the center line of the body. (If this cannot be accomplished, traction or soft tissue release is indicated before fitting can proceed.) The shoes are put on the patient's feet so that the edge of the sole is traced rather than the edge of the foot itself, because the shoes are a part of the total structure. The following information should be indicated on the tracing (<b>Fig. 7</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical tracing needed for fabrication of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The position of the thigh cuffs, which should be 1 in. above the patella and 2 in. below the groin.</li><li>The position of the shoe, when the sole of the shoe is placed at a 90-deg. angle to the long axis of the leg.</li><li>The position of the knee axis.</li><li> Measurements of the lower (LC) and upper (UC) circumferences of the thigh cuffs.</li></ol> <p>The frame, joint block, tie rods, foot blocks, and thigh cuffs are outlined on the tracing to facilitate fabrication.</p> <h3>Frame</h3> <p>The frame, which supports the thigh cuffs and joint block, is made from 1 in. X 1/4<i> </i>in. 24ST-4 aluminum bar, bent cold into a more or less diamond shape to conform to the tracing, and attached to the upper sides. The joint block is attached to the lower apex.</p> <h3>Joint Block</h3> <p>The purpose of the joint block is to provide a firm mounting for the ball joints to which the tie rods are attached. The block is assembled from five sections cut from 3 in. X 3 in. X 1/2 in. 65 ST (or equivalent) aluminum angle. Two automotive-type tie rods and joints are used for the ball joints,<a style="text-decoration:none;">*</a> which are located in the block so that they are in line with the knee axis. The threaded shank of the socket is bent to a 45-deg. angle before being brazed to the tie rod (<b>Fig. 8</b>). The tapered shank (Morse taper no. 1) on the ball of the joint is fitted to a hole in the joint block when the Chevy II part is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Method of bending threaded shank of the ball joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Tie Rods</h3> <p>The tie rods which connect the joint block with the foot blocks are made from chrome molybdenum tubing, 3/4 in. O.D. X .056 in. wall thickness. Tubing of this strength is required to resist damage that may be encountered with curbs, steps, etc. One end of the tie rod is brazed to a foot-block plate and the other end to the threaded shank of the joint.</p> <h3>Foot Blocks</h3> <p>The foot blocks are used to secure the shoes to the rods and support the shoes at the correct angle. Each foot block consists of a metal plate and a triangular block of wood. The metal plate is brazed to the distal end of the tie rod, and the wooden block is fastened to the plate with epoxy resin and wood screws. The shoes are fastened to the sloping surface of the wood block with rubber cement and wood screws. Note that the shoes are aligned on the block with approximately 15 deg. to 20 deg. internal rotation, as shown in <b>Fig. 6</b>. The bottom surface of the blocks should be covered with a tough soling material. A section of automobile tire is very serviceable, but tends to mark floors. It can be fastened on with rubber cement and wood screws. Frequent replacement is usually necessary.</p> <h3>Thigh Cuffs</h3> <p>The thigh cuffs should fit from 2 in. below the groin to 1 in. above the proximal border of the patella. The distal posterior edge should be flared to minimize discomfort in the popliteal area when the knees are flexed. The cuffs should be made to fit (not too tightly) over the trousers. They should be made from a semi-flexible material with a lateral opening so that the brace can be put on and taken off readily. Velcro straps provide a convenient method of adjustment. Cuffs made at the Centre were formed from a thermoplastic material from Smith and Nephew called "San Splint." A similar material, "Orthoplast," is marketed by Johnson and Johnson. The thigh cuffs and Velcro straps have required frequent replacement in active patients.</p> <h3>Gait Training</h3> <p>Usually about three days of intensive training by a physiotherapist are required for the child to learn to walk in the brace. Two crutches are used. They are usually held in front of the body, although the occasional child keeps one crutch behind. Stairs and curbs can be negotiated with little difficulty, and some patients learn to walk without crutches for short distances.</p> <p>The braces are removed for bathing, swimming, and sleeping, but the child must never be allowed to stand, kneel, crawl, or walk without the brace.</p> <p><b>References:</b></p> <ol> <li>Craig, William, Personal communication, 1967.</li> <li>Petrie, Gordon, Personal communication, 1968.</li> <li>Salter, Robert B., <i>Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip</i>, J. Bone Joint Surg. (Brit.), 43B:3:5l8-539, August 1961.</li> <li>Salter, Robert B., Personal communication, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Joints from a 1965 Chevy II have been used satisfactorily.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Petrie, Gordon, Personal communication, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. James A. Petrie, Orthopaedic Surgeon, Royal Victoria Hospital, Montreal, P.Q., 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Craig, William, Personal communication, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. William Craig, 328 W. 23rd St., Los Angeles, Calif. 90007.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, 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>C. A. McLaurin, B.A.Sc, P.Eng </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, 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. P. Bobechko, M.D., F.R.C.S.(C.) </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-08.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 Toronto Orthosis for Legg-Perthes Disease Creator An entity primarily responsible for making the resource W. P. Bobechko, M.D., F.R.C.S.(C.) * C. A. McLaurin, B.A.Sc, P.Eng * W. M. Motloch * https://staging.drfop.org/files/original/a35cfabdeded6efeb701fabb13e0203a.pdf 1c6c0d675c28db96ad766418ff443a9b https://staging.drfop.org/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg 14d5744670f9a9f1540367bb959c02c2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_001.pdf Text Any textual data included in the document <h2>Transfer of Rehabilitation Research and Development Results into Clinical Practice</h2> <h5><a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D.&nbsp;*</a></h5> <p><i>For more than thirty years, Dr. Margaret Giannini has been a pioneer in creating programs for the diagnosis, treatment, education, rights and affairs of the mentally retarded, developmentally disabled and the handicapped.</i></p> <p><i>In 1950, Dr. Giannini founded and directed the Mental Retardation Institute at New York College. In 1980, she accepted a Presidential appointment as the first Director of the National Institute of Handicapped Research, a branch of the U.S. Department of Education. In April, 1981, Dr. Giannini took over the position of Director for the VA Rehabilitation Research and Development Service (Rehab R&amp;D).</i></p> <p><i>In addition to these positions, Dr. Giannini is past-president of the American Association on Mental Deficiency and past-president of the American Association of University Affiliate Progams, two of the most influential organizations concerned with the mentally and physically handicapped.</i></p> <p><i>Dr. Giannini is the recipient of many awards from varying organizations in recognition of her professional and humanitarian services and achievements. She also has authored and co-authored numerous publications; presented many lectures, papers, keynote addresses; and participated in panel discussions and workshops throughout the world.</i></p> <p>The Veterans Administration, Rehabilitation Research and Development Service (Rehab R&amp;D) funds approximately 100 projects a year aimed at developing new methods or improving existing techniques for assisting disabled veterans. The program was created by a Congressional mandate, U.S.C. 38, Sec. 4101, (c)(1) and (2), which directs that the VA "carry out a program of medical research including prosthetics research. Prosthetics research should include research and testing in the field of prosthetic, orthotic and/or orthopedic appliances and sensory devices."</p> <p>A review of Rehab R&amp;D scientific and engineering accomplishments provides insight into the VA/Rehab R&amp;D technology-transfer programs. Some of the recent and ongoing research conducted under this sponsorship includes: maxillofacial restorations—to include use of biomaterials and their clinical applications; development and evaluation of robotic aids for the severely disabled; seat cushions for the paralyzed to prevent decubitus ulcers; functional electrical stimulation (FES) systems for upper extremity control; physiological effects of FES on paralyzed muscles; walking restored in a paralyzed man using FES; a motion-guiding load-bearing external frame for the knee; possible myoelectric controlled above-knee prosthesis; oprimum prosthetic foot characteristics for the dysvascular below-knee amputee.</p> <p><b>Image: Dr. Giannini</b></p> <p>In addition to sponsoring such research in the past, Rehab R&amp;D has established a program concerned with the transfer of research into clinical practice. This program consists of the following six parts:</p> <ol> <li> <p>Establishing clinically relevant research priorities.</p> </li> <li> <p>Insuring that the significant research encompasses clinically relevant factors.</p> </li> <li> <p>Dissemination of research findings to the scientific community.</p> </li> <li> <p>Evaluation of research results for suitability for transfer to clinical settings.</p> </li> <li> <p>Support to private industry to make new devices and equipment commercially available.</p> </li> <li> <p>Dissemination of new methods to clinical practitioners.</p> </li> </ol> <p>Each of these is examined at length in the remainder of this paper.</p> <h3>Establishing Clinically Relevant Research Priorities</h3> <p>In the past, the VA had only general research priorities for award of Rehab R&amp;D funds. Oftentimes researchers focused proposals on esoteric topics which were of little or no clinical significance while major clinical issues went unaddressed. To remedy this situation, a series of workshops were held with consumers and clinical leaders to develop priorities for research on clinically significant issues.</p> <p>Many of the workshops sponsored by RESNA and the VA have been published. Workshop topics have included sensory aids, functional electrical stimulation, and prosthetics/amputation. Rehab R&amp;D also has participated in meetings of the International Standards Organization (ISO) which established specific priorities within the areas of prosthetics/amputation, spinal cord injury (including wheelchairs), and sensory aids. Rehab R&amp;D now has a policy of soliciting and approving funding for only those proposals which fall within these priorities.</p> <h3>Ensuring that Research Addresses Relevant Clinical Issues</h3> <p>There is a vast distance between research and clinical application of methods and devices. Rehab R&amp;D has the responsibility not only to fund research, but also to initiate and support the development of the clinical methods necessary for effective application. For example, the outstanding work done by Ernest Burgess, M.D., in Seattle, and others on immediate postoperative fitting requires new and complex clinical procedures. A necessary step in promoting clinical application of this method has been the development of a clinical procedures manual and the training of practitioners and patients.</p> <h3>Dissemination of Research Findings</h3> <p>The new VA <i><i></i>Journal of Rehabilitation R&amp;D</i> replaces the earlier <i>Bulletin of Prosthetics Research</i> with a number of major changes. Aimed at the entire scientific community, and charged with following the highest standards of scientific quality, the <i>Journal of Rehabilitation R&amp;D</i> is designed to offer an interdisciplinary vehicle for publication of technical materials which can most directly reach rehabilitation professionals. In addition to the <i>Journal</i>, the first edition of a new annual publication <i>Rehabilitation R&amp;D Progress Reports</i>, is now in press. This publication is aimed at providing a comprehensive overview of research and development now in progress both in the United States and internationally. One of the publication's functions will be to serve as a guide to sources of information within the areas of Rehab R&amp;D priorities.</p> <p>Rehab R&amp;D, in the planning stage of developing, will work in coordination with professional organizations in the field to facilitate the translation of scientific results into technical clinical information of direct relevance to practicing clinicians.</p> <h3>Evaluation of Research Results</h3> <p>The Chief Medical Director of the VA has given approval to establish the Development and Evaluation Program (DEP) for the evaluation of research and development findings to determine their suitability for adoption into clinical practice. The program is designed to stimulate, evaluate, and acquire and disseminate information, including the development of educational guidelines and technical manuals.</p> <p>The educational guidelines will be coordinated between the Continuing Education Resources Service and the Prosthetics and Sensory Aids Service (PSAS). Thus, both the people who will prescribe and/or use these new devices, techniques, or concepts, will be trained. Rehab R&amp;D will not actually provide the training, but it will provide the data and/or research scientists as instructors for the training program. This Rehab R&amp;D program is currently limited to devices specifically developed in VA or other federally funded R&amp;D projects.</p> <p>Rigorous evaluation will provide objective and comprehensive information to the key decision makers related to clinical adoption. Information will be provided to funding agencies—including the VA—which must formally approve reimbursement of the devices or use of procedures in clinical practice; to industry so they can decide whether to add the devices to their commercial lines; and to clinicians who must decide on how to apply the new methods or devices. VA responsibility for evaluation will be shared cooperatively between Rehab R&amp;D on new research, and by the VA's Prosthetics and Sensory Aids Service on devices which are already commercially available, but have not been previously evaluated.</p> <h3>Support to Private Industry to Make New Devices Commercially Available</h3> <p>No matter how good research and engineering results are, they are of no value unless they become available to clinicians. Many useful devices which have resulted from research are not commercially available. To overcome this gap, discussions have been held with industrial leaders who have offered advice on the nature of the rehabilitation market, which is just one impediment. Based upon the input of these industrial leaders, commercial availability is being attacked on two fronts.</p> <p>First, an interagency agreement with the Department of Commerce has been developed to assist small minority business firms in tooling-up for offering new products as a part of their commercial lines. Specifically, the interagency agreement provides for the study of marketing and development methods to fully utilize the research and development of new devices for the disabled. The purpose of this interagency agreement is to utilize existing programs in the Minority Business Development Agency (MBDA) and stimulate marketing for devices that result from VA-sponsored R&amp;D.</p> <p>The National Commission of Technology Transfer, of the Department of Commerce, is in the process of offering funding in order to:</p> <ul> <li> <p>plan for an international conference on making prosthetic and orthotic devices and sensory aids readily available to the handicapped population;</p> </li> <li> <p>identify and develop potential markets and financing for such devices;</p> </li> <li> <p>examine the use of microcomputers and other high technology areas;</p> </li> <li> <p>examine the impediments to obtaining funding for high-technology products; and,</p> </li> <li> <p>develop a process that leads to the commercialization of technology researched and developed by the VA, with emphasis on providing access to these markets for minority entrepreneurs.</p> </li> </ul> <p>Arrangements have been made to encourage private industry to adopt the results of individual research products which are judged to have particular merit. As a result of these efforts, the Johns Hopkins Manipulator will soon be commercially available. Other negotiations are continuing. To facilitate this process, VA Rehab R&amp;D has assisted in the creation of a National Commission for Technology Transfer, which is concerned with making research results commercially available to handicapped people.</p> <h3>New Directions</h3> <p>Future plans by VA Rehab R&amp;D to assist in the transfer of technology from research to clinical practice are as follows:</p> <ul> <li> <p>Continued publication of the <i>Journal of Rehabilitation R&amp;D</i> and the <i>R&amp;D Progress Reports</i>;</p> </li> <li> <p>Publication and distribution of papers on subjects potentially relevant to future clinical practice (e.g. training manual for use of robotic systems for the severely disabled);</p> </li> <li> <p>Design and implementation of a formal research program, based at the Office of Technology Transfer, to evaluate and improve the transfer of technology, including:</p> <ol> <li> <p>The collection of clinical practice data from VA facilities to give a chronological picture of the gap between state-of-the-art devices and actual clinical practice;</p> </li> <li> <p>A series of consumer surveys to determine their needs and to uncover problems or frustrations with existing rehabilitation procedures and equipment; and,</p> </li> <li> <p>A series of surveys among clinical practitioners to collect data on clinical needs, problems and priorities.</p> </li> </ol> </li> <li> <p>A periodical and/or a technical communication in existing periodicals for clinicians, designed in cooperation with PSAS, the Academy, AOPA, AAOS, Paralyzed Veterans of America, Disabled American Veterans, National Institute of Handicapped Research, and other organizations to further enrich the transfer of new research findings to clinicians in a format tailored to their practical needs. In the long run, a computerized reference system may be developed;</p> </li> <li> <p>Seminars on selected topics between recognized clinical leaders and senior researchers who have achieved scientific breakthroughs relevant to clinical practice; and,</p> </li> <li> <p>Access to national and international scientific and clinical literature.</p> </li> </ul> <p>These thrusts are ambitious and will take time, but they convey the depth of Rehab R&amp;D commitment to technology transfer.</p> <em><b>*<a href="/files/original/f04ea874efa3438a19ffdff439d8fa3f.jpg">Margaret Giannini, M.D</a>. </b> A native of New York, Dr. Giannini is married to Louis J. Salerno, M.D. and has raised four sons. Dr. Giannini is scheduled to speak at the Academy Annual Meeting in Orlando on January 26, 1984.</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 3 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_001/1984_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Transfer of Rehabilitation Research and Development Results into Clinical Practice Creator An entity primarily responsible for making the resource Margaret Giannini, M.D. * https://staging.drfop.org/files/original/de497b398ace75dc2d796c805105fa2b.pdf 27d26b0e9c1554ef1390a967e60ce082 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_001.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Transition</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> With this issue, <i>Artificial Limbs </i>embarks upon a new pattern of activity, changing from monographs covering major aspects to issues with articles on more diversified topics related to artificial limbs. A brief review of the philosophy and contents of prior publications may illuminate the logic of this transition. </p> <p> In nearly every issue, stress has been laid upon the management of the amputee through a clinic team. This noble idea, arising from the follow-up of the cases fitted immediately after the suction-socket schools in 1947, was destined to have a profound impact not only upon prosthetics but also, through this program and many parallel developments, upon the management of other disabilities as well. </p> <p> Early issues, many of them now out of print, were devoted to explanations of the total program of research, development, and evaluation in the fields of upper- and lower-extremity prosthetics. In a series of monographs, with copious references, <i>Artificial Limbs </i>has considered nearly every important level of amputation and has discussed the medical and psychological management of amputees, whether typical cases or those with special problems. Other related journals and reference books have become available to the clinician and to the research scholar. </p> <p> With the establishment of this solid base of reference literature, both in previous issues of this journal and elsewhere, it now seems appropriate to deviate from the classic monograph style so as to permit relatively more rapid publication and greater freedom in pursuing timely yet widely varied topics. In the past, one of the major causes for frustrating delay in the publication of this journal has been the necessity to wait upon the last manuscript needed to round out a comprehensive monograph. Those concerned with the policy of the journal, of course, have long recognized that more rapid publication of a reasonably useful document could be obtained with far less effort and suspense. A series of manuscripts, each individually worthy yet not necessarily directly related to the others, could simply be accumulated until the bundle "weighed enough to print." </p> <p> The articles in this transitional issue, however, are related to the background of past issues and to other publications of the Committee on Prosthetics Research and Development. In the traditional role of the editorial or lead article, this is an attempt to correlate the articles in this issue, to comment on them, and to stimulate each reader to apply them to his problems. </p> <p> Dr. Glattly's preliminary report on a survey of amputees, conducted with the cooperation of the prosthetics profession of this country, discloses a number of fascinating facts yet leads to interesting speculations. Obviously, the information in the article is related to the important considerations of methods of treatment for each level of amputation covered in past monographs and in the "case studies" issue of Spring 1957. Improved prostheses are available for every level of amputation; but perhaps more important are the principles of management valid for all levels which have evolved since World War II. The great preponderance of geriatric amputees in civilian practice points up the value of the report arising from a conference sponsored by CPRD in 1961-<i>The Geriatric Amputee. </i>At the other extreme, the number of child or juvenile amputees emphasizes the importance of the work of CPRD's Subcommittee on Child Prosthetics Problems and of the slowly growing number of special children's clinics engaged in a cooperative program. Fortunately, high-level and bilateral upper-extremity amputees are relatively limited in number, but they especially emphasize the need for auxiliary power, as discussed in the record of a conference held at Lake Arrowhead, California, in 1960 under the auspices of CPRD-<i>The Application of External Power in Prosthetics and Orthotics.</i> </p> <p> Indeed, the entire problem of amputation emphasizes the role of the Committee on Prosthetics Education and Information in widely disseminating information to the medical and paramedical professions through their professional schools, and local and national meetings, and by exhibits, publications, films, and slides. In fulfilling its important role, CPEI will join CPRD in sponsoring <i>Artificial Limbs, </i>beginning with the next issue. Dr. William J. Erdman, II, a member of CPEI, will join the Editorial Board. </p> <p> Mr. Colin A. McLaurin's article on independent-control harnessing for upper-extremity prostheses is clearly related to previous issues on the upper-extremity problem as a whole, harnessing for artificial arms, and discussions of problem cases. Elbow flexion independent of operation of the terminal device has long been sought, as shown by the patent literature in this country and by the German literature of World War I. Immediately after World War II, many of the amputees working with Northrop Aircraft in the relatively warm climate and casual atmosphere of Los Angeles preferred to sacrifice independent control in favor of simplicity of harnessing. However, the amputees fitted in the relatively cooler German climate by Professor Hepp after his return from his 1951 trip to the United States laboratories were more willing to accept his expert judgment that some form of "triple control" was important for function. Thus they were more willing to tolerate the more restrictive type of harness. As a result of experience with problem cases seen at the Rehabilitation Institute of Chicago and at the Michigan Area Child Amputee Center at Grand Rapids, Mr. McLaurin and Mr. Sammons have decided that independent control is important for selected amputees. Their suggestions, presented in one of the major articles of this issue, deserve careful consideration. </p> <p> The article on porous laminates in this issue, by Mr. Hill and Dr. Leonard of the Army Prosthetics Research Laboratory, is closely related to the discussion of perspiration and its consequences in a past issue on dermatological problems of amputation stumps. Readers of that classic will no doubt remember the cartoons of gremlins representing perspiration and bacteria attacking the stump within the typical air-tight socket. Porous sockets in the past have been only imperfectly approximated with porous, wicklike stump socks worn within wooden or metal shells, sometimes with numerous drilled holes, or in sockets molded of leather, which is slightly porous but undesirable from so many other hygienic aspects. The typical above-knee suction sockets of lacquered solid wood or of molded plastic laminate, both completely impermeable, have been worn without a stump sock. An early goal of the Sarah Mellon Scaife Foundation Fellowship on Orthopedic Appliances at Mellon Institute, in 1947 and following, was the development of a porous-plastic material. Though techniques of the time for attaining porosity were not satisfactory, the project made an important indirect step-the introduction to the orthotics and prosthetics field of epoxy laminate which later proved to be a key feature in the early development of porous laminates. After many years of effort, techniques only recently have been developed for the production of porous laminates of polyester resins as well as epoxy. </p> <p> The adjustable coupling for alignment of lower-extremity prostheses, developed by Messrs. Staros and Gardner of the Veterans Administration Prosthetics Center, is obviously related to the early issue of May 1954 in which tools to aid in achieving alignment based upon biomechanical principles were discussed by Professor Radcliffe. The adjustable coupling is particularly useful in aligning prostheses containing special knee joints intended for better control of the limb, though it is also applicable in alignment of the patellar-tendon-bearing below-knee prosthesis. The present coupling, useful though it is, seems only a step toward a light, expendable coupling which may be left in the prosthesis, thus obviating the need for transfer of alignment. </p> <p> Though amputees represent a relatively small fraction of the disabled of the country, the serious physical and psychological aspects of their problems demand special attention. Neglect of these severely disabled persons has sometimes, as at the end of World War II, been the cause of public criticism and emotional or even unjust reactions. It is gratifying that, since then, the systematic and steady work of many devoted individuals and organizations has led to the body of knowledge outlined in the literature now available and to many thousands of persons being trained through intensive short courses in the field, and thus to the present happier state when this highly specialized publication may move from a series of monographs to the greater freedom enjoyed by other journals. </p> <p> Eventually, it is hoped to cover such other problems as fluid mechanisms and children's prosthetics, to provide a review of clinical experience, and to enter the much broader and more complex field of bracing, or orthotics. Also, it will be a pleasure to consider for publication voluntary contributions, without placing continual pressure upon a few devoted contributors. In the meantime comments will be appreciated from our readers throughout the world. </p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York 1, N Y.; member, Editorial Board, Artificial Limbs.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Transition Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/c4b9c484b01dbcb349e2f7553d8c16d3.pdf a0e06974f43dc39c32206828207898bb https://staging.drfop.org/files/original/6b9aa45d405b3eb6edf60ed6f2583718.jpg ec3cec476e908cf5388f484ed47c4021 https://staging.drfop.org/files/original/ad87bb362ff24b53b0bd4c87f0bc9055.jpg e2e1755f9d34505fd352ad608b70b1b4 https://staging.drfop.org/files/original/e4ef8c646c8299dea2dcaf82690c7033.jpg 6f834bb52cdba95d3228c37cdfe360fe https://staging.drfop.org/files/original/0495aa63dee60d41844c8045ccfe9f17.jpg 8ed64542446ac701a3e0cb8696d61f00 https://staging.drfop.org/files/original/2b9b8acc8d0d10ae27922541c7846cf9.jpg b1aeeea2be400bc3155d32ec17438c86 https://staging.drfop.org/files/original/838448779f3df30146197fb16d701a12.jpg 67e983e840d84f6fd7d70e0ac5bdc721 https://staging.drfop.org/files/original/2c2e777bb3d61d2e18a76c9eb109d2fc.jpg 3d695f19795573f5c956f14eba7bf3d5 https://staging.drfop.org/files/original/905f9f7a7990bdd2e91147c76b480421.jpg 8097f171d6eaefdbbdd1b0648a85ccbb https://staging.drfop.org/files/original/d365de13e8ef358378928b8d72c355f6.jpg a155984092d328cef91c3a43e36ed846 https://staging.drfop.org/files/original/c00d56cd7eb635ebe196a82082567556.jpg 728482c9abdc3071fab1d4d5a219c141 https://staging.drfop.org/files/original/bc6d72ff9c92b0b0b491c095cb2c1e9a.jpg 3e9426381c4011ee132611a0e63a8988 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_045.pdf Text Any textual data included in the document <h2>Transparent Preparatory Prostheses for Upper Limb Amputations</h2> <h5>Terry J. Supan, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The use of preparatory prostheses for lower extremity amputations has been widely published and publicized throughout the United States. Although techniques may differ from thermoplastic, laminated, or synthetic casting material for the socket, the concept of early fitting with a prosthesis to reduce the volume of the residual limb are fairly well adhered to. However, little has been publicized about preparatory fitting for arm amputations.</p> <p>Since 1982, the Southern Illinois University School of Medicine has extensively used preparatory prostheses within the 30 day post-amputation time period. Techniques have changed gradually over the last four years, but a fairly constant, successful technique has evolved at the present time. Although myoelectric prostheses with their ease of therapy training have been the componentry of choice, the prosthesis design can also use conventional componentry.</p> <p>The technique has also allowed us to utilize different componentry on an experimental basis to best determine the optimum componentry for the individual amputee. Prostheses have been used on all levels of amputation from wrist disarticulation through forequarter amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg"><b>Fig. 1</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg"><b>Fig. 2</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg"><b>Fig. 3</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg"><b>Fig. 4</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg"><b>Fig. 5</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg"><b>Fig. 6</b></a>). Since 1984, all prosthetic interfaces have been fabricated out of transparent material. Materials have either been Surlyn® or Durr-Plex. The transparent materials were chosen to improve monitoring of the residual limb during volume change. Surlyn™ is used for below and above fitting sockets, while Durr-Plex is used for shoulder disarticulation and forequarter frames. With each of these systems, the prosthesis can be altered through heat forming as the patient's volume changes.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg"><strong>Figure 1. Left wrist disarticulation amputation secondary to trauma.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg"><strong>Figure 2. Left wrist disarticulation myoelectric prosthesis with supracondylar cuff to maximize supination and pronation.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg"><strong>Figure 3. Right mid-shaft below-elbow amputation, secondary to trauma and reattachment failure.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg"><strong>Figure 4. Right below-elbow prosthesis with supracondylar suspension and electric wrist rotator. Note that electronic controls, Otto Bock #, are mounted parallel to the electric rotator.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg"><strong>Figure 5. Right humeral neck above-elbow amputation secondary to trauma.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg"><strong>Figure 6. Shoulder disarticulation frame type prosthesis fitted to short above-elbow amputation.</strong></a><br /> <p>Standard electric prosthetic componentry has been used in all cases. However, minor modifications to the prosthesis/componentry interface have been necessary. Componentry which utilizes separate stainless steel electrodes from the amplifiers (Motion Control, VANU, and UNB) have been modified to use the stainless steel electrode developed for the Motion Control systems. Prostheses which utilize one piece electrode amplifiers (Otto Bock, Liberty Mutual) are primarily held in place utilizing Velcro® compression straps (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg"><b>Fig. 7</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg"><b>Fig. 8</b></a>). All loose wires are held in place with either strapping tape or duct tape. Manufacturers' recommendations concerning shielding of wires and electrodes are also followed.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg"><strong>Figure 7. Close-up view of electrode site in Surlyn® wrist disarticulation prosthesis. The area of the Otto Bock electrode extension tabs have been modified in the socket with a Dremmel tool to prevent rotation of electrode on skin.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg"><strong>Figure 8. Otto Bock electrode mounted into preparatory prosthesis. Velcro® maintains the electrode from passing completely through the socket.</strong></a><br /> <p>An amputee's decrease in limb volume is monitored monthly until the volume has stabilized. If revisions of scar tissue, skin grafts, etc., are necessary, it is recommended that they be done during this time period as well. Modifications to the prosthesis must be made to maintain good electrode contact as well as suspension. Sockets may be split and Velcro® compression straps added if necessary. Electrodes may be replaced or locations adjusted if necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg"><b>Fig. 9</b></a>). Although this is easily done with the Motion Control stainless steel electrodes by simply drilling another hole, it also can be accomplished with the Otto Bock or Liberty Mutual electrodes. If a hole saw is used to drill out the new location for the electrode, the cut-out material can be utilized to repair the previous location in the preparatory prosthesis.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg"><strong>Figure 9. Close up view of preparatory below-elbow prosthesis. Hook Velcro® adhesive backing is used to suspend the electrode in the prosthesis. Previous incorrect electrode site is repaired with cut-out from new electrode site. Battery pack is held in place with adhesive backed Velcro® as well.</strong></a><br /> <p>Since 1982, 25 upper extremity amputees have been fit with this system. It has allowed us to closely monitor the development of the maturation process of the residual limb. Adjustments to the prosthesis have been made with minimal fabrication time. Total replacement of the preparatory prosthesis was only necessary in two cases. All other cases could be accommodated by modifying existing prostheses. All but one patient (forequarter amputation) went on to fitting and delivery of their permanent prosthesis. The results of these patients' permanent prostheses are consistent with the findings of Malone, et al.<a></a></p> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg"><b>Fig. 10</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg"><b>Fig. 11</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg"><strong>Figure 10. Posterior view of preparatory shoulder disarticulation prosthesis. Elastic strap superior to the shoulder improves comfort. Split of posterior frame into sections allows sitting comfort without electrode displacement.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg"><strong>Figure 11. Lateral view of shoulder disarticulation prosthesis. Auxiliary switch is used to alternate EMG control between electric wrist rotation, hand opening, and closing.</strong></a><br /> <p><b>References:</b></p> <ol> <li>Malone, J.M., M.D., et al., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," <i>Veterans Administration Journal of Rehabilitatio</i>n, Volume 21, No. 1, May, 1984, pp. 33-42.</li> </ol> <em><b>*Terry J. Supan, C.P.O. </b> member of the clinical faculty at Southern Illinois University School of Medicine. Correspondence should be addressed to Southern Illinois University, Orthotic and Prosthetic Services, Room 102. 707 North Rutledge Street, Springfield, IL 62702.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 45 - 48 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.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 Transparent Preparatory Prostheses for Upper Limb Amputations Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * 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/. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_030.pdf Text Any textual data included in the document <h2>Two-Stage Cast-taking Procedure for PTS Prosthesis</h2> <h5>Kurt Marschall, CP&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Proper cast-taking and accurate measurements of a patient's remaining extremity, combined with careful evaluation and modification of the positive mold, are the most important steps in the fabrication and fitting of any prosthetic-orthotic device. Success or failure in prosthetic-orthotic fitting is directly related to the cast taken and the modifications incorporated in the positive mold.</p> <p>It is my firm belief that the person taking the cast should also be the one to modify it. Ideally, the modification of any master mold should be accomplished as soon after cast-taking as possible. The reasons are obvious. It makes it possible to recall the characteristics of the patient's extremity and to pay special attention to particular landmarks and problem spots that have been identified. Long delays will only serve to wipe out the memory of these characteristics. Granted, the caseload in some facilities does not permit this ideal situation of an immediate cast-modification procedure. Therefore, it should be the aim that the cast-taker produce a cast that can be easily understood and interpreted by the person modifying it. In the case of the PTS cast, landmarks should be well identified, circumference and length measurements should be accurate and special consideration or conditions should be carefully recorded. These are preconditions for proper cast modification and subsequent fabrication of a superior fitting socket, and form the foundation of any successful below knee fitting procedure.</p> <p>It is now well over twenty years since I first introduced, together with my colleague and partner, Robert Nitschke, CP, the American concept of the PTS prosthesis in Palm Springs, California. It now enjoys a widespread acceptance in the field of prosthetics and has become an integral part of the prosthetic armamentarium.</p> <p>Since then, deviations from the original PTS concept, dictated by physiological reasons, geographic location or climactic conditions have been introduced. The Fillauer removable medial wedge,<a></a> as well as the removable medial brim version,<a></a> are such a case in point. The supracondylar fitting with the anterior portion of the socket cut distal to the midpatella level, which thus sacrifices intimate contact with the quadriceps, should also be mentioned.</p> <p>All of these different techniques have their place. They work well, if, as a prerequisite to socket fabrication, a cast of superior quality and accurate cast modification can be supplied.</p> <p>Twenty years ago, we advocated a one step cast-taking technique, necessitating the use of a cast cutter in the posterior portion of the medial and lateral hamstrings for cast removal. The noise of the cast cutter, accompanied by some heat development when the blade oscillates through the cast, proved to be quite troublesome and sometimes frightening, especially to children and geriatrics. For these reasons we have employed for many years now a two-stage casting procedure in our facilities that produces a cast of superior quality with built-in characteristics that are easily identifiable in our positive molds prior to modification.</p> <h3>MEASURING AND CASTING PROCEDURE</h3> <ol> <li> <p>Materials and tools necessary for cast-taking procedure (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg"><b>Fig. 1</b></a>):<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg"><strong>Figure 1. Materials and tools necessary for PTS prosthesis cast-taking procedure.</strong></a></p> <blockquote> <p>2 light cast socks<br />1" elastic belt and 2 holding clamps<br />PTS caliper<br />A-P tension clamp<br />Bandage scissor<br />Goniometer<br />Modified Ritz stick<br />Orthoflex plaster bandage, 4"<br />Regular plaster of Paris bandages, 4", extra fast setting<br />Revere rubber bands, size 33 or equivalent<br />Otto Bock separation gel (Gipsisoliercreme) or vaseline</p> </blockquote> </li> <li> <p>After positioning patient properly and comfortably on table, examine and palpate extremity carefully. Record findings on measurement sheet. Apply two light cast socks over patient's extremity and identify with indelible pencil all pertinent landmarks and bony protuberances (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg"><strong>Fig. 2</strong></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg"><strong>Figure 2. Identify all landmarks and bony protuberances.</strong></a></p> <ol> <li> <p>Record circumference at three levels: mid-patellar tendon, mid-portion and around distal end of extremity.</p> </li> <li> <p>Record length of amputated extremity with modified Ritz stick (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg"><b>Fig. 3</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg"><strong>Figure 3. Record length of extremity with modified Rita stick.</strong></a></p> </li> <li> <p>Record M-L dimension with PTS caliper at widest margin of knee (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg"><strong>Figure 4. M-L dimension at the widest margin</strong></a></li> <li> <p>Record M-L dimension above the medial and lateral femoral condyles (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg"><b>Fig. 5</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg"><strong>Figure 5. M-L dimension above medial and lateral femoral condyles.</strong></a></p> </li> <li> <p>Record A-P dimension with knee relaxed and slightly flexed. The amount of flexion depends on the length of the remaining extremity. Seven-10 degrees is usually sufficient for medium sized amputations. Shorter ones may require more flextion (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg"><b>Fig. 6</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg"><strong>Figure 6. A-P dimension with knee relaxed and slightly flexed.</strong></a></p> </li> </ol> </li> <li> <p>Wrap the amputated extremity with Ortho-flex bandage starting at distal end and terminating at the mid-patella level. Reinforce with regular, extra fast setting plaster of Paris bandage, and identify with thuimbs the patellar-tendon bridge (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg"><b>Fig. 7</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg"><b>Fig. 8</b></a>).</p> </li> <li> <p>With plaster of Paris cast still soft and moldable, apply A-P tension clamp (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg"><b>Fig. 9</b></a>). This makes it possible to shape the cast with both hands while it hardens, thus keeping later cast modifications to a minimum (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg"><b>Fig. 10</b></a>). Please note clamp and hand-induced characteristics of hardened first stage of mold (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg"><b>Fig. 11</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg"><strong>Figure 9. Apply A-P tension clamp.</strong></a></p> </li> <li> <p>Use Otto Bock separating gel or vaseline and apply a thin layer to the proximal 1 1/2" of the superior portion of the cast (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg"><b>Fig. 12</b></a>). Measure out six layers of 4" regular, extra fast setting plaster of Paris bandage or splints, sufficient in length to reach slightly past medial and lateral hamstrings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg"><b>Fig. 13</b></a>). Apply to patient's extremity, overlapping first stage cast by at least one inch and extending over the patella and covering quadriceps tendon by one inch. Use six inch wide splints if necessary. Apply two thin rubber bands to superior edge of wings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg"><b>Fig. 14</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg"><strong>Figure 14. Apply two rubberbands to superior edge of wings.&nbsp;</strong></a></li> <li> <p>Place thumbs in the indentations of the mid-patellar tendon bridge and use the index and middle fingers of both hands to apply sufficient pressure to reach the depth of the recorded narrow M-L dimension just superior to the femoral condyles. The fingers should always straddle the ilio-tibial band on the lateral side (<b>Fig. 15</b>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg"><strong>Figure 15. Apply sufficient pressure to reach the depth of the recorded narrow M-L dimension.&nbsp;</strong></a></li> <li> <p>After the second stage of the cast has set enough to hold finger impressions in place, remove the rubber bands and mark juncture between first and second stage with indelible pencil (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg"><b>Fig. 16</b></a>). Remove second stage by carefully lossening and lifting medial and lateral wings free (<b>Fig. 17</b>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg"><strong>Figure 16. Mark juncture between first and second stage.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg"><strong>Figure 17. Carefully loosen and lift medial and lateral wings free</strong></a></p> </li> <li> <p>Reflect the top cast sock distally. Let patient's musculature relax completely. While pulling the bottom cast sock proximal, slowly remove first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg"><b>Fig. 18</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg"><strong>Figure 18. Slowly remove first stage while pulling the bottom cast sock proximal.</strong></a><br /> <p>Cut off excess cast sock adhering to first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg"><b>Fig. 19</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg"><strong>Figure 19. Cut off excess cast sock adhering to first stage.</strong></a></li> <li> <p>Join both stages together again by matching the separation marks exactly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg"><b>Fig. 20</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg"><strong>Figure 20. Join both stages together, matching the separate marks exactly.</strong></a><br /> <p>While holding both stages securely together with the left hand, place plaster of Paris bandage about the juncture and wrap all the way to the top of cast.</p> </li> <li> <p>The negative wrap should display all landmarks clearly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg"><b>Fig. 21</b></a>). Check for correct flexion angle. Negative cast can now be filled.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg"><strong>Figure 21. The negative wrap should display all landmarks clearly</strong></a></li> </ol> <p>During the cast-taking procedure, I make it a point to involve the patient by explaining each and every step. I use proper nomenclature and anatomical description of the remaining extremity. We should remember that each patient has gone through a very traumatic, cosmetically and functionally destructive surgical procedure. His or her spirits need to be lifted and encouraged. Most patients appreciate an intimate involvement in their prosthetic rehabilitation. Some of them even retain the knowledge gained during their cast and fitting procedures and answer subsequent questions on a sophisticated level. Treatment of your patient as a human being, rather than as a number among many makes being in this profession such an outstanding experience.</p> <h3>Conclusion</h3> <p>The importance of a good cast-taking technique has been stressed. Ideally, the positive mold should be modified by the cast-taker. In the absence of such a luxury, the cast modifier, with the aid of the measurements and the recording of special considerations, should be able to readily understand the characteristics that have been built into the cast. Proper cast modification will contribute immeasurably to good socket fit and superior function and performance by the amputee.</p> <p>Where the above guidelines have not been followed, an inferior socket fit will result. In such a case, the cast-taking procedure should be repeated and a new socket should be fabricated. Successfully fitting 10 to 20 patients in a row does not make any of us an infallible super-prosthetist. Every once in a while we all have to admit defeat due to oversight of basic principles or failure to adhere to prescribed guidelines and procedures. These infrequent failures will keep us on our toes and make us humble again. But, admitting defeat or failure and correcting it without a moment's hesitation, will make you, in the eyes of your peers, in the eyes of your physician, but foremost, in the eyes of your patient, the better practitioner.</p> <p><b>References:</b></p> <ol> <li>Marschael, K. and Nitschke, R., "Principles of the Patellar Tendon Supracondylar Prostheses," <i>Orthopedic Appliance Journal</i>, Vol. 21, No. 1, March, 1967, pp. 33-38.</li> <li>Fillauer, C., "Supracondylar Wedge Suspension of the PTB Prostheses," <i>Orthotics and Prosthetics</i>, Vol. 22, No. 2, June, 1968, pp. 39-44.</li> <li>Fillauer, C., "A Patellar-Tendon-Bearing Socket with a Detachable Medial Brim," <i>Orthotics and Prosthetics</i>, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> </ol> <div style="width: 400px;"><em><b>*Kurt Marschall, CP </b> Kurt Marschall, CPO is President of Empire Orthopedic Laboratories, a division of Rochester Orthopedic Laboratories, Inc., 249 East Adams Street, Syracuse, New York 13202.</em><br /><br /><br /></div> Page Number(s) 30 - 34 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg Figure 20 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.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 Two-Stage Cast-taking Procedure for PTS Prosthesis Creator An entity primarily responsible for making the resource Kurt Marschall, CP * https://staging.drfop.org/files/original/06ff7c1b1ffe661ec3d52637ad1de5da.pdf d8e5e270866afbfeb1b0266021a3a456 https://staging.drfop.org/files/original/804147ec07f70a2ca9e68a7b5ad89752.jpg b8a5d08a40fc781da05fe270deedf973 https://staging.drfop.org/files/original/8060708851663a4e6b62705fd7673f48.jpg 48236d34b6e57e8fa3a8387180393966 https://staging.drfop.org/files/original/2621e70fa9f05b60c976cc6cd29949c0.jpg e16ad7168af90c3478c397208003756c https://staging.drfop.org/files/original/ea8672ccbfec15496887409c07bc2c68.jpg 4daa18a0bad84c931e0b84608e5180cb https://staging.drfop.org/files/original/ffda58be9b5b16824849380aef2798af.jpg df73e68e301073a206b5d54d322da7de https://staging.drfop.org/files/original/7dae03305294afa143bc899a07a7129e.jpg 81d0d6713066127f6689dd6f0bcef436 https://staging.drfop.org/files/original/9cba1e671bf7f65cc2aeac456c3cf265.jpg 25fa44df76c98369324d4692347573fd https://staging.drfop.org/files/original/0beb3fc2157b3219025430a21eb0f941.jpg bfc34be909d07c0f42d627d81681018e https://staging.drfop.org/files/original/c08f7b6c633291f9377ffe0a0662c0c7.jpg 8f0942b1cf85ffb6fd1e0cf158bf0400 https://staging.drfop.org/files/original/5ae9805eeac3afaf5817bc688515587d.jpg aaba8ada7145d82e8f00581e1b5f39cd https://staging.drfop.org/files/original/d24fb122adb3f7233341da58b557dd98.jpg a40ceb0ba4464673b1acc2d203cbe62e https://staging.drfop.org/files/original/5622b27f22b681d9faa779542276d256.jpg f3c6445361e54a612ebe16c8e7d71793 https://staging.drfop.org/files/original/e6be1213fe9bee96128e219d45e6bcf4.jpg 91ab67336ea16438dae2c542ec1a7d5d https://staging.drfop.org/files/original/839347574cabd58a2ec12adb88564d53.jpg 8504e432305c805881c15fe15c27eb1f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_025.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 25 - 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/1971_02_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Ulnar Hemimelia</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br />Ronan O'Rahilly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Isolated deficits of the long bones form a well-recognized group of anomalies. They may be described as <i>terminal, </i>in which there are no unaffected parts distal to and in line with the deficient portion (<b>Fig. 1</b>); or <i>intercalary, </i>in which a middle part is deficient while those portions proximal and distal to it are present. (<b>Fig. 2</b>)<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Terminal longitudinal paraxial hemimelia, ulnar. There is absence of one or more digits (the absent parts have been ghosted in). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Intercalary longitudinal paraxial hemimelia, ulnar. Note that all five fingers are present. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Ulnar hemimelia is a postaxial longitudinal deficiency of the upper limb, wherein the ulna is completely or partially absent. Clinically, because of the multiplicity of forearm and hand deformities or contours, it may be very difficult to recognize precisely the deficiency without roentgen studies (<b>Fig. 3</b> and <b>Fig. 4</b>). The elbow joint may be in extension or in acute flexion. There may be fusion of the radiohumeral joint. The range of motion, if present, may be markedly limited. The proximal part of the radius may articulate with the underdeveloped capitulum, or it may be completely luxated. If the deficiency is incomplete, the ulnar remnant may vary in length and contour. The digits of the hand may vary greatly in number (<b>Fig. 5</b> and <b>Fig. 6</b>). At the shoulder girdle, one may observe considerable muscular atrophy, ligamentous relaxation, and a deep web in the axilla.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. <i>Left, </i>the short left upper limb is phocomelic. Note the severe atrophy of the left shoulder girdle. There are three digits in the hand. The right arm (ulnar hemimelia) demonstrates good shoulder musculature and motion. <i>Center, </i>abduction and forward flexion are limited by the axillary web. <i>Right, </i>X-rays reveal fused right radiohumeral joint (failure of cavitation). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. <i>Left, </i>bilateral ulnar hemimelia, with monodigital hands. <i>Right, </i>note the deep web at the cubital fossa (pterygium). <i>Center, </i>X-rays reveal the radiohumeral relationship. There is no true elbow joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. <i>Left, </i>bilateral ulnar hemimelia. The left is intercalary, since there are five digits; the right is terminal because there are only four digits. Patient has complete anonychia with distinctive pulp prints on the dorsum of the fingers. <i>Right, </i>X-rays reveal complete dislocation of the radiohumeral joints. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. <i>Left, </i>monodigital ulnar hemimelia, incomplete. <i>Right, </i>X-rays reveal proximal remnant of the ulna with a bowed radius. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 1932, Kanavel<a></a> reported 60 cases of ulnar deficiencies. Comparison of Kanavel's findings with those of the cases presented here reveals the digit deficits as shown in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>O'Rahilly<a></a> presented a resume of 65 cases in the literature up to 1950. This deficit is seen much less frequently than is radial hemimelia, the literature indicating a ratio of 18:1. O'Rahilly's analysis revealed that 67% of the cases were unilateral, and 69% involved the right upper limb. The incidence in males was more common, with a ratio of 2:1. Radiohumeral fusion and/ or digital syndactyly were not mentioned.</p> <p>The absence of a radiohumeral joint (fusion) indicates the failure of cavitation of this structure. It is suggested that the lack of cavitation is an integral part of the total deficit seen in some cases of ulnar hemi-melia (38.5% of Frantz's patients).</p> <p>During the past 15 years, the staff at the Area Child Amputee Center has examined and managed 26 children with ulnar hemi-melia. An analysis of these cases reveals a follow-up of from 1 to 15 years. There were 16 males and 10 females.</p> <p>This deficit appears to be a sporadic lesion, in that there were 59 normal siblings of the 26 patients studied. One patient had a fraternal twin who had no skeletal deficits.</p> <p>Ten of the patients (38.5%) had unilateral ulnar hemimelia with no other skeletal deficiencies. Three children (11.5%) had bilateral ulnar hemimelia; seven also had lower-limb deficits. Six patients with unilateral ulnar hemimelia had varying deficiencies in the contralateral upper limb. These included terminal transverse hemimelia, phocomelia, absent thumb, and absent fifth finger. Ten patients (38.5%) had radiohumeral fusion accompanying the ulnar hemimelia.</p> <p>The involvement of carpals and metacarpals is complex. The triquetrum and capitate often are absent. There is an increasing frequency of metacarpal failure as one passes from the radial to the ulnar side of the hand.</p> <p>The frequency of digital absence is shown in <b>Table 2</b>. It is of interest to note that the three-fingered hand is preponderant, followed closely in occurrence by the mono-digital hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Management</h3> <p>In our experience, most of these children can be managed without surgical intervention. The goal, of course, is to improve function, with or without the use of a prosthesis. Whether surgery is indicated depends upon whether both arms are involved, and on the range of motion, the number of digits present, and the presence or absence of syndactyly (<b>Table 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nonsurgical</h4> <p><i>No Fitting</i></p> <p>Some of these children had radiohumeral synostosis (<b>Fig. 3</b> and <b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. <i>Left, </i>ulnar hemimelia with three-digit hand (left). The right upper limb is phocomelic. <i>Right, </i>X-rays show radiohumeral fusion (failure of cavitation). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Opponens Post</i></p> <p>Children with one digit (monodigital hand) possessing good flexion power and lateral stability of the metacarpophalangeal joint were fitted to advantage (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. This boy was born with bilateral ulnar hemimelia with monodigital hands (see fig. 4). At 4 years of age the right upper limb was fitted with an opponens post. The left limb was managed by elbow disarticulation and prosthetic replacement. The elbow unit has 11 positions, allowing from 45degrees flexion to 180degrees extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Below-elbow Prosthesis</i></p> <p>Modified below-elbow sockets were sometimes prescribed (<b>Fig. 9</b>). However, range of elbow motion is significantly lacking.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. <i>Left, </i>monodigital ulnar hemimelia, with extension limited to 70degrees. Web release in the cubital fossa offered little additional motion. Initially the child was fitted with a below-elbow type of prosthesis <i>(center). </i>After a 2-year trial, the family expressed dissatisfaction with the limited motion and function of the arm. At 4 years of age an elbow disarticulation was performed and prosthetically fitted <i>(right).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-elbow Prosthesis</i></p> <p>This is a highly satisfactory method of fitting patients with unilateral, monodigital, ulnar hemimelia. The forearm segment is acutely flexed against and parallel to the humeral shaft and then encased within the humeral socket. The elbow-locking mechanism has a lever with which the single digit controls the elbow lock and unlock mechanism (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. <i>Left, </i>ulnar hemimelia with a monodigital hand. Note the acute flexion and the deep cubital web. <i>Center, </i>the radiohumeral angle is 20degrees. <i>Right, </i>the monodigital segment is encased in a fenestrated humeral socket in an elbow-disarticulation type of prosthesis. The digit operates the elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Surgical</h4> <p><i>Elbow Z-plasty</i></p> <p>Z-plasty in the cubital fossa was performed in two instances in an endeavor to decrease the cubital web and in the hope of allowing a greater range of elbow flexion and extension. This procedure is somewhat advantageous in that it allows a better fit of the forearm socket, but it fails to offer any significant increased range of motion and therefore is not recommended (see <b>Fig. 9</b>).</p> <p><i>Elbow Disarticulation</i></p> <p>This surgical procedure is followed by fitting the limb with an elbow-disarticula-tion type of prosthesis. The surgeon should be meticulous in his technique so as not to disturb the distal humeral epiphysis during the disarticulation procedure.</p> <p>The application of the elbow-disarticulation type of prosthesis with an outside locking elbow offers 11 different positions of the elbow joint.</p> <p><i>Humeral Derotation Osteotomy</i></p> <p>Two children received a humeral derotation osteotomy of at least 90 degrees (<b>Fig. 11</b>). One was lost to follow-up after early union.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. <i>Left, </i>ulnar hemimelia, left; there is radiohumeral fusion (failure of cavitation) with 90degrees rotation. <i>Center, </i>derotation osteotomy of the humerus at 4 years of age. <i>Right, </i>arm position following derotation osteotomy. Note the three-fingered hand; the parents refused to have a syndactyly-release performed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>From this brief outline of management, it is obvious that the treatment of these children is highly individualized. The timing and procedure may be dictated by the age of the patient, the question of bilateral-ity, and the scope of the handicap. The decision as to whether or not to prescribe a prosthesis may be a difficult one. The approach to handling these children with ulnar hemimelia has been developed over the years by trial and error and by functional analysis.</p> <p>In <b>Fig. 3</b>, severe as the deformities may appear to be, the right shoulder functions normally, and the boy is able to abduct and forward-flex the shoulder, which allows him to prehend with his right hand. The left upper limb is phocomelic; however, he has a functional "pinch force" with the digits for close-in functioning. In the occupational therapy department, he demonstrated a very acceptable level of accomplishment in the activities of daily living and therefore was not fitted with prostheses.</p> <p>This logic is in accord with the problem faced by the boy shown in <b>Fig. 7</b>. The ef-ficency of this four-year-old's performance in dressing, undressing, and toilet care is such that he needs no prosthetic aids. Utilizing the ulnar hemimelic limb, this boy is able to feed himself and care for most of his daily living demands.</p> <p>Bilateral ulnar hemimelia with monodi-gital hands is a severe handicap (see <b>Fig. 4</b>). One male in this group had the Cornelia de Lange syndrome. If a child is seen at an early age (i.e., before two years), one may be tempted to procrastinate. How long? The major question is whether one should fit one or both sides with a passive type of prosthesis (terminal devices with no cables, but with small rubber bands on the hooks) or whether to interfere surgically.</p> <p>It has been stated that a Z-plasty at the cubital fossa offers little improvement of the radiohumeral arc of motion.</p> <p>One approach may be to fit one side with an opponens post and the opposite side with a modified below-elbow prosthesis. Should the prosthetic side prove to be inadequate with a below-elbow type of prosthesis, one may then elect to perform an elbow disarticulation one year before kindergarten, allowing a year of prosthetic wearing before formal schooling. This was done in the patient shown in <b>Fig. 8</b>. At this writing, the boy is 14 years old. He is in junior high school and is the manager of the football team. Also, he is a fair bowler, for which he utilizes a special attachment to his prosthesis.</p> <p>Unilateral, monodigital, ulnar hemimelia with a normal contralateral upper limb is not as serious a handicap. The patient shown in <b>Fig. 9</b> was fitted at two years of age with a modified standard below-elbow pros- thesis. At the age of four years, the patient and her mother were dissatisfied with the function afforded, because of limited elbow motion. (The Z-plasty at the cubital fossa offered little additional motion.) The child received an elbow disarticulation and was subsequently fitted with a standard elbow-disarticulation prosthesis with a medially placed outside-locking elbow. At the time of writing, she is 18 years of age, ready to enter college, and is considered a very good prosthesis-wearer.</p> <p>The patient in <b>Fig. 10</b> was seen in 1964 at 15 years of age; she has a monodigital, left-sided, ulnar hemimelia. Her degree of radiohumeral flexion was more severe than that of the girl in <b>Fig. 9</b>. This patient was not particularly concerned with the cosmetic effect (and still is not). She was fitted with a prosthesis that encased the acutely flexed forearm within the humeral socket. The anterior, or ventral, wall of the socket was then fenestrated and a lever was attached to the elbow-locking cable, which permitted her to use the single digit to operate the elbow locking/unlocking mechanism. At this writing, she is in her second year in college and now wears a mechanical hand with a cosmetic glove. The upper arm is usually covered by a fluffy-sleeved blouse.</p> <p>To summarize, there are four approaches to treatment of the monodigital hand: op-ponens post; below-elbow prosthetic fitting; elbow-disarticulation prosthetic fitting, encasing the forearm in the humeral socket; or no fitting, which is the least recommended procedure.</p> <p>Rotational deformities occasionally are seen in which there may be up to 180 degrees of medial rotation of the forearm on the humerus. The hand rests at the side of the thorax, pointing dorsally. One patient was seen at eight months of age (see <b>Fig. 11</b>). There were three digits in the left hand with soft-tissue syndactyly. She received a derotation osteotomy of the humerus at the age of four years, and a fair result was ob- tained. Unfortunately, she was lost to clinic follow-up shortly after surgery.</p> <p>Dislocation of the radiohumeral joint is rare. One such patient was first seen at four years of age. He has five digits on the left hand and four on the right. There were no fingernails. It is of interest to note that this boy has distinctive prints on both the palmar and dorsal surfaces of his fingers. His radiohumeral joint anatomically is nonexistent (see <b>Fig. 5</b>). The intrinsic muscles of the hands are weakened, and the wrists are unstable. The forearms and hands have been encased in a half-sleeve of plastic attached to crutches (he also has bilateral amelia of the legs). He is now 18 years old and attends a trade school.</p> <p>Incomplete ulnar hemimelia occurred twice in this series. The proximal portion of the ulna is present, thus affording a normal-appearing elbow joint with an excellent range of motion (see <b>Fig. 6</b>). That child was seen at four years of age and fitted with a standard below-elbow prosthesis, which she is currently wearing.</p> <p>Syndactyly was encountered four times in 26 cases. Two cases have been corrected surgically.-<i>Charles H. Frantz, M.D.</i></p> <h3>Pathogenesis</h3> <p>The term "hemimelia" was introduced in 1836-37 by Isidore Geoffroy Saint-Hilaire <i>, </i><a></a> who also introduced the term "teratology". In 1877, Verneuil proposed subdivision (of "ectromelia") into longitudinal and transverse varieties <i>. </i><a></a> In addition to absence of the distal half (two of the four segments) of a limb, it became clear that, in some cases, only one side of the distal half was affected, and such instances were named (after the defective portion) "radial," "ulnar," "tibial," and "fibular" hemimelia. By 1903, a further distinction, that between terminal and intercalary varieties of hemimelia, had been made<a></a>. Finally, in 1951, O'Rahilly suggested the term "paraxial hemimelia" for the longitudinal variety, because either the preaxial or postaxial side of the limb is involved in such cases.</p> <p>It is not proposed to discuss here either the terminological basis<a></a> or the terato- genesis<a></a> of limb malformations in general, as these aspects have been considered recently elsewhere.</p> <p>Ulnar hemimelia was first reported in 1683 by Goller<a></a> and hence is probably the first of the paraxial hemimelias to be identified as such, there being some doubt about the true identity of the case of hemimelia described by Pare in 1573 <i>.</i><a></a> Although chronological tables of all the early cases of radial, tibial, and fibular hemimelia are available in the literature, no such list other than the bibliography provided by Rabaud and Hovelacque<a></a> seems to have been prepared for ulnar hemimelia.</p> <p>Among the hemimelias involving one of the four bones of the third limb segment, or "zygopodium" (forearm and leg), the ulnar type occurs the least. It differs from the others also in that a partial deficiency is more commonly found than complete absence. However, it resembles radial, tibial, and fibular hemimelia in that it is more frequently unilateral, more commonly seen on the right side, and more often observed in the male <i>. </i><a></a> Of particular interest are those cases in which thorough dissection has been possible <i>.</i><a></a> Several additional cases of ulnar hemimelia have been reported in the literature during the past two decades. The higher incidence of unilaterality and of right-sided involvement has been confirmed.<a></a> It is important to appreciate that the hemimelias may occur as isolated anomalies, or they may, as shown in this paper, be associated with other malformations. Ulnar hemimelia, for example, is sometimes a component of a sporadic syndrome that includes femoral and fibular defects.<a></a> The cause of the "FFU" (femur, fibula, ulna) syndrome is unknown; such factors as parental age and thalidomide have been ruled out, and familial occurrence has not been observed.</p> <p>A striking example of familial occurrence in several generations was recounted to Roberts<a></a> by a patient with ulnar hemimelia. Partial ulnar hemimelia of the intercalary type, together with hypoplasia of the thumbs and fibular hemimelia, has more recently been described and illustrated in two brothers <i>. </i><a></a> A different condition, ulnofibular dysplasia, characterized by shortening of the ulna and fibula, was found to be inherited as an autosomal dominant <i>.</i><a></a> Ulnar hemimelia accompanied by Polydactyly is not unknown <i>, </i><a></a> and the coexistence of Polydactyly and a long-bone deficiency in the same limb has been noted previously (e.g., heptadactyly and tibial hemimelia) <i>. </i><a></a> In such cases, it has been suggested that this seeming paradox of excess associated with deficiency may perhaps result from an excessive outgrowth, which occurs relatively late in the early embryonic period, "involved only the digital area, and attracts some of the tissue immediately proximal to the area of excess outgrowth" <i>. </i><a></a> In the human, the hand appears in mesenchyme at about 41 postovulatory days (stage 17), so that it may be expected that Polydactyly would be observable by about six weeks after fertilization. Indeed, an example of this as an isolated anomaly has been described <i>.</i><a></a> What are generally termed "fusions" of skeletal elements-that is, the occurrence as a single structure of something that is usually composed of two or more elements-may be found either as an isolated anomaly or in association with other disturbances. Carpal and tarsal fusions, for example, are not infrequent in the paraxial hemimelias, and, as emphasized in this paper, ulnar hemimelia may include humeroradial fusion. Normally, of course, certain bony fusions, such as those between the epiphyses and their diaphyses and between the neural arches and their centra, are of constant occurrence. Even in areas where synovial cavities might be expected, however, fusions are not infrequent, such as symphalangia between the middle and distal phalanges of the little toe. The histological development of phalangeal fusion has been studied in detail<a></a>, and it is of interest to note that carpal and tarsal fusions have been observed in both the embryonic and the fetal period.<a></a> That such fusions arise early during embryonic development as an absence of joint cavitation<a></a> is also suggested by studies of experimentally paralyzed chick embryos, in which articular cavities do not form.<a></a> The cartilaginous skeletal elements, which are at first united by mesenchyme, become, under these conditions, joined together by fibrous tissue or by cartilage. In other words, fusion takes place across the presumptive joint regions.</p> <p>That hemimelia occurs at a very early stage of embryonic life is indicated by the important, but neglected, observations of Hovelacque and Noel<a></a> on a strain of mice presenting tibial hemimelia. It was found that "the first manifestations of the anomaly are disclosed at a very early stage of development. They can be detected in embryos when the undifferentiated blastema begins to undergo change." In the tibial zone of the blastema, a "fibrous tract" appeared, and was connected to the fibula by the interosseous membrane. In some of these embryos, cartilaginous nodules developed in the area (especially proximally) where the tibia would normally form. Such nodules were in direct continuity with the fibrous tract; both constituted a unit that represented the tibia. The vascularization of the limbs was entirely normal. It was concluded<a></a> that "the tibia is never completely absent despite appearances; one can always find a trace of the element although it may be represented by only a nodule of pinhead size." There is no reason to believe that the above statements would not apply equally to the other types of paraxial hemimelia.</p> <p>To return to the human-the mesenchymal femur, tibia, and fibula appear at about 41 postovulatory days (stage 17), and the humerus, radius, and ulna appear at about 37 postovulatory days (stage 16). In other words, it may be expected that, in the light of the French workers' observations, paraxial hemimelia could be detected in the human before six weeks after fertilization.</p> <p>Prior to the first appearance of these specific skeletal elements, a sensitive period for teratogenic agents exists, as have been shown by correlations between the time of ingestion of thalidomide during pregnancy and the types of resultant anomalies.<a></a> Thus, tibial defects occurred mostly when ingestion began before the 46th menstrual day (perhaps about 32 post-ovulatory days). In one illustrated case, ingestion that commenced at 46 menstrual days resulted in bilateral radial hemimelia and malformations of the femur and tibia.</p> <p>Finally, it may be mentioned that ulnar hemimelia has been found sporadically in various animals, such as the pig.<a></a> It also has been produced experimentally by the inclusion of large doses of acetazol-amide (a carbonic anhydrase inhibitor) in the diet of rats during pregnancy <i>. </i><a></a> Of particular interest in these experiments is the circumstance that the ulnar hemimelia was practically restricted to the right side of the body.-<i>Ronan O'Rahilly, M.D.</i></p> <h3>Summary</h3> <p>The management of 26 cases of ulnar hemimelia has been discussed. This deficit is seen 18:1 less frequently than radial hemimelia. Bilaterality was present in 23% of the cases. Prior to determining the plan of treatment, a complete functional analysis should be carried out. Most of these children do not need surgery and may be treated by prosthetic fitting only. The pathogenesis of paraxial hemimelia and the embryogenesis of associated conditions, such as Polydactyly and joint fusions, are discussed.</p> <p><b>References:</b></p> <ol> <li>Drachman, D. B., and Sokoloff, The role of movement in embryonic joint development, <i>Develop. Biol. </i>14:401-420, 1966.</li> <li>Duken, J., Uber der Beziehungen zwischen As-similationshypophalangie und Aplasie der Inter-phalangealgelenke, <i>Virchows Arch. Path. Anat. Physiol. </i>233:204-225, 1921.</li> <li>Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, <i>J. Bone Joint Surg. </i>43-A: 1202-1224, 1961.</li> <li>Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, <i>J. Bone Joint Surg. </i>41-A: 847-876, 1959.</li> <li>Hovelacque, A., and R. Noel, Processus embryo-logique de l'absence congenitale du tibia, C. <i>R. Soc. Biol. Paris </i>88:577-578, 1923.</li> <li>Kanavel, A. B., Congenital malformations of the hands, <i>Arch. Surg. </i>25:1-53, 282-320, 1932.</li> <li>Klippel, M., and E. Rabaud, Sur une forme rare d'hemimelie radiale intercalaire, <i>Nouu. Ponograph. Salpetriere </i>16:238-251, 1903.</li> <li>Ku'hne, D., W. Lenz, D. Petersen, and H. Schoneberg, Defekt von Femur und Fibula mit Amelie, Peromelie oder ulnaren Strahldefekten der Arme, Ein Syndrom, <i>Humangenetik </i>3: 244-263, 1967.</li> <li>Laurin, C. A., and A. W. Farmer, Congenital absence of ulna, <i>Canad. J. Surg. </i>2:204-207, 1959.</li> <li>Layton, W. M., and D. W. Hallesy, Deformity of forelimb in rats: association with high doses of acetazolamide, <i>Science </i>149:306-308, 1965.</li> <li>Lenz, W., Zur Genese der angeborenen Hand-fehlbildungen, <i>Chir. Plast. Reconstr. </i>5:3-15, 1968.</li> <li>Lenz, W., Der Zeitplan der menschlichen Organogenese als Massstab fur die Beurteilung teratogener Wirkungen, <i>Fortschr. Med. </i>87: 520-526, 1969.</li> <li>Malgaigne, J. F., <i>Oeuvres Completes d'Ambroise Pare, </i>vol. 3, Paris, Bailliere, 1841.</li> <li>Meckel, J. F., <i>Handbuch der pathologischen Ana-tomie, </i>Leipzig, Reclam, 1812.</li> <li>Murray, P. D. F., and D. B. Drachman, The role of movement in the development of joints and related structures: the head and neck in the chick embryo, <i>J. Embryol. Exp. Morph. </i>22:349-371, 1969.</li> <li>Nishimura, H., <i>Chemistry and Prevention of Congenital Anomalies, </i>Springfield, HI., Charles C Thomas, 1964.</li> <li>O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, <i>Amer. J. Anat. </i>89: 135-193, 1951.</li> <li>O'Rahilly, R., The development and the developmental disturbances of the limbs, <i>Irish J. Med. Sci. </i>pp. 30-33, January 1959.</li> <li>O'Rahilly, R., The nomenclature and classification of limb anomalies, <i>Birth Defects: Original Article Series </i>5:14-17, 1969.</li> <li>Pfeiffer, R. A., and K. Reinhardt, Ulno-fibulare Dysplasie, Eine autosomaldominant vererbte Mikromesomelie ahnlich dem Nievergeltsyndrom, <i>Fortschr. Roentgenstr. </i>107:379-391, 1967.</li> <li>Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, <i>Bull. Biol. France Belg. </i>57:401-468, 1923.</li> <li>Roberts, A. S., A case of deformity of the fore-arm and hands, with an unusual history of hereditary congenital deficiency, <i>Ann. Surg. </i>3:135-139, 1886.</li> <li>Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, <i>Z. Orthop. Chir. </i>23:1-157, 1909.</li> <li>Stroer, W. F. H., Die Extremitatenmissbildungen und ihre Beziehungen zum Bauplan der Extremitat, <i>Z. Anat. Entwicklungsgesch </i>108:136-160, 1938.</li> <li>Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, <i>Nunt. Radiol. </i>26: 1040-1054, 1960.</li> <li>Zwilling, E., and J. F. Ames, Polydactyly, related defects and axial shifts, a critique, <i>Amer. Naturalist </i>92:257-266, 1958.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Layton, W. M., and D. W. Hallesy, Deformity of forelimb in rats: association with high doses of acetazolamide, Science 149:306-308, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, Z. Orthop. Chir. 23:1-157, 1909.</td></tr><tr><td class="clsTextSmall"><b> 24.</b> </td><td class="clsTextSmall">Stroer, W. F. H., Die Extremitatenmissbildungen und ihre Beziehungen zum Bauplan der Extremitat, Z. Anat. Entwicklungsgesch 108:136-160, 1938.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Lenz, W., Der Zeitplan der menschlichen Organogenese als Massstab fur die Beurteilung teratogener Wirkungen, Fortschr. Med. 87: 520-526, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hovelacque, A., and R. Noel, Processus embryo-logique de l'absence congenitale du tibia, C. R. Soc. Biol. Paris 88:577-578, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Drachman, D. B., and Sokoloff, The role of movement in embryonic joint development, Develop. Biol. 14:401-420, 1966.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murray, P. D. F., and D. B. Drachman, The role of movement in the development of joints and related structures: the head and neck in the chick embryo, J. Embryol. Exp. Morph. 22:349-371, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, J. Bone Joint Surg. 41-A: 847-876, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Duken, J., Uber der Beziehungen zwischen As-similationshypophalangie und Aplasie der Inter-phalangealgelenke, Virchows Arch. Path. Anat. Physiol. 233:204-225, 1921.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, J. Bone Joint Surg. 41-A: 847-876, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Nishimura, H., Chemistry and Prevention of Congenital Anomalies, Springfield, HI., Charles C Thomas, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Zwilling, E., and J. F. Ames, Polydactyly, related defects and axial shifts, a critique, Amer. Naturalist 92:257-266, 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">O'Rahilly, R., The development and the developmental disturbances of the limbs, Irish J. Med. Sci. pp. 30-33, January 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, Nunt. Radiol. 26: 1040-1054, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Pfeiffer, R. A., and K. Reinhardt, Ulno-fibulare Dysplasie, Eine autosomaldominant vererbte Mikromesomelie ahnlich dem Nievergeltsyndrom, Fortschr. Roentgenstr. 107:379-391, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, Nunt. Radiol. 26: 1040-1054, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Roberts, A. S., A case of deformity of the fore-arm and hands, with an unusual history of hereditary congenital deficiency, Ann. Surg. 3:135-139, 1886.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Ku'hne, D., W. Lenz, D. Petersen, and H. Schoneberg, Defekt von Femur und Fibula mit Amelie, Peromelie oder ulnaren Strahldefekten der Arme, Ein Syndrom, Humangenetik 3: 244-263, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Laurin, C. A., and A. W. Farmer, Congenital absence of ulna, Canad. J. Surg. 2:204-207, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, Z. Orthop. Chir. 23:1-157, 1909.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Malgaigne, J. F., Oeuvres Completes d'Ambroise Pare, vol. 3, Paris, Bailliere, 1841.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Meckel, J. F., Handbuch der pathologischen Ana-tomie, Leipzig, Reclam, 1812.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Lenz, W., Zur Genese der angeborenen Hand-fehlbildungen, Chir. Plast. Reconstr. 5:3-15, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">O'Rahilly, R., The nomenclature and classification of limb anomalies, Birth Defects: Original Article Series 5:14-17, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Klippel, M., and E. Rabaud, Sur une forme rare d'hemimelie radiale intercalaire, Nouu. Ponograph. Salpetriere 16:238-251, 1903.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">O'Rahilly, R., The nomenclature and classification of limb anomalies, Birth Defects: Original Article Series 5:14-17, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Kanavel, A. B., Congenital malformations of the hands, Arch. Surg. 25:1-53, 282-320, 1932.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. 43-A: 1202-1224, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ronan O'Rahilly, M.D. </b></td></tr><tr><td class="clsTextSmall">Director of the Carnegie Collection, Dept. of Embryology, Carnegie Institution of Washington, Baltimore, Md. 21210; Professor of Anatomy, Wayne State Univ. School of Medicine, Detroit, Mich.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Codirector, Area Child Amputee Program (Mich. Dept. of Public Health), 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-28.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-29.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-30.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-31.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-32.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-33.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-39.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-40.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-41.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-34.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-35.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-36.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-37.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-38.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 Ulnar Hemimelia Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * Ronan O'Rahilly, M.D. * https://staging.drfop.org/files/original/a16c64d7ccf859685483448cdaa30655.pdf 030e2ddd7f33ca508ab0109a9cb77990 https://staging.drfop.org/files/original/20971c1df6a94f651c41c24f4b2fa35b.jpg 2531dc6b54ab731bd857b99ad1648727 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_001.pdf Text Any textual data included in the document <h2>Up-Date on Immediate Post Surgical Fittings</h2> <h5>Robert F. Hayes, CP.&nbsp;</h5> <p>I would like to express some thoughts regarding the use of the technique of immediate post-surgical fittings of prostheses for below-knee amputees.</p> <p>Nearly all of us certainly agree that there are definite advantages to the patient in the use of prosthesis immediately after amputation, especially in the case of the BK amputee. However, the I.P.S.F. technique is not being used as standard practice in many areas. Perhaps one of the reasons is the lack of continuing education courses dealing with immediate postsurgical procedures.</p> <p>When the concept of immediate postsurgical fitting was first introduced approximately fifteen years ago there was a heavy concentration to the point of saturation on the application of prostheses in the operating room. This was good, because it gave us all an opportunity to be educated in such a revolutionary technique of treatment. However, today, there are many people entering the field involving amputation and amputee care every year, surgeons and prosthetists and in most cases they have only a limited knowledge of the I.P.S.F. techniques.</p> <p>Obviously, and for good reason, most surgeons are reluctant to use a technique with which they themselves are not familiar. It then becomes the role of the prosthetist to educate and encourage the use of I.P.S.F. and, ideally, apply the concept himself.</p> <p>Another reason for lack of use of I.P.S.F. is the inconvenience created by scheduling between doctor, prosthetist, and operating room. Often hours of valuable time are wasted when things are not proceeding on schedule, which is the norm rather than the exception.</p> <p>Another reason why I.P.S.F. techniques are abandoned is that when a surgeon and prosthetist first attempt this technique, they sometimes use a patient whose probability of healing is marginal under the best of circumstances. And sometimes ambulation is attempted too early, causing stump breakdown. The result is a surgeon convinced that this technique is not for his patients.</p> <p>Still another factor that discourages use of the I.P.S.F. concept is the application of a poorly fitting weight-bearing cast by individuals not fully trained. There have been individuals who, after reading an article or hearing a thirty-minute lecture on I.P.S.F., attempted to apply a weightbearing cast. Some of the more skilled are able to do this, but most have problems. If a cast is intended to bear weight, it must fit well, have proper relief areas and distal padding to provide relief if the patient should atrophy and settle in the socket.</p> <p>It is my opinion that no weight-bearing cast at all is better than a poor application of one that is supposed to bear weight. Please note, I said "weightbearing cast" and not a rigid dressing, which is and should be more readily applied immediately after the operation and does not require the same precision as does the weight-bearing cast. This will be taken up later.</p> <p>Now that we have discussed some of the problems that may have discouraged the utilization of I.P.S.F.- and I'm sure there are many more- let's constructively consider a couple of approaches that seem to work well.</p> <p>Since the inception of I.P.S.F., most of us have changed our thinking for some very solid reasons. One of the primary problems arose in the attempt to have the patient weightbearing and often ambulating within forty-eight hours postoperatively. We have learned that, in most cases, this concept is a disadvantage rather than an advantage and can be the cause of stump breakdown. If we agree that early ambulation is not intended, we may apply an immediate rigid dressing with the appropriate snugfitting sterile stump sock.</p> <p><b><a href="/files/original/20971c1df6a94f651c41c24f4b2fa35b.jpg">Fig 1:</a> Schematic lateral view of method first recommended in the U.S. for immediate past surgical fitting of below-knee prostheses. From "<i>Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees</i>, Ernest M. Burgess, Joseph E. Traub, and A. Bennett Wilson, Jr., Veterans Administration, TR 10-5, April 1967.</b></p> <p>When the rigid dressing is not intended for weightbearing, most surgeons will make the application since they need not be concerned about felt pads for relief over pressure areas. The initial rigid dressing can be left on for approximately two weeks. During this time we have:</p> <ol> <li> <p>Protected the wound by</p> <ol> <li> <p>Keeping external contaminates out</p> </li> <li> <p>Preventing injury to the stump</p> </li> <li> <p>Protecting the posterior flap from undue pressure</p> </li> </ol> </li> <li> <p>Maintained the size of the stump, preventing edema, which alleviates pain</p> </li> <li> <p>Made the patient more comfortable and able to move about without fear of injury to the stump</p> </li> <li> <p>Prevented knee flextion contracture</p> </li> <li> <p>Greatly reduced complaints of phantom limb</p> </li> </ol> <p>After two weeks the initial rigid dressing is removed; or, in some cases, the surgeon will remove the sutures and wait for an additional week or two. At the end of the two-week postoperative period, the prosthetist is called in to apply an early post-surgical prosthesis usually with a plaster socket and a pylon with a SACH foot.</p> <p>In the fabrication of our plaster sockets, we strive to keep the plaster high up over the condyles to the mid thigh area. We find this is beneficial in eliminating knee flexion contractures and, most importantly, eliminating piston action within the socket, a very hazardous condition, especially in the early stages of fitting.</p> <p>I know attempts are made to trim plaster to a P.T.B, level for increased knee motion. The advantages of enclosing the knee offset the short time needed for patients to regain knee motion. I also use a waist belt and fork strap for added suspension. This temporary prosthesis is worn for approximately six weeks.</p> <p>The very thin patient may not need a cast change before the end of six weeks, but more muscular and fatty tissue will require cast changes according to the amount of atrophy.</p> <p>After the patient has been ambulating for approximately six weeks, the plaster socket is bi-valved and a negative mold is taken for the definitive prosthesis. The plaster socket is then put back on the patient and closed with plaster or tape. The plaster socket and pylon stay on the patient until delivery of the definitive prosthesis and removed as needed for fittings. When minor changes in stump size occur, stump socks may be added while using the plaster pylon prosthesis.</p> <p>To reduce some expense to the patient, the hospital can inventory several pylon assemblies suitable for temporary use. We also supply various sizes of used SACH feet that can be used temporarily. The patient is then charged only for the professional services of the prosthetist, thus saving the considerable expense of components.</p> <p>I hope that some of my comments may be of assistance to others who would like to employ more immediate postsurgical prosthetic care for patients, and hopefully stimulate others to respond with other approaches so that we may all benefit.</p> <p>I would like to acknowledge Dr. Elmer Franseen, from whom I have used references many times in this paper. Dr. Franseen is an Orthopedic Surgeon at Baystate Medical Center, Springfield, Mass. I am sad to say that Dr. Franseen is retiring this month, and I will miss working with this truly professional man. In the past fifteen years of working with Dr. Franseen, I have witnessed him employing I.P.S.F. on all of his B.K. amputees and only on rare occasions was a revision necessary.</p> Page Number(s) 1 - 3 Year 1978 Volume 2 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1978_04_001/1978_04_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Up-Date on Immediate Post Surgical Fittings Creator An entity primarily responsible for making the resource Robert F. Hayes, CP.  https://staging.drfop.org/files/original/527606029dde597c9241e01480a56072.pdf 4c755f2a1ca5cf1398a468e307fd2dea Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_087.pdf Text Any textual data included in the document <h2>Upper Extremity Cosmetic Gloves</h2> <h5>Sandra Bilotto, M.A., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Upper extremity rehabilitation includes the restoration of function and cosmesis to simulate the human hand.<a></a> Producing a replica of the hand which is functionally and psychologically beneficial to the amputee and quite importantly, acceptable to those with whom the amputee socially interacts,<a></a> is both challenging and of high priority.</p> <p>The technology for producing either custom made or mass produced cosmetic gloves has changed little in more than 20 years.<a></a> However, within the last several years, with the advent of new materials, there have been new developments. More specifically, there have been developments in a family of silicone elastomers the application of which offers solutions to problems associated with existing cosmetic glove technology.</p> <p>Briefly, cosmetic gloves have been made with latex, urethanes, and RTV silicones, but these materials were not successful because they had serious drawbacks. Latex skins were impermanent, coloration was unacceptable, tear strength was very low, absorption of clothing dyes was common,<a></a> and they did not last very long before deteriorating. Urethanes held promise, but the components to produce a plastic film are very difficult to control in small laboratories. They are too sensitive to moisture and extraneous contaminants, and require precise measuring. After limited use, they are weakened by ultraviolet light and thus their useful life as terminal device coverings is limited.<a></a> RTV or room temperature curing silicones, when first utilized in prosthetic restorations and glove-making, proved ineffective because the material required complicated molding procedures, was often manufactured pre-colored, had extremely low tear strength, and had very low elasticity and flexibility. In addition, one small tear would easily propagate, rendering the glove useless.</p> <h3>PVC Gloves</h3> <p>PVC, or polyvinyl chloride, has dominated glove making and still does to the present. Historically PVC is inexpensive and readily available. Gloves can be fabricated en masse in metal molds or custom made in flexible slush molds. In either technique, the plastisol cures against the wall of the mold, producing a thin skin of vinyl which can either be intrinsically and/or extrinsically colored.<a></a> Stabilizers and plasticizers are introduced to make the cosmetic glove flexible and resistant to degradation by ultraviolet light. Replication of the human hand has been adequate using PVC and thus these gloves have been widely available for most amputees. However, there are disadvantages associated with PVC as a material for use in prosthetic gloves.</p> <p>First and foremost is the inability of PVC to resist attack by most chemicals, soiling and staining agents, and newsprint. These substances are absorbed by the plasticizing agents and are impossible to remove. At temperatures close to freezing, the PVC stiffens and its flexibility is greatly reduced. This can inhibit the proper functioning of an electric or mechanical hand as the inability to open a finger or thumb can render a terminal device useless.<a></a> In warm temperatures, the plasticizers and stabilizers tend to bleed to the surface of the glove, causing peeling of the extrinsic coloring, as well as darkening and stiffening. PVC "feels" like plastic and not like human tissue, and for the most part, unless a PVC glove is custom made and tinted, the surface is rather opaque and cadaverous looking. Custom made PVC gloves present all of the above problems, but do match skin tone, hand shape, and surface characterization of the intact hand better. The time required to fabricate a custom glove is much longer because the technique is more elaborate, and as a result more expensive. Of course, the success of the glove is directly proportional to the ability of the prosthetist to make the cosmetic glove appear natural and reasonably well matched to the other hand.</p> <p>No matter what technique is utilized, the consensus is that PVC gloves are rather short lived: two weeks to eight months on average. Efforts to strengthen the glove with nylon fabric reinforcement or to retard discoloration by spraying clear solutions on the surface of the glove produce disappointing results.<a></a> Finally, there is a problem donning and doffing a PVC glove due to the inflexibility of the material proximal to the wrist. This gave rise to the practice of sewing zippers into gloves. Besides being bulky and unsightly, zipper installation is time consuming and the zipper may be easily jammed or broken. Thus, a better material which might resolve some of the above problems is needed.</p> <h3>Silicone Gloves</h3> <p>Silicone rubber offers excellent solutions to some of the aforementioned problems, and they now have properties which make them more readily processed in glove making.<a></a> In general, the new generation of silicones are tougher, more resilient, more durable, and more permanent than previously utilized materials. While not ideal, the silicone gloves presently being developed resist chemicals, dyes, soiling, and staining almost completely. The skins may be washed with mild detergents and water for cleaning. Unlike PVC, lower or higher temperatures have little effect on the strength, flexibility, or elasticity of the glove.<a></a> The result is better functioning of electro/mechanical hands, and in some cases, the elastic resistance of gloves can actually enhance functioning of the terminal device.</p> <p>Unlike PVC, silicone rubber may be modified to increase its elasticity where necessary without loss of tear strength. Cosmetic gloves of silicone elastomers may be intrinsically or extrinsically colored as with PVC. However, there is much greater adhesion of external pigments to silicone gloves and the resultant glove rarely sheds its external tinting. It is more color stable and is less affected by ultraviolet light than its PVC counterpart; Silicone neither darkens nor stiffens with the passage of time. Once fabricated, the glove is non-toxic as compared with PVC. This is an obvious advantage when fabricating gloves for babies and toddlers, as harmful agents do not leach out to the surface of the glove to enter the baby's mouth. Silicone can be formulated to reflect and absorb light in much the same way human skin does, producing a more natural and life like appearance. Likewise, silicone also simulates the "feel" of skin more closely as it relates to softness and texture.<a></a> Its higher coefficient of friction helps prevent glasses and other objects from falling out of the hand's grasp.</p> <h3>Discussion</h3> <p>There are some disadvantages in the production of silicone gloves which need to be addressed. The cost of manufacturing, the increase in fabrication time, and the slightly higher cost of silicone rubber<a></a> is retarding the availability of such gloves.</p> <p>However, if the technology to produce silicone gloves improves, and if they become more widely available, their cost and fabrication time should decrease. They have greater durability and esthetic appeal than PVC, and there can be no doubt that silicone offers possibilities heretofore unavailable with PVC.</p> <p>Silicone cosmetic coverings for the lower extremity are a future possibility. Swim and sport legs could be greatly inhanced by these tough, resilient and cosmetic coverings. Silicone compounds are presently used in maxillofacial prosthetics, breast prostheses, partial hands, partial feet, leg and arm buildups, and other body restorations.<a></a></p> <p>There is no doubt that a more natural, functional, esthetically and psychologically appealing cosmetic glove is needed by upper extremity amputees and that silicone gloves, despite some imperfections, will prove to be more promising and acceptable than PVC gloves.</p> <p><b>References:</b></p> <ol> <li>Arkles, B., "Look what you can make out of Silicones," <i>Chemteck</i>, Vol. 13, No. 9, pp. 542-555, September 1983.</li> <li><a href="al/1955_02_057.asp">Carnelli, W.A.; Defries, M.G.; and Leonard, F., "Color Realism in the Cosmetic Glove," <i>Artificial Limbs</i>, Vol. 2, pp. 57-65, May 1955.</a></li> <li>Davies, E.W.; Douglas, W.B.; and Small, A.D., "A Cosmetic Functional Hand Incorporating a Silicone Glove," <i>Journal of International Society of Prosthetics and Orthotics</i>, Vol. 1, No. 2, pp. 89-93, September 1977.</li> <li><a href="al/1955_02_047.asp">Dembo, T. and Tane-Baskin, E., "The Noticeability of the Cosmetic Glove," <i>Artificial Limbs</i>, Vol. 2 pp. 47-56, May 1955.</a></li> <li>Fillauer, C and Quigley, M., "Clinical Evaluation of an Acrylic Latex Material used as a Prosthetic Skin on Limb Prostheses," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 4, pp. 30-38, December 1979.</li> <li><a href="al/1955_02_078.asp">Fletcher, M. and Leonard, F., "Principles of Artificial Hand Design," <i>Artificial Limbs</i>, Vol. 2, pp. 78-94. May 1955.</a></li> <li>Lee, D. and Harlan, W., "Medical Sculpture: A Valuable Aid to Patient Rehabilitation," <i>American Family Physician</i>, Vol. 15, pp. 110-114, February 1977.</li> <li>Journal American Dental Assoc., "Maxillofacial Prosthetic Materials," <i>Council on Dental Materials and Devices</i>, Vol. 90, pp. 834-848, April 1975.</li> <li>Klasson, Bo, Personal communication, Een-Holmgren, Stockholm, Sweden.</li> </ol> <em><b>*Sandra Bilotto, M.A., C.P.O. </b> Sandra Bilotto, M.A., C.P.O., currently resides in Yonkers, N.Y. She received her education in prosthetics and orthotics at N.Y.U. Prior to that she received training in sculpture. Cosmetic restoration is a particular interest of hers.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 87 - 89 Year 1986 Volume 10 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Extremity Cosmetic Gloves Creator An entity primarily responsible for making the resource Sandra Bilotto, M.A., C.P.O. * https://staging.drfop.org/files/original/6c2c63ddffe3d550de617cddd2fd3dd0.pdf a968d5b9bd58a10b866f2865888702c4 https://staging.drfop.org/files/original/f79b3b23e95dbeb5afa6c8473cde777c.jpg 8fb5942309fbf39e9a7f9d5b0faa3ad4 https://staging.drfop.org/files/original/c220a5b7800edb8c2f03fbae92a1461e.jpg 87cbf6d646ea79dfe843e1acabdda96f https://staging.drfop.org/files/original/c51a8772e852e3c455899c6ff2c762ce.jpg 33046249d3204db97c4c086dfd5599b3 https://staging.drfop.org/files/original/6900141d8663452725d64428373f8d50.jpg 53e19138614db7dc6c7fb8957ab80aae https://staging.drfop.org/files/original/d95b5a36a5716b9d244ed4df81c74f3e.jpg 4b6a6d211a5d773b43c6faab345690df https://staging.drfop.org/files/original/c9e2d2419431e40d357277310450bc3e.png afc4e7e2abd9dbe853ea3aae3159c753 https://staging.drfop.org/files/original/7097692bfc548e8b707cf8c2c5d4cd0d.png 5eceeff5f79d833e8f2e3a8c26694e06 https://staging.drfop.org/files/original/90edd7a8ef69e6ec44df2371f663927a.png c617fbfef726b1388adcfd1e4d2c584e https://staging.drfop.org/files/original/d1b765c7055d84a8a7222ccbc9c30ff1.png 7cbeda763ee9076246a237debce1071b https://staging.drfop.org/files/original/584c3a08b5ad54660112b465920dd0d6.png d9a078f202590efd229a906944609682 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_066.pdf Text Any textual data included in the document <h2>Upper Limb Powered Components and Controls: Current Concepts</h2> <h5>John W. Michael, M.Ed., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In order to review the current offerings in powered upper limb components, it is necessary to agree upon certain standardized terms. The following suggestions, based upon a survey of the existing literature, are intended to help insure we are all speaking a common language.</p> <p>Practitioners with strong opinions regarding alternate definitions are encouraged to publish their views as well. It is critical that we agree upon some definition; which particular version is of much less importance.</p> <p>The focus of this paper will be on externally powered prostheses—specifically, those that are electrical in nature. The opposite concept is the familiar body powered prosthesis, which is powered by muscular action and transmitted from remote body locations.</p> <p>Many prosthetists have some experience at the below-elbow level with the components produced by Otto Bock, and assume they have fitted myoelectric devices. Technically, that is not completely correct.</p> <p>The MyoBock system is most accurately termed "Myoswitch" control. This is a much simpler version than true myoelectric control. In the Otto Bock system, the residual myoelectric signal does not directly control the terminal device. Instead, the patient must generate a sufficiently strong signal to cross a threshold, which triggers an electronic switch.</p> <p>A good analogy would be that of sound-activated devices which can be installed in lieu of a standard light switch. Clapping one's hands turns the light on. If the clap is too faint, nothing will happen, but an extremely loud clap has no more effect than one just loud enough to trigger the switch. This is sometimes described as "digital control."</p> <p>This approach does not allow proportional control. That is, the light is either all on, or all off. There is no in-between. Proportional control is provided by a rheostat, which allows one to gradually dim or brighten the lights as the mood dictates.</p> <p>Proportional control is, in this author's opinion, the key distinction in true myoelectric systems. The below-elbow system marketed by Fidelity Electronics is an example of such a design. In this version, a mild myoelectric impulse causes a slow, gentle movement of the hand, while a strong impulse creates a rapid, powerful movement of the hand. Many authorities feel this is the most physiologically natural control, and offers the greatest degree of prehension control as well.<a></a></p> <p>A good analogy is the accelerator in an automobile, which allows proportional control of the speed of the vehicle. Imagine a switch-controlled car with the throttle either at idle or wide open! Otto Bock has a very clever solution to this dilemma: the automatic transmission.</p> <p>The MyoBock prosthesis has two speeds: a quick, gentle motion when opening and closing, and a slow, powerful motion once the fingers grip an object. This might not be a reasonable solution for the auto industry, but it has proved to be clinically acceptable in prosthetics.</p> <p>The third available control mode is pure Switch Control. This is the least expensive approach and generally requires less bulky electronics. For these reasons, it is often used in juvenile below-elbow designs (for example, Variety Village). It also does not require any myoelectric signals, which can be helpful when control sites are limited or unavailable.</p> <p>Switch controls come in three basic varieties.</p> <ol> <li> <p><b>Rocker Switches</b> are similar to the on-off control for stereo equipment, and are sometimes used where a mobile acromion is present.</p> </li> <li> <p><b>Button Switches</b> are also adaptable for acromion control, for use with phoco-melic digits, and any other mobile body parts. They are the electronic analogue of mechanical nudge control.</p> </li> <li> <p><b>Pull Switches</b> are useful when harness control is desired. Most are multiposi-tional, where initial excursion will cause one motion, and further excursion the opposite motion. These are somewhat analogous to the alternating lock used in the conventional elbows with one motion controlling two or more functions.</p> </li> </ol> <p>These are simply the most common types; literally hundreds of variations can be obtained from electronic supply stores. On rare occasions, they can be arranged in a piano keyboard array, allowing several degrees of freedom to be controlled from one location.<a></a></p> <p>Another set of related concepts are "site and state."12 Site refers to the number of distinct muscle signals required. Thus, the original Myobock system was a "two site" version, requiring one myosignal for hand opening and a separate signal for hand closing.</p> <p>The University of New Brunswick (UNB) was one of the first groups to develop a commercial system that required only one myosignal. This is particularly advantageous when dealing with young congenital below-elbow patients. Very often they can only generate one mass contraction in the residual limb, and space considerations alone may preclude more than one electrode. UNB termed their system "Single Site/Three State" control. The term "Three State" means that the myopulse both opens and closes the hand; the "third" state is "off."</p> <p>In the last couple of years, Otto Bock has introduced their version of this concept. As in the UNB design, it is a digital "Myoswitch." A quick, hard myopulse causes the hand to open, while a slow, gentle myopulse causes closure. Bock calls this "Double Channel Single Site" control. "Double Channel" accurately identifies the capabilities: one channel opens and the other closes.</p> <p>Unfortunately, the word "channel" has established meanings in other fields that may be a source of confusion. For maximum clarity, the term "Function" is probably preferable.<a></a> This has a clear intuitive meaning. Thus, the system just described would be termed a "One Site-Two Function" system.</p> <p>With suitable changes in the terminal device electronics, Otto Bock can offer what they term "Grip Force" control which is a kind of psuedo-proportional control. In this application, the patient can use the quick, strong pulse to automatically downshift the transmission, thereby increasing the grip strength.</p> <p>A logical extension of this approach is Bock's "Four Channel" design. One electrode controls terminal device opening and closing while the other controls electric wrist pronation and supination—four distinct functions.</p> <p>Clearly, if suitable sites could be found, additional degrees of freedom could be controlled using existing technology. Experience has shown, however, that this is rarely feasible.</p> <p>In the above-elbow realm, the developers at Motion Control argue strongly that proportional control is the ideal. Therefore, they avoid the digital control mentioned thus far. Yet, they have developed a system permitting only two muscle sites to operate elbow raising and lowering, as well as terminal device opening and closing. Thus far, their solution is unique in the field of powered components.</p> <p>The Motion Control design uses a very clever method of electronic switching to separate elbow and terminal device functions. When the arm is first powered on, the two muscle sites proportionally control elbow flexion and extension. (In an ideal candidate, biceps and triceps are the remnant muscles yielding physiologically normal control as well.) Whenever the elbow is in motion, things remain in this mode.</p> <p>However, if the elbow is stopped in a flexed position and held steady for a moment, the arm "senses" that one intends to perform a grasping function. It then locks the elbow and automatically switches itself into a "grasping" mode. The same two sites now control proportional, bidirectional grasp. To return to the "elbow" mode, the patient co-contracts in a specific fashion. The co-contractures cancel each other out so that no motion of the TD occurs, and the electronic switch senses this and changes modes.</p> <p>This strategy can be termed "Sequential Control", and is directly analogous to the familiar mechanical elbow joint where the same shoulder motion moves first the elbow and then the terminal device.</p> <p>The most sophisticated control for a high level amputee would be Simultaneous Proportional Control. Northwestern has done some fascinating work in this area,<a></a> as has the Illinois Institute of Technology and others.<a></a> This would be the most natural-appearing motion, since our biological arms move through multiple degrees of freedom simultaneously with every gesture.</p> <p>However, there are numerous technical and control difficulties with this approach, and all seem to be far from commercial production right now. One major issue is control site availability. Even if one conceives of an arm offering twenty simultaneous degrees of freedom, where on the high-level amputee are twenty independent controlable sites to be found?</p> <p>Much of the current research involves reading data from a few sites and using computer algorithms to simulate multi-degree control.<a></a> Most currently require a mainframe computer to process the data in real time, but perhaps the future will see microchip processors with these capabilities built into upper limb devices.</p> <p>But, for now there are less spectacular components to choose from. What follows is an overview of currently available hardware. Specific details change almost weekly; contact the manufacturer for the latest updates.</p> <p>The final caveat is: the ideal system does not exist. All the components have strengths and weaknesses. When prescribed correctly, one can achieve very satisfying results. When used inappropriately, failure is the inevitable result. As prosthetists gain more collective experience and confidence in the realm of powered upper limb prosthetics, perhaps we can learn to "mix and match," as we do in body powered fittings, to maximize the benefits for our patients.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg"><b>Fig. 1. <span>Otto Bock electric hand and electric hook (Greifer). Bilateral powered fittings can be successful in carefully selected cases. (Courtesy of Otto Bock Industries.)</span></b></a></p> <h3>Otto Bock</h3> <p>In the United States, Otto Bock is viewed as the "father" of electrically controlled prostheses. Although all their current designs are digital controls, they offer one of the largest arrays of interchangeable electric components of any manufacturer. At this time, all Otto Bock components are designed for below-elbow use, although they are equally adaptable for higher levels.</p> <p>One ramification of this is that since 1976, they have been using six volts as their standard. (Twelve volt terminal devices can be obtained for use with other manufacturers' systems.) Six volts offers lower battery weights while still providing adequate power for terminal device operation.</p> <p>Otto Bock's battery is a relatively small package, easily interchangeable, but for slow recharge only. Their "Griefer" is the only adult-sized powered hook currently on the market, and it readily interchanges with their adult hands. They also have the only electric wrist rotator currently available.</p> <p>They currently offer four hand sizes, for older children, teens and ladies, standard adult, and large adult males. These have become the <i>de facto</i> standard in the industry; virtually every other company can interface their system with a MyoBock hand. An assortment of wrists are also available.</p> <p>All their electrodes are digital, myoswitch types, as already discussed. They offer optional floating electrode mounts for cases where a change in residual limb volume is anticipated.</p> <p>Since their terminal devices are set up for myoswitch control, it is relatively easy to use regular switch control as well. Otto Bock offers both a rocker switch and a harness pull switch version.</p> <p>With their typical attention to detail, a complete set of <i>Technical Information Bulletins</i>, courses, and specialized tools are available. Otto Bock also offers a variety of well thought out accessories, such as a tweezer (pincer) for the hands, blank Griefer tips for machining custom gripping surfaces, and so on.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg"><b>Fig. 2. <span>Variety Village VV2-6 electric hand: the smallest and lightest powered hand commercially available. (Courtesy of Variety Village Electrolimb Production Centre.)</span></b></a></p> <h3>Variety Village</h3> <p>Variety Village components complement Otto Bock's nicely, as they are targeted for smaller children, and include a powered elbow. All their components are switch controlled.</p> <p>They market three switch types: a toggle for phocomelics, a button type, and a pull strap version. In addition, their elbow can have the pull switch built in, or be ordered for use with remote switches.</p> <p>Their elbow is available in either 6 or 12 volts; their hands are 6 volts exclusively. Their smallest hand (for 2-6 year olds) has just been redesigned. Although similar to the Swedish hand, it is three ounces lighter.</p> <p>Their original hands (Models 105 and 106) have been discontinued. Research is currently underway to create the smallest electric hand yet available: thirty percent smaller than their VV2-6. Only prototypes exist at this time, however.</p> <p>They market several battery configurations, including a "Battery Saver Circuit" designed to prevent children from draining the electrical charge by stalling the motor. None are of the quick-charge variety, however.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg"><b>Fig. 3. <span>Electric hands imported by Liberty Mutual. The smallest is the System-Teknik from Sweden; balance are Steeper hands from England. (</span><i>Courtesy of Liberty Mutual Research Center.</i><span>)</span></b></a></p> <h3>Hugh Steeper Limited</h3> <p>Steeper is the British corporation responsible for upper limb prosthetics in the United Kingdom. They have recently announced the availability of powered hands for small children.</p> <p>These are now being distributed by Liberty Mutual in the United States. The sizes complement the Swedish hand, in that the Steeper hands are a bit larger than either Swedish version. Sometime in 1986, they will probably offer a larger hand for the early teen.</p> <p>These are 6 volt, switch controlled devices for the most part. However, Steeper also offers a "Servo-Control" option. This is a unique kind of proportional switch control: the harder the child pulls on the switch cable, the stronger the grasp. With minor adaptations (which Liberty Mutual will make), they can also be controlled by Otto Bock or UNB myos witches.</p> <h3>System-Teknik</h3> <p>System-Teknik is a Swedish company with two children's hands on the American market. Production rights for these hands have just been aquired by Steeper, so design changes can be expected. Liberty Mutual is the American distributer.</p> <p>At the present time, two Swedish hands are available: one for 2-6 year olds and another for 5-9 year olds. Both are 6 volts, and they use the same size forearm laminating ring for easy interchange.</p> <p>They can be controlled by either the UNB or Otto Bock myoswitches and switch controls. UNB designed its batteries to be mounted within the forearm shell. If space permitted, Otto Bock's could be used as well.</p> <p>To simplify the fitting procedure, Liberty Mutual plans to offer a special wrist unit option, containing all necessary electronics. Planned for use with both the System Teknik and Steeper hands, it will come in one version containing the battery supply, and a shorter version for longer residual limbs with remote battery mounting.</p> <p><b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg">Fig. 4. <span>Variety of powered components supplied by Liberty Mutual, including the UNB Toy Controller. (</span><i>Courtesy of Liberty Mutual Research Center.</i><span>)</span></a><br /><br /></b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg"><b>Fig. 5. <span>Fidelity components, including harness pull switch, electric elbow, and VANU hand. (</span><i>Courtesy of Fidelity Biomedical Products.</i><span>)</span></b></a></p> <h3>University Of New Brunswick</h3> <p>All UNB products are available through Liberty Mutual in the United States. When ordering their "Single Site" system, there are three options for battery placement: built-in to the electronics package, mounted inside the forearm section, or mounted externally. As is the case with all manufacturers, you must purchase their particular myotester/trainer to properly adjust their system.</p> <p>In addition, UNB offers a unique single site system with built-in sensory feedback. To aid in myotraining small children, they also market a "Toy Controller," which can be adapted to run with Otto Bock electrodes as well.</p> <h3>Fidelity Electronics</h3> <p>Fidelity Electronics distributes the proportional below-elbow system originally developed at Northwestern University. At one time the United States Manufacturing Company also carried these components, but Fidelity is currently the sole source. This is sometimes referred to as the "VANU" hand.</p> <p>Several things are unique about this product. First, it is a 12 volt system. Secondly, all the electronics are located in a "wrist module," including the battery. Therefore, it is self-contained with minimal risk of wire damage. However, this also prevents fitting very long residual limbs and concentrates all the weight at the distal portion of the prosthesis.</p> <p>Long residual limbs require the use of a switch-controlled version, thus eliminating the wrist module. This hand is sized for adult males only (7 3/4).</p> <p>Fidelity also offers a switch-controlled elbow (again, in adult size only). This is an 8.75 volt system, with its own built-in battery pack. It utilizes an exoskeletal soft foam forearm set-up.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg"><b>Fig. 6. <span>The Prehension Actuator provides powered opening for a variety of conventional hooks. Closing force is controlled by the number of rubber bands applied. (</span><i>Courtesy of Hosmer Dorrance Corporation.</i><span>)</span></b></a></p> <h3>Hosmer Dorrance</h3> <p>As the "grandfather" of upper limb prosthetics in North America, Hosmer is in a unique position to develop a system of powered components. Their basic philosophy has been to focus on light-weight, straightforward, relatively inexpensive designs.</p> <p>For years, they have offered the "Michigan Hook," which is the familiar child's hook, closed by a rubber band, but opened with a small motor winding a string. Last year, they announced an adult version of this concept, called the "NYU Prehension Actuator." This is a conventional forearm set-up with an electric "winder" included. It can be mated with a variety of voluntary opening hooks, using up to five rubber bands or so. Although it is currently switch-controlled, a single-site "MyoPack" will soon be available, offering the option to convert both the Michigan Hook and the Prehension Actuator to myoswitch control.</p> <p>Hosmer has also released the "NYU Hush" elbow. This is unique in several respects. First, it is designed to permit the familiar mechanical elbow to be substituted for the electric one, even in a finished prosthesis. Secondly, they elected to use standard "grocery store" nickel cadmium batteries to power the system. This dramatically reduces the cost to the consumer. Four AA NiCad cells yield a 5 volt system; if desired, five can be used for 6.25 volts. Either version is rechargable with an inexpensive "dimestore" trickle charger.</p> <p>Hosmer hopes to offer in 1986 a "Free Swing" option for their elbow, which could be retro-fitted to existing units in the field. Once the elbow attains full extension, it would automatically enter the free-swing mode. In addition to enhancing the dynamic cosmesis during ambulation, this may offer some special benefits to bilateral patients. Those who depend on the prosthesis for feeding would then have the option of resting the forearm against the table and using "body English" for elbow flexion.</p> <p>Finally, it can be used with either an endo-skeletal or exoskeletal forearm, as desired. This is a switch-controlled elbow, again keeping the costs lower, which is currently available in a large and medium size, corresponding to the familiar E-400 and E-200 mechanical elbows. Thus, it is suitable for many older children as well as adult men and women.</p> <p>Hosmer's switches have recently been redesigned to increase reliability. In addition to the familiar button and harness switches, they also offer a "Three-Position Harness Switch," permitting one control motion to operate both elbow flexion-extension and the NYU Prehension Actuator.</p> <p>The latest addition to the Hosmer line is an adult male (7 3/4) switch-controlled hand to complement their elbow. This also uses readily available NiCads for 5 or 6.25 volt operation. The "Synergetic Hook" designed by Dr. Dudley Childress at Northwestern University<a></a> should be available sometime in 1986. Beyond that, work is ongoing for a myoelectric elbow and hand, but neither is presently available.</p> <p><b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg">Fig. 7. <span>Boston elbow, combined with a Hosmer mechanical shoulder joint and Otto Bock electric hand. Combining various international components can enhance prosthetic restoration. (Prosthetic Design by John C. Hodgins, C.P.O.; (</span><i>Courtesy of Liberty Mutual Research Center.</i><span>)</span></a><br /><br /></b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg"><b>Fig. 8. <span>Exploded view of the Utah elbow. Highly modular construction facilitates servicing in the field. (</span><i>Courtesy of Motion Control, Inc.</i><span>)</span></b></a></p> <h3>Liberty Mutual</h3> <p>Liberty Mutual is the world's largest workmen's compensation insurer. In the United States, one in fifteen workers is insured by this company. Thus, they have a dual motivation in offering sophisticated prosthetic components: both to help the clients they insure, and also to enable the clients to return to work, thus reducing the company's liability.</p> <p>The 12 volt Liberty Mutual "Boston Elbow" can be categorized as a working man's device. And, in fact, it is one of the most durable electric elbows on the market. Although the original version was widely criticized because of the noise it made when operating, the current generation is markedly improved.</p> <p>This is the only elbow offering dual battery chargers. Although Liberty Mutual recommends overnight "trickle" charging for longer battery life, they offer a "quick charge" option, in case the internal battery becomes discharged before the day is over.</p> <p>This is also the only elbow designed to easily convert from proportional myoelectric control to switch control. Simply altering one wire makes the conversion. This can be very useful, for example, in fitting patients early with switch control, then later upgrading to myo-control as their residual limb matures.</p> <p>As mentioned elsewhere, Liberty Mutual also distributes the UNB, System-Technik, and Steeper components.</p> <h3>Motion Control</h3> <p>Motion Control is marketing the powered elbow system originally developed by the University of Utah. In contrast to Hosmer's strategy, this group sought to offer the most technologically advanced components possible. Undoubtedly, they have succeeded in this goal.</p> <p>However, most sophisticated does not necessarily mean best; simpler technology is often more reliable than state-of-the-art. Nevertheless, Motion Control has a unique addition to the prosthetic armamentarium.</p> <p>Their electronic locking mechanism and Sequential Proportional Control have already been discussed. Originally designed for mechanical terminal device operation, this 12 volt elbow can also be ordered with an Otto Bock hand. In this case, however, Motion Control discards the electronics and substitutes their own, thus offering true proportional myoelectric control of the Otto Bock hand.</p> <p>Of all the systems on the market, particularly above-elbow systems, this is the most "pros-thetist friendly." All the inner components are modular and easily exchangeable in the field. The quick-change battery pack is built into the humeral section, but below the elbow axis. This permits fitting longer residual limbs than is possible with other systems, and means there are no external wires to fray and fail.</p> <p>Further, this version offers by far the most adjustments to "fine tune" the elbow for a particular patient. There is a price to pay for this degree of technology, of course. In addition to being the most sophisticated, the Utah Arm is also by far the most expensive powered device available today.</p> <p>It is now possible to add an Otto Bock powered wrist rotator to the Utah Arm, using a variety of control strategies, including UNB or Otto Bock's single-site electrodes, two-site electrodes, and assorted switches. If a mechanical terminal device has been used, the Utah Arm mechanism can be modified to provide dedicated proportional control of the wrist unit. Also, their highly sensitive myotester is finally a commercial reality.</p> <p>Beyond that, Motion Control has just announced the availability, to prosthetists trained in the elbow fitting procedures, of a proportionally controlled below-elbow system, using Motion Control electronics to power an Otto Bock hand with 12 volts in a below-elbow prosthesis. Currently, this requires mounting two Otto Bock batteries, which can present some difficulties, although other battery sources can be utilized in selective cases.</p> <p>Finally, and perhaps most significantly, Motion Control has become the first supplier to offer a rental program for myoelectric components. In marginal cases, if funding has been conditionally approved, the components can be rented on a monthly basis for about ten percent of the total cost. Most of the rental is applied toward purchase of the arm if the fitting proves successful; if not, the parts are returned to Motion Control.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg"><b>Table 1</b></a>, <b><a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.jpg">Table 2</a><br /><br /></b><strong>Summary</strong></p> <p>Our powered upper limb armamentarium is now surprisingly complete. Although one must select components from all over the world, it is possible to fit virtually any patient from two years old to adulthood with an externally powered prosthesis.</p> <p>Otto Bock components remain the most widely utilized, and their hands and connectors are becoming the <i>de facto</i> standards in the field. Their own components are designed for below-elbow use, but are routinely adapted to higher levels. Otto Bock has chosen to develop a variety of myoswitch controls, but does not offer true proportional control.</p> <p>Although several voltages are used, a general trend toward 12 volts for above-elbow systems and 6 volts for below-elbow is apparent. And, switch control is used almost exclusively for very small children, progressing to myoswitch control as they mature; proportional control is most commonly reserved for adults.</p> <p>The children's components are all from outside the United States: Sweden, England, and Canada currently offer toddler hands. American designs are often targeted to adults: the Hosmer and VANU hands and Boston Elbow toward males, in particular.</p> <p>Hosmer is aggressively pursuing the inexpensive, low-tech end of the market, emphasizing interchangeability with the familiar mechanical counterparts. Motion Control is equally aggressive in pursuing the high tech, high cost end.</p> <p>Lack of funding is probably the major factor limiting the number of powered fittings currently undertaken. With the ready availability of various switch, myoswitch, and proportional controls, virtually any patient could operate an electric prosthesis.</p> <p>Questions about who is a suitable candidate for powered fittings are still largely unanswered. The evidence suggests that the highest failure rate is with bilateral fittings.<a></a> Perhaps the simplicity and resultant reliability of body powered prostheses makes mechanical solutions more succcessful here.</p> <p>The best system cannot be found, and few practitioners are brave enough or experienced enough to freely mix these international components. The issues of proportional vs. digital control, high tech vs. low tech design, hybrid vs. purely mechanical vs. purely powered fittings are all open to debate.</p> <p>And some very provocative data is emerging suggesting that the issue of when to fit is at least as significant as the issue of what to fit.<a></a></p> <p>It is beyond the scope of this paper to resolve these complex issues. Rather, the intent is simply to bring into focus the basic concepts, components, and controversies in the field of powered upper limb fittings. It is hoped that clarifying these issues will encourage prosthetic practitioners to deepen their involvement and understanding in this rapidly evolving area. As we struggle collectively with these problems, our patients and our profession will ultimately reap the benefits.</p> <h3>Appendix</h3> <p><i>V.A.N.U. Products</i><br />Fidelity Biomedical Products<br />6000 N.W. 153 Street<br />Miami Lakes, Florida 33014<br />(800) 327-7939</p> <p><i>Hush Elbow; Prehension Actuator</i><br />Hosmer-Dorrance Corporation<br />561 Division Street<br />P.O. Box 37<br />Campbell, California 95008<br />(800) 538-7748</p> <p><i>Boston, UNB, Steeper, Systek Products</i><br />Liberty Mutual Research Center<br />71 Frankland Road<br />Hopkinton, Massachusetts 01748<br />(617) 435-9061</p> <p><i>Utah Elbow, BE System</i><br />Motion Control, Inc.<br />1005 South 300 West<br />Salt Lake City, Utah 84101<br />(800) 621-3347</p> <p><i>MyoBock Products</i><br />Otto Bock Industry<br />4130 Highway 55<br />Minneapolis, Minnesota 55422<br />(800) 328-4058</p> <p><i>Variety Village Products</i><br />Variety Village Electrolimb Production Centre<br />3701 Danforth Avenue<br />Scarborough, Toronto<br />CANADA MIN 2G2<br />(416) 698-1415</p> <p><em><b>*John W. Michael, M.Ed.</b>,<strong> C.P.O.</strong> John W. Michael is Director of Prosthetics and Orthotics, Duke University Medical Center, Box 3885, Durham, North Carolina 27710.<br /></em><b><span><br /></span><br />References:</b></p> <ol> <li><a href="poi/1981_02_092.asp">Agnew, J.P., "Functional Effectiveness of a Myo-Electric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," <i>Prosthetics and Orthotics International</i>, 5(2), pp. 92-96, 1981.</a></li> <li><a href="cpo/1985_01_023.asp">Billock, John N., "Upper Limb Prosthetic Management-Hybrid Design Approaches," <i>Clinical Prosthetics and Orthotics</i>, 9(1), pp. 23-25, 1985.</a></li> <li>Childress, D.S., "An Approach To Powered Grasp," <i>Proceedings of the Fourth International Symposium on External Control of Human Extremities</i>, Dubrovnik, Yugoslavia; pp. 159-167, 1973.</li> <li>Doubler and Childress (1984), "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," <i>Journal of Rehabilitation Research and Development</i>, 10(39), pp. 19-31.</li> <li><a href="http://www.acpoc.org/library/1983_04_001.asp">Ferguson, Shirley, "Electric Power In Upper Limb Prosthetics: The Michigan Experience," <i>Inter-Clinic Information Bulletin</i>, 18(4), pp. 1-8, 1983.</a></li> <li>Graupe, et al., "A Multifunctional Prosthesis Control System Based on Time Series Identification of EMG Signals Using Microprocessors," <i>Bulletin of Prosthetics Research</i>, 10(27), pp. 4-16, 1977.</li> <li>Jacobsen, et al., "Development of the Utah Artificial Arm," <i>IEEE Transactions on Biomedical Engineering</i>, BME-29, (4), pp. 249-269, 1982.</li> <li>Malone, et al., "Immediate, Early, and Late Post-surgical Management of Upper-Limb Amputation," <i>Journal of Rehabilitation Research and Development</i>, 21(1), pp. 33-42, 1984.</li> <li>Millstein, Heger, and Hunter, "A Review of Failures in Use of the Below-Elbow Myoelectric Prosthesis," <i>Orthotics and Prosthetics</i>, 36(2), pp. 29-34, 1982.</li> <li>Murphy and Horn, "Myoelectric Control Systems- A Selected Bibliography," <i>Orthotics and Prosthetics</i>, 35(1), pp. 34-47, 1981.</li> <li>Northmore-Ball, et. al., "The Below-Elbow Myo-Electric Prosthesis: A Comparison of the Otto Bock Myo-Electric Prosthesis with the Hook and Functional Hand," <i>Journal of Bone and Joint Surgery</i>, 42-B(3), pp. 363-367, 1980.</li> <li>Scott, Robert NL, "My?-Electric Control of Prostheses," <i>Archives Of Physical Medicine and Rehabilitation</i>, 47(3), pp. 174-181, 1966.</li> <li>Scott, R.N., <i>An Introduction to Myoelectric Prostheses</i>. Bio-Engineering Institute, University of New Brunswick, Fredricton, N.B., pp. 37, 1984.</li> <li>Spaeth and Klotz, <i>Handbook of Externally Powered Prostheses for the Upper Extremity Amputee</i>, C. Thomas, Springfield, IL, p. 107, 1981.</li> <li>Wirta, Taylor, and Finley, "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," <i>Bulletin of Prosthetics Research</i>, 10(30), pp. 8-35, 1978.</li> </ol> Page Number(s) 66 - 77 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg Figure 9 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg Figure 10 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Limb Powered Components and Controls: Current Concepts Creator An entity primarily responsible for making the resource John W. Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/3eac73a4c08366301177654204d8badb.pdf 6c0ab74d419d52358a0371839fc85799 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_023.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Management Hybrid Design Approaches</h2> <h5>John N. Billock, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the advent of electric powered components and control systems in the past 20 to 25 years, there has been considerable transition in the prosthetic management and rehabilitation of individuals with traumatic and congenital upper limb deficiencies. Furthermore, it has only been within the past 5 years that electrically powered upper limb prostheses have gained clinical acceptance in the U.S. There now exists a complex variety of approaches from which the prosthetics practitioner must choose, in order to provide appropriate prosthetic restoration services. Along with the traditional variety of bowden cable control systems for actuating mechanical components, there now exists a number of myoelectric and switch control systems for use with electrically powered hands, wrists, and elbows. The introduction of these new components and control techniques has greatly increased the complexity of designing an appropriate upper limb prosthesis.</p> <p>As a result, some researchers and manufacturers have worked to develop total systems for the various levels of upper limb deficiencies. These systems generally are designed around a modular concept, where the batteries, electronics, electrodes, etc., are packaged as individual modules for easier handling and assembly. They also utilize a common electrical connection system, which may or may not be compatible with other components and control systems. The modular systems approach reduces the overall complexity in designing prostheses. However, it does not always provide the patient with the most appropriate prosthesis when his individual physiological and psychological needs are considered. It is in such a situation that thought must be given to the possibility of developing a hybrid prosthesis. A hybrid designed prosthesis utilizing components and control methods from various "systems" can, in many cases, enable the prosthetist to design and develop a prosthesis which is more functional and acceptable.</p> <p>The hybrid design approach becomes even more important when managing individuals with upper limb deficiencies above the elbow and higher. Many cases require a combination of electrically powered components that are switch and/or myoelectrically controlled and mechanical body powered bowden cable controlled components. A classical example of this situation occurs in the design of an above elbow prosthesis for an individual with a distal humeral deficiency. A limb deficiency at this level generally does not require the use of an electrically powered elbow since the individual should have sufficient range of motion at the shoulder joint and adequate muscle strength to control a mechanical elbow. A myoelectrically controlled hand introduced into the design of the prosthesis, for this level, can significantly improve it's functional capabilities and aesthetics. This particular hybrid design allows the individual to simultaneously control the elbow and hand rather than sequentially. It has been the author's experience that individuals with this particular design infrequently utilize the mechanical elbow lock to maintain the hand and forearm in a fixed locked position for functional activities. Rather, the elbow is allowed to flex freely and is held momentarily stable with cable tension. The overall control of the prosthesis is more natural since use of the elbow lock is not necessary the majority of the time.</p> <p>Unfortunately, many of the electric powered components and control systems are not designed for hybrid use even though they may have application. In many cases, they are not compatible and require electronic and/or mechanical changes before they can be incorporated into an appropriately designed prosthesis which best meets an individual's needs. Prosthetists of today must expand their technical expertise and knowledge in the areas of electronics and engineering to meet this challenge. With all the complexities surrounding the design and development to today's upper limb prostheses, this additional technical expertise and knowledge becomes even more essential when assessing and evaluating the particular needs of a patient.</p> <p>The clinical assessment and evaluation of individuals with upper limb deficiencies should involve a careful study of their psychological, as well as their psychological needs. All too often, this is an area of overall prosthetics management that receives too little attention. In the author's opinion, it is an essential foundation for successful prosthetic management and rehabilitation. The psychological aspects of an upper limb amputation and its resulting disabilities are too often considered secondarily when determining what will be the most appropriate prosthesis for an individual patient. As professionals, we tend to stress function over aesthetics, when in fact, a primary concern of the majority of patients is the appearance of the prosthesis. These psychological aspects are the greatest barriers an individual patient must overcome if successful prosthetic management and rehabilitation is to be achieved. Their personal acceptance of their disability and motivation to return to society is essential for successful rehabilitation. Their reaction to the prosthesis plays a major role in this acceptance and motivation.</p> <p>The reaction of their immediate family and friends also plays an important role in their acceptance of the prosthesis. Many patients have rejected a prosthesis not because of their own personal feelings, but because of the reaction of others. This is most apparent in the management of children with congenital upper limb deficiencies, since in most situations when the child is under the age of 5, you are managing the parent's desires and not the child's. If the parents have difficulty accepting the child's disability or the prosthesis, they will not encourage normal development and use of the prosthesis. Unfortunately, because many profesisonals are not responding to the psychological needs of the parents, many children are going with a prosthesis today.</p> <p>With adequate information gathered in the initial prosthetic evaluation, further clinical assessment and evaluation procedures should be carried out to determine the most appropriate interface design, control source, and components to be used in the fabrication of the prosthesis. These procedures initially involve the development of a test interface (check socket) for determining the best fitting and suspension techniques to be utilized in the prosthesis. A variety of interface designs and suspension techniques exists for both adults and juveniles at all levels of upper limb deficiencies. All require the development of an appropriate test interface.</p> <p>The development of a test interface is also necessary for use in establishing definitive E.M.G. potential sites when myoelectric control is being considered. When the E.M.G. potential are not adequate or when the patient requires further E.M.G. training, the test interface becomes essential for maintaining consistent placement of the electrodes relative to muscle stress. Further, the test interface allows the practitioner to evaluate a variety of optional control sources and components by developing a test prosthesis around it. This allows pre-prosthetic training and evaluation of the prosthesis in a variety of configurations before the development of a definitive prosthesis. The use of a test prosthesis is essential in evaluating "hybrid" and "system" design approaches for the definitive prosthesis.</p> <p>Myoelectric control systems vary considerably depending on the desired function and availability of adequate muscle sites. In some cases, it is necessary to utilize more than one type of myoelectric control system to achieve the desired functions in a prosthesis. Some systems utilize a single E.M.G. potential from a single site to control a single function, such as in the traditional Otto Bock or Veterans Administration/Northwestern University (VANU) myoelectric control systems. This type of control system would, therefore, require two E.M.G. potential sites to control two functions, such as, hand opening and hand closing. It is suggested that this type of system should commonly be referred to as a "2-site/2-function myoelecric control system." Another system may utilize a single E.M.G. potential from a single site to control two functions, such as in the University of New Brunswick system. This system utilizes one E.M.G. potential site to control two functions. In this type of system a light or low level contraction produces one function and a strong or high level contraction produces another function. It is suggested that this type of system be referred to as a "l-site/ 2-function myoelectric control system." Yet another system may utilize two E.M.G. potentials from two sites to control multiple functions, such as in the Utah Artificial Arm elbow-hand system. This system utilizes two E.M.G. potential sites to control five functions. In this system a single E.M.G. potential from each site (biceps and triceps) controls one function in each electric powered component (hand and elbow), while a co-contraction of both muscles together unlocks the elbow, switching from hand control mode to elbow control mode. It is suggested that this myoelectric control technique be referred to as a "2-site/5-function myoelectric control system."</p> <p>Switch control systems also vary depending upon the desired function and availability of body motions to actuate them. In many cases, in order to provide the desired functions in a switch controlled prosthesis, various types of switch control systems must be incorporated, achieving a hybrid design approach. The most commonly used switch control systems utilize a pull type switch which is actuated by a single body motion to actuate two functions, such as hand opening and hand closing. It is suggested that this switch control technique be referred to as a "1-motion/2-function pull switch control system." Another type of system utilizes a push button type switch, to operate the opposing function. It is suggested that this switch control technique be referred to as a " 1 -motion/1-function push button switch control system." Yet another type of system utilizes a rocker type switch which is actuated by two body motions to actuate two functions in the prosthesis, which in most cases oppose each other. It is suggested that this control technique be referred to as a "2-motion/2-function rocker switch control system."</p> <p>When body motion is being used to actuate a bowden cable control system in a hybrid manner along with switch and/or myoelectric control, it should always be remembered to activate the mechanical component with the primary body motion available. The theory behind this approach is that a bowden cable control system requires significant muscle activity and body motion to produce the force and excursion necessary to actuate a mechanical component. Myoelectric and switch control systems require less muscle activity to produce the force and excursion necessary for actuation of an electric component.</p> <p>The choice of controls utilized in the design and development of an upper limb prosthesis should involve a careful study of an individual's particular needs. Since the terminal device is the most important component of the prosthesis, it is necessary to choose a control technique which will provide the most appropriate actuation of that device. It is felt that myoelectric control provides the most physiological and natural source of control and that whenever possible, it should be given primary consideration. Furthermore, the majority of individuals with upper limb deficiencies generally prefer a hand as a terminal device. In many cases, this desire may be purely psychological, and as professionals we should respect that need. The majority of individuals with upper limb deficiencies are unilateral with the prosthesis obviously becoming the nondominant side. Therefore, it is important that the prosthesis first meet the individual's psychological needs, and secondarily, that it be easily controlled and provide adequate prehension for stabilizing objects, which is the primary function of the non-dominant side during bilateral hand activities. This would obviously seem to indicate that myoelectric control, which best utilizes the residual neuro-muscular system, and an electric powered hand, which provides forceful prehension, should be the first choices in developing a functional prosthesis.</p> <p>Electric powered components have been felt by many not to be sufficiently reliable and durable. This, however, has not proven to be the case when they are appropriately incorporated into a prosthesis and the patient is properly orientated to their care and use. There are those individuals and situations who are abusive to an electric powered prosthesis as well as a mechanical prosthesis. However, they are not the majority and require appropriate consideration prior to design and development of a prosthesis. Hybrid design concepts can also be utilized to enhance the reliability and durability of a prosthesis by allowing the encapsulation of components within the prosthesis that would otherwise be external. This is a concept known as self-containment.</p> <p>Hybrid prostheses can significantly improve the functional restoration and rehabilitation of an individual with an upper limb deficiency. They are an important consideration in the prosthetic management of such individuals and can be the difference between total rejection or functional use of a prosthesis. Unfortunately, upper limb prostheses of this type will most likely continue to be provided in specialized centers and not find their place in common practice unless developers and manufacturers work towards making their components more compatible and interchangeable with those of other systems.</p> <em><b>*John N. Billock, C.P.O. </b> John N. Billock, C.P.O. is with the Orthotic and Prosthetic Centre of Warren, 145 Shaffer Drive, N.E., Warren, Ohio 44484.<br /><br /><br /></em> Page Number(s) 23 - 25 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Limb Prosthetic Management Hybrid Design Approaches Creator An entity primarily responsible for making the resource John N. Billock, C.P.O. * https://staging.drfop.org/files/original/74c6246acf34d3fe13807d14ce98dc43.pdf 6441dedb6d6cc9c3408c00c008e17f34 https://staging.drfop.org/files/original/5fad73a9eef3f2a1ab53ce2f213efece.jpg 087d0de996c5b8aedb032fcd6c2b18af https://staging.drfop.org/files/original/46e79972c3cbe07d3d9a3bf9ee340543.jpg ed3a48b7a53ce8a61cd8625552177b7e https://staging.drfop.org/files/original/e6c3404c22e5309a73c20747e6ed1a13.jpg 9272df686c0c19c8ad1dda4d9c346ec6 https://staging.drfop.org/files/original/281142d97946d38fc471de221b5faf8f.jpg bf1e5c9c2e488ceb7a1e4cfe23204140 https://staging.drfop.org/files/original/c47ee86296fe96d24d9bd4f980c48f92.jpg b3b28bcd274b720de45e627bfb56fb30 https://staging.drfop.org/files/original/6428da51018c9c2b4e7abbee2e25edb7.png 1647605a0dec60c4196c094faf88d769 https://staging.drfop.org/files/original/68cd1ff085e2984407091e0d7a6c5d37.png 9904eb51a9b616c598335dfad75c4a5e https://staging.drfop.org/files/original/0615e189294ec61bfdf16988f8a7b884.png c338f0114ebb1696a89da2d560ae081c https://staging.drfop.org/files/original/7ec5171e3138ef5823db95a0fc0c969c.png b27d019d267f9fe4bf3c8a2e1dcbf8f3 https://staging.drfop.org/files/original/371c70ccf0c7354316fbbb481fe93334.png 66509ce03e3cd337dcfb9ff45cd414eb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_057.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks</h2> <h5>John N. Billock, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>No one would argue that the human hand is the most complex and challenging structure of the human anatomy to replace and restore. The hand is an extremely complex structure which moves with a precision and dexterity that has long challenged the minds of researchers in medicine and engineering. Beyond its kinematic capabilities, the hand is also one of the most intricate sensory mechanisms of the human body-with unequaled proprioceptive and sensory feedback capabilities. With this in mind, it is easy to understand why prosthetic terminal devices today (hand and/or hook) offer very little in the way of true functional restoration to individuals with upper limb deficiencies.</p> <p>This is not meant to be critical of past developments, but puts into proper perspective the complexities and challenges of duplicating the human hand. Further emphasis of this is found in a commentary by Murphy<a></a> in which he stated, "Though engineers and prosthetists have made substantial contributions, they need perspective and humility to inspire and guide the very long, sustained efforts required to replace even a few of the roles of the hand." This challenge will doubtlessly keep researchers in prosthetics, and now those involved in robotics, busy with the task of trying to duplicate the kinematic and sensory capabilities of the human hand for years to come.</p> <h3>Prosthetic Terminal Devices Today</h3> <p>There exists today a significant number of prosthetic terminal devices for treating both adult and juvenile complete hand deficiencies. These terminal devices are designed as either mechanical or electromechanical systems and, as such, are either body-powered or electric powered. The body powered terminal devices function by utilizing forces generated by body movement as described by Taylor.<a></a> An electric powered terminal device functions by utilizing the electrical force stored within and generated from a battery. Further, these sources of power can activate or control a terminal device in different ways. The three most commonly used control systems are the Bowden cable control, myoelectric control, and switch control. In order to fully understand the functional potential of a particular terminal device, it is important to understand the control approach or system being used to actuate the device.</p> <h3>Prosthetic Control Systems</h3> <p>Professional opinions vary considerably regarding the most appropriate terminal device and control system to utilize in the design and development of a functional upper limb prosthesis. Bowden cable control systems harness the motions and forces generated by gross body movement to actuate and control, primarily, a mechanical terminal device. They require an adequate degree of force and excursion to actuate and control an upper/limb mechanical terminal device.<a></a> The most common example of this would be the Bowden cable control system of a totally mechanical below-elbow prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg"><b>Fig. 1</b></a>). This type of control system harnesses the body motion and forces generated by flexion-abduction movements at the glenohumeral joint to actuate and control the terminal device. It is important to note that this form of control does produce a certain degree of sensory feedback related to force and position.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg"><span><strong>Figure 1. Illustration of a typical conventional body powered Bowden cable controlled below-elbow prosthesis with a mechanical hook terminal device actuated by "gross" body movements</strong>.</span></a><br /> <p>Myoelectric control systems utilize the existing neuro-muscular system for actuation and control of an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg"><b>Fig. 2</b></a>). EMG potentials are monitored with surface electrodes placed over appropriate muscle or muscle groups within the residual limb and are used for either digital or proportional control of the terminal device. This type of control is considered to be quite natural since it utilizes the existing residual neuromuscular system for control.<a></a> This is especially true with synergistic muscle contractions, particularly related to natural hand functions, which can be selected for actuation and control of the terminal device. The use of myoelectric control enhances the feasibility of designing a totally self-contained and self-suspended prosthesis which has proven to be an acceptable and reliable design approach.<a></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg"><strong>Figure 2. Illustration of a typical electric powered, myoelectrically controlled below-elbow prothesis with an electromechanical hand terminal device actuated by EMG potentials.</strong></a><br /> <p>Switch control systems are those which utilize the motions and forces generated by "fine" body movements to actuate and control an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg"><b>Fig. 3</b></a>). They require considerably less force and excursion than a Bowden cable controlled system to actuate and control a terminal device. Switch control systems can incorporate a variety of different types of switches, such as, pull, rocker, push-button or toggle type switch for activation of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg"><b>Fig. 4</b></a>). This type of control is typically indicated in situations when limited body motion and forces are available for Bowden cable control and/or when EMG potentials are inadequate or inappropriate for control of the terminal device.</p> <span><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg"><strong>Figure 3. Illustration of a typical electric powered switch controlled below-elbow prosthesis with electromechanical hand terminal device actuated by "fine" body movements.</strong></a><br /></span><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg"><strong>Figure 4. The actuation characteristics of a typical pull, rocker, push button and toggle switch are illustrated. Switches are generally designed to produce one or more functions such as opening and/or closing of an electromechanical terminal device, (a) Pull (sliding) switch for actuation of two functions; (b) Rocker switch for actuation of two functions; (c) Push Button switch for actuation of one function; (d) Toggle switch for actuation of two functions.</strong></a><br /> <h3>Mechanical Hooks And Hands</h3> <p>Following World War II and especially since the development of the APRL Voluntary Closing Hand and Hook in 1945, considerable controversy has existed regarding the functional aspects of hands versus hooks as terminal devices. Prior to the introduction and clinical use of electric hands in the early 1960's, this controversy only related to mechanical hands and hooks. Mechanical hands, although certainly more aesthetic, were felt by many professionals to be too heavy and awkward for fine prehension activities. Mechanical hooks, by way of contrast, weigh approximately one third the weight of a mechanical hand and provide dexterity comparable to a pair of tweezers. Mechanical hooks were also considered to be more durable because of their simple mechanical design, and the fact that a cover to protect internal mechanisms or provide aesthetics is unnecessary. Because of these mechanical advantages, very little regard was given to the social-psychological advantage and need for a prosthetic hand versus the hook terminal device.</p> <p>In fact, it became common practice within prosthetic clinics and teaching institutions to encourage use of a hook terminal device first before providing the individual with a hand terminal device. The purpose of this practice, which continues today, is to develop the individual's appreciation for the functional advantage of the mechanical hook over the mechanical hand. Further, it was the opinion and experience of many clinics and prosthetists that many individuals, if provided a hand and hook terminal device simultaneously, tended to reject the hook for aesthetic reasons and not develop an appreciation for its functional advantage. Conservative estimates indicate, however, that approximately only fifty percent of those individuals provided with conventional type mechanical prostheses are wearing their prosthesis as reported by LeBlanc.<a></a> This estimate does not distinguish between actual functional use versus simple wearing of the prosthesis.</p> <p>It is the author's opinion and experience that the introduction of a hook terminal device in the early stages of the prosthetic rehabilitation process may in fact be the primary cause of the high incidence of total prosthetic rejection since little, if any, attention is given to the social-psychological aspects of the individual's limb deficiency. The social-psychological aspects of an acquired or congenital upper limb deficiency should be regarded as the first and most significant problem which has to be understood and dealt with appropriately if successful prosthetic rehabilitation and functional use of a prosthesis is to be achieved. Dembo, Leviton, and Wright<a></a> clearly identified the social-psychological problems individuals, as well as those around them, have to deal with in accepting limb loss as part of the total rehabilitation process. If an individual has not accepted a limb loss, or in the case of a congenital limb deficiency, the parents have not accepted the limb loss, it is unlikely that successful prosthetic rehabilitation and functional use of a prosthesis will be achieved.</p> <p>Dr. Howard A. Rusk, recognized by many as the "father of physical medicine and rehabilitation," has identified motivation and timely rehabilitation services as the key elements to achieving successful rehabilitation of an individual's disability.<a></a> An individual can receive the best rehabilitation services available and be provided with the best prosthesis today's technology has to offer. However, if they are not motivated to overcome their disability or adjust to it, acceptable rehabilitation is unlikely. Likewise, the child born with a congenital limb deficiency will not be encouraged to adapt to or functionally utilize a prosthesis if the parents have not accepted their child's disability.</p> <h3>Electric Powered Hooks And Hands</h3> <p>The introduction of electric powered hands into clinical practice in the early 1960's brought about a new era in prosthetics. Acceptance of these "electric hands" by the American prosthetics profession was much slower than in the European countries where they were initially developed. They are, moreover, still considered by many to be not as functional as mechanical hook terminal devices. It is felt that much of this belief can be traced to the attitude that regards mechanical hands as being less functional than mechanical hooks. Electric powered hands, however, have one primary major functional advantage over mechanical hooks and hands.</p> <p>Electric hands can produce finger prehension force which is equal to, and in some cases greater than, that of an adult or juvenile human hand. The average adult male, for instance, can produce an average of 20 to 24 lbs. of finger prehension. The average tolerable amount of prehension that an adult male can generate with a Bowden cable controlled prosthesis and the more commonly used voluntary opening mechanical hook terminal device is approximately 8 to 10 lbs. Voluntary closing mechanical hands and hooks obviously are able to provide greater finger prehension than voluntary opening hooks or hands; however, they have not been widely accepted or used.</p> <p>Another key advantage of an electric powered hand is that it provides forceful "3 jaw chuck" palmar type prehension. This type of prehension has been identified as early as 1919 by Schlesinger,<a></a> to be the most commonly utilized hand-finger prehension pattern for picking up and holding objects in activities of daily living (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg"><b>Fig. 5</b></a>). <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg"><b>Fig. 1</b></a> shows the percentage of use to pick up and hold objects with an electric powered hand. The predominance of "3 jaw chuck" palmar prehension in our activities of daily living accounts for the reason all mechanical and electric powered hands of today are designed with the thumb in opposition to the second and third fingers. The forceful palmar prehension of the electric powered hand, therefore, enhances its overall functional value as a prosthetic terminal device.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg"><strong>Figure 5. Of the six commonly used hand/finger prehension patterns, described by Schlesinger, "3 jaw chuck" palmar type, tip type and lateral type prehension are considered to be the most frequently used during activities of daily living.</strong></a></p> <p>The only electric powered hook available for clinical use at this time is the Otto Bock "Griefer"<a></a> which was introduced in the U.S. in the late 1970's. As an electric powered terminal device, it has the quality of providing "forceful" prehension. Along with this, it is uniquely designed with multi-axis fingers to keep the grasping surfaces parallel during the entire range of opening and closing (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg"><b>Fig. 6</b></a>). This design feature allows for even pressure throughout its range of opening and closing which enhances its grasping ability over mechanical hooks. The grasping surfaces of a mechanical hook angle away from one another as the active finger moves in relationship to the stationary finger (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"><b>Fig. 7</b></a>). Therefore the larger the object to be held in the mechanical hook terminal device, the less contact with the object and, consequently, the more force required to stabilize the object, dependent upon its shape. The "Griefer," on the other hand, is heavier than the heaviest stainless steel mechanical hook and is not as durable, primarily because its design is more complex than the single axis mechanical hooks.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg"><b>Table 1</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg"><strong>Figure 6. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a multi-axis prehension design approach, such as in the Otto Bock "Griefer."</strong></a><br /> <p><b><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"><span>Figure 7. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a single-axis prehension design approach, such as in the Hosmer/Dor-rance</span></a><span><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"> mechanical hook series.</a><br /><br /></span></b>Clinical Experience<b><span><br /></span></b></p> <p>The terminal device of the prosthesis plays an important key role in developing the motivation which will, hopefully, lead to successful prosthetic rehabilitation. It has been the author's experience, in over 300 cases involving individuals with congenital and acquired limb deficiencies from the wrist to the shoulder, that 95 percent or better of those individuals preferred to have a prosthetic hand rather than a hook terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg"><b>Table 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg"><b>Table 3</b></a>). In all cases involving juvenile subjects (which represents approximately ten percent of the total case load), the parents and children over the age of five years preferred hand terminal devices to hooks. Forty percent of the total juvenile case load involved children under the age of five years, and in all cases, the parents preferred hand terminal devices. Parents were also found to prefer a passive nonfunctional hand as opposed to the more typically used passive type nonfunctional mitten for children up to 1 1/2 years of age.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg"><strong>Table 2</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.jpg"><strong>Table 3</strong></a><br /> <p>One might quickly draw the conclusion that this preference was specifically related to the aesthetics of the hand and not necessarily related to function. There is no doubt that the aesthetics of the hand played a key role in the decision. However, this preference also emphasizes the strong social-psychological need for individuals, as well as the parents of children with limb deficiencies, to visually feel as normal as possible within our society. The aesthetics of a hand terminal device obviously satisfies this need more appropriately than a hook terminal device.</p> <p>Beyond this, it is also interesting to note that approximately only one percent of those provided a prosthesis with hand are utilizing a mechanical hand terminal device. Therefore, 99 percent utilize electric powered hands in their prostheses; eighty percent of these are controlled myoelectrically. It is estimated that total rejection of an electric powered hand prosthesis has been approximately 15-20 percent. Actual percentages of rejection have been difficult to verify because of lack of follow-up by the patients, and it is felt that 5-10 percent of the patients are now being followed-up elsewhere. Nevertheless, total prosthetic rejection is considerably less than those provided with conventional upper limb prostheses.<a></a> It is not felt that the acceptance rate of electrically powered hand prostheses is specifically related to aesthetics of the hand. If this were the case, one would expect more individuals to have been utilizing mechanical or passive hands prior to the development of electric powered hands.</p> <h3>Conclusion</h3> <p>Clinical experience has definitely proven, in the author's experience, that an electrically powered prosthetic hand terminal device which is proportionally controlled, utilizing myoelectrical EMG potentials from synergistically related muscles within the residual limb, is the most acceptable and functional upper limb prosthetic design for individuals with complete hand deficiencies.</p> <p>It is further felt that the terminal device is the most important component of the prosthesis; just as the hand is to the normal upper limb. Whenever possible, a prosthetic hand should be preferred to a hook terminal device, in consideration of the individual's social-psychological needs. The individual's social-psychological needs must be of primary concern initially and must be considered before vocational needs can be effectively addressed. This is also true when managing children and is especially important in addressing the social-psychological needs of parents of children born with congenital upper limb complete hand deficiencies.</p> <p>If the vocational or avocational needs clearly indicate the need for a hook terminal device, this must be clinically tested and proven, or the individual must personally desire the hook terminal device. This has been found to be true for all levels of upper limb deficiencies involving the hand, wrist, elbow, and shoulder. This criteria is obviously not the case for everyone with an upper limb deficiency; however, it is felt to be true for the majority and especially those with unilateral upper limb involvement.</p> <p>The prosthetic hand should be thought of as an assistive device to the sound limb, just as the nondominant normal hand is to the dominant normal hand. Many have felt it is important to be able to perform fine motor prehension activities with a prosthetic terminal device and this has been a major argument in favor of hook terminal devices. The fact is, the majority of those individuals with upper limb deficiencies are unilaterally involved and do not use their prosthesis for fine motor prehension activities; just as a non-involved individual does not typically utilize the nondominant hand for such activities. The prosthetic terminal device is most important for gross prehension activities, to hold and stabilize objects while the sound limb performs the fine motor prehension activities. An electrically powered hand terminal device, with adequately controlled functional prehension, best serves this need for the majority of an individual's activities of daily living. It is important to remember that we live in a world made for hands, and most everything we encounter in our activities of daily living is made to be hand held.</p> <h3>Acknowledgments</h3> <p>The author is deeply indebted to those individuals who have sought and benefited from the research which made this paper possible. Special appreciation is given to my wife, Dottie, Jean Ann Pasini, and Gordon L. Grimm for their editorial input and assistance in preparation of this paper, and to the other staff members of the Orthotics and Prosthetics Centre of Warren for their continued understanding and support of the author's professional interests. The illustrations and art work of Jean Ann Pasini are particularly appreciated.<br /><br /><em><b>*John N. Billock, C.P.O. </b>John N. Billock, C.P.O. is Clinical Director at the Orthotics and Prosthetics Centre of Warren in Warren, Ohio. He is also Chairman of the Research and Evaluation Committee of the American Academy of Orthotists and Prosthetists.</em></p> <p><b>References:</b></p> <ol> <li>Billock, J.N., "The Northwestern University Supracondylar Suspension Technique for Below Elbow Amputations," <i>Orthotics and Prosthetics</i>, Vol. 26, No. 4, pp. 16-23, 1972.</li> <li>Billock, J.N., "Upper Limb Prosthetic Management: Hybrid Design Approaches," <i>Clinical Prosthetics and Orthotics</i>, Vol. 9, No. 1, pp. 23-25, 1985.</li> <li>Childress, D.S. and Billock, J.N., "Self-containment and Self-suspension of Externally Powered Prostheses for the Forearm," <i>Bulletin of Prosthetics Research</i>, Vol. 10, No. 14, pp. 4-21, 1970</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," <i>IEEE Transactions on Biomedical Engineering</i>, Vol. BME-20, No. 3, pp. 200-207, May, 1973.</li> <li>Childress, D.S.; Holmes, D.W.; and Billock, J.N., "Ideas on Myoelectric Prosthetics Systems for Upper-Extremity Amputees," <i>The Control of Upper-Extremity Prostheses and Orthoses</i>, pp. 86-106, 1974.</li> <li>Dembo, T.; Leviton, G.L.; and Wright, B.A., "Adjustment to Misfortune: A Problem of Social-Psychological Rehabilitation," <i>Selected Articles from Artificial Limbs</i>, pp. 117-175, New York, July, 1970.</li> <li>Gwynne, G., "Mechanical Components," <i>Manual of Upper Extremity Prosthetics</i>, Department of Engineering, University of Southern California at Los Angeles, Second Edition, pp. 33-68, 1958.</li> <li>Le Blanc, M.A., "Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," <i>Orthotics and Prosthetics</i>, Vol. 27, No. 3, p. 38-44, 1973.</li> <li>Murphy, E.F., "Commentary," <i>Selected Articles from Artificial Limbs</i>, New York pp. vii-xii, July, 1970.</li> <li>Rusk, H.A., "Rehabilitation," <i>Journal of the American Medical Association</i>, Vol. 140, pp. 286-292, 1949.</li> <li>Rusk, H.A., "Advances in Rehabilitation," <i>Practitioner</i>, Vol. 183, pp. 505-512, 1959.</li> <li>Schlesinger, G., "Der Mechanische Aufbau der kunstlichen Glieder," <i>Ersatzglieder und Arbeitshilfen</i>, Vol. 3, Berlin, 1919.</li> <li>Taylor, C.L., Schwarz, R.J., "The Anatomy and Mechanics of the Human Hand," <i>Selected Articles from Artificial Limbs</i>, New York, pp. 49-62, 1970.</li> <li>Taylor, C.L., "Biomechanics of Control," <i>Selected Articles from Artificial Limbs</i>, New York, pp. 63-84, July, 1970.</li> <li>Otto Bock "Griefer" is a registered trade mark of the Otto Bock Orthopedic Industry, Inc., Duterstat, West Germany/Minneapolis, Minnesota.</li> <li>Hosmer Dorrance is a registered trade mark of the Hosmer Dorrance Corporation, Campbell, California.</li> </ol> Page Number(s) 57 - 65 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg Figure 9 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg Figure 10 TABLE III http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks Creator An entity primarily responsible for making the resource John N. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_131.pdf Text Any textual data included in the document <h2>Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation</h2> <h5>Bob Radocy&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The population of upper-extremity amputees, including congenitally limb-deficient persons, in the United States and abroad is placing increased demand upon the profession for improved prosthetic designs and devices which will allow its members to participate competitively in sports and recreation activities.<a></a> Recreation trends indicate that these demands will most likely increase.</p> <p>Until recently, prosthetics did not directly address the needs of the sports-oriented amputee. Prosthetic designs focused on domestic and vocational needs and did not necessarily target the criteria necessary to perform in the vigorous environments of sports or recreation. Over the years, select prosthetists working with individual amputees have developed "one of a kind" sports devices for their patients. These devices sometimes proved adequate, but most were never made available commercially.</p> <p>Two commercially available sports terminal devices have been available for many years: the Baseball Glove Attachment and the Bowling Attachment.<a></a> Recently, other specialized prosthetic devices have become available to meet the sports-minded amputee's needs. These are the SUPER SPORTs,<a></a> Amputee Golf Grip,<a></a> and the Ski Hand.<a></a> Additionally, new variations in the designs of body-powered terminal devices are allowing amputees to participate in many sports activities without the need for specialized aids or radical modifications.<a></a></p> <p>The measure of performance by the amputee in any activity, as always, depends upon proper limb design. Socket design, materials, alignment, and components all play a vital role in any amputee's ability to perform competitively. Another important factor is the amputee's physical condition. The prosthesis, no matter how well designed and constructed, cannot supplement atrophied muscle, limited range of motion, or inadequate strength.</p> <p>Sports prosthetics begins with the evaluation of the need and of the capacity of the amputee being served. A physical therapist and potentially a clinic physician will be important components in the rehabilitation of an amputee wishing to become active in sports and recreation.</p> <p>Exercise and conditioning with or without a prosthesis will be required as a preliminary step for an amputee who wishes to excel without injury in sports. Exercise can take multiple forms. Proven exercise techniques exist. Isometric, isotonic, and passive and active resistance all have specific goals and methods. Education is required so that the amputee is knowledgeable about how to proceed with an exercise program and to determine the objectives, i.e. is muscle hypertrophy (bulk) required for strength or is muscle endurance more appropriate? Additionally, how are flexibility and range of motion impacted?</p> <p>Preprosthetic exercise may be required or desired. Weight harnesses<a></a> (<b>Figs. 1, 2, and 3</b>) rather than strap or cuff weights are a better way to approach exercise without a prosthesis. A properly designed harness will prevent weight slippage during exercise and will enable many variations of upper-extremity conditioning (<b>Figs. 4, 5, and 6</b>).</p> <strong>Figures 1, 2, and 3. Weight harnesses, rather than strap or cuff weights, are a better way to approach exercise without a prosthesis.</strong><br /><br /><strong>Figures 4, 5, and 6. A properly designed harness will prevent slippage during exercise and will enable many variations of upper extremity conditioning.</strong><br /> <p>Bilateral exercise using a dumbbell on the non-affected side is important to maintain muscle balance and reduce spinal stress. A full length mirror aids the amputee in viewing him or herself in order to correct postural deficiencies or extraneous movements to optimize resistance exercise efforts.</p> <p>Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to specific muscle groups (<b>Fig</b><strong>s. 7, 8, 9, and 10</strong>). Complete upper-body conditioning will be most effectively accomplished while wearing a prosthesis. Furthermore, exercise while wearing a prosthesis will help condition the residual limb to the skin stresses and shears a prosthesis will create when under load. Modern exercise equipment systems, such as Nautilus, Hydra-Fitness, and Universal, are available virtually everywhere in YMCAs, community recreation centers, health and sports clubs. A planned program for the amputee can be structured by professional instructors to the amputee's goals. Free weights are another alternative or can complement a weight conditioning program with the convenience of low cost and home use. Equipped with a proper terminal device (<b>Fig. 11</b>), an arm amputee can safely handle dumbbells or barbells in weight training.</p> <strong>Figures 7, 8, 9, (above) and 10 (right). Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to certain muscle groups.</strong><br /><br /><strong>Figure 11. Amputee lifting dumbbell with a terminal device.</strong><br /> <p>Proper conditioning balanced by flexibility achieved through passive stretching, aerobics or any number of alternatives will result in the range of motion and strength an amputee will need for high performance in sports and recreation. A regular conditioning program will especially enhance the use of body-powered prostheses which require activation through body-controlled movements.</p> <p>Sound limb design, mentioned previously, is a major component in an amputee's performance potential. Lightweight yet strong prostheses are ideal, but strength should not be sacrificed just to achieve reduced weight. Socket design is dictated to a certain extent by stump configuration, but it is the author's belief that, if at all possible, a supra-condylar socket should be used.<a></a> Supra-condylar sockets with all their variations (Muenster, Bock, etc.) have evolved rapidly with advances in electromechanical limbs. A supra-condylar socket need not be unduly restrictive, and such a limb allows for less complicated harnessing.</p> <p>Carbon fiber and acrylic resins are two materials which lend well to the lightweight but high strength prosthetic objectives. Socket padding,<a></a> whether fully or partially lined, aids in protecting the condyles, olecranon, and distal residual limb end from trauma. If adequately reinforced, ISNY<a></a> style sockets may prove to be applicable for sports as well, but the published data on below-elbow applications is scarce.</p> <p>In addition to padding, the author recommends a heavy residual limb sock or two regular weight socks for most sports activities. Highly absorbent terry lined socks (designed for athletic footwear) are excellent. A polypropylene sock can be used effectively as a liner if heavy perspiration is a problem.</p> <p>An adjustable excursion harness,<a></a> such as the modified Northwestern (<b>Fig</b>. <strong>9</strong>) which allows for excellent range of motion and terminal device control, can be applied, although other designs will work. Rapidly adjustable excursion is a plus for actuation of voluntary closing terminal device systems and in sports where gross motion of the arms is required, i.e. archery, golf, baseball, etc. Cable efficiency may also be targeted for consideration. Several experienced amputees known to the author wax the stainless steel cables before assembly into the cable housing. The wax is clean and reduces cable to cable housing friction, thus improving efficiency.</p> <p>Alignment of the prosthesis on the residual limb also requires consideration, depending upon the amputee's sports needs. Preextended, as opposed to pre flexed, socket designs have useful applications in sports. They allow for full elbow extension while limiting flexion only slightly and usually not unacceptably. Wrist alignment is also of consequence and affects the manner in which the prosthesis torques on the residual limb when load is applied. It is important to emphasize the need for prosthetists to be concerned with dynamic forces on the prosthesis. A mere static fitting with a check socket will not suffice because it doesn't accurately duplicate what will occur in the definitive prosthesis. A secondary fitting session with a foamed, but unlaminated, prosthesis donned and the chosen wrist unit and terminal device in place can determine the optimum alignment of the components. Changes can be made accordingly and retested so that the definitive prosthesis will fit correctly. Testing the prosthesis in this manner will also determine if undesirable trim lines exist in the socket or whether extended padding is required. A supra-condylar fit socket on short residual limbs can cantilever on the epicondyles and cut in proximal to the olecranon when the prosthesis is loaded distally making it impossible to carry any significant load (<b>Fig. 12</b>). Extending the trim line can direct pressures to the back of the humerus instead of into the joint.</p> <strong>Figure 12. A supra-condylar fit socket with an undesirable trim line.</strong><br /> <p>Two other techniques which can aid in creating a more suitable sports prosthesis are external padding and suspension sleeves. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis (<b>Fig. 13</b>). Thicknesses from 3 mm to 1/4" are available. The material provides a good cushion for contact sports, helps reduce limb trauma during a fall, and the thicker materials have enough bouyancy to float a prosthesis. This technique has satisfied the requirements for a padded prosthesis in several school systems around the country.</p> <strong>Figure 13. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis.</strong><br /> <p>Suspension sleeves can improve a supracondylar fit, especially when using a passive recreational device where the cable is absent or does not play a role in prosthetic suspension. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper-extremity use simply by cutting them down in length (<b>Fig. 14</b>). The advantages of using a commercially available below-knee sleeve is that angulation for a joint is already built in. The author prefers neoprene due to its durability. Both cause increased perspiration within the socket. Designed properly, a neoprene prosthetic cover can function as a suspension sleeve as well.</p> <strong>Figure 14. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper extremity use.</strong><br /> <p>The remainder of this article will focus on modifications for specific sports and recreation to which the author has been exposed either directly or indirectly. In some cases, the solutions are simple; in others, performance dictates a more complex technical solution. Photographs and drawings have been used as often as possible rather than the written descriptions to illustrate a modification, device, or technique. Activities are dealt with alphabetically for convenience sake.</p> <h3>Archery</h3> <p>Modern archery equipment is easily adaptable to certain types of terminal devices. <b>Fig. 15</b> illustrates how a bow riser (handle) can be wrapped with consecutive layers of rubber, foam, and bicycle inner tube to create a durable, functional bow grip.<a></a> A chuck or pin can be used to jam the thumb of the terminal device closed around the riser or the amputee can just "hold on" as illustrated by <b>Fig. 16</b>.<a></a> Performance capabilities are exemplified by the amputee archer in this photo. He is a skilled hunter who has harvested three deer in a four year period.</p> <strong>Figure 15. A bow riser (handle) can be modified to create a functional bow grip.</strong><br /><br /><strong>Figure 16. An amputee can simply hold on to the bow as shown.<br /></strong><br /> <h3>Basketball, Soccer, Volleyball, and Football</h3> <p>Until recently, aids for amputees in ball-sports were limited to padded hooks, cosmetic hands, and custom one-of-a-kind terminal devices. Although these devices were useful, they rarely provided the type of high performance characteristics the sports-minded amputee required to compete successfully.</p> <p>One possible answer or solution is now available. The SUPER SPORTs devices, sized for all ages, are designed specifically for ball-sports and other rigorous recreations in which hand/wrist flexion/extension is needed. Additionally, they absorb shock as well as store and release externally applied energy (<b>Figs. 17, 18, and 19</b>). SUPER SPORTs are passive, not cable activated, but are helpful in catching and ball control when used in opposition to an anatomical hand or another device. SUPER SPORTs combined with padded arm covers create a safe, effective prosthesis for sports, such as football, basketball, and soccer in which interpersonal contact is inevitable.</p> <strong>Figures 17, 18 and 19. The SUPER SPORTs devices sized for all ages, designed specifically for ball sports and other rigorous recreations in which hand/wrist flexion/extension is needed.<br /></strong><br /> <h3>Bicycling, Tricycling, and Motorcycling</h3> <p>Bicycling or tricycling has proven to be an aggravation for amputees equipped with conventional style hooks. Lack of adequate gripping strength and finger shapes have hampered performance. Presently, however, children and adults equipped with newer style voluntary closing terminal devices (<b>Figs. 20 and 21</b>) can control two or three wheeled cycles as well as their two-handed peers. No modifications are required except when hand brakes are present. Front and rear brakes can be actuated from a single hand lever. Brake pressure must be regulated so that braking forces are always applied to the rear wheel first for safe handling. Your local bicycle shop can usually solve hand brake complications.</p> <strong>Figures 20 and 21. Children and adults equipped with newer style voluntary closing devices can control two or three wheeled cycles as well as their two handed peers.</strong><br /> <p>Special adapters have been designed for or by individuals interested in competitive bicycle racing (<b>Fig. 22</b>).<a></a> The prototype illustrated is simple and is designed for safety to "quick disconnect" or "break away" at certain levels of force.</p> <strong>Figure 22. Special adapter for use in bicycle racing.</strong><br /> <p>Motorcycling is a natural extension of bicycling. Again, hand brakes and, in this case, a clutch hand lever complicate the situation. Unilateral amputees missing their left hands can shift and clutch with one hand with practice. Brakes again can be combined. A single foot lever is practical for driving dual master cylinders for hydraulic brakes. The rear wheel braking must occur first however. A local motorcycle mechanic or custom motorcycle shop can provide ideas or adaptations and modifications to standard equipment.</p> <h3>Canoeing and Kayaking</h3> <p>The author's experience with conventional terminal devices proved frustrating during these types of recreation. Split hook finger shapes did not adequately adapt to a paddle or oar. Lack of prehension inhibited the bilateral arm function required for these activities. Locking type terminal devices should never be used in water sports activities. <b>Figs. 23 and 24</b> illustrate how new technology and minor modifications to paddles can overcome problems in canoeing.</p> <strong>Figures 23 and 24. New technology and minor modifications to paddles can overcome problems in canoeing.</strong><br /> <p>Kayaking (<b>Fig. 25</b>) with a double-bladed paddle requires only coordination and practice. Rubber rings on the paddle which are used to keep water off the central shaft work equally well in preventing terminal device slippage.</p> <strong>Figure 25. Kayaking with a double-bladed paddle requires only coordination and practice.</strong><br /> <p>Gross arm movements, such as paddling or rowing, inherently activate voluntary closing devices and keep them closed. Rowing using an oar and oar lock can be enhanced by adding a stop or flange to the oar handle to prevent the terminal device from inadvertently pulling off during a power stroke.</p> <h3>Dance/Floor Exercise and Gymnastics/Tumbling</h3> <p>Activities, such as dance, tumbling and floor exercise gymnastics, have been treated similarly to ball sports in the past due to a lack of specialized terminal devices that were readily available. Padded hooks, cosmetic hands and some custom pedestal style terminal devices have been applied to attempt to satisfy the amputees' needs for balanced bilateral function. <b>Fig. 26</b> illustrates how the SUPER SPORT terminal devices can be applied to satisfy these specialized recreation niches.</p> <strong>Figure 26. SUPER SPORT terminal devices can be applied to satisfy specialized recreation niches.<br /></strong><br /> <h3>Fishing</h3> <p>Fishing is a sport and pastime everyone has access to and should be able to enjoy. Amputees using split hooks who wish to have improved control of reels might want to consider the Ampo Fisher I<a></a> which adapts to their prosthesis and reel (<b>Fig. 27</b>).</p> <strong>Figure 27. Amputees using split hooks may want to consider the Ampo Fisher I which adapts to their prosthesis and reel.</strong><br /> <p>Another alternative for the high level amputee is the Royal Bee Electric Retrieve Fishing Reel system (<b>Fig. 28</b>).<a></a></p> <strong>Figure 28. The Royal Bee Electric Retrieve Fishing Reel systems.</strong><br /> <p>Amputees equipped with voluntary closing terminal devices do not require many modifications to fish. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel, due to the improved prehension of these types of terminal devices (<b>Figs. 29 and 30</b>).</p> <strong>Figures 29 and 30. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel.</strong><br /> <p>Casting with a prosthesis is awkward due to lack of wrist flexibility. Amputees usually control the pole with their natural hand then switch hands to reel or reel with the terminal device. Most reels are available in left and right handed models to suit various physical conditions.</p> <p>Fly fishing poses more of a challenge due to the two-handed dexterity required in handling the fly line. One alternative is the Fly Fishing Reel for Amputees<a></a> (<b>Figs. 31 and 32</b>). This system has been used successfully, although the author feels there is still a need for improved alternatives.</p> <strong>Figures 31 and 32. The Fly Fishing Reel for Amputees.</strong><br /> <p>Automatic fly reels have been experimented with unsuccessfully due to the difficulties involved in "pulling out line" to wind up the return spring in these reels. Additionally, it was discovered that the spring force was only sufficient to pull in slack line, not with line under drag or a fish engaged.</p> <h3>Golf</h3> <p>Due to its popularity, golf has rules (USGA 14-3/15) regarding artificial limbs established by U.S. Golfing Association for tournament play.</p> <p>Variations in golf aids have evolved over the years primarily as individual designs to suit specific amputee's needs. Recently, however, a device called the Amputee Golf Grip (AGG)<a></a> has been introduced. The AGG is a standardized manufactured product which meets the USGA requirements (<b>Figs. 33 and 34</b>). The device is somewhat similar to the Robin-Aids Golfing device<a></a> (<b>Figs. 35 and 36</b>). Both devices utilize a flexible member to attach to the prosthesis and do not require club modification. They allow for <i>complete</i> wrist/club flexion and extension. The Amputee Golf Grip also allows for unrestricted rotation.</p> <strong>Figures 33 and 34. The Amputee Golf Grip is a standardized manufactured product which meets the USGA requirements.</strong><br /><br /><strong>Figures 35 and 36. The Robin-Aids golfing device.</strong><br /> <p>Other attempts to produce a functional aid should also be noted. One custom device is designed to have clubs attach directly to the prosthesis (<b>Fig. 37</b>).<a></a> Similarly, another model, the Atkins Golf Aid,<a></a> also attaches into the end of the club, but uses a ball-socket swivel. The swivel allows for a limited degree of wrist/ club, flexion/extension, and complete rotation.</p> <strong>Figure 37. A custom device designed to have clubs attach directly to the prosthesis.</strong><br /> <p>The author has tried several devices and prefers those that do not require club modification and which provide for total flexion/extension/rotation at the wrist/club interface. This allows for a complete back swing and smooth follow through capability.</p> <p>It is important to note that certain of these designs function more easily with one hand than another and must be played cross-handed for opposite side amputations.</p> <h3>Guns/Hunting</h3> <p>Almost any amputee can redevelop the skills necessary to handle a firearm safely with some simple gun modification. In many cases, a standard military sling can prove useful for handling a rifle. Another technique is to add a ring to a forearm sling mount which can then be grasped or engaged with a terminal device. Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun (<b>Figs. 38 and 39</b>). This modification will even allow for the safe operation of pump style shotguns or rifles. Consult with your local gunsmith for help in this regard as he has the knowledge and the tools to perform the modifications correctly.</p> <strong>Figures 38 (above) and 39 (left). Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun.</strong><br /> <p>Terminal devices can be used to trigger guns as illustrated in <b>Fig. 40</b>, but practice is obviously important.</p> <strong>Figure 40. Terminal devices can be used to trigger guns, but practice is obviously important.</strong><br /> <p>Other modifications/aids like the Blevin's gun yoke (<b>Fig. 41</b>) illustrate what inexpensive devices amputees have designed for themselves to regain access to a favorite recreation.</p> <strong>Figure 41. The Blevin's gun yoke illustrates what inexpensive devices amputees have designed for themselves.</strong><br /> <p>Persons with higher level amputations, multiple leg/arm amputations, strokes, or paralysis resulting in para or quadreplegia can also participate in shooting and hunting. Many states have now legalized hunting from parked vehicles to aid severely disabled sportsmen. Additionally, devices such as the SR-7721 (<b>Fig. 42</b>) or home-made Para-Quad Shooting System<a></a> (<b>Fig. 43</b>) offer capabilities not easily accessed in the past.</p> <strong>Figure 42. The SR-77.</strong><br /><br /><strong>Figure 43. The Para-Quad shooting system.</strong><br /> <p>One final design illustrates how an over and under shotgun can be modified to shoot one handed (<b>Fig. 44</b>).</p> <strong>Figure 44. An over and under shotgun modified to shoot one-handed.<br /></strong><br /> <h3>Hockey</h3> <p>A terminal device for hockey<a></a> (<b>Fig. 45</b>) developed in Canada is an ingenious aid for the hockey enthusiast. It is composed of an adjustable tension ball socket which fits with an adaptor onto the end of a hockey stick. The design allows for the stick to pivot under external force and quick release/flex during a fall. The original model pictured was custom designed for the young hockey player, but if modified with stronger materials, it would be applicable to adults as well.</p> <strong>Figure 45. A terminal device for hockey developed in Canada.<br /></strong><br /> <h3>Mountaineering</h3> <p>Mountaineering is a less accessible, less popular sport for most of the population, but it does attract enthusiasts and disabled persons. <b>Figs. 46 and 47</b> illustrate the author during a technical climbing training session. Voluntary closing devices, because of their ability to grasp rope and control gripping force, have proved useful to mountaineering. Instruction and guidance by professional climbing instructors is a must, and "safety first" procedures are always dictated.</p> <strong>Figures 46 and 47. The author during a technical climbing training session.<br /></strong><br /> <h3>Music</h3> <p>Information and devices to aid amputees playing instruments is scarce. Recently, however, information on a new guitar prosthesis was published in Canada<a></a> (<b>Fig. 48</b>). Dan Roy, the guitarist, in conjunction with specialist Armand Viau have developed a prosthesis which allows Roy to use his shoulder to strum the guitar. The arm is lighter than a conventional prosthesis and can hold a guitar pick.</p> <strong>Figure 48. A new prosthesis which enables guitarists to strum their instrument using their shoulders.</strong><br /> <p>Figures <b>Figs. 49 and 50</b> illustrate how some newer terminal devices, such as the ADEPT,<a></a> have proved to be viable solutions for children wishing to "play" musician.</p> <strong>Figures 49 and 50. Newer terminal devices, such as the ADEPT, have proved to be viable solutions for children wishing to "play" musician.</strong><br /> <h3>Photography</h3> <p>Custom photography and camera adapters have been fabricated for years. Now a device called the Amp-u-Pod<a></a> (<b>Fig. 51</b>) is a standardized, manufactured product which has proved to be an extremely effective aid for the amputee photographer. Designed to replace the amputee's regular terminal device, the Amp-u-Pod mounts directly to the prosthesis and adapts to any 35mm, movie, or video camera equipped to receive a tripod.</p> <strong>Figure 51. The Amp-u-Pod has proven to be extremely effective for amputee photographers.<br /></strong><br /> <h3>Sailing</h3> <p>Amputees are less restricted in this recreation, but handling rope lines and other types of sailing gear can place demands on the sailor to have two-handed capabilities. <b>Fig. 52</b><a></a> illustrates a triple amputee who found a GRIP<a></a> terminal device to be one of his best assets for sailing.</p> <strong>Figure 52. A GRIP terminal device used for sailing.<br /></strong><br /> <h3>Snow Skiing</h3> <p>Amputees have experimented with a number of ways to attach a ski pole to a prosthesis with little functional success. The Ski Hand<a></a> (<b>Fig. 53</b>) is the first standardized manufactured terminal device designed specifically for skiing. Available in varying sizes, the amputee force fits the Ski Hand over a ski pole after removing the standard hand grip. The Ski Hand proved worthwhile for cross-country skiing where upper-body strength is required for propulsion. During downhill skiing, the author found the device of less advantage due to the shallow angle to which the pole enters the hand. The pole basket had a tendency to drag in the snow and was therefore more difficult to control. Novice skiers, however, will find the Ski Hand useful because it enhances maintaining balance and getting up after a tumble.</p> <strong>Figure 53. The Ski Hand.<br /></strong><br /> <h3>Swimming</h3> <p>Swimming for many upper-limb amputees requires no aid whatsoever. However, for those individuals who wish to perform better or compete in the water, several devices have evolved as custom, one-of-a-kind solutions. The Viau-Whiteside Swimming Attachment<a></a> (<b>Fig. 54</b>) and the P.O.S.O.S./Tablada Swimming Hand Prosthesis<a></a> (<b>Figs. 55 and 56</b>) are two with which the author is most familiar, although others may exist.</p> <strong>Figure 54. The Viau-Whiteside swimming attachment.</strong><br /><br /><strong>Figures 55 and 56. The P.O.S.O.S./Tablada Swimming Hand Prosthesis.</strong><br /> <p>The Tablada hand is flat rather than curved to prevent submarining of the prosthesis during pre-stroke arm extension (Australian Crawl) in order to generate greater stroke volume. Additionally, note that the Tablada system uses a prosthesis which is close to actual anatomical arm length, whereas the Viau system has a shortened forearm section. Both utilize a pre-flexed, rigid elbow design. The Viau arm was designed primarily for back stroke swimming and may therefore account for the curved terminal device shape which would not hamper this style of swimming.</p> <p>The author is also aware of the use of SUPER SPORT devices for swimming, especially for children unaccustomed to the water.</p> <p>Pistoning of the prosthesis can be one of the most common occurrences during swimming. A suspension sleeve can aid in eliminating this action. An additional consideration related to swimming and skin or scuba diving is that the prosthesis is not as buoyant as the body and can seem heavier than normal in water and sometimes will impair performance.</p> <h3>Water-Skiing</h3> <p>Water-skiing can be an extremely dangerous recreation if not approached with caution. The author suggests the following rules of good judgment if water-skiing is on an amputee's wish list of recreational pursuits. First, don't ever lock onto a ski rope handle with any terminal device or use a terminal device which requires a cable and harness system. Second, use a ski rope equipped with a single handle. Third, wear a self-suspending, condylar socket that can be twisted free of under stress. A suspension sleeve will aid support but not impair release of the socket due to the flexibility of the material. Fourth, have a neoprene arm cover for the prosthesis which will float the arm in the water if it comes off. Fifth, <i>always</i> wear an approved floatation vest.</p> <p>The Water Ski Hook<a></a> (<b>Fig. 57</b>) is a simple solution to water skiing that has proved safe when set up and used properly. The Ski Hook should be mounted on the prosthesis in a canted position and tightened into place so that it cannot rotate freely. The shallow hook design provides support, yet will twist off a ski rope handle. Should a fall occur where twisting off is impaired, the supra-condylar socket can be "torqued off" the arm and save the amputee's shoulder from potential trauma.</p> <strong>Figure 57. The Water Ski Hand is a simple solution to waterskiing problems.</strong><br /> <p>Another solution to prevent injury is to have the tow rope attached to the boat with a quick release, or equipped with a second handle (for small children only) and always manned by an observer/handler. Should the amputee skier go down, the observer can release the rope instantly, preventing injury.</p> <p>The Ski Seat<a></a> (<b>Fig. 58</b>) and E-Ski<a></a> illustrated in <b>Fig. 59</b> are viable answers for the high level bilateral amputee and the paraplegic or quadraplegic who wishes to enjoy the thrill of skiing. The sled is custom constructed and has two skis. The E-Ski, a newer device, has only one ski and a cage seat.</p> <strong>Figure 58. The Ski Seat.</strong><br /><strong><br /></strong><strong>Figure 59. The E-Ski.<br /></strong><br /> <h3>Wind Surfing</h3> <p>Wind surfing is a relatively new recreation which combines aspects of sailing, surfing, and hang gliding. Load coordination and balance compounded by the need to grasp, maneuver, and rapidly let go of a cylindrical boom as well as uphaul a rope with mast and sail in tow are some of the obstacles the amputee windsurfer faces. A prototype voluntary closing wind surfing terminal device is illustrated in <b>Figs. 60 and 61</b>. Other considerations should include special adjustable harnesses and cable systems for ocean or cold water sailing. Salt accumulation can foul cable function and negate terminal device operation. Wet suits, due to their tight elastic fit, will also interfere with cable function if the cable is worn inside the suit. The harness and cable system must be designed to fit on the outside of the wet suit for unrestricted terminal device operation. Leather on the prosthesis or harness should be avoided, as well as hardware which corrodes. Performance wind surfing is a physically and mentally demanding sport, and the amputee needs to be cautious and prepared to participate safely.</p> <strong>Figures 60 (above) and 61 (right). A prototype voluntary closing wind surfing terminal device.<br /></strong><br /> <h3>Summary</h3> <p>The varied demands of sports and recreation create a multitude of factors which impact the design, construction, and use of a sports prosthesis.</p> <p>Physical fitness and conditioning, prosthetic design and materials, harness styles, and terminal devices all have roles in determining whether an amputee can engage in a sports activity successfully and safely.</p> <p>New improved prosthetic devices and designs will continue to evolve to meet these varying demands. Communication between professionals is important in order to share information on the improvements which are made. Designs for high performance limbs and devices for sports and recreation may well pave the way for improved prosthetic technology as a whole.</p> <p>An open mind, a fresh outlook, an understanding attitude, as well as the patience and willingness to experiment and develop, will inevitably lead to a brighter future for the disabled in sports and recreation.</p> <p><b>References:</b></p> <ol> <li>Chadderton, O.C., C.A.E., "Survey: Consumer Interests," <i>The Fragment</i>, Winter, 1986, Vol. 151, pp. 29-31.</li> <li>Robinson, W.D., B. Pflanz, B. Watkins, and A. Viau "Recreational Limbs AMPUTATION III," <i>The War Amputations of Canada</i>, April, 1986, pp. 19-33.</li> <li><a href="poi/1986_03_129.asp">Mensch, G. and P.E. Ellis, "Running Patterns of Transfemoral Amputees: A Clinical Analysis," <i>Prosthetics and Orthotics International</i>, 1986, Vol. 10, pp. 129-134.</a></li> <li>Products and trade names of Hosmer-Dorrance Corporation, Campbell, California.</li> <li>Products and tradenames of T.R.S., Inc. of Boulder, Colorado.</li> <li>Product and tradename of Recreational Prosthetics, Inc., North Dakota.</li> <li>Radocy, R., "Sports Designs for Upper Extremity Amputees," a symposium presentation at the National Sports Prosthetics and Orthotics Symposium, U.C.L.A. Prosthetics/Orthotics Education Program, October, 1985.</li> <li>"Bow Modifications Serve Amputees," <i>Archery World</i>, February, 1987, p. 22.</li> <li>Weight harnesses designed and tested by Bob Radocy, T.R.S., Boulder, Colorado {not commercially available}.</li> <li>Radocy, B. and Randall D. Brown, "Technical Note: An Alternative Design for a High Performance Below-Elbow Prosthesis," <i>Orthotics and Prosthetics</i>, 1986, Vol. 40, No. 3, pp. 43-47.</li> <li>Billock, John N., "Northwestern University Supracondylar Suspension Technique for Below-Elbow Amputations," <i>Orthotics and Prosthetics</i>, December, 1972, Vol. 26, No. 4, pp. 16-23.</li> <li>Berger, N., et al, "The Application of ISNY Principles to the Below-Elbow Prosthesis," <i>Orthotics and Prosthetics</i>, Winter, 1985/86, Vol. 39, No. 4, pp. 10-20.</li> <li>Radocy, Bob, "The Rapid Adjust Prosthetic Harness," <i>Orthotics and Prosthetics</i>, 1983, Vol. 37, No. 1, pp. 55-56.</li> <li>Courtesy of Bill White, bilateral amputee using two GRIP terminal devices, Waterford, Pennsylvania.</li> <li>Courtesy of Kent Barber &amp; Bill Dalke, Prototype bicycle aid not commercially available. Inquiries to T.R.S. of Boulder, Colorado.</li> <li>Courtesy of Bassamatic, Inc. of Canton, Ohio.</li> <li>Courtesy of Royal Bee Corporation, Pawhuskas, Oklahoma.</li> <li>Courtesy of Robin-Aids Prosthetics of Vallejo, California.</li> <li>Courtesy of The War Amputations of Canada, Ottawa, Ontario.</li> <li>Tradename and product of Innovation Research Corporation, Milwaukie, Oregon.</li> <li>Courtesy of SR-77 Enterprises, Inc. of Chadron, Nebraska.</li> <li>Courtesy of R.F. Meyer's photograph of R. Wityczak, a triple amputee.</li> <li>Courtesy of Carmen Tablada, CP., Professional Orthopedic Systems of Sacramento, California.</li> <li>Ski Seat, Mission Bay Aquatic Center of San Diego, California.</li> <li>E-Ski, Courtesy of E.S.C.I. of Gretna, Louisiana.</li> <li>Courtesy of the Rehabilitation Centre for Children, Winnipeg, Manitoba, Canada.</li> </ol> <em><b>*Bob Radocy </b> Bob Radocy is President, TRS, Inc. 1280 28th St., Suite 3, Boulder, CO. 80303-1797<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 131 - 153 Year 1987 Volume 11 Issue 3 Figure 2 FIGURES 4,5,&6 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-02.jpg Figure 3 FIGURES 7,8,9,& 10 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-03.jpg Figure 4 FIGURE 11 ttp://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-04.jpg Figure 6 FIGURE 13 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-06.jpg Figure 7 FIGURE 14 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision-See Trello Figure 8 FIGURE 15 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-08.jpg Figure 1 FIGURES 1,2,& 3 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-01.jpg Figure 5 FIGURE 12 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-05.jpg Figure 9 FIGURE 16 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-09.jpg Figure 10 FIGURE 17,18,19 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-10.jpg Figure 11 FIGURE 20 & 21 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-11.jpg Figure 12 FIGURE 22 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-12.jpg Figure 13 FIGURE 23 & 24 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-13.jpg Figure 14 FIGURE 25 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-14.jpg Figure 15 FIGURE 26 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-15.jpg Figure 16 FIGURE 27 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-16.jpg Figure 17 FIGURE 28 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-17.jpg Figure 18 FIGURE 29 & 30 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-18.jpg Figure 19 FIGURE 31 & 32 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-19.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 Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation Creator An entity primarily responsible for making the resource Bob Radocy * Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL https://www.3d4e.org/freehand Contact Name/Title Madelina Pratt - Director Address 3670 Trousdale Pkwy City Los Angeles State/Province California Countries Served USA Postal Code 90089 Email 3d4e.freehand@gmail.com Services Provided Prosthetic Fitting, Medical Equipment / Supplies, Adaptive Mission Printing customizable 3D- printed prosthetic hands free of charge for children in need in the Los Angeles area Additional Info & Comments "The prostheses that we assemble are all based on digital 3D model files created by Enabling the Future, an organization dedicated to promoting the usage and distribution of 3D printed prostheses. If you would like to learn more about them, their website can be found at http://enablingthefuture.org/. " Facebook Page https://www.facebook.com/usc3d4e/ 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 USC Project Freehand Description An account of the resource Freehand is a project within USC 3D4E, whose mission is printing customizable 3D- printed prosthetic hands free of charge for children in need in the Los Angeles area.