19 20 371 https://staging.drfop.org/files/original/3474e7ecce4c2562d559a2ef5a3224c3.pdf 752179c0caddf3dd354a38e5884fa076 https://staging.drfop.org/files/original/091d1855d334557fc5d055ca98125283.jpg 99405891fc0b427f417be5fcdd10911e https://staging.drfop.org/files/original/623d2eb93d60e3d4c25639ae39dbf858.jpg fa3d556e9fe28696987a8f633f4776bd https://staging.drfop.org/files/original/60653bedb7f2f194a3abf694e94b72d4.jpg 25e03e2ad856469b5230d75e9fbff306 https://staging.drfop.org/files/original/40d8e3d76404f9b60a1a92c7c194361a.jpg 4e59435fca4d2ecb3e37e2073e385370 https://staging.drfop.org/files/original/a673985d199872ddfb5ca0cf2df6a4c2.jpg 38aca28e8cd192cd8b5cb162dd8163fa https://staging.drfop.org/files/original/10477ecf47f98610dc14231a7fb101f2.jpg a738c99a5bd4d53e10f1c4bb9632e49b https://staging.drfop.org/files/original/1ae495556d9d18674597daab58f7343a.jpg f53f76de628d841c6b8c1c15925fc8c6 https://staging.drfop.org/files/original/5c970469f1caacd2dc19113bb317726a.jpg 4289918c2044368e7b9555ecf174aed6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_011.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 11 - 15 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_011.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The CAPP Electric Cart: Recent Developments</h2> <h5>Carl Sumida, C.P.O. <a style="text-decoration:none;">*</a><br />Yoshio Setoguchi, M.D. <a style="text-decoration:none;">*</a><br />Julie Shaperman, M.A., O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Since the development of the first Child Amputee Prosthetics Project (CAPP) electric cart<a></a> the device has been completely redesigned. A limited number were produced in 1968-69, and a field test was conducted by New York University. This article describes the mechanical changes that have been made in the cart. The report of the field test is presented elsewhere in this issue.</p> <p>The changes in no way altered the basic concept of the cart, and the design is still consistent with the original criteria: (1) the cart should be a powered vehicle which provides mobility to severely limited, limb-deficient children; (2) the controls should be simple to operate; (3) the cart should be compact, highly maneuverable, yet very stable and transportable; and (4) it should require minimal maintenance, and be attractive in appearance without resembling a wheelchair.</p> <p>Earlier models of the cart are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. These prototypes were built between 1962 and 1966. The changes made since prototype III have made the production of the 14 carts needed for the field test less costly. <b>Fig. 4</b> and <b>Fig. 5</b> show the cart produced in 1968-69 for the field test. The differences between this model and the 1966 prototype are described below.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Prototype I, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Prototype II, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Prototype III, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Field-test cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Field-test cart folded. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Structural Changes</h3> <p>The chassis, redesigned to simplify construction, is built of 1-in.-square mechanical tubing. The seat frame is made of 1/4-in. square, chromed mechanical tubing. The front axle was redesigned to allow torsional or vertical movement by means of a central pivot stud that is located at the center of the axle, which allows the chassis to travel over an uneven surface and still maintain four-wheel contact and stability.</p> <p>A new folding-seat arrangement makes the cart more compact for transport and adds lateral support from the side arms. The arms are set back far enough to allow the cart to be placed close to a table, desk, or washbasin. The frame for the backrest can be folded flat by lifting it slightly out of its locking notch and allowing it to fold forward onto the seat cushion.</p> <p>A shell made of metallic-green fiber glass covers the chassis and power equipment. The upholstery for the seat cushion and backrest is black Leatherette (TM). The seat frame is slightly larger than the seat cushion, thus leaving a small space for storage behind the cushion. Eight-inch, spoked casters with one-inch, solid-rubber tires (wheelchair type) are used on all four wheels.</p> <h3>Power-System Changes</h3> <p>The two drive motors are positioned independently on each side of the chassis. Each motor drives a specially designed worm-gear reduction box. The rear wheels are mounted directly on the output shaft of the gearbox, which is bolted to the frame. Power is fed into the gearbox through a Browning gear belt.</p> <p>A third motor powers seat raising and lowering. This motor is mounted adjacent to the right drive motor and is connected to the two rear screw jacks by a Browning gear belt and to a single front screw jack by a flexible shaft. These screw jacks raise the seat platform nine inches.</p> <p>The battery is positioned between the rear wheels and is easily accessible from the rear of the cart. This arrangement is more convenient than the side opening in the previous model, but it necessitated repositioning the motors and gear boxes, which had been a single package at the rear of the cart in prototype III.</p> <p>The control box is a specially designed unit developed at CAPP. It has toggle switches for directional control and a separate switch to raise and lower the seat. A circuit breaker was added to prevent an overload of the drive system. The switch controls are housed in a compact cylindrical unit that is mounted at the end of an reshaped control arm, which is attached to the left side of the seat frame and extends to the child's chin. The control arm can be adjusted for height and distance from the seat back. The chin receptacle is positioned next to the seat-elevation-control lever and is foam-padded (see <b>Fig. 4</b> and <b>Fig. 5</b>). The control arm is held in position in front of the child by a ramp lock. When lifted slightly, the control arm swings out for seat folding, the child's use of the table top, or transfer.</p> <p>The specifications for the cart's power equipment, size, turning radius, etc., are shown in <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Dimensions and specifications of CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Changes Since Field Test</h3> <p>In November 1970, two additional changes were made. (The modified cart, with the new wheels and control unit, is shown in <b>Fig. 7</b>.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Cart with solid rear wheels and new control unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>A new solid-state proportional control unit, now available commercially, was selected to replace the previous control unit. This new unit (manufactured by the Motorette Corporation of Reseda, California) provides proportional (variable-speed) control and an on-off master switch. The manufacturer provided a control for raising and lowering the seat so that the unit could be used with the electric cart. The control box can be positioned for control by the chin or an extremity. The circuitry unit fits on the storage rack behind the seat.</li><li>The rear drive wheels were changed from spoke casters to specially designed cast-aluminum wheels to eliminate the possibility of breakage due to high torques, but they have the same solid-rubber tires as the front casters. Although the use of pneumatic tires is being considered, solid-rubber tires have been retained for the present because they provide less rolling resistance and thus prolong the life of the battery. Also, solid-rubber tires are more reliable for a testing program because no problems arise from variations in air pressure.</li></ol> <h3>Production</h3> <p>The gear box, control box, chassis, body, and seat-lifting mechanisms for the carts used in the field test were specially de- signed by Mr. Carl Sumida at the Child Amputee Prosthetics Project at UCLA. These items were manufactured by subcontractors, and other components were purchased from commercial sources. The fourteen carts were assembled for the field test at the CAPP (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Assembly of field-test carts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the field test, all mechanical repairs were made at CAPP. At the end of the test, all the carts were rechecked, new control boxes were installed, and new wheels were applied. The carts have been returned to the children who participated in the field test, who will continue to use them as long as necessary.</p> <p>Attempts are now being made to find a commercial manufacturer for the electric cart because it has proven to be an extremely valuable aid to the mobility of the severely limb-deficient child.</p> <p><b>References:</b></p> <ol> <li><i>Artificial Limbs </i>8:2:42-44, Autumn 1964.</li> <li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, <i>Eighth Annual Report 1962, </i>pp. 51-53.</li> <li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, <i>Ninth Annual Report 1963, </i>p. 20.</li> <li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, <i>Tenth Annual Report 1964, </i>pp. 1-10.</li> <li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, <i>Eleventh Annual Report 1965, </i>pp. 9-11. (Reprinted in <i>Inter-Clinic Inform. Bull. </i>5:9:12-14, 1966.)</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs 8:2:42-44, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, Eighth Annual Report 1962, pp. 51-53.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, Ninth Annual Report 1963, p. 20.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, Tenth Annual Report 1964, pp. 1-10.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, Eleventh Annual Report 1965, pp. 9-11. (Reprinted in Inter-Clinic Inform. Bull. 5:9:12-14, 1966.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Julie Shaperman, M.A., O.T.R. </b></td></tr><tr><td class="clsTextSmall">Mrs. Shaperman is a research therapist with the project.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Yoshio Setoguchi, M.D. </b></td></tr><tr><td class="clsTextSmall">Mr. Sumida is a research prosthetist.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carl Sumida, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Dr. Setoguchi is the medical director of the Child Amputee Prosthetics Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-11.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-13.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-14.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-15.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-16.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-17.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The CAPP Electric Cart: Recent Developments Creator An entity primarily responsible for making the resource Carl Sumida, C.P.O. * Yoshio Setoguchi, M.D. * Julie Shaperman, M.A., O.T.R. * https://staging.drfop.org/files/original/9f82190e18cf5ca09443da6fd68df3b9.pdf 43555eca290035ea7155e9a0312babce https://staging.drfop.org/files/original/41b75dea6e7a15877cc0a8243b4c4874.jpg b6438828e00e3ff265f4c6c3376559b7 https://staging.drfop.org/files/original/41ffa86db5a06c67178da1fe6aee4968.jpg 20d75a09605e3e2b68d200f44cc3f96a https://staging.drfop.org/files/original/402a3a26ceb04de8b1318dcabf4f5b30.jpg e1b78c19f91d79fac7635c1e04b7cb5b https://staging.drfop.org/files/original/5965cf7dfd7eb969f1a55b331bba978f.jpg 0f5897ea65b406960ef356aae8745014 https://staging.drfop.org/files/original/ce3704752c65bafb933002528b66de97.jpg 303919967c08f033368701a299f0dca1 https://staging.drfop.org/files/original/f3eaed68459cebb323caf8eac4f369f5.jpg b0b7b29cc73946063cd1cb85e8b07b5c https://staging.drfop.org/files/original/26d45afef759ecc508cb2fa1d00073fa.jpg def29cc322ce2288598609261fc453e6 https://staging.drfop.org/files/original/59d21c2e70e154cf05aebf3b2e8f05f2.jpg 3e4a48d0000f890a2ee4e1e639e6ca9f https://staging.drfop.org/files/original/058fa502bdf14434b5d3e4059b53c36b.jpg f86fdd1ac02b515fee07f9d0a83b6086 https://staging.drfop.org/files/original/15c2883e9508c92984a80cc01fb90f85.jpg 220753ac354d321682550677971639e4 https://staging.drfop.org/files/original/1599535e386e2026f4cc72d91bfd2cca.jpg 44adc9faa4fbe64b6d148b43dc5bacc2 https://staging.drfop.org/files/original/51e5edca62a38d9594e025c03ccac11b.jpg bb869d0a8ea128b30044b3213c4ca4fc https://staging.drfop.org/files/original/3598305f5c89bedf991c4f6548c90cf5.jpg 6d9b445e128c0fec74c50bf67157e15d https://staging.drfop.org/files/original/42655d7b96617f3031e4cfe4b384377a.jpg fca7110d2166127a2bad387fed992c5a https://staging.drfop.org/files/original/1637b57b9c0c9bd6f3aecc78d40064ba.jpg 28995acfac6dc5b1e438cc86f3f50219 https://staging.drfop.org/files/original/a28f64fb749dd90466694e6f74a7a7da.jpg 5405cbe2389ef56b993d6396a98106ac https://staging.drfop.org/files/original/d1f903fa6ec56d3011b93c35b07b5284.jpg be76fb64fc2e1785acd322b5062bda99 https://staging.drfop.org/files/original/0677d944077501669f0b3fdbb2af91fa.jpg 739231039457e940d8d4a1cb1bea9428 https://staging.drfop.org/files/original/799403b2935896e2bb5d55a38e9779f2.jpg 4739ce28a1715e3bf9ef1d2d7e7c9d51 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_027.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 27 - 45 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Technique for Fitting Converted Proximal Femoral Focal Deficiencies</h2> <h5>Carman Tablada. C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Proximal femoral focal deficiency (PFFD) is a congenital limb deficiency affecting the proximal end of the femur and, usually, the iliofemoral joint. The condition is characterized by shortness of the affected limb; flexion, abduction, and external rotation of the extremity; inadequate proximal musculature; and unstable proximal joints. <a></a> The condition may be unilateral or bilateral, and other anomalies may be present (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Aitken <a></a> has demonstrated four types of PFFD based on serial X-rays of patients before and after skeletal maturity:</p> <ul> <li><i>Class A: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are joined at maturity.</li> <li><i>Class B: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are not joined at maturity.</li> <li><i>Class C: </i>Severely dysplastic acetabulum. Femoral head never ossifies. Short femur.</li> <li><i>Class D: </i>No acetabulum or femoral head. Short, deformed femoral segment.</li> </ul> <p>At the Child Amputee Prosthetics Project (CAPP) in Los Angeles, the preferred treatment for children who have unilateral PFFD and functional upper extremities is conversion of the limb deficiency to an above-knee amputation. The surgical procedure consists of a Syme's amputation of the foot in all cases, and fusion of the knee in selected cases to give a single skeletal lever (<b>Fig. 2</b>). The children are then fitted as above-knee amputees, using a specially designed socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since 1967, the prosthetists at CAPP have used a socket with a flexible inner wall to fit PFFD patients who have had the surgical conversion described above. This paper describes the total fabrication and fitting procedure as it is done at CAPP. Only its application to the patient with PFFD will be considered here, although we have used the same principle with success in fitting other amputees who have a stump with a bulbous end.</p> <h4>The Stump</h4> <p>The converted PFFD stump is relatively fleshy in the proximal area. The shape of the proximal portion is related to the patient's classification: In those with class A or B involvement, the shape is normal enough for the usual anatomic landmarks to be seen, and in those with class C or D involvement, the proximal stump is cylindrical.</p> <p>The shaft is usually narrow and bony, and the distal end is bulbous, with soft tissue padding its inferior surface. There are bony projections in the bulb which may not be seen but which can be located by palpation. These projections are sensitive to pressure.</p> <p><i>Telescoping</i></p> <p>When the structures in the hip region do not provide adequate articulation between the pelvis and the lower-extremity elements, upward pressure under the end of the stump causes upward displacement of the bony elements and apparent shortening of the limb. This motion is called "telescoping," and is frequently seen in patients with PFFD. As much as three inches of telescoping can be demonstrated in some patients.</p> <p>Telescoping can be a passive or an active motion. In varied cases, some patients can voluntarily retract their limbs and others cannot; they can, however, voluntarily lengthen it beyond the resting position by thrusting down. Traction on the stump also causes lengthening. This apparent shortening and lengthening of the stump in response to pressure and traction has important implications for measuring the stump length, for making the cast, and for weight-bearing (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Socket</h4> <p>The socket consists of a rigid outer shell and a three-layered flexible inner wall, with an air space between the flexible layers and the hard socket. The flexible layers extend from the bottom of the socket to at least the level at which the bulbous end can pass through freely, comparable to the placement of the window in a standard Syme prosthesis. This arrangement provides room for expansion of the flexible wall as the bulb is inserted into the socket. Once the stump is fully inserted, the flexible wall closes around it, giving a total-contact fit without using a window and making it possible to use the bulb for suspension.</p> <p>Since the patient has a Syme's amputation, it would seem logical to fit him with an end-bearing socket. However, if this were done, pressure under the end of the stump during the stance phase of gait would cause telescoping and relative shortening of the leg. The patient would then have excessive lateral trunk bending during stance. For this reason, the socket is designed to be ischial weight-bearing, with the patient taking light contact on the end of the stump. The ischial weight-bearing minimizes the amount of telescoping and therefore decreases the lateral trunk bending. The light contact at the distal end gives him better control over the prosthesis.</p> <h4>Materials and Components</h4> <p>The hard outer socket is formed with 4110 polyester resin.</p> <p>Considerable thought was given to selecting the materials for the flexible layers. Our clinical experience has shown that, with continued use, RTV develops an odor and the material becomes fuzzy; nor will RTV bond to the rigid shell of the outside socket.</p> <p>Therefore, flexible polyester resin was selected for the layer closest to the skin. It is durable, is easy to keep clean and free of odor, and has a surface that is relatively friction-free. 384 RTV was used for the center layer because it laminates readily and will stretch and return to the same shape repeatedly. Flexible polyester resin was also used for the layer next to the outer socket, for it bonds to the hard material if the polyester resin is "roughed up" sufficiently. The polyester resin also protects the RTV from impregnation by wax during socket fabrication. In all the cases in our experience, the materials have retained these properties until the child outgrew the prosthesis.</p> <p>Primary suspension is provided by closure of the flexible layers over the bulbous end of the stump. A Silesian bandage, worn about an inch below the iliac crest, gives lateral support and secondary suspension.</p> <p>We have used a constant-friction knee and SACH foot for all children fitted with this type of prosthesis. The constant-friction knee is light in weight and has provided good function. All of the children have had adequate strength to lock the knee joint during stance.</p> <h4>Special Measurements</h4> <p>Before describing the fabrication procedure, a brief discussion of the measurements is in order, for much of the success of this method of fitting depends upon having ischial weight-bearing and a total-contact fit.</p> <p><i>Socket Brim Aand Ischial Seat</i></p> <p>In patients with class A or B involvement, the shape of the proximal thigh is normal enough to enable the prosthetist to make the A-P and M-L measurements as he would for a patient with a standard above-knee amputation. The socket will have a modified quadrilateral shape at the ischial level.</p> <p>In patients with class C or D involvement, the shape of the proximal stump is cylindrical, and there is no area comparable to the adductor-longus-tendon area of the standard above-knee amputee. In these cases, the M-L dimension is measured with outside calipers at the level of the adductor fold, and the ischial-seat measurement is made on a horizontal line from the ischium to the lateral edge of the stump at the ischial level.</p> <p>The inside measurements of the socket must be the same as the circumferential measurements of the stump. The prosthe-tist must reproduce the size and shape of the stump in the cast, positive mold, and socket to insure total contact without looseness or constriction.</p> <p>The stump length is measured from the ischium to the distal end of the stump with the stump at its greatest stretched length. The importance of measuring the length and taking the wrap with the stump fully elongated cannot be overemphasized, for two reasons: First, it helps ensure that the patient will take most of his weight on the ischium so that telescoping will be minimal; second, the length of the cast can be modified by only 3/8 in. in either direction.</p> <h3>Measurements</h3> <h4>Brim</h4> <p><i>Mediolateral</i></p> <p>In class A and B patients, take the M-L measurement as for a standard above-knee amputee.</p> <p>In class C and D patients, caliper the horizontal distance from the adductor fold to the lateral aspect of the stump (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Anteroposterior</i></p> <p>Take standard above-knee A-P measurements for classes A and B.</p> <p>For classes C and D, to measure the ischial seat, caliper the horizontal distance from the inferior edge of the ischium to the lateral aspect of the stump (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Socket Length</h4> <p>With the stump at its greatest length and vertical to the floor, measure from the ischium to the end of the stump (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Circumference</h4> <ol> <li>Measure the circumference of the largest part of the bulb, and from this point to the distal end of the stump (<b>Fig. 7</b>).</li><li>Measure the circumference of the narrowest part of the shaft, and from this point to the distal end of the stump (<b>Fig. 8</b>)</li><li>Beginning at the narrowest part of the shaft, measure the circumference at one-inch intervals to the adductor fold (<b>Fig. 9</b>).</li></ol> <h4>Bulb</h4> <ol> <li>Caliper the A-P and M-L dimensions at the largest part of the bulb (<b>Fig. 10</b>).</li><li>Palpate the bulb to locate the bony prominences and mark them with indelible pen.</li></ol> <h4>Overall Length</h4> <p>Measure the sound side as for a standard above-knee amputee.</p> <h4>Stump Sock</h4> <p>Make a tracing of the stump to accompany the measurements for ordering stump socks.</p> <h3>Cast Fabrication</h3> <h4>Materials</h4> <ul> <li>Fast-setting Johnson and Johnson plaster bandage</li> <li>Elastic plaster bandage (Johnson and Johnson Orthoflex)</li> <li>Cast sock</li> <li>Stockinette</li> <li>1-in. elastic webbing</li> <li>A-P caliper</li> <li>Yates clamp</li> </ul> <h4>Fitting The Cast Sock</h4> <ol> <li>Mark the shaft at the level where the A-P or M-L dimension is slightly larger than the A-P or M-L dimension of the bulb.</li><li>Measure the distance between the two points selected and cut one piece of stockinette that length (<b>Fig. 11</b>).</li><li>Cut five more pieces of stockinette, each 1/2 in. shorter than the last, and place them on the stump to fill in the narrow part. Place the shortest piece on the stump first, then the longer ones over it, <i>in reverse of what is shown in <b>Fig. 12</b>. </i>This facilitates removal of the cast.</li></ol> <h4>Making The Cast</h4> <p>The patient should stand with his stump vertical to the floor.</p> <ol> <li>Using the same technique as for a standard above-knee amputee, make the brim with the 4-in. elastic bandage, beginning at the lateral side of the stump at the level of the iliac crest (<b>Fig. 13</b>).</li><li>Complete the wrap with the 3-in. regular plaster bandage (<b>Fig. 14</b>).</li><li>Form the ischial seat while the bandage is still wet. With the A-P caliper set to the length measurement of the stump plus 3/16 in., place the short end under the ischium and line up the long end under the end of the stump. Then apply pressure under the ischium and have the patient thrust down until the stump end touches the caliper (<b>Fig. 15</b>).</li><li>At the same time, apply three-fingers' firm pressure to the proximal anterior medial aspect of the cast (<b>Fig. 16</b>). This prevents the socket from rotating internally on the stump.</li><li>The patient must remain in this position and the pressures must be maintained until the plaster sets.</li><li>Remove the cast.</li></ol> <h4>Checking The Cast</h4> <ol> <li>Check the M-L and ischial-seat measurements of the cast against those of the patient. Be sure that the ischial seat has a large enough surface for the patient to sit firmly upon it. If necessary, build up the seat with plaster before filling the cast (<b>Fig. 17</b>).</li><li>Check the length of the cast against the patient's stump length. They should be the same. If the cast is longer than the stump, pressure was not applied directly under the ischium. If the cast is shorter than the stump, the patient was not thrusting down to maximal stretch. If the difference does not exceed 3/8 in., the mold can be modified. If there is a greater than 3/8-in. difference, a new cast should be made.</li></ol> <h4>Modifying The Mold</h4> <p>To correct the length measurement:</p> <ol> <li>Measure from the ischial seat to the end of the mold.</li><li>Remove or add enough plaster (but no more than 3/8 in.) to the ischial seat to correct the length.</li></ol> <p>To correct the flexion or extension angle (<b>Fig. 18</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Draw a line down the medial aspect of the mold, bisecting it into medial and posterior halves.</li><li>Set the goniometer at 90 deg.; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the medial aspect of the mold.</li><li>Shape the surface of the seat along this line. The shaft should be at 0 deg. of flexion and extension.</li></ol> <p>To correct the abduction or adduction angle (<b>Fig. 19</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Draw a line down the posterior aspect of the mold, bisecting it into medial and lateral halves.</li><li>Set the goniometer at 90 degrees ; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the posterior aspect of the mold.</li><li>If the shaft is in <i>adduction, </i>remove plaster from the outside edge of the ischial seat. If the shaft is in <i>abduction, </i>add plaster to the outside edge of the ischial seat. The shaft should be at 0 degrees of abduction or adduction.</li></ol> <p>To modify the anterior brim (<b>Fig. 20</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Form the height of the anterior brim: Draw a line at the ischial level across the anterior aspect of the mold from point A to point B. Divide the line in half at point C. From point C, draw a line at right angles to AB, extending it two inches proximal to point D. Line CD forms the height of the anterior brim.</li><li>To establish the anterior brim line, extend a line from point B one inch medially to point E. Point E should be in line with the ischial seat when viewed from the front. Draw a line on a smooth curve from point D to point E (<b>Fig. 20</b>).</li><li>Form a reverse curve along line DE to facilitate sitting and bending. Using a rasp or gouge, remove up to 1/4 in. of plaster from the area medial to line CD. This will ensure good contact along the anterior brim wall with the stump. If necessary, build up with plaster along line DE to form the reverse flare (<b>Fig. 21</b>).</li></ol> <p>To modify the lateral brim:</p> <ol> <li>Continue line DE from the anterior brim proximally to encompass two-thirds of the distance between the ischium and the iliac crest. Continue laterally, following the contour of the lip, then distally to the posterior-lateral corner of the ischial seat (<b>Fig. 22</b>).</li><li>Contour the lateral wall. Do not remove plaster below the ischial level (<b>Fig. 23</b>). Establish flare along the lateral brim line.</li></ol> <p>To modify the shaft:</p> <ol> <li>Correct the circumference measurements. Mark off the levels at which the circumference measurements were obtained. Note each measurement on the mold. Where it is necessary, the circumference measurements of the mold should be modified to be the same as those of the stump (<b>Fig. 24</b>).</li><li>At the brim area, blend the medial and posterior walls smoothly with the medial brim and ischial seat (<b>Fig. 25</b>).</li></ol> <p>To modify the bulb:</p> <p>Build up over the bony projections no less than 1/4 in. (These projections should be marked during the measurement and casting procedure.) <i>Be extremely careful while accomplishing this, as attempting relief in this area is extremely difficult </i>(<b>Fig. 26</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Recheck the mold measurements. Smooth the entire mold (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Flexible-Socket Fabrication</h3> <h4>Materials</h4> <ul> <li>Ambroid varnish or the equivalent</li> <li>Five PVA sleeves (regular size and shape)</li> <li>Two 1-oz. fitted Dacron (TM) sleeves</li> <li>Four or five regular-length fitted nylon stockinettes (for fabricating the flexible layers)</li> <li>Three extra-long fitted nylon stockinettes (for fabricating the hard socket)</li> <li>Cast sock(s) (to equalize the stump sock)</li> <li>Flexible polyester resin #4134</li> <li>RTV elastomer Dow Corning #384</li> <li>Rigid polyester resin #4110</li> <li>150-A yellow wax (available from E. S. Browning Co., Los Angeles, Calif.) or any wax suitable for shaping</li> <li>Outside calipers</li> <li>Wood rasp</li> <li>Vacuum machine</li> <li>Oven with at least 200 degrees F temperature range</li> </ul> <p>Make the Dacron sleeves to fit the entire brim area. The Dacron must not be incorporated in the flexible layers.</p> <p>The number of stockinettes needed depends upon the size and activeness of the patient. Four are used on the less active patient, and five on the more active. These are separate pieces, sewn on one end and trimmed to 1/2 in. of the stitching. The width of the stockinette should be such that it stretches very minimally in what is to be the flexible wall.</p> <p>The three extra-length stockinettes must be long enough to double over in the brim area.</p> <p>One heavy and one lightweight cast sock are used for a 3-ply wool sock; two heavy and one lightweight cast sock are used for a 5-ply wool socket, etc.; or an old wool stump sock of the same weight can be used.</p> <p>The 150-A yellow wax is heated until it is soft enough to work with a spatula. With this type of wax, it is never necessary to melt it completely and pour it into a cone.</p> <h4>Procedure</h4> <ol> <li>With the outside calipers, measure for the area where the bulb can pass through freely. Mark this area heavily with a pencil (<b>Fig. 28</b>).</li><li>If the cast is wet, seal it with three coats of ambroid varnish.</li><li>Apply the appropriate number of cast socks (or an old stump sock) needed for stump-sock clearance. Tie them off securely on the mandrel.</li><li>Apply the first PVA sleeve, which will be the parting agent. Cap it on the end and tie it off on the mandrel.</li><li>Apply two Dacron sleeves, being sure not to overlap into the flexible walled area which starts at the mark made in step 1. It is advisable to leave at least 1 in. between the mark and the Dacron sleeves (<b>Fig. 29</b>).</li><li>Apply one layer of stockinette and tie it off on the mandrel. If necessary, separate and smooth the extra half-inch of material. With the outside calipers, measure again for the area where the bulb can pass through freely, and mark this area with a pencil.</li><li>With pressure-sensitive tape, make a full turn around the model at the mark made in the previous step (<b>Fig. 30</b>). This seals off the proximal end of the flexible wall.</li><li>Attach the vacuum line.</li><li>Apply the second PVA sleeve and seal it off on the mandrel, then repeat step 7.</li><li>Mix thoroughly enough 4134 flexible polyester resin to cover the area from the tape to the end of the model. Using vacuum, laminate this area <i>only. </i>(It is helpful if, at the end of each laminating step, the excess is tied off, thus saving the time of grinding it away.) Allow to set well (<b>Fig. 31</b>).</li><li>Remove the second PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette. Do not break through to the parting PVA (<b>Fig. 32</b>). Apply two more layers of stockinette, again separating and smoothing down the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the third PVA sleeve, seal it off at the mandrel, and repeat step 7.</li><li>Mix thoroughly enough 384 RTV to cover the laminated area. Using vacuum, laminate this area only. Allow to set well (<b>Fig. 33</b>).</li><li>Remove the third PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette beyond the stitching (as in <b>Fig. 32</b>).</li><li>Apply one or two more layers of stockinette, again separating and smoothing the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the fourth PVA sleeve, seal it off on the mandrel, and repeat step 7.</li><li>Repeat step 10.</li><li>Remove the fourth PVA sleeve. Remove the pressure-sensitive tape around the model.</li><li>For the wax build-up (<b>Fig. 34</b>), apply wax to the model from the proximal end of the flexible wall distally to the <i>largest </i>circumference of the bulb end. The thickness of the build-up should be sufficient to allow the bulb to expand the flexible wall through the narrow area. Use the outside calipers to measure the thickness of the build-up. Allow 3/16-in. thickness for the flexible-wall lamination. (Keeping in mind some goals for the finished prosthesis, such as cosmesis and lightness in weight, in most cases it is possible and advisable to "go overboard" on the wax build-up. Cosmetic build-up is kept to a minimum, and air space is weightless.) Allow the wax to cool and harden (<b>Fig. 35</b>).</li><li>Smooth the surface and taper the proximal and distal edges (<b>Fig. 36</b>).</li><li>Using the wood rasp, roughen the exposed tip of the bulb end enough to cut through to the RTV layer and to raise the half-inch of stockinette beyond the stitching on the final 4134 resin layers. <i>This step is extremely important, </i>as it will securely bond the flexible portion of the socket to the rigid outside shell (<b>Fig. 37</b>).</li><li>Apply the three extra-long nylon stockinettes, doubling the first two layers back at the brim (<b>Fig. 38</b>).</li><li>Apply the fifth PVA sleeve and seal it off on the mandrel. Mix enough 4110 polyester resin to cover the entire mold. Using vacuum, laminate the entire mold. Allow it to set (<b>Fig. 39</b>).</li><li>After the resin has set, cut a flap through it 3/4 in. in diameter at the distal edge of the wax build-up. Tape the flap back (<b>Fig. 40</b>).</li><li>Hang the entire laminated cast in the oven (heated to 175 degrees F) and allow <i>all </i>the wax to drain out.</li><li>Remove the laminated cast from the oven after the wax has drained. Allow the lamination to cool just enough for the rigid shell portion to harden. Mark the approximate trim line and cut along it with a Stryker saw. A strong tug, along with use of a hammer and piece of wood when needed, will separate the socket from the cast (<b>Fig. 41</b>).</li><li>To complete the socket, finish sanding the brim down to the trim lines.</li></ol> <h3>Fitting</h3> <h4>Materials</h4> <ul> <li>Fitting stool</li> <li>Talcum powder</li> <li>Stump sock</li> <li>Mandrel padded at the end with stockinette in the shape of a bulb</li> <li>Heat gun</li> <li>Silicone amputation-stump spray</li> </ul> <h4>Procedure</h4> <ol> <li>Set the socket in a wood block with the seat level.</li><li>Place the block on a fitting stool to get the correct ischium-to-floor length.</li><li>Lightly powder the socket.</li><li>Have the patient apply the stump sock and hold it firmly at the top as he pushes his stump into the socket (<b>Fig. 42</b>). (If the patient cannot push all the way into the socket, the flexible layers will need to be stretched as described in the next section.)</li><li>Check to see that the patient's ischium is firmly on the seat, and that he has light contact at the end of the stump. Do this by having him bear weight on the socket and by requesting him to "reach down into the socket" with his stump. If as he does this, he loses firm contact with the seat, the socket is too short. If he cannot feel contact on the bottom, the socket is too long. A sponge pad in the bottom of the socket may give the necessary light contact.</li><li>Have the patient lift his hip to take weight off the socket. There should be no more than 1/4 in. of piston action (<b>Fig. 43</b>).</li><li>Check for pressure areas in the bulb. With the patient standing, have him flex his hip while you apply resistance to the distal anterior end of the socket. Then have the patient abduct, extend, and ad-duct the hip, each time applying resistance to the distal end of the socket. There should be no pain from these maneuvers. (Pain may be caused by a wrinkle in the sock, by the presence of wax in the air space, or from inadequate relief over the bony prominences in the bulb.)</li><li>Establish the anterior and posterior trim lines. In the posterior lateral area, trim the socket so that it does not encase the gluteal area. Then have the patient sit in a chair and lean forward. Check for discomfort in the anterior area, and trim the socket to fit. There should be no gapping of the lateral wall. The anterior brim of the socket should be in firm contact with the skin, for looseness here would allow the socket to rotate internally on the stump when the patient walks.</li><li>To remove the socket, the patient should pull up on the top of the stump sock while pulling down on the socket. In a few cases, this was the only way in which the socket could be removed (<b>Fig. 44</b>).</li></ol> <p><i>Stretching the Flexible Layers</i></p> <p>If the patient cannot push his stump all the way into the socket, it will be necessary to stretch the flexible layers to allow the bulb to pass through the narrow part of the socket. This can be accomplished as follows:</p> <ol> <li>Place the padded mandrel in a vise.</li><li>Heat the inside of the socket to soften the flexible layers.</li><li>Work the socket back and forth on the mandrel, stretching the flexible layers.</li><li>Let the socket cool on the mandrel, with the padded end of the mandrel at the narrowest part of the socket.</li><li>Refit as in the preceding section, using silicone spray in the socket if necessary.</li></ol> <h3>Alignment</h3> <h4>Bench</h4> <p>The initial set-up is made with the ischial seat level. The posterior plumb line for the heel center passes between the center of the end of the socket and the point where the ischium rests on the ischial seat (<b>Fig. 45a</b>). The lateral plumb is taken from the center of the end of the socket and passes % in. anterior to the knee center (<b>Fig. 45b</b>). The socket is set in 15 degrees -30 degrees of internal rotation to the line of progression to compensate for the patient's tendency to internally rotate the pelvis to advance the prosthetic leg (<b>Fig. 45c</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45a. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45b. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45c. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional</h4> <p>The prosthesis is the correct length when the patient's spine is as straight as possible when he stands with his weight on both legs, i.e., in the finished prosthesis. The iliac crests of these patients are not always symmetrical, and it may not be a reliable reference point for judging the length of the prosthesis (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dynamic alignment is done with the socket set on a child-size above-knee jig. Optimal dynamic alignment is based on standards set for the standard above-knee amputee.</p> <h3>Summary</h3> <p>This fitting technique can also be used on other stumps with bulbous ends: Syme's and above-elbow amputations and wrist disarticulations, for example.</p> <p>At CAPP, more than 20 patients have been fitted in this manner: 18 PFFD's, 2 bilateral Syme's amputations, 1 wrist disarticulation, and 1 above-elbow amputation. All of these patients' deficiencies were congenital in origin.</p> <p>The procedure described does require more fabrication time and material. Once the technique is mastered, it requires about three hours of the prosthetist's time, whereas a solid socket can be fabricated in an hour. However, the CAPP patients have shown a marked preference for this type of socket. It provides a very precise fitting, and in every case the child has expressed a feeling of greater security when wearing this socket (<b>Fig. 47</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another advantage is the apparent absence of skin breakdown. When the patient comes to the clinic for post-fitting examination, the characteristic blanching of the stump skin is absent, as are signs of rubbing, blistering, or callousing so often seen with use of the solid socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Marx, Herbert W., An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 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>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 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>Carman Tablada. C.P. </b></td></tr><tr><td class="clsTextSmall">Mr. Tablada is a clinical prosthetist at the Child Amputee Prosthetics Project, University of California, Los Angeles. This study was made under MCH Project No. 204, Division of Health Services and Mental Health Administration, Maternal and Child Health Service, Department of Health, Education, and Welfare. The photographs were taken by Mary Louise Histon.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-19.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-20.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-26.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-27.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-45.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-46.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-47.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-48.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-49.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-07.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-08.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-09.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 A Technique for Fitting Converted Proximal Femoral Focal Deficiencies Creator An entity primarily responsible for making the resource Carman Tablada. C.P. * https://staging.drfop.org/files/original/8ecb54a3012ed38f7b171812350a731d.pdf 05c8e25798ef9b43b1cb55d9b9839e68 https://staging.drfop.org/files/original/6098481d015061b362e56ee04136384f.jpg 11d8c7e9bba2ec02aa1e933df086c33a https://staging.drfop.org/files/original/46a799d6d2420300645917eaf2723c59.jpg e63018f515b90c2eb69c4ec89a8898ca https://staging.drfop.org/files/original/624a1233ecee23ac46ae637b18ba146b.jpg a6de0ab1da660648e99d40c903b27f11 https://staging.drfop.org/files/original/ab290fff59eadd267873a2decbd4e440.jpg 5bbfa7208d171dc56b90017e06f551e2 https://staging.drfop.org/files/original/520e88e49706cc661d53c602c6e33230.jpg 24830d3188a99030c51f97e3e6dea71a https://staging.drfop.org/files/original/de6139b99b662a5dfe5610dfbab30787.jpg 8947cfdfdd64cad477ba692f14656a82 https://staging.drfop.org/files/original/c3b9f7080112397202c2fbd0564d6efe.jpg e1aed6122e85990b09b25c20ed48a2a8 https://staging.drfop.org/files/original/230a7ff66eb4ce78118fada1bc78690f.jpg d1ad6fe57d3b51df0d72ad4bb9ab701c https://staging.drfop.org/files/original/38421551a83fa4614592b3b366304871.jpg e537771eaa35ec2c0fec8c6fd155000b https://staging.drfop.org/files/original/8905983959c857a3fe44468e0648daa2.jpg c124186a879f11ce49da830054807aaf https://staging.drfop.org/files/original/9507fd0de770b04b5b6b8e66a960c096.jpg 7243d43f3f603331b9462b61af3bd63c https://staging.drfop.org/files/original/acdca25dbb06cf22df9a79b8cf50487c.jpg ed2380d140dd85f67e802126564821f4 https://staging.drfop.org/files/original/ba2951f2e3d1435d01cfab4a4e31b29a.jpg 07a034fc807db2900fe28dd8c647f4ce https://staging.drfop.org/files/original/eff10f36de6ee111d6f50738c3442319.jpg 1f3a3b4d0f9af8451b1947b0c7e73341 https://staging.drfop.org/files/original/38b0e67c23198fd71257d8e8feed8cc6.jpg b2cf1ba3890019f43e712145bfd7b3d3 https://staging.drfop.org/files/original/b952520c020ff58786ca31aa71420aef.jpg 2c49308b27810bfa3ae14cb5897584ae https://staging.drfop.org/files/original/921292d7f6c4054098369270f1c94ceb.jpg 104f419a0f65a4dd1c13dbf1c3905dd3 https://staging.drfop.org/files/original/88a9ff9aebe0c40faa2273099450814e.jpg 8abd9344644628bec1edebd0dc336e1a https://staging.drfop.org/files/original/37804103eaaa550d65be09f5159b801b.jpg 8f81c43924b242f36e3c7f23e9daf146 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_046.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 46 - 67 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_01_046.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_046.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>Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace</h2> <h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5> <p>In certain pathological conditions of the lower extremity, the stress of weight-bearing cannot be tolerated because of pain or the possibility of actual tissue damage. Pathologies encountered in such situations fall into three broad categories: <a></a> those affecting bone-delayed unions or nonunions of fractures; <a></a> those involving the ankle or foot joints, such as traumatic arthritis or similar conditions; and <a></a> those involving the soft tissue, such as ulcers and traumatic loss of the heel pad or other soft tissues.</p> <p>In these circumstances, bracing is frequently used as an aid to management, the brace serving as a weight-bearing device to relieve the skin-muscle-bone complex of intolerable stresses.</p> <p>Historically, the application of a brace to unweight the lower extremity has involved provision for support of the body weight at the level of the pelvis, typically some form of ischial weight-bearing. A variable proportion of body weight is then transmitted to the ground through side bars and a locked knee. This type of brace is inherently disadvantageous because of its bulk and because the locked knee imposes a stiff-legged gait which increases energy costs. In situations where the pathology is located above the knee, avoidance of these disadvantages may be impossible. However, in selected below-knee lesions, a brace which bears weight about the knee (like the patellar-tendon-bearing prosthesis) appears not only desirable but possible. A brace of this type would not only allow unrestricted knee motion, and hence a more natural gait, but it would have the advantages of reduced bulk and the absence of equipment above the knee.</p> <p>In 1958, VAPC designed such a below-knee weight-bearing brace. <a></a> The VAPC design was based on the then current below-knee patellar-tendon-bearing (PTB) prosthetic techniques. The primary weight-bearing component is a partial socket of laminated plastic with a soft (Kemblo [TM]) liner similar to the proximal portion of a PTB prosthesis (<b>Fig. 1</b>). Stainless-steel uprights were used with a stainless-steel limited-motion stirrup (<b>Fig. 2</b>). The ankle joints were modified to permit 10 degrees of plantar flexion and to limit dorsiflexion at 90 degrees. The stirrup and uprights were fitted and aligned as in a conventional ankle brace. In wearing the brace, an open-end wool stump sock was used as with a below-knee prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Proximal weight-bearing portion of the PTB 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. Completed brace of initial design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As experience with the PTB-type brace accumulated at VAPC, a number of modifications were introduced (<b>Fig. 3</b>). A compressible heel, similar to that of the solid-ankle cushion-heel (SACH) prosthetic foot, and a rocker bar attached to the sole of the shoe became incorporated as standard components of the device. The SACH heel wedge and rocker bar were incorporated in the shoe to simulate plantar flexion and provide a more natural roll from heel to toe, thus minimizing gait deviations imposed by limited ankle motion. <a></a> The SACH heel wedge is also considered to function as a shock absorber, contributing to a smoother gait. Some patients with painful ankles were unable to tolerate motion in the ankle joint at the brace and were fitted with rigid joints.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Views of the modified brace showing application of SACH heel and rocker bar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center submitted the PTB weight-bearing brace to the Committee on Prosthetics Research and Development for evaluation. Unfortunately, at that time procedures for the testing of orthotic devices were not available. However, in December 1963 an orthotic evaluation program was inaugurated by New York University, and the VAPC device was selected by CPRD as a suitable item for this program.</p> <p>The initial phase of the NYU evaluation involved the review and examination of patients fitted by VAPC. Of the 22 patients who had been fitted by VAPC between 1958 and November 1963, 8 accepted the invitation to appear for interview and examination. The findings of this review study indicated that the VAPC pa-tellar-tendon-bearing brace was an effective device from the medical, orthotic, functional, and wearer-reaction points of view. <a></a></p> <h3>Clinical Fittings</h3> <p>On September 1, 1966, the National Academy of Sciences-National Research Council entered into Contract SAV-1053-67 with the Vocational Rehabilitation Administration (now the Social and Rehabilitation Service) to establish a pilot program for the clinical evaluation of prosthetic and orthotic devices under the jurisdiction of the Committee on Prosthetics Research and Development. Two orthotic items were selected to initiate this program: the Baylor (Engen) hand orthosis and the University of California dual-ankle control system. The Engen study was undertaken <a></a> but, for various reasons, the UC study could not be undertaken, and evaluation of the VAPC PTB brace was substituted for the UC item.</p> <p>Since the earlier favorable NYU review, an instructional manual has been prepared by the developer. <a></a> Accordingly, five treatment centers were recruited as participants in a clinical application study of the VAPC PTB brace: the University of Alabama Medical Center, Birmingham, Ala.; Goldwater Memorial Hospital, New York, N.Y.; Jackson Memorial Hospital, Miami, Fla.; Rancho Los Amigos Hospital, Downey, Calif.; and the Rehabilitation Institute of Chicago, Chicago, Ill.</p> <p>A course of instruction in the fabrication and application of the VAPC PTB brace was conducted at the Veterans Administration Prosthetics Center, New York, by the developers. Orthotists from the participating clinics undertook training for five days (May 8-12, 1967), while physicians had a one-day orientation (May 12, 1967).</p> <p>A protocol for the study, together with appropriate data-recording forms, was prepared by the CPRD staff.</p> <p>Following the instructional course, several fittings were accomplished at each of the participating centers. Subsequently, a number of factors arose to militate against the completion of the planned course of study. Two of the clinics suffered the loss of the physician member of the participating team, and two other centers became engaged in studies of cast braces for fractures of the lower extremity. These fracture-cast braces had some of the same characteristics and performed similar functions as the test item. The physician member of the fifth participating team suffered a prolonged illness, which disrupted the progress of the study at his center.</p> <p>The clinical study of the VAPC PTB brace was reactivated early in 1970 when the physician who had been ailing recovered his health and it was discovered that the orthotics clinical group at the Duke University Hospital had been fitting the test item since 1962 and had accumulated a sizable series of patients. Arrangements were made, therefore, to review patients fitted in Birmingham and Durham. The data obtained in these reviews form the basis for this report. The experience of these two centers is presented in the following sections of this report.</p> <h4>Birmingham, Alabama</h4> <p>Following the return of the physician—orthotist team from the instructional course at VAPC, seven patients were fitted in the study. Two of these patients were civilians (one woman and one boy) and five were veterans. The injuries of three of the veterans were non-service-connected.</p> <p>Review of the data available on these seven patients fitted in Birmingham indicates that in four instances the experimental brace was used satisfactorily and successfully. In two cases, the results were inconclusive in that the follow-up data are not available. The seventh patient must be considered a probable failure, although again follow-up data are not available. Condensed case histories on these patients follow.</p> <h4>Successful Outcomes</h4> <p><i>Case No. 1</i></p> <p><i>P.S. </i>was born on February 28, 1953. He suffered from congenital pseudarthrosis of the right tibia and fibula, essentially constituting a defect similar to an ununited fracture. Prior to referral to the Crippled Children's Service Clinic in Birmingham, he had undergone surgery at an early age. This surgery, involving the use of metallic screws and sutures, was unsuccessful. Further surgical procedures were attempted subsequently, an onlay bone graft being done on July 20, 1965. This surgery was followed by infection and was unsuccessful. A sliding bone graft was attempted on June 6, 1967, but this also was unsuccessful.</p> <p>The VAPC PTB brace was fitted in April 1968. The condition of the right tibial and fibular defects at that time is shown in <b>Fig. 4</b>. The brace prescription included a SACH heel and a rocker bar incorporated into the shoe build-up (the right leg being shorter than the left). Initially, no motion was provided at the ankle joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. X-ray of P.S.'s leg at time of fitting the VAPC PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following application of the brace, the leg shrank rapidly, and a new socket was required in approximately one month. Because of this loss of fit, the amount of weight borne on the defective limb was increased. This boy was a very active user; he played basketball and reported that he went hunting almost every day. As a result of this active use, numerous breakages occurred at the junction of the brace upright and shoe plate. The upright was eventually strutted for extra strength, and after about a year and a half of wear a few degrees of motion were introduced at the ankle joint. This limited motion resulted in reduction of the breakage problems.</p> <p>Although the patient was well pleased with the brace and wore it satisfactorily, the tibial and fibular defects failed to unite (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. P.S.'s leg after wearing the experimental brace approximately 14 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The physician, orthotist, and patient all considered this brace to be superior to any previously worn.</p> <p><i>Case No. 2</i></p> <p><i>C.S. </i>was born on April 17, 1915. He was injured on March 2, 1967, when he slipped on the ice and fell, sustaining fractures of the left tibia and fibula. He was treated with plaster casts, but union of the tibial fracture was delayed.</p> <p>He was fitted with the VAPC PTB brace in September 1968. The prescription was standard, and included a SACH heel, a rocker bar, and a rigid ankle. A full leather cuff was applied over the fracture site.</p> <p>This patient's treatment program proceeded uneventfully, and by June 1969 a good bone union was evident clinically and confirmed by X-ray (<b>Fig. 6</b>). This patient was discharged from the doctor's care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. C.S.'s X-rays after wearing the experimental brace for 9 months Good bone union is evident at the fracture site. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 3</i></p> <p><i>H.E. </i>was born on October 25, 1933. He was hit by a car on October 12, 1966, sustaining a fracture of the right tibia, which failed to unite. Draining osteomyelitis also was present.</p> <p>He was fitted with the experimental brace on October 25, 1968. The prescription included a SACH heel, a rocker bar, a fixed ankle, a short leather cuff, and a high shoe. He initially walked with crutches or canes but later discontinued these aids.</p> <p>This patient is a large, heavy man and very active. Many repairs were required at the shoe-plate junction, and eventually a strut had to be added for additional strength.</p> <p>This patient's treatment program proceeded relatively uneventfully. In August 1969, the brace was reported as working well, and no drainage had been experienced since October 1968. Although the fracture had not healed, X-rays revealed some indications of healing (<b>Fig. 7</b>). In March 1970, apparent ankylosis of the ankle joint was noted, and progressive ossification within the fracture area was evident. The patient continues to wear the brace and tolerates it well. He still wears an elastic below-knee stocking, but this is apparently more for insurance than because of actual need.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. H.E.'s X-rays show indications of healing of fracture after the brace was worn for 10 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 4</i></p> <p><i>J.C. </i>was born on October 27, 1948. He was injured by shrapnel on May 14, 1967, sustaining a fracture of the neck of the talus on the right leg and loss of soft tissue on the right heel. <b>Fig. 8</b> shows the condition of his right ankle approximately five months after the injury.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. X-ray of J.C.'s right ankle 5 months after injury. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The experimental brace was prescribed for this patient on November 21, 1967, and it was delivered on December 13. The prescription incorporated a SACH heel, a rocker bar, a reinforced foot plate, and no ankle motion. This patient experienced no particular problems other than the need for shoe changes. He found the brace useful and comfortable. X-rays taken on April 9, 1968, showed marked improvement (<b>Fig. 9</b>). His injuries proceeded to complete healing, and he is no longer wearing the VAPC brace.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marked improvement is evident in J.C.'s ankle after wearing the experimental brace approximately 5 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 5</i></p> <p><i>S.D. </i>was born on May 18, 1927. She was injured on August 30, 1967, sustaining a comminuted fracture of the right tibia and fibula. The tibial fracture failed to unite.</p> <p>She was treated with long and short leg casts and fitted with the PTB brace on May 29, 1968. The prescription was standard, and included a SACH heel, a rocker bar, and no ankle motion. The patient tolerated the brace well, and X-rays taken on July 1, 1968, indicated satisfactory progress (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. S.D. shows satisfactory progress one month after fitting with a PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Few maintenance requirements were found, except that the shoes had to be changed and one upright and one foot plate broke.</p> <p>The patient was seen in August 1969, at which time she was using the brace with crutches. She has not been seen since, so the end result is unknown.</p> <p><i>Case No. 6</i></p> <p><i>D.E. </i>was run over by a truck in May 1966, and he sustained fractures of both legs and the left foot. The left tibia failed to unite, as indicated in X-ray films taken six months after the injury (<b>Fig. 11</b>). He was fitted for the VAPC PTB brace in December 1968, but left the hospital before the brace was delivered. The brace was delivered at home just before Christmas 1968, and he apparently has not been seen since except for a casual encounter with the or-thotist on the street, when it was reported that the fracture had healed and that the patient no longer needed the brace. Again, because of the loss of this patient to active follow-up, the full story is not known.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Condition of D.E.'s leg prior to fitting with a PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Assumed Unsuccessful Outcome</h4> <p><i>Case No. 7</i></p> <p><i>R. McK. </i>was born on May 21, 1908. His injury occurred as a result of a land-mine explosion on February 27, 1942. He sustained the loss of the os calcis and the heel pad bilaterally.</p> <p>He was fitted with the VAPC PTB brace on the right side only, the device having a fixed ankle, SACH heel, and rocker bar.</p> <p>This patient was apparently dubious about the brace from the outset, and expressed lack of confidence in the doctors and the course of treatment. He wore the experimental brace for a very limited period (approximately five days) and claimed that it limited his freedom, particularly when driving. This patient subsequently became lost to follow-up, and all indications were that the application of the brace in this case was unsuccessful as well as perhaps ill-advised.</p> <h4>Discussion And Conclusions</h4> <p>The evidence in the Birmingham fittings of the VAPC PTB brace was strongly positive with respect to its value as a means of patient management. In some instances, this value was in providing partial un-weighting so that the damaged part could heal. In other instances, the unweighting provided by the brace permitted the patients to engage in vigorous programs of activity despite a lack of union in the tibia.</p> <p>In addition to these general findings, some specific findings of interest emerged.</p> <ol> <li>Following application of the VAPC PTB brace, shrinkage of the limb enclosed by the plastic cuff was encountered. Close control of the fitting during this period is essential in order to avoid the development of loose fit and a reduction in the amount of weight borne by the brace.</li><li>As in all prosthetic-orthotic applications, judicious selection of patients is essential. In the Birmingham group, one fitting was apparently doomed to failure from the outset because of the patient's attitude, while another patient was a chronic alcoholic, so that the possibility of securing follow-up data was negated from the outset.</li></ol> <p>It should be emphasized that the Birmingham fittings closely followed the technique practiced and taught by the Veterans Administration Prosthetics Center. Review by one of the co-developers of the device on a number of the cases fitted early in the study indicated good workmanship and generally excellent fit and alignment.</p> <p>Some observations by the orthotist member of the fitting team were:</p> <ol> <li>Fabrication of the VAPC PTB brace requires experience in both prosthetics and orthotics, since elements of both specialties are involved.</li><li>A course of instruction in the technique during which the braces are actually fabricated under competent instructors is a most desirable means of transmitting fitting knowledge and skill.</li><li>The selection of patients for the device is most important and should include not only considerations of psychological factors such as those described above but also of physical factors which may increase the difficulty of fitting. (The presence of loose tissue around the knee which could become a flesh roll above the brace cuff was cited as an example of this type of difficulty.)</li><li>All patients fitted in the Birmingham group were initially provided with braces with no provision for motion at the ankle joint. In active and/or heavy patients, this resulted in numerous brace-upright and shoe-plate breakages. Later, some patients were provided with a small amount of ankle motion, and this had the effect of reducing incidence of breakage. Criteria for the prescription of fixed or limited motion in ankle joints should therefore be defined more carefully.</li></ol> <h4>Durham, North Carolina</h4> <p>Mr. Bert Titus, director of the Department of Prosthetics and Orthotics, Duke University, began fitting the VAPC-PTB-type brace in 1962. The initial braces were fabricated in accordance with the VAPC manual of January 3, 1961. <a></a> Over the years, however, the original VAPC procedures were modified at Duke in a number of ways. Although the original concept of patellar-tendon weight-bearing for reduction in the amount of weight borne by the affected part of the limb was maintained, the changes are significant enough to be worthy of note.</p> <ol> <li>The socket, which in the VAPC version was hinged on the medial side, was first changed to a bivalve construction involving anteroposterior sections joined by adhesive tape (<b>Fig. 12</b>). The type of socket now fitted in Durham involves a plastic laminate without liner which is flexible on the posterior aspect and the posteromedial corner (<b>Fig. 13</b>). The socket is split along the posterolateral corner and closure is effected by two or more Velcro (TM) straps (<b>Fig. 14</b> and <b>Fig. 15</b>). The fabrication of this socket is described in a report being prepared by Titus. An abbreviated description of the Duke procedures appears as a supplement to this article.</li><li>The sidebars in the Durham version of the weight-bearing brace are of either stainless steel or aluminum, and most recently have been attached to the outside of the socket with rivets. This procedure is in contradistinction to the VAPC method, which involves insertion of the proximal ends of the sidebars into prepared channels. Distally, the bars are detachable from the shoe.</li><li>All the VAPC-type braces fitted at Durham incorporated some degree of ankle motion. Typically, this was 20 degrees to 25 degrees of dorsiflexion with a 90 degrees stop. However, some of the ankle joints were completely free. This feature again contrasts with the VA practice in which the brace ankles are frequently of the rigid type. It was reported that none of the braces fitted at Durham had completely rigid ankles.</li><li>Typically, the Durham version of the weight-bearing brace does not include either a SACH heel or a rocker bar. Doubtless, the need for such aids to roll-over is reduced or eliminated by the provision of ankle motion.</li></ol> <p>Between the initial fittings in 1962 and June 15, 1970, the Duke Limb and Brace Shop fitted approximately 27 PTB-type braces. Of these patients, 20 were civilians seen through the Orthopaedic Department of Duke University Hospital and 7 were veterans who were treated through the Veterans Administration Hospital at Durham. Three additional braces were being fabricated at the time of this review.</p> <p>On June 22-23, 1970, the author, accompanied by William McIlmurray from the VAPC, reviewed 8 patients who had been fitted through the Duke University Department of Prosthetics and Orthotics. The group of patients reviewed included 5 civilians and 3 veterans. The case-history files of 12 additional patients were also reviewed. The data obtained in these reviews are presented below in three sections-one indicating the types of disabilities for which the brace was used, the second containing illustrative case histories of patients treated, and the third containing comments on fit and alignment. In general, the outcomes of the fittings appeared to be very positive.</p> <h4>Types Of Disabilities</h4> <ul> <li>Chronic osteomyelitis with secondary deformity of distal tibia and fibula and partial ankle fusion.</li> <li>Slow-healing spiral fracture of the tibia and fibula.</li> <li>Compound fracture of the tibia and fibula and fracture of the left foot followed by infection and numerous operative procedures culminating in ankle fusion.</li> <li>Fracture of the tibia and fibula.</li> <li>Nonunion of the tibia and fibula with compression-plate fixation.</li> <li>Nonunion of a tibial fracture with draining osteomyelitis.</li> <li>Comminuted fractures of the distal right tibia and proximal right fibula and fracture dislocation of the right ankle. A painful ankle led to the performance of a triple arthrodesis.</li> <li>Comminuted fractures of the ankle mortice bilaterally (right medial malleolus and tibia, left spiral fracture of tibia and fibula; both ankles stabilized with pins). Six pins were subsequently removed.</li> <li>Traumatic arthrosis of the right ankle following fracture of the distal right tibia and fibula.</li> <li>Compound trimalleolar fractures of the left ankle with dislocation.</li> <li>Nonunion of a left tibial fracture with osteoporosis.</li> <li>Calcaneal valgus deformity of the right foot treated with a triple arthrodesis of the right foot and ankle; delayed healing of subtalar, talonavicular, and calcaneocuboid joints with severe osteoporosis.</li> <li>Pain on plantar aspect of heel following fracture of the os calcis.</li> <li>Foot pain following football injury; triple arthrodesis performed.</li> <li>Degenerative changes in left knee secondary to old fracture of the tibial plateau.</li> <li>Nonunion of medial malleolus following trimalleolar fracture sequelae of traumatic arthrosis and arthrodesis.</li> <li>Comminuted fracture of os calcis leading to a crushed heel pad, osteoporosis, and triple arthrodesis subsequently.</li> <li>Right heel pain, characteristic of traumatic or degenerative arthritis.</li> <li>Fracture of the right os calcis with painful right foot and ankle.</li> </ul> <h4>Case Histories</h4> <p><i>Case No. 1</i></p> <p><i>W.J. </i>was born on April 3, 1927. From early childhood, he had suffered from a defect in his left leg which had been attributed to an aftermath of diphtheria. His condition was reported as being chronic osteomyelitis with a secondary deformity of the distal tibia and fibula combined with partial ankle union.</p> <p>The patient was fitted with a PTB brace in August 1962, and thus had worn the device for almost eight years. The brace worn had an ankle with a positive 90 deg. stop and approximately 30 deg. of dorsiflexion motion. He wore a low shoe with a 2 1/2-in. build-up. Otherwise, the brace was of the Durham type as described previously. He reported that he wore the brace for more than nine hours daily, and that it was generally quite comfortable and satisfactory. His condition was reported to have stabilized, although his ankle and shin sometimes ached after prolonged standing or walking. He stated that he felt that he was bearing more than 50% of his weight on the brace. From his remarks, it would appear that the brace was a definite aid to his mobility.</p> <p><i>Case No. 2</i></p> <p>J.G. is a 30-year-old male garbage collector who was jammed between the garbage truck and a brick wall, sustaining a fracture of his left tibia and fibula on March 22, 1967. A nonunion of the fractures with a draining osteomyelitis ensued (<b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. J.G., with nonunion of fractures and draining osteomyelitis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient was fitted with a PTB brace in September 1969. He reported that he was feeling fine, the osteomyelitis had stopped draining, and he had returned to work driving a garbage truck.</p> <p>The brace worn was the Durham bivalve device with the ankle completely free (<b>Fig. 17</b>). He wore the brace all day every day and reported absolutely no problems with it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. J.G,, with Durham bivalve-type brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>From the patient's remarks, his return to work, and his comments concerning the brace, it would appear that this fitting was quite successful.</p> <p><i>Case No. 3</i></p> <p><i>T.L., </i>a physician, sustained a spiral fracture of the tibia and fibula on February 5, 1969. He wore a long leg cast for six months following the injury, and on August 8, 1969, he was fitted with the PTB brace. The condition of his fractures just prior to fitting is shown in <b>Fig. 18</b>. With the device, he was able to return to his medical practice. The fracture was pronounced healed in November 1969, and the PTB brace was discarded. His brace was of the standard Durham type with a completely free ankle joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Views of T.L.'s fractures before fitting with PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When interviewed, the patient's comments concerning the brace were very positive. So much so, in fact, that when the interviewer remarked that he seemed like a happy customer, he retorted that he was more than happy—he was delighted—and in fact had sent two patients with fractures to be fitted with the same type of brace.</p> <p><i>Case No. 4</i></p> <p><i>F.E., </i>a 43-year-old male, was buried under eight to ten tons of chemical in March 1966, sustaining compound fractures of the left tibia and fibula, a fracture of the left foot, and fractures of the pelvis and of the right upper femur. Following open reduction and internal fixation, the injury became infected and the fixation was removed. The patient had a number of operative procedures on his right hip, and on October 3, 1967, underwent multiple fusions of the ankle bones.</p> <p>He was fitted with a PTB brace on March 27, 1968, and thus had worn it for slightly more than two years. The device is of a standard Durham type with a 90 degrees ankle stop and with approximately 5 degrees of dorsiflexion. The sidebars were of aluminum with an anterior aluminum calf band. A low shoe was worn with a build-up on the opposite side because of a shortening of the right leg related to the pelvic and femoral fractures. The brace was of the bivalve type. <b>Fig. 19</b> and <b>Fig. 20</b> show the condition of the foot and distal tibia and fibula over the period from January to October 1969. The patient reported that without the brace he experienced discomfort at the fracture sites, but that with the device he was reasonably comfortable and could wear the brace all day. He claimed that he took about 30<i>% </i>of his weight on the brace. Again, it appeared that this brace is a highly acceptable aid to the mobility of the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. X-rays of F.E.'s distal leg, ankle, and foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Condition of F.E.'s limb 9 months later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 5</i></p> <p><i>H.H., </i>40 years of age, sustained multiple fractures of the lower extremities on August 4, 1969. His injuries included fractures of the left femur, tibia, and fibula, and right tibia and fibula. He was fitted with a PTB-type brace in February 1970. His condition two months after fitting (eight months after injury) is shown in <b>Fig. 21</b>. His device was of the single-lamination type and incorporated a free ankle and a high shoe. The fit of the socket was somewhat loose, and the patient expressed the opinion that no weight was being taken on the socket. He used Canadian-type crutches bilaterally. The clinical notes on his condition indicated good alignment of the bony fragments and no pain. He was wearing the brace all day and had no problems with it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Condition of H.H.'s fractures 8 months after injury (2 months' wear of PTB brace). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 6</i></p> <p><i>J.H., </i>born in 1927, suffered his injury in December 1966. Nonunion of the left tibia and fibula ensued, with compression-plate fixation.</p> <p>The patient had been fitted initially with the bivalve-type socket (separate anterior and posterior sections), but was currently wearing the one-piece laminated socket with a flexible posterior section. The brace incorporated a free ankle, and a low shoe was worn.</p> <p>Recent clinical notes on this case indicated that on March 25, 1970, there was good alignment of the bony fragments, and early bridging of bone had begun in the tibia and fibula. On May 27, 1970, the patient was reported to be feeling well, but there was still nonunion of the fibula (<b>Fig. 22</b>). The patient reported no problems with the brace.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Persisting nonunion of fibula approximately 4 1/2 years after injury. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 7</i></p> <p><i>R.C.M., </i>39 years old, sustained a comminuted fracture of the left tibia and fibula when a tree fell on his leg in March 1967. Nonunion of the left tibial fracture ensued, with chronic osteomyelitis and drainage (<b>Fig. 23</b>). A bone graft to the tibia was attempted in March 1968.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Nonunion of tibial fracture 10 months after accident. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient wore a long leg cast, followed by an initial weight-bearing brace. He was fitted with the PTB device in December 1969. His clinical record indicated that there was intermittent drainage in December and January but no drainage in February or March 1970 (<b>Fig. 24</b>). On April 1, 1970, it was reported that no active osteomyelitis was evident. However, at the time of the review (June 24, 1970), the patient reported that drainage had restarted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Nonunion persisting 3 years after accident. PTB brace worn 3 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>His brace included a 90 degrees posterior stop with about 10 degrees of dorsiflexion motion evident. The patient wore a built-up low shoe to accommodate a 2 1/2-in. shortness of the affected limb. His socket was of the two-part (bivalve) type. He used a cane as an aid in ambulation.</p> <p>The patient reported that the brace felt comfortable most of the time, although he had occasional swelling of the leg after long use and some discomfort at the site of the fracture after prolonged sitting.</p> <p><i>Case No. 8</i></p> <p><i>R.McC, </i>69 years old, was injured in an automobile accident on November 15, 1969. He sustained fractures of the head of the tibia, the head of the fibula, and the proximal third of the fibula (<b>Fig. 25</b>). He was fitted with the PTB brace on April 6, 1970 (<b>Fig. 26</b>). Thus, at the time of the review, he had been wearing the device for approximately two and one-half months. He reported that the brace was generally comfortable, but that he had had some problems with swelling and stiffness in the ankle. He estimated that the brace was taking approximately 25% of his body weight. His brace was a standard Durham type with a 90 degrees posterior stop and dorsiflexion motion of approximately 30 degrees. When first fitted with the PTB brace, he had used two crutches, but now was only using one.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. <i>Left, </i>R.McC.'s initial injury, Nov. 15, 1969. <i>Right, </i>after open reduction and internal fixation, Jan. 2. 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. <i>Left, </i>R.McC.'s fractures at time of fitting the PTB brace, 4 1/2<i> </i>months after injury, April 1970. <i>Right, </i>after 1 month's wear of PTB brace, May 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this instance the period of brace wear was too short for definite conclusions to be drawn, the brace was being tolerated well by the patient and was of assistance to him in ambulation.</p> <p><i>Case No. 9</i></p> <p><i>J.B., </i>67 years old, was admitted to Duke University Hospital on March 12, 1969, with a closed comminuted fracture of the left distal tibia, fibula, and ankle joint, and an open trimalleolar fracture of the right ankle. Operative procedures were carried out the same night, and the patient was discharged from the hospital on April 11, 1969, with the wounds healed and the feet in apparently satisfactory condition, with the right foot in a better state than the left.</p> <p>X-rays taken on January 12, 1970, showed an old fracture of the right ankle with fixation by metallic pins and screws and good external bony bridging and normal alignment (<b>Fig. 27</b>). On the left side, internal-external bridging of the fibula with marked angulation, as well as poor healing of the tibial fragments, was evident.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. <i>Left, </i>J.B.'s left ankle 10 months after reduction, Jan. 1970. <i>Right, </i>views of ankle 12 months after reduction (1 month after fitting with PTB brace) March 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He was fitted with the PTB brace in February 1970. Four weeks later, the clinic notes reported that the fibula had healed, and that the tibia was nontender.</p> <p>No significant further changes were noted at examination on May 26, 1970. However, that patient reported that since wearing the PTB brace he had experienced practically no pain in the ankle or foot. He was to continue wearing the brace.</p> <h3>Critique Of Fabrication And Alignment</h3> <p>William McIlmurray of the Veterans Administration Prosthetics Center, one of the co-developers of the PTB brace, participated in the review of patients at the Durham facilities. Mr. Mcllmurray described the fitting and alignment of the braces seen as generally good. He noted some of the characteristics of the Durham devices previously mentioned: the one-piece socket lamination, the ankle motion provided in all prostheses in contrast to the need that VA found to fit some braces with rigid ankles, the external attachment of the sidebars, the use of detachable stirrups, and the absence of SACH heels and rocker bars on the shoes of the patients. The absence of a liner in the sockets fitted and the fact that some patients did not wear stump socks was also noted.</p> <p>Mr. Mcllmurray subsequently discussed these features of the Duke fittings with Werner Greenbaum, the other co-developer of the VAPC technique. Their joint comments follow.</p> <blockquote><p>No objection is raised to the use of hard, unlined sockets which have a flexible medioposterior corner. However, it should be emphasized that, if this portion of the socket is too flexible, it will not offer support and the weight-bearing effectiveness of the brace will be reduced.</p> <p>In courses of instruction on the PTB brace, it would be desirable to teach fabrication methods for both lined and unlined sockets. Clinics would then have the choice of using either method, thus creating a situation similar to current practice in the prescription of PTB prostheses.</p> <p>VAPC also employs a one-piece socket fabrication procedure, and the use of this method is endorsed by the Duke experimentation.</p> <p>The channels which are prepared in the socket for insertion of the sidebars result in a product which is cosmetically more acceptable than one with bars externally attached. Moreover, these channels are very necessary for alignment adjustability during the fitting procedures. They permit us to make minute height adjustments and to tilt the socket either medially or laterally. This adjustability is a most important feature, and we would not agree to its elimination.</p> <p>We think that, in general, detachable stirrups are contraindicated, although they might possibly be used on lightweight, inactive patients.</p> <p>Usually we do allow some ankle motion if warranted by the pathology. However, the weight-bearing characteristics of the brace are better maintained if only plantar flexion is allowed. When mechanical ankle-joint motion is not provided, SACH-heel and rocker-bar principles are applied.</p> </blockquote> <h4>Discussion And Conclusions</h4> <p>The clinical records of 27 patients fitted with the patellar-tendon-bearing brace through the Department of Prosthetics and Orthotics at Duke University were reviewed. A number of the patients in this series were interviewed and examined. From the data gathered, it appears incontrovertible that this type of brace has useful applications for a variety of below-knee problems.</p> <p>Two broad areas of application were noted:</p> <ol> <li>In instances where fractures or operative procedures were slow to heal, the brace was used as a means of mobilizing the patients more rapidly than might otherwise have been the case.</li><li>In cases of chronic pain in the leg, ankle, or foot arising from fractures, traumatic arthritis, and the like, the weight-bearing relief provided by the brace permitted patients to be ambulatory with considerably less pain and discomfort than was the case without the brace.</li></ol> <p>The review data indicated that the outcomes of the application of the brace were viewed very positively by the orthopedists, the orthotists, and the patients.</p> <p>The variations in fabrication and fitting procedures used at Durham as compared with those originally promulgated by VAPC are noteworthy:</p> <ol> <li>One-piece fabrication of the PTB-type socket or cuff without a liner appears to be a possible improvement over the original VA procedure.</li><li>The external attachment of sidebars appears somewhat less cosmetic than the original technique, but is probably somewhat simpler and faster to do.</li><li>Detachable stirrup-type upright applications showed some loosening tendencies.</li></ol> <p>In some cases, the provision of ankle motion in the brace undoubtedly eliminated the need for a SACH heel and a rocker bar, and resulted in less breakage of sidebars at the shoe attachment. However, the question as to whether some of these patients should have had rigid ankles with a SACH heel and/or rocker bar is unclear. The rule of thumb used at Duke appeared to be that, the closer the disability was to the ankle joint, the less motion had to be provided. However, as reported, all patients were given some degree of ankle motion.</p> <p>In conclusion, it would appear that the Duke application of the PTB brace was in general highly successful. Some of the changes made in the original VAPC procedures appeared to have definite merit.</p> <h3>Recommendations</h3> <p>Since the results of this study indicate that the VAPC PTB brace can be successfully and beneficially applied by unaffiliated treatment centers, thus corroborating the developer, it is recommended that: (1) the results of the study be broadly disseminated by publication in <i>Artificial Limbs </i>and by other means, (2) the prosthetics-orthotics schools be encouraged to include instruction in the PTB brace as part of the lower-extremity orthotics curriculum, and (3) the fabrication modifications introduced by the Duke University Department of Prosthetics and Orthotics be tried at VAPC, and that following these trials the two institutions collaborate on the production of a fabrication manual for the PTB brace which will incorporate the best procedures currently known.</p> <h3>Summary</h3> <p>In the late 1950s, a brace to unweight the leg was designed at the Veterans Administration Prosthetics Center (VAPC), New York, N.Y. This brace incorporated a lined plastic cuff essentially similar to the proximal portion of the patellar-tendon-bearing (PTB) prosthesis. By varying the tightness of this cuff and the lengths of the uprights connecting it to the shoe, the amount of body weight borne on the proximal shank could also be varied. By these mechanisms, the distal portions of the limb could be unweighted to the desired degree.</p> <p>The VAPC PTB brace was reported by the developer as having beneficial applications in cases of delayed or ununited fractures (tibia and fibula), painful ankles, and soft-tissue damage to the heel and the plantar aspect of the foot. It appeared potentially useful in any leg condition which produced pain on weight-bearing. Patients fitted by VAPC were reviewed by an independent agency (New York University) in 1963, and the developer's claims for the device were essentially substantiated.</p> <p>The present report presents the results of VAPC PTB brace fittings performed by two groups other than the developer. The clinical records of 36 patients were reviewed, and approximately one-third of the patients were examined and interviewed.</p> <p>The studies generally corroborated the positive findings previously reported by the developer. Wide dissemination of information concerning the VAPC item and its incorporation in orthotics instructional courses is recommended.</p> <h3>Acknowledgments</h3> <p>To all who participated in the various phases of the VAPC PTB brace evaluation study, we express our sincerest appreciation. To Chestley L. Yelton, M.D., Moody L. Smitherman, Jr., of Birmingham, Ala., and Bert R. Titus of Durham, N.C., we extend our special thanks for their extraordinary efforts in scheduling and reviewing patients and in providing the X-rays and pictures for this report.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Front, rear, and side views of PTB brace with earlier Durham bivalve socket lined with horsehide, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Front, rear, and side views of current Durham socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Medial, lateral, rear, and oblique views of socket with sidebars and shoe attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Current version of Durham modification fitted to patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</li> <li>McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</li> <li>McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 1959.</li> <li>Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 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>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 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>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 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>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 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>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 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>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 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>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-16.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-17.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-18.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-19.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-20.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-21.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-22.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-23.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 Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace Creator An entity primarily responsible for making the resource Hector W. Kay * https://staging.drfop.org/files/original/a6f72a14629b7806dcca3b174e3141dc.pdf 59d6595db93d81ef8929c3f4dac05b45 https://staging.drfop.org/files/original/90a87026994734a6ca6470b2110bb6cb.jpg 4b459bfe7868166c8ebfce729b080b79 https://staging.drfop.org/files/original/ef5dbe6f889849aa0064644747edf282.jpg 5b9bbfcfb4d77f3ff2fcd6ed5c8a1773 https://staging.drfop.org/files/original/d52c95869fe6d55ff552dd83c67c000c.jpg e09a2be085c93cad6c6099eee0d57d8f https://staging.drfop.org/files/original/3a77241eaf3995510f53411b3c346397.jpg b8f4051742685bfa4f3ea535cb826cac https://staging.drfop.org/files/original/51816043e9faf56d792b7228710319bb.jpg 3a6888379382529c2f6cdfab9d8a8bcb https://staging.drfop.org/files/original/22957bf7e72d6292125d2fb56abe1b8a.jpg 5fa81fef76fccc4f2a1bbc19d49c4e1b https://staging.drfop.org/files/original/14aae14f9431ce4eb09dfe905d0c906b.jpg 98caf1dd5d9ab89ad4631f844719cc23 https://staging.drfop.org/files/original/b9d22a554d95e70fadd9e859a74c569d.jpg 869fcfb814ec950a3cc1f7428854b5b9 https://staging.drfop.org/files/original/e84537af8c9d23e37d303e3e0ebb5e04.jpg 7d06dc402deaaa85101fcb82ce962d8f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_016.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 16 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_016.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_016.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of the CAPP Cart</h2> <h5>Barbara A. Gehant <br /></h5> <p>Recent studies of juvenile amputees in the United States and Canada have revealed a sizable number of severely handicapped limb-deficient children. Fortunately, many of these amputees have been fitted with prostheses that enable them to perform skills necessary for daily activities. The quadrimembral amputee, however, presents particularly serious problems. While he may achieve considerable arm function with one or two upper-limb devices, the leg loss may not be adequately compensated for, especially in high-level amputees, and locomotion remains at best an exercise. In an effort to solve the problem of mobility for the most severely handicapped children, the Child Amputee Prosthetics Project at UCLA developed an electric cart. This article presents a study that was designed to determine the extent to which the CAPP cart assists children with quadrimembral deficiencies to achieve independent mobility.</p> <p>The CAPP cart (<b>Fig. 1</b>) is 17 in. wide and 23 in. long, and consists of a seat mounted on a chassis. In the driving position, the seat is 18 in. from the floor. The seat can be raised to 27 in. to enable the child to sit at a table or to transfer to a standard chair or bed. The cart, powered by a 12-volt battery, travels at a constant speed of 1 1/2 mph. It is guided by a lever that is controlled by the chin, and which operates on a "joy-stick" principle. The control arm can be swung to the side to facilitate transfer or activities at a table or desk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The CAPP cart. Power is provided by a 12-v battery; direction is controlled by the chin-operated lever. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sample</h3> <p>Since the cart was designed for the child with quadrimembral deficiencies, priority consideration was given to such candidates. The children were selected on the basis of the number of limb deficiencies and the degree of limitation. Eleven children from ten clinics participated in the study (<b>Table 1</b>). A twelfth child was provided with a cart (see Appendix) but not included in the sample, because this clinic already had two subjects represented in the study; additional data from the same reporters might have biased the study.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The sample included four boys and seven girls, six to fourteen years of age. Their weights ranged from 20 to 74 lb; the average weight was 30 lb. Trunk measurements were taken of each child from the bottom of the buttocks to the crown of the head. Sitting height averaged 25 in. and ranged from 20 to 32 in.</p> <p><b>Table 2</b> shows the skeletal deficiencies and prosthetic fittings for the eleven children. Of the five children with bilateral proximal femoral focal deficiencies (PFFD), two had not been fitted with lower-limb prostheses. One child ambulated with a lateral-sway walker, one wore below-knee orthoses bilaterally, and one wore a "brace-prosthesis" on the left and a socket, pylon, and SACH-foot prosthesis on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Four children had bilateral amelias. One wore hip-disarticulation prostheses with the knees locked, two used lateral-sway walkers, and the fourth child had not been fitted with any prostheses.</p> <p>One child had a very short below-knee stump on the right, and a knee disarticulation on the left; the last child had a fusion of the right knee and a left knee contracture. Neither had been fitted with prostheses.</p> <p>Again referring to <b>Table 2</b>, two children had bilateral upper-limb phocomelia, and neither had ever been fitted with arm prostheses.</p> <p>Of the two children with bilateral amelia, one wore two conventional shoulder-disarticulation prostheses, and the other had been fitted unilaterally, alternating between an experimental Michigan feeder arm and a conventional shoulder-disarticulation prosthesis.</p> <p>Of the four children with bilateral hemi-melia, three wore conventional above-elbow prostheses, and the fourth was fitted bilaterally with elbow-disarticulation prostheses.</p> <p>Three children had a combination of right amelia and left hemimelia. One wore a Michigan feeder arm on the left only, another wore a conventional shoulder- disarticulation prosthesis on the amelic side and an above-elbow prosthesis contralaterally, and the third had not been fitted with any prostheses.</p> <p>Three of the children were scoliotic, and three had skeletal problems involving the mouth. One child had bilateral hip dislocations; another had sacral agenesis, with associated loss of muscular mass in the lower extremities and bowel and bladder incontinence. Other abnormalities included hearing and visual deficiencies, and one child had an unspecified neuromuscular disorder manifested by generalized weakness.</p> <p>Five children alternated between the use of wheelchairs pushed by others or walked with their prostheses. Two children either were pushed in a wheelchair or carried by adults. Two were able to push themselves in regular wheelchairs, and one child used an electric wheelchair. One child used an adapted cart that had been constructed by his father.</p> <p>Six children lived in homes with steps at the outside entrance. The families of five of the children had ramps built to accommodate the CAPP cart. The sixth child lived in a two-story house, but used the cart only at school. Five children lived in homes with no stairs either outside or inside the building.</p> <p>All the children were of school age. Six attended special schools for the handicapped, and four attended regular classes in public schools. One child received private tutoring at home.</p> <h3>Procedure</h3> <p>The study was conducted over a six-month period, with evaluations performed at the clinics on three occasions. The results were submitted to New York University. Each clinic was responsible for the routine maintenance of the cart, with major repairs or adjustment that required disassembly of the cart being referred to NYU.</p> <p>The characteristics of each child, his physical and environmental conditions, and his prosthetic experience were recorded on the Selection Forms, which were returned to NYU.</p> <p>A representative of the New York University research staff was present when each cart was delivered and described the study to the child, parents, and clinic team. The training instructions and evaluation forms were discussed with the clinic therapist, and the maintenance instructions with the parents and the prosthetist.</p> <p>The child operated the cart under supervision until the clinic members felt that the child could drive it independently with safety. At the end of the training period, the therapist completed the Training Evaluation Form.</p> <p>The child returned to the clinic after he had used the cart for three months. The therapist, in consultation with the child's parents, evaluated the cart in terms of design, safety factors, and function, and recorded the information on the appropriate form. A maintenance check was made, and any necessary repairs and adjustments were also recorded.</p> <p>The child returned again to the clinic with the cart after six months. The clinic personnel recorded suggestions for improvements in the cart, the child was questioned as to his overall reactions to the cart, and all maintenance problems were recorded. The child's parents and teachers completed forms in which they described their reactions to the cart in terms of suggestions for cart modifications.</p> <h3>Results</h3> <p>Ten of the eleven children who participated in the study preferred the CAPP cart to other modes of transportation. Their parents were equally enthusiastic about the cart. The child who ultimately rejected the cart had a personality problem from the beginning; a strong mutual dependence between the child and her father was threatened by the increased independence offered her by the CAPP cart.</p> <p>The features of the cart that were most appreciated by both the parents and the children were the increased independence and mobility it provided. The main objection voiced by the parents was the weight of the cart. <b>Table 3</b> lists the features the children and parents liked best and least about the cart.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Operational Skills</h4> <p>As seen in <b>Table 4</b>, most of the children learned to control the cart with relative ease. The average training time was 5 1/2 hours. The oldest child (14 years) learned to operate the cart in 1/2 hour, while the youngest (6 years) required 14 hours of instruction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training items were divided into ' 'starting and stopping," "driving," and "turning". The children were asked to start and stop smoothly while driving forward and backward. Most of the children learned this with little difficulty; four learned with no formal training.</p> <p>The driving test consisted of moving forward and backward in a straight line and on a diagonal, crossing doorsills, and changing direction on command. The children learned to ascend and descend inclines of 10 degrees, to avoid obstacles, and to drive through a "slalom" course.</p> <p>Finally, the children were taught to turn the cart on its base, using a rear wheel as a pivot, 90 degrees forward and backward. Three children required no training to perform these tasks, and all of the children learned to perform all activities independently.</p> <p>Two of the younger children began training programs using cars with six-volt batteries because the speed of the cart with the larger battery frightened them at first. After training, they found the cart too slow, and the original twelve-volt batteries were reinstalled.</p> <p>Seven children considered driving backward the most difficult operation to learn. Other areas of difficulty mentioned by the subjects were the delicate control required in confined areas, and turning.</p> <p>Three children lost their balance while learning to operate the cart. One child lost his balance while turning and driving backwards and two, when they changed directions rapidly on a level surface. However, none of them lost sufficient balance to fall from the cart during the training period.</p> <p>Six children damaged property while learning to drive the cart: scraping walls, door frames, or furniture. One child scratched the family car; another, through continued reckless driving, endangered other persons who were in his way.</p> <h4>Safety</h4> <p>Five children wore safety belts while driving the cart.</p> <p>One child fell from the cart while at school. She was not wearing a safety belt, because it restricted her movements while in, and transferring in and out of, the cart. She had swung the control arm away while leaving the battery connected to the motor, and a classmate accidently touched the drive control, which sent the cart forward and caused the child to fall from the cart. Although the child was not injured, the episode dramatized the need for additional safety features.</p> <h4>Extent of Use</h4> <p><b>Table 5</b> shows the extent of cart usage. On the average school day, four children were in the cart at least 75% of their waking hours, three children utilized it between 40 and 70% of the day, and four children less than 10% of the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On weekends, two children used the cart more than 75% of the time; two children, 25 to 30%; and seven children, less than 25% of the day.</p> <p>In considering where the cart was used primarily, we found that four children used it both at home and at school; five, only in the home; and two, only at school. The principle reason for using the cart in only one location was its excessive weight, which made transportation difficult. Nine people commented on this problem. Those who used the cart only at home considered the danger of driving a cart with such sensitive controls too great to permit unsupervised use. Two clinics stated they were unable to rely on school personnel to pro- vide daily care for the cart, such as charging and filling the battery and reporting breakdowns.</p> <p>As shown in <b>Table 6</b>, most children were independent in such activities as driving through a 24-inch doorway, entering and leaving an elevator, approaching objects, and adjusting the seat height. The children with upper-extremity amelia and phoco-melia continued to require assistance for activities involving reaching, such as pushing elevator buttons and opening and closing cupboards and drawers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The majority of the children were independent in transfer activities (<b>Table 7</b>), e.g., cart to bed, toilet, or chair. The most troublesome transfer activities involved the toilet; presumably, these difficulties arose because of the narrowness of many bathroom doors and the lack of removable armrests on the cart.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After three months of use, most reporters noted a general improvement in driving and maneuvering skills.</p> <h4>Advantages And Disadvantages</h4> <p>Seven clinics reported that the greatest functional advantage of the cart was the adjustable seat (<b>Table 8</b>). Other assets reported were the increased maneuverability, easy control, the movable control arm that facilitated transfers, and the stability of the cart. The greatest disadvantages were the lack of an "on-off" switch, and insufficient ground clearance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Six children depended less on adult help while in the CAPP cart; four reported no change in the amount of adult help required; no information was available for the eleventh child. Nine parents reported that their children required less lifting; however, one child required more lifting. Before the arrival of the cart, this girl spent most of her time on the floor, where things had been built to accommodate her. Since she was unable to transfer in and out of the cart from the floor, she had to be lifted each time.</p> <p>One child was unable to use his prosthesis while in the cart, because the control arm was on the same side and interfered with its use. Most of the children felt that the chin control was not the optimal control site, and they preferred to use their arm stumps. Two therapists suggested that, if the control arm were placed to the side, a child could control the cart more efficiently with his stump. One therapist objected to the chin control because she feared damage to the child's lower jaw while driving the cart over rough terrain, although there was no report that this occurred. It was suggested that, if the control arm were relocated, a child could maintain a more normal sitting posture and turn his head for driving, and the control arm would not hinder activities at a desk.</p> <h4>Cart Maintenance</h4> <p>The twelve-volt battery required recharging every 24 hours. The batteries normally were charged overnight, and none needed replacement during the test period. Filling the battery with water was a considerable problem for parents because of the small storage space in the cart, which made battery-removal difficult.</p> <p>Most maintenance problems concerned the rear wheels and switches; five carts required wheel replacements. The rear wheels attach to the gear box and receive the power to drive the cart. Since they do not swivel as the front wheels do when the cart turns, a torque is applied. These wheels, which were commercially available as wheelchair casters, were not designed for this amount of force and broke as a consequence of the torque overload.</p> <p>All the carts required replacement of the switches in the control mechanism. The original switches were not the model ordered, but, for reasons of expediency (low cost and commercial availability), they were installed in the carts. When it became apparent that these were unsatisfactory, they were replaced with the model originally ordered, and the problems were eliminated.</p> <h3>Conclusions</h3> <p>With one exception, all the children and their parents were very enthusiastic about the CAPP cart and preferred it to other modes of transportation. It provided increased independence to ten of eleven children with quadrimembral deficiencies.</p> <p>Training did not present a problem, even for the youngest child; however, consideration should be given to introducing the very young or apprehensive child to the cart with a six-volt battery. Since the cart is very stable, most driving hazards arose because of recklessness or poor driving skills. Perhaps greater care should be directed toward predriving instructions, and the children should be given more opportunity to practice driving skills under supervision. It must be remembered, however, that children tend to be less responsible and less coordinated than adults, and more accidents are to be expected from them.</p> <p>The CAPP cart afforded the children more independence in terms of mobility and endurance. Hemimelic children were able to perform many activities, such as opening and closing cupboards and drawers, as a result of the adjustable seat, which allowed them to approach objects more closely and normally.</p> <h4>Design Considerations</h4> <p>Although a number of clinics suggested the inclusion of a seat belt, this would tend to restrict a child's independence if he were able to transfer in and out of the cart without assistance, since most arm amputees would be unable to manipulate the belt independently. Seat belts are readily available or easily devised, and the application of a belt might best be left to the discretion of the clinic or the child's parents. Another suggestion was the incorporation of an "on-off" switch that could be controlled by the child, or a switch that would automatically cut the power when the control arm is swung to the side.</p> <p>Although the present velocity of the cart is satisfactory for forward maneuvers, it is clearly too fast for driving backwards or for delicate control. Consequently, consideration should be given to including a variable speed-control mechanism.</p> <p>Although wheelchair casters are commercially available and relatively inexpensive, they are not designed to absorb the high torque forces that are applied to the rear wheels of the CAPP cart. Stronger drive wheels would probably have prevented many of the mechanical breakdowns that occurred. Consideration should also be given to including pneumatic tires, which provide greater traction and more comfort.</p> <p>Since most of the children preferred to control the cart with their arm stumps, consideration should be given to placing the control arm to one side, close to the shoulder or stump. This would also avoid interference with use of an upper-limb prosthesis. A second possibility, particularly for the upper-limb amelic child, is to lower the control arm to the level of the chair seat, which would allow the child to control the cart with his foot or leg stump while enabling him to sit straight and to turn his head freely.</p> <p><i>Note: </i>As a result of the findings of the evaluation study, a new control box was developed that incorporates a variable-speed mechanism, and an "on-off" switch that can be controlled by the child. All carts have been recalled to UCLA, where a detailed analysis is also being conducted of the effect of use on the mechanical segments of the cart. The new control mechanism and a set of stronger wheels have been installed, and the carts were returned to the children for continued use. Each clinic will provide any further training required to operate the cart with the new control system. After six to eight weeks of additional use by the child, the clinic and the children will be asked to record their reactions to the modified cart.</p> <h3>Recommendation</h3> <p>On the basis of the results of the clinical evaluation of this item, and the design modifications implemented by the developer, it is recommended that the CAPP cart be made available to all limb-deficient children for whom conventional methods of transportation are unsatisfactory.</p> <h3>Appendix</h3> <p>J. T. was an eight-year-old girl with bilateral upper-limb amelia and lower-limb terminal-transverse hemimelia (A/K type). Initially, the control arm on the cart was lowered to the seat level to allow her to operate it with her leg stump. She did not wear lower-extremity prostheses while she was in the cart.</p> <p>This child learned to operate the cart in approximately 2 1/2 hours; driving backwards and turning were the most difficult tasks for her to learn. As with the other amelic children, she was able to move about independently, but she continued to be totally dependent in activities involving the arms.</p> <p>She used the cart for the entire school day, but she did not use it at home because her parents found that its weight made transporting the cart very difficult.</p> <p>Both the child and her parents found that the cart was too slow for her to keep up with the other children. The child's other reactions were similar to those of the other children; that is, she liked the adjustable seat and the increased independence, but disliked the lack of an "on-off" switch and of sufficient ground clearance. Her teacher reported that the cart often became stuck in the school yard because of insufficient clearance.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-19.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-20.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-21.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-22.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-24.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-25.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-26.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_016/ArtificialLimbs-Autumn1971-27.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 Evaluation of the CAPP Cart Creator An entity primarily responsible for making the resource Barbara A. Gehant  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. 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During the contraction of the muscles involved in this activity, chemical energy is converted first into mechanical energy, then into work and heat. Some of this chemical energy is required for maintenance of body functions. In movement, however, much of the mechanical energy is required to overcome friction and tissue displacement at the joints, gravity, inertial forces, air and water resistance—all of which oppose the action desired.</p> <p>Biomechanics is the science that is concerned with such effects. In order to understand better the biomechanics of movement, it is necessary to know certain characteristics of the segments involved. Among these characteristics are the mass of the segments, their centers of mass, and their mass moments of inertia. The characteristics (body parameters) themselves are not readily obtained on living subjects.</p> <p>It was the purpose of two studies conducted at the New York University School of Engineering and Science to obtain some of these body parameters. The first of these studies, <a></a> completed in 1966, was conducted on normal, healthy American males in the age range of 20-40 years. The second study, <a></a> completed in 1970, was conducted on a random selection of adults, young males and females 20-30 years of age, some females in the 40-50 age bracket, and a number of amputees and hemiplegics, male and female, in all age ranges.</p> <p>A history, survey of measurement techniques, and data developed over the years was given in "Body Segment Parameters: A Survey of Measurement Techniques," which appeared in <i>Artificial Limbs, </i>Spring 1964. <a></a> Also, a condensation of four of the most important monographs in this field ("Center of Gravity of the Human Body" by W. Braune and O. Fischer; "Theoretical Fundamentals for a Mechanics of Living Bodies" by O. Fischer; "The Human Motor" by J. Amar; and "Space Requirements of the Seated Operator" by W. T. Dempster) has been prepared by Krogman and Johnston <a></a> under the sponsorship of the United States Air Force.</p> <h3>Methods</h3> <p>Most studies undertaken previously used cadavers, but in a few studies, including those at New York University, living subjects were used. Although some available measuring techniques for compiling the data are similar for live subjects and for cadavers, other techniques must obviously differ. In general, the techniques covered here are for living subjects; thus, all techniques used on dissected cadavers are not included. When living subjects are used, particularly the elderly and those suffering with some affliction or disability, any technique utilized must be at the convenience of the subject. Some subjects cannot comfortably assume the necessary postures during the measurement processes, while for some others the procedures are physically impossible. As a result, not all measurements can be taken on all subjects, but, because of the various techniques available, most of the desired data can be obtained.</p> <p>The techniques are only briefly presented here because more adequate descriptions are available in other references.</p> <h4>Volume Determination</h4> <p>The body and all of its segments are irregular solids. The volume of an irregular solid may be obtained or approximated in a number of ways: by mensuration, immersion, or photogrammetry. Only the first two were used in both studies.</p> <p><i>Mensuration</i></p> <p>A relatively good approximation of body-segment volume can be obtained by using circumferential measurements at certain selected stations on the segment and the linear dimensions between any two consecutive circumferential measurements. If all these measurements are known for the full length of the segment, then an approximate volume can be determined. Accuracy will increase with the increased number of such measurements. This technique assumes that any two successive cross sections of the member are parallel and essentially similar geometrically. In that event, the volume contained within the two cross sections may be expressed as: <b>Equation 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is obviously impossible to obtain cross-sectional areas on the body segments of living subjects. If it is assumed, however, that the cross sections of the limbs are elliptical, it is possible to establish a relationship between the cross-sectional area and the perimeter at any chosen level. For any segmental portion between two levels, the volume may now be expressed as: <b>Equation 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a total limb divided into n segments, each <i>h </i>distance apart: <b>Equation 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The derivation of this equation is given in reference. <a></a></p> <p><i>Immersion</i></p> <p>In this method, the segment whose volume is to be determined is immersed in water. Incremental volumes are taken of the segment whose total volume then is the sum of these increments. For these studies, four tanks were specially designed: an arm tank, a hand tank, a leg tank, and a foot tank. Each tank was constructed of Plexiglas, the first three cylindrical in cross section, and the last, rectangular.</p> <p>The limb or body segment was completely immersed in the tank. Water was permitted to drain off in controlled increments, each representing a known change in cylinder height. Drained water was collected and measured. The difference in volume between that collected and that obtainable without the body segment in place (the actual volume of the tank for that increment) represents the volume of the body segment contained within the height increment. Whenever possible, these increments were 2.0 cm apart, but, if subjects with limited physical tolerance had minimal cross-sectional variation, the increments were increased to every 4.0 cm apart.</p> <p><i>Photogrammetry</i></p> <p>Two types of photogrammetric techniques are available-mono and stereo. In the former, lines or colored shadows are projected on the subject in such fashion as to produce a contour map on the particular segment of interest. The areas contained within these contours may be measured with a planimeter, and the same general equation for determining the volume as given previously may be used. Again, the sum of all the incremental volumes of the segment represents its total volume.</p> <p>In stereophotogrammetry, two cameras are used side by side to create an illusion of depth when the two photographs are juxtaposed. The resulting picture is treated as an aerial photograph of terrain upon which contour levels are applied. These then are treated as in monophoto-grammetry.</p> <h4>Density Determination</h4> <p>To obtain the overall body density of living subjects is extremely difficult. To obtain the density of individual segments on living subjects is virtually impossible. There are ways, however, to obtain fairly accurate values. The problems involved will not be discussed here; some of them are described in the two referenced reports. <a></a></p> <p><i>Empirical (Whole Body)</i></p> <p>Whole-body volume may be approximated in several ways. The mass may be obtained by weighing accurately. The density is the ratio of mass to volume. For lean bodies, the density is higher than for fat bodies. One provisional formula for determining density, developed by Dupertuis in 1950, <a></a> makes use of Sheldon's somatotyping system <a></a> and introduces the first component (x) of the system into the equation:<br /><i>d(ensity) =</i> 1.094 - 0.0119x</p> <p>A second equation developed by the Biomechanics Group at NYU, using data developed by Behnke, <a></a> is based on the height <i>(H) </i>in inches, and weight <i>(W) </i>in pounds of the individual (<b>Fig. 1</b> and <b>Fig. 2</b>): <b>Equation 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Anthropometric (Whole Body)</i></p> <p>Many studies have established the reasonably close relationship between body fat and certain skin-fold thicknesses. <a></a> The equations used for the NYU study were those developed by Pascale. <a></a></p> <p>The first depends on the measurement of the skin-fold thickness at the triceps:</p> <p><i>d(ensity) </i>= 1.0923 - 0.0202(S_t) x 10^-1</p> <p>The second depends on the measurement of the skin-fold thickness at the scapula:</p> <p><i>d</i> = 1.0896 - 0.0179(S_s) x 10^-1</p> <p><i>Mensuration (Whole Body)</i></p> <p>Skerlj in 1954 <i>(13) </i>developed a method for determining whole-body volume. He measured 10 circumferential dimensions and 6 linear dimensions (<b>Fig. 3</b>). From these he developed a formula that gives an approximate value for whole-body volume.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Linear measurements: measurements for body-volume determination (after Skerlj). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The NYU group presented <a></a> a modified equation using the Skerlj notation and included some correction factors derived by applying the equation to five subjects for whom the volume of the various body segments was known. The modified formula is: <b>Equation 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the volume so determined, the mass may be obtained by direct weighing and the overall (whole body) density may be obtained: <i>d(ensity) = M(ass) /V(olume)</i></p> <p><i>Empirical (Body Segments)</i></p> <p>Until recently, very little work has been done to establish segment densities. Harless <a></a> conducted some studies with cadavers, as did Dempster. <a></a> At NYU, in the first of the two studies, the mass of certain body segments was established by the reaction-board method, which is described below.</p> <p>Based on these studies, two graphs were developed that relate whole-body density to body-segment density (<b>Fig. 4</b> and <b>Fig. 5</b>). These are approximations only, since no exact data are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Mass Determination</h4> <p>In studies conducted with cadavers, weight and eventually mass are obtained directly by accurate weighing techniques applied to the total segment or to its increments. In studies with live subjects, this cannot be done. The reaction-board method may be used.</p> <p><i>Reaction-Board Method</i></p> <p>This method is dependent on the validity of two assumptions. The first is that the center of mass can be established if the center of volume is known. This is true only if the density of the segment is constant along its entire length. The studies conducted by the Aerospace Medical Research Laboratory showed that the density is not constant along the segment and the variation in density is not the same for all segments.</p> <p>The second assumption is that the rotation of a segment occurs about a single axis. If this were so, in the movement of a segment the centers of mass of all other body segments would remain fixed relative to the center of rotation. Since no body joint is uniaxial, and since the muscle masses shift in the course of any movement, this also is not quite correct.</p> <p>Nonetheless, the method has been used (<b>Fig. 6</b>). For the purpose, a board or platform is supported on two knife edges- one on a fixed base, the other on the platform of a weighing scale. The subject is. placed on the board in a position that can be maintained or reproduced if necessary. A reading is taken on the scale. The subject is then asked to flex the segment of interest (forearm, arm, etc.) through a given angle-usually 45 deg., 90 deg., or 135 deg. A new reading is taken. The mass of the segment can then be determined substituting the appropriate readings in the formula: <b>Equation 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Determination of the arm mass (reaction-board method). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Empirical</i></p> <p>For body segments the mass may be determined if the volume and density have been established. The mass, of course, is the product of the volume of the segment and the density of the segment. <i>M_s = V_sd_s</i></p> <h4>Center-of-mass Determination</h4> <p>The center of mass of the whole body may be determined readily by several methods since the mass is readily obtainable. The center of mass of a body segment on a live individual is not easily obtained, but may be approximated by one of several techniques.</p> <p><i>Volumetric Approximation</i></p> <p>A number of researchers, the NYU group included, have assumed that the density along the segment is constant and thus have concluded that the center of mass is coincident with the center of volume. Under this assumption, the center of volume, hence the center of mass, is found in the following way:</p> <p>A base line is established, usually the proximal joint of the segment. This segment is divided into a number of increments for which the volume is obtained by one of several methods (<i>V1, V2, V3</i>,..., <i>Vn). </i>The distance to the center of volume is measured from the base line (<i>d1, d2, d3, . . ., dn</i>).</p> <p>The center of volume is determined by dividing the sum of the products of each volume times its distance from the base line, by the sum of the volumes. <b>Equation 7</b>, <b>Equation 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Reaction-Board Method</i></p> <p>With cadavers, segments, or with plaster models of body segments, the center of mass may be obtained by use of the reaction board, previously described.</p> <p>Of these techniques, the one using the cadaver segment and the reaction board is the most accurate; the true center will vary in this technique only by the change that has occurred in the body tissues after death. Use of the plaster-of-paris cast creates the same error as that obtained by use of the volumetric technique; i.e., the error is introduced because it is assumed that the density along the segment is constant, whereas the density in any segment usually increases from the proximal to the distal end. This occurs because the ratio of bone to muscle and fat increases distally.</p> <h4>Segment Mass Moment Of Inertia</h4> <p>The motions of body segments are essentially rotatory, and linear movement is the result of a number of coordinated rotatory motions. The motion is assumed to occur about a fixed axis that is perpendicular to the plane in which the motion occurs. It is assumed that frictional and inertial forces occur in the plane of rotation. Rotation can be caused by a force at some distance from the axis of rotation, or by a force couple. In rotation, an inertial force resists angular acceleration which acts at the center of mass resulting in an inertial moment. This mass moment of inertia depends on the size, shape, and mass distribution of the body.</p> <p>The mass moment of inertia may be determined in several ways.</p> <p><i>Empirical</i></p> <p>The mass moment of inertia of a body with respect to a given axis of rotation is the sum of the products of the mass increments <i>mi </i>(into which the total mass may be divided) by the square of their respective distances from the particular axis of rotation: <b>Equation 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Quick Release</i></p> <p>If a force <i>(F) </i>is applied to a segment at some distance <i>(d) </i>from the axis of rotation of the segment, it will be imparted at an angular acceleration (a) in accordance with the equation: <i>Fd = Ia</i></p> <p>Because of this relationship, it is possible to determine the mass moment of inertia (<i>I</i>) experimentally by this quick-release method.</p> <p>In this method, the body segment of interest is arranged so that it may be free to swing about the proximal joint, which in turn is restrained from motion. At some distance (<i>d</i>) from the axis of rotation, a cable is attached to the segment such that it will prevent rotation in one direction. The other end of the cable is attached to a spring restraint, which in turn is attached to a force-measuring device. The subject is instructed to pull against the spring with a force <i>(F), </i>which is recorded. The cable is cut suddenly and the segment accelerates with an acceleration <i>(a) </i>that is appropriately recorded. By substitution of the known values <i>F, d, a, </i>the mass moment of inertia <i>(I) </i>can be obtained. <i>I</i> = Fd/<i>a</i></p> <p><i>Pendulum</i></p> <p>The period of a pendulum is related to the mass moment of inertia of the pendulum. For a simple pendulum, i.e., one where the mass is concentrated at some distance from the center of oscillation, the relationship is expressed by the equation: <b>Equation 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This method utilizes plaster casts of body segments or the severed cadaver segments. The segment or its counterpart is suspended at one point near the end of the segment. It is permitted to swing through an arc of limited magnitude. The period of oscillation is obtained by some appropriate instrumentation. The values that are obtained are substituted in the above equation.</p> <h3>Results</h3> <p>Results are given for tests conducted both in the first and second series of experiments. In the first series of tests, data were collected on 12 male subjects in the age range of 20-40 years. In the second series of tests, data were collected on 9 male subjects in the age range of 20-30 years, 5 female subjects ages 17-20 years, and 3 female subjects ages 40-50 years, all without disabilities. Data were also recorded on 19 additional subjects with either hemiplegia or an amputation. In the second series of tests, not all data were recorded for every subject. The following tables contain the most valid data acquired.</p> <h4>VOLUMES</h4> <p><b>Table 1</b> contains the volume of body segments recorded during the first series of tests. There is only one major difference between the two series on males. In the first series, the value for volume of the upper arm—and hence the value for the whole arm—included the shoulder cap, i.e., the volume from the axilla to the acromion process. In the second series (<b>Table 2</b>), the values of volumes for the upper and whole arm are only up to the axilla. On the basis of the mean values for the upper arm in the two series, the volume of the shoulder cap is approximately 36% of the whole upper arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the second series of tests, a limited number of shoulder caps were cut off from the plaster-of-paris arms at the level of the axilla. Their dimensions, circumference at the axilla (c), and height to the acromion process <i>(h) </i>were taken. The volumes were obtained by immersion.</p> <p>An approximate equation for determining the volume of the shoulder cap was then established: <i>Volume </i>(shoulder cap) = 0.0526 <i>hc</i>²</p> <p>This equation is approximate to + 20% of the true value.</p> <p>In all other respects, the two series of tests give comparable results. The differences in mean values are of the order of 1%-10%. Considering the limited numbers of subjects, 12 and 8 in the respective samples, the differences are not serious, and the mean values are useful in general computations. Of interest in the second series of tests is the close relationship between mean values for right-hand and left-hand volumes. The variation between means in most instances is less than the variation between the volume of right and left segments in any subject.</p> <p><b>Table 3</b> indicates similar values for female subjects. There was greater inter-subject variation in this population than in that for the males. In view of this, and because there was such a limited number of subjects both in the younger and older age groups, the values for the two groups were combined. Even so, these mean values may be less accurate than those for the male population. They are presented, however, because few other similar data are available.</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>The body-segment volume may be expressed as a ratio or percentage of the whole-body volume. If it is desired to estimate body-segment volume, it is better to do so on the basis of the segment volume as a percentage of whole-body volume. This probably will give a more accurate result than using an average value for the volume of body segment.</p> <p><b>Table 4</b> gives such values for the first series of males. <b>Table 5</b> gives similar values for the second series of males, and <b>Table 6</b> gives these values for females.</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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Densities</h4> <p>As mentioned previously, it is very difficult to determine densities accurately. In <b>Table 7</b>, the densities have been determined by the equations shown in the section III-B for males first series. The densities for both males and females, second series, have been determined by dividing the mass (weight) by the volumes derived by using the NYU and Skerlj formulas and by using Pascale's equations A and B and skin-fold thicknesses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Center Of Volume</h4> <p>In the absence of satisfactory techniques for determining the center of mass, it has been assumed to be coincident with the center of volume. <b>Table 8</b> shows the location of mass centers (volume centers) obtained by various researchers. Some studies conducted on cadavers are probably more truly mass centers. Others, conducted on live subjects, are probably the centers of volume.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 9</b> has been prepared to provide information as to the location of the center of volume of the various body segments, measured from the proximal joint. Again, it should be noted that the values for the upper arm are measured from the axilla. In both <b>Table 8</b> and <b>Table 9</b>, the value indicated is in percent of the segment length.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A study was conducted on seven above-knee amputees. There was considerable variation in the length and contour of the stumps, although all of them could be described as modified truncated cones. The average distance from the crotch, measured downward and expressed as a percentage of the total stump length, was 32.1%, with an upper limit of 44.0% and a lower limit of 23.0%. The standard deviation was + 6.4%.</p> <h4>Radius Of Gyration</h4> <p>The radius of gyration (p) is a distance measured from the true center of mass to a point within the mass at which, if all the mass were concentrated, its effect in rotatory movements would be similar to the effect of the mass as it is actually distributed. For geometrically similar shapes, the radius of gyration along a particular axis may be expressed as a percentage of the length of that shape along that axis.</p> <p>It has been assumed that every body segment-arm, leg, upper arm, forearm- for one subject is geometrically similar to that of any other subject. If it were so, then the radius of gyration expressed in percentage of the length <i>(p/L) </i>should be relatively constant. It was found to be so, with minor variations. The values of <i>p/L </i>for the various body segments obtained by previous researchers and in the first NYU study are given in <b>Table 10</b>. Values for the second NYU study are given in <b>Table 11</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 12</b> has been included as a guide against which the computed values of <i>p </i>may be compared. This table indicates the average values of <i>p </i>(the radius of gyration) for the populations included in the second series of NYU studies; not all values were determined for each category, and the table reflects this. The results were computed on the basis of tests and measurements were made as previously described.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>The data may be used in a number of ways. Consideration must be given to the nature of the problem for which a solution is sought and the accuracy desired. If a situation exists where a prosthesis or orthosis is desired for a specified individual, it would be best to obtain data directly on the individual. In such a case, judgment should be made as to which of the various techniques available would be adapted best to the set of conditions present, i.e., the condition of the subject, the skills of available personnel, and the facilities available.</p> <p>When extreme accuracy is not required, or in cases when the problem is confined to a class of individuals, or the solution may have a general application, the data may be used in various ways, with differing degrees of accuracy. In successively decreasing order of accuracy, the following maybe done:</p> <ol> <li>Obtain the weight and height of the subject and length and circumferences of the segments under consideration; use tables and graphs judiciously and, where several sets of data are available, use the most appropriate.</li><li>Obtain weight and height of the subject only and use tables as suggested.</li><li>Obtain weight and height of subject and use average data only. Data may be used for determining the length of a segment, its volume, mass, center of volume, center of mass, radius of gyration, and moment of inertia.</li></ol> <h4>Sample Computation</h4> <p>To determine the mass moment of inertia of the upper arm, forearm, and hand for a male patient (possibly for application of an externally powered orthosis), only the height and weight of the subject need be known.</p> <p><i>Procedure</i></p> <p>If the subject weights 190 pounds and is 73 inches in height:</p> <ol> <li>On graph (<b>Fig. 1</b>), join the weight in pounds (190) to the height in inches (73) by a straight line. At the intercept of this line with line c a value for c, approximately 12.8, is obtained.</li><li>On graph (<b>Fig. 2</b>), locate c = 12.8, proceed vertically upward to intersect solid black line, then proceed horizontally from this point to determine the value of whole-body density <i>d: d = </i>66.8 pounds per cubic foot</li><li>On graph (<b>Fig. 4</b>), proceed as in, <a></a> from <i>d = </i>66.8 vertically downward to intersect lines of segment densities:<br /><i>d, </i>upper arm = 68.1 lb/ft^3<br /><i>d, </i>forearm = 70.7 lb/ft³<br /><i>d, </i>hand = 72.2 lb/ft³</li><li>Given the weight of 190 pounds and whole-body density of 66.8 pounds per cubic foot, we may compute whole-body volume: 190/66.8 = 2.85 cubic feet</li><li><b>Table 4</b> gives values of volume for body segments in percentage of whole-body volume:<br />volume, upper arm = 3.495 x 0.01 x 2.85 = 0.0995 ft^3<br />volume, forearm = 1.70 x 0.01 x 2.85 = 0.0485 ft³ volume, hand = 0.566 x 0.01 x 2.85 = 0.0161 ft³</li><li>Multiplying the volumes of the segments by their respective densities, the mass (or weights) of the segments are obtained:<br /><i>m (w), </i>upper arm = 0.0995 x 68.1 = 6.78 lb<br /><i>m (w), </i>forearm = 0.0485 x 70.7 = 3.43<br />lb <i>m (w), </i>hand = 0.0161 x 72.2 = 1.16 lb</li><li>To obtain the approximate lengths of the body segments when they have not been measured, <b>Fig. 7</b> and <b>Fig. 8</b> may be used. The mean lengths expressed in terms of body height are 0.189<i>H</i>, 0.145<i>H</i> and 0.128<i>H</i> for the upper arm, forearm, and hand respectively. The lengths then are:<br /><i>Lv </i>= 0.189 x 73 = 13.8 in.<br />L<i>f </i>= 0.145 x 73 = 10.6 in.<br />L<i>h</i> = 0.128 x 73 = 9.35 in.</li><li>Having obtained the lengths of the segments, the location of the center of volume (mass) can be determined using values given in <b>Table 8</b> and <b>Table 9</b>: <br />c, upper arm = 0.461 x 13.8 = 6.37 in.<br />c, forearm and hand = 0.420 (10.6 + 9.35) = 8.38 in.</li><li>The radius of gyration (p) for the segments may be obtained using the values in <b>Table 10</b> or <b>Table 11</b>:<br /><i>p, </i>upper arm = 0.268 x 13.8 = 3.70 in.<br /><i>p, </i>forearm and hand - 0.263 x (10.6 + 9.35) = 5.25 in.</li><li>The moment of inertia about its proximal axis of rotation is expressed by the equation: Ij = m(p^2 + c^2)</li></ol> <p><b>Fig. 7</b> and <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The moment of inertia of the upper arm about the shoulder: <b>Equation 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The moment of inertia of the forearm about the elbow: <b>Equation 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the moment of inertia of the forearm and hand about the shoulder joint is desired, then the equation is: <b>Equation 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 9</b>, <b>Fig. 10</b>, <b>Fig. 11</b>, <b>Fig. 12</b>, and <b>Fig. 13</b> have been included to facilitate any computations, to ease conversion from metric to British systems of measurement, and for graphically determining the moments of inertia.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Acknowledgment</h3> <p>Appreciation is expressed to Dr. Rudolfs Drillis and Messrs. Darrell Hill, Howard Gage, Maurice Bluestein, Albert Yatkauskas, and George Vadell for their contributions to this research project, and to Mrs. Mary Klaus for the preparation of the reports.</p> <p><b>References:</b></p> <ol> <li>Behnke, A. R., Jr., B. G. Feen, and W. C. Welham, The specific gravity of healthy men; body weight devided by volume as index of obesity, J.A.M.A. 118:495-498, Feb. 14, 1942.</li> <li>Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</li> <li>Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</li> <li>Dempster, W. T., Space Requirements of the Seated Operator, U.S. Air Force WADC Tech. Rept. 55-159, Wright-Patterson Air Force Base, Ohio, July 1955.</li> <li>Dempster, W. T, The anthropometry of body action, Ann. N.Y. Acad. Sci. 63:559-585, 1956.</li> <li>Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</li> <li>Drillis, Rudolfs, Renato Contini, and Maurice Bluestein, Body segment parameters-a survey of measurement techniques, Artif. Limbs 8:1: 44-66, Spring 1964.</li> <li>Dupertuis, C. W., and J. M. Tanner, The pose of the subject for photogrammetric anthropometry, with especial reference to somatotyping, Amer. J. Phys. Anthrop. 8:1:27-47, March 1950.</li> <li>Harless, E., The static moments of human limbs, Treatises of the Math.-Phys. Class of the Royal Academy of Science of Bavaria 8:69-96, 257-294, 1860.</li> <li>Krogman, Wilton Marion, and Francis E. Johnston, Human Mechanics: Four Monographs Abridged, U.S. Air Force Systems Command Tech. Rept. AMRL-TDR-63-123, Univ. Pennsylvania Graduate School of Medicine, Philadelphia, December 1963.</li> <li>Pascale, L. R., M. I. Grossman, H. S. Sloane, and T. Frankel, Correlations between thickness of skinfolds and body density in 88 soldiers, Hum. Biol. 28:165-176, May 1956.</li> <li>Sheldon, W. H., C. W. Dupertuis, and C. McDermott, Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages, Harper, New York, 1954.</li> <li>Skerlj, B., Volume, density and mass distribution of the human body by means of simple an-thropometrical means, Bulletin Scient., Conseil Acad. RPFV, hub. 2:11, 1954.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Dempster, W. T., Space Requirements of the Seated Operator, U.S. Air Force WADC Tech. Rept. 55-159, Wright-Patterson Air Force Base, Ohio, July 1955.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Dempster, W. T, The anthropometry of body action, Ann. N.Y. Acad. Sci. 63:559-585, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Harless, E., The static moments of human limbs, Treatises of the Math.-Phys. Class of the Royal Academy of Science of Bavaria 8:69-96, 257-294, 1860.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Pascale, L. R., M. I. Grossman, H. S. Sloane, and T. Frankel, Correlations between thickness of skinfolds and body density in 88 soldiers, Hum. Biol. 28:165-176, May 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Behnke, A. R., Jr., B. G. Feen, and W. C. Welham, The specific gravity of healthy men; body weight devided by volume as index of obesity, J.A.M.A. 118:495-498, Feb. 14, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Sheldon, W. H., C. W. Dupertuis, and C. McDermott, Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages, Harper, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Dupertuis, C. W., and J. M. Tanner, The pose of the subject for photogrammetric anthropometry, with especial reference to somatotyping, Amer. J. Phys. Anthrop. 8:1:27-47, March 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Krogman, Wilton Marion, and Francis E. Johnston, Human Mechanics: Four Monographs Abridged, U.S. Air Force Systems Command Tech. Rept. AMRL-TDR-63-123, Univ. Pennsylvania Graduate School of Medicine, Philadelphia, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, Renato Contini, and Maurice Bluestein, Body segment parameters-a survey of measurement techniques, Artif. Limbs 8:1: 44-66, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini </b></td></tr><tr><td class="clsTextSmall">Prosthetic-Orthotic Education Program, UCLA, Los Angeles, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-05.jpg Figure 5 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-06.jpg Figure 6 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-10.jpg Figure 10 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-11.jpg Figure 11 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-14.jpg Figure 12 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-09.jpg Figure 13 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-12.jpg Figure 14 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-13.jpg Figure 15 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Body Segment Parameters, Part II Creator An entity primarily responsible for making the resource Renato Contini * https://staging.drfop.org/files/original/7e93e0bcdf041bdab2526ad50b967102.pdf 67579faec9e3dcdd1e35e26939cf8fcb https://staging.drfop.org/files/original/e1b9eed5d68adfbea036b532c62633f8.jpg 56019fdc49083b59c5913801b8cb4f31 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1972_01_020.pdf Year 1972 Volume 16 Issue 1 Page Number(s) 20 - 50 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1972_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1972_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management</h2> <h5>Barbara L. Sypniewski <a style="text-decoration:none;">*</a><br /></h5> <h3>Introduction</h3> <p>This independent-study honors project dealt with congenital skeletal limb deficiencies. This paper discusses and reviews the literature concerning the prosthetic management of the individual with unilateral terminal transverse partial hemimelia of the upper extremity. Specific topics considered are: a general description of the entity, including etiology and incidence; psychological factors affecting the limb-deficient child and his parents; normal and abnormal biomechanics of the upper extremity; components of the prosthesis (terminal devices, wrist units, elbow hinges, cuffs, harnessing, and sockets); prosthetic prescription and fitting; the trend toward early fitting; preprosthetic therapy; and prosthetic training. One section discusses the information elicited from a survey conducted by letters and questionnaires that were sent to the 28 clinics participating in the Child Prosthetics Research Program, conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development to ascertain the age of the congenitally skeletally limb-deficient child at the time of his initial fitting for a prosthesis. An analysis of the data from the 12 clinics replying is presented, along with the developmental criteria for fitting.</p> <p>The scope of this paper is limited to the unilateral upper-extremity, below-elbow congenital amputee. Bilateral amputees, cineplasty, surgical conversion, or externally powered prostheses are not considered. The literature review was limited by time to the books and journals published in 1960 or later, with selected earlier articles. Articles published before 1960, as well as those not available at the Albany Medical College Library or through the inter-library loan system, are listed in the "Bibliography." Both reference lists were compiled from <i>Index Medicus; Amputees, Amputations, and Artificial Limbs </i>(published by the Committee on Pros-thetic-Orthotic Education of the National Academy of Sciences-National Research Council, Washington, D.C.); and the bibliographies of articles I reviewed.</p> <p>Terminal transverse hemimelia indicates congenital absence of the entire distal part of the limb below the elbow. The term is part of the modified Frantz-O'Rahilly<a></a> classification nomenclature. Hemimelia is the absence of a large part of a limb, from the Greek <i>melos </i>meaning limb and <i>hemi, </i>half. <i>Partial </i>hemimelia indicates that less than half the limb is missing. The defect we are considering is transverse rather than longitudinal, presenting a short or very short stump similar to that of an acquired below-elbow amputation.</p> <p>The etiology of skeletal limb deficiencies is largely unknown, except for the well-documented teratogenic effects of thalidomide. The thalidomide tragedy has led to an increased interest in, and awareness of, what can be done for the congenital amputee. <a></a></p> <p>The list of proposed etiological factors includes environmental conditions such as drugs, maternal health and nutrition, genetic factors or predisposition, and chromosomal aberrations.<a></a> Most congenital defects have their origin during the first eight weeks of embryonic life.<a></a></p> <p>Glessner<a></a> indicates that there are two distinct groups of congenital absence of limbs: (1) spontaneous intrauterine amputation after limb formation, caused by focal deficiencies, and (2) limb-bud arrests or agenesis of the terminal part of the limb. Amniotic bands wrapped tightly around part of an extremity may lead to necrosis and eventual intrauterine amputation.<a></a> Terminal deficiencies due to limb-bud arrests are by far the most common type of congenital absence.<a></a> The terms <i>congenital amputation </i>and <i>congenital skeletal limb deficiency </i>are used interchangeably in the literature.</p> <p>Terminal transverse partial hemimelia is the most common type of congenital limb deficiency. There is unexplained preponderance of left-sided absence (2 or 3 to 1), and females are involved more frequently than males. Studies by Bergholtz,<a></a> Davies, Friz, and Clippinger,<a></a> Munson and Dolan, <a></a> and Gehant<a></a> failed to show the greater incidence in females exhibited in Kay and Fishman's report.<a></a></p> <p>The measures of prosthetic management in habilitation of a congenital amputee are somewhat different than those employed in the rehabilitation of an "acquired" amputee. The child must learn functional skills that he never possessed, rather than relearning substitute functional activities. The fact that the juvenile amputee is neither skeletally nor emotionally mature is an important consideration in the prosthetic management. The growth and development of the limb-deficient child is essentially the same as that of the normal child; the environmental stimuli to motor development are not decreased significantly by unilateral deficiency. Ideally, prosthetic management should extend from birth through vocational training.</p> <p>Function of the upper extremity is extremely complex and relatively independent of the contralateral extremity. With unilateral absence, there is an increased use of the remaining extremity, since the ability of a prosthesis to compensate for the loss of an arm is significantly less than is possible in the lower extremities. Below-elbow amputees are least in need of externally powered prostheses.<a></a> They can effectively use body power to activate the prosthesis and receive the benefits of sensory feedback through the socket and harness. The prosthesis should be considered as an assistive device in bimanual activity. Because absence of one extremity can be easily compensated for, getting the unilateral amputee to use his prosthesis presents a great challenge. Fitting and training should be started as early as possible, before these compensations can develop.</p> <p>It is generally believed that a team approach is most successful in the management of the limb-deficient child. The foremost members are the mother, who spends the most time with her child and influences him the most,<a></a> and the child. Other possible members of this interdisciplinary team are the physician, orthopedist, prosthetist, occupational therapist, physical therapist, psychologist, social worker, and biomedical engineer. Each child presents unique problems to be met. Epps and Brennecke<a></a> outlined a sequence of treatment that includes referral, history and medical examination, intake evaluation, preprosthetic physical and occupational therapy, prescription, fabrication, thorough check-out by the team, training, and regular recheck every three or four months.</p> <p>Factors influencing the cost of the prosthesis are: age at initial fitting, regular maintenance, frequency of harness adjustment, wearing pattern, operating skill, acceptance, and components prescribed.<a></a>Average service for a prosthesis ranges from two to three years, but a child fitted during infancy may require three to five prostheses before school age.<a></a> The additional cost of early fitting is compensated for over the years,<a></a> especially in regard to the benefits of skill and acceptance.</p> <h3>Psychological Aspects</h3> <p>The importance of parental attitudes towards the child, his disability, and the idea of a prosthesis, and their effect on the eventual acceptance or rejection of a prosthesis, has been emphasized throughout the literature. There is no direct correlation between the degree of the child's deficiency and the mother's perception of the child's abnormality, her feelings toward him and the way she handles him.<a></a> The way in which parents deal with the birth of a limb-deficient child depends to a great degree on how they have coped with previous crises. Replacement of a missing extremity with a well-functioning artificial one is valuable only if the parents can accept the idea of a prosthesis. Often, children have rejected prostheses because the parents, consciously or unconsciously, could not accept the fact that it was necessary.<a></a></p> <p>The way in which the parents are informed of the child's deficiency may influence their later reactions. If he desires to do so, the father should be allowed to inform the mother, in the presence of a physician.<a></a> Mothers can be profoundly influenced by the reactions of the delivery-room staff.<a></a> The training of the limb-deficient child can best begin by providing the parents with a detailed, factual, realistic, and sympathetic appraisal of their baby and his prospects for future educational, vocational, and social rehabilitation.<a></a> Unrealistic claims that modern prosthetics and engineering can provide artificial devices as natural-looking and as efficient as the human hand can seriously hinder the habilitation program. The first few hours after the birth of the child are crucial; it is during this period that parents form attitudes and defenses that can have tremendously far-reaching effects.</p> <p>With the birth of a deformed child, the parents suffer a severe psychological shock, for which they are totally unprepared. Certain emotions have been commonly expressed by parents of congenital amputees: guilt, hopelessness, death wishes, fear, anger, rejection, despair, shame, repulsion, grief, shock, hostility, and abandonment.<a></a> The need for prompt, professional assistance is crucial. </p> <p>Parents are extremely sensitive to the reactions and attitudes of others, and they need help to know that they and their child are accepted. In addition to individual counseling by a psychologist, social worker, or other qualified persons, group sessions have been established.<a></a> Parents benefit from the opportunity to verbalize their feelings and receive support and help in handling their emotions and in developing constructive attitudes. Wallace<a></a> noted the impact of these group-therapy sessions on the fathers, citing fewer absences, less hesitation about expressing their feelings, and awareness that their attitudes affect the child's adjustment and help to mold his self-image.</p> <p>If, instead of realistic acceptance, strong defense mechanisms are built up by the parents during this early period, they will not be able to communicate with their child when he becomes aware of and questions his deficiency. One indication of the mother's acceptance of the child is the way she handles the baby. Some important factors to look for in observing parental behavior are: avoidance of direct contact with the baby, ritualistic organization and emphasis on cleanliness, barriers to communication, aggression toward professionals, and subconscious refusal to accept the existence of the child's abnormality.<a></a> The mother will eventually become the child's best therapist, and the early months must provide a basis for her later role. Parents must be aware of the importance of their love in the future rehabilitation of their child. Hall<a></a> and Mongeau and others<a></a> advocate that children become an integral part of the family immediately. Mongeau found that children taken home directly from the hospital after birth have shown greater capacity for adaptation than those who were institutionalized. A strong family basis can be of great help to the child when he may later face repeated hospitalizations for prosthetic training or other reasons. According to Gesell and Amatruda,<a></a> a child's basic behavior traits are fairly well established by the time he is a year old. Some of these traits are hereditary and some are absorbed from the attitudes of the family.</p> <p>Crisis intervention, as described by Brooks and others<a></a>, is the awareness of impending crises in the development of the limb-deficient child and the intervention by qualified professional personnel to aid in making those transitory periods as easy as possible. One such crisis is that of homecoming. The curiosity and concern of relatives and friends must be faced. The effect of the birth of a limb-deficient child naturally has a great impact on his siblings.<a></a> They too must be aided in adjusting to this stress situation. Other potential crisis periods are prosthetic fitting, entering school, and adolescence.<a></a> During the child's period of growth and development, he has the same needs for independence and self-sufficiency that normal children have. Dependence and overprotection must be avoided. Discipline must be consistent and realistic, neither extremely permissive nor extremely restrictive. The profound effects of the parents on the child cannot be overemphasized.</p> <p>The manner and degree to which the child is influenced by his deficiency is determined before he reaches conscious awareness of his condition. If he has been provided with a sense of security, acceptance, and love, he will have a strong basis from which he can develop a positive self-image and achieve independence. The limb-deficient child faces the same problems and sequence in emotional and social development as normal children, but each crisis is likely to be of greater intensity and magnitude.<a></a> The child who has received encouragement and support from his family will expect the same type of relationship from outsiders and will approach social contacts spontaneously, rather than attempting to avoid them. The child will attain a balance between the dominance of his parents' influence and the satisfaction he gains from his independence.<a></a> He should be encouraged to enter into social relationships with a minimum of special attention.</p> <p>Taylor<a></a> has discussed at length the psychological needs of handicapped children. In addition to the fundamental needs of love and acceptance, she cites the needs for adventure and exploration, rebellion to release pent-up frustration, limitation of freedom, friends and social experience, privacy, achievement as a basis of self-esteem, and the need for awareness of the child as a person. These needs are the same as those operating in all nonhandi-capped individuals.</p> <p>Gouin-Decarie<a></a> recognized that a pertinent problem in studying the psychology of a limb-deficient child relates to his conception of space, which is closely associated with the formation of the body image. She found that these children made use of a visual, rather than a tactile, image in recognizing familiar objects. Several authors have discussed the concept of body image, or schema, in child amputees.<a></a> All have indicated the absence of marked distortion of body image in most of these individuals. Alteration of body image is, however, a significant problem in noncongenital amputees. Centers and Centers<a></a> analyzed the results of a draw-a-person test administered to congenital amputees. The majority of amputees represented themselves realistically, either leaving out the missing limb or including the prosthesis. They concluded that, while body images differed in a matter-of-fact way, they did not differ markedly in signs of greater conflict, anxiety, or defensiveness. The study did not support the authors' hypothesis that amputee children will have more conflict and defensiveness about their bodies than will nonamputee children.</p> <p>The body image is critical in relation to the acceptance or rejection of a prosthesis. Congenital amputees experience the same processes in the formation of body image as normal children. The earlier the child is trained to wear a prosthesis, the easier it will become a part of his body image.<a></a> One factor in the ready incorporation of the prosthesis is that modern prostheses are functionally adequate for many of the activities engaged in by young children.<a></a> A prosthetic device is never really useful until it is integrated into the body schema. Acceptance and rejection of the prosthesis is more extensively considered in the section on early fitting.</p> <p>The question of the possibility of the phenomenon of phantom sensation in congenital amputees is an interesting one. A discussion of the theories concerning the cause of this phenomenon is beyond the scope of this paper. Hoover,<a></a> Lambert,<a></a> and Simmel<a></a> believe that neither phantom-limb sensation nor pain exists in this group of individuals. Lambert bases his belief on the principle that nerve endings going to the distal limb have never developed. Simmel attributes the impossibility of phantom sensation to the fact that the absent part has never been represented in the body schema. In their census of the juvenile-amputee population, Kay and Fishman<a></a> reported three instances of phantoms in congenital amputees, but these could not be substantiated by further interrogation. Weinstein and Sersen<a></a> reported phantoms in 5 out of 30 children with congenital deficiencies. If the presence of a phantom reflects the "need" of the child to experience a missing part, it should have functional properties. The phantoms reported in this study were usually shrunken, telescoped parts with gaps and missing appendages.</p> <p>Certain other psychological aspects can best be discussed as they relate to the chronological age groups of the congenital amputee. The significant divisions are: preschool, entry into school, latency, and adolescence.</p> <p>In the preschool category, a period of negativism and resistance occurs around two years of age. This is a normal reaction; the child is trying to establish his personality and achieve a little independence.<a></a> This period of negativism often conflicts with prosthetic-training procedures, especially terminal-device activation.</p> <p>Entry into school is an important milestone for any child. He moves from the security of his home environment into a competitive social society. The limb-deficient child needs a reliable basis for dealing with this new group of people. This is provided by his parents and family during the early childhood years. In his group experience, the child will test and validate ways of dealing with people outside his family <a></a>. Adjustment is facilitated if the teacher and class are prepared and informed in advance. Healthy curiosity is the most frequent reaction of classmates, and a factual explanation of the prosthesis and its use should lead to acceptance by the classmates and increased self-confidence of the limb-deficient child. Wilson <a></a> expresses the belief that it is preferable for the limb-deficient child to attend regular school. Unnecessary special consideration should be avoided. The handicapped child may experience feelings of social devaluation, which any member of a minority group feels.<a></a> Centers and Centers<a></a> discuss the results of a social-discrimination questionnaire. The hypothesis that peer-group children express more covert rejecting attitudes toward amputees than toward nonamputee children was supported. They attribute this finding to the fact that one of the most significant variables operating in social interaction is personal appearance. Centers and Centers conducted their study almost ten years ago. It would be interesting to retest this hypothesis in light of recent social trends toward greater acceptance of minority groups and increased emphasis on individual merit as opposed to sterotyped generalizations.</p> <p>The preadolescent latency period is relatively calm, with no major crisis periods. The normal child experiences many conflicts during adolescence, many of which are associated with appearance. These conflicts are all compounded in the limb-deficient child. During this period, a cosmetic hand is often prescribed for the adolescent amputee to replace the functional hook for social occasions. Vocational guidance becomes increasingly important during this period of adolescence.</p> <h3>Normal and Abnormal Biomechanics</h3> <p>The arm enables the hand to be placed in position for skilled functional activities. The most commonly recognized forms of prehension include tip, palmar, three-jawed-chuck, lateral, hook grasp, cylindrical grasp, and spherical grasp. Palmar prehension employing opposition of the thumb predominates in picking up objects and holding them for use. Long tendons with muscles at a distance permit the great variety of motion characteristic of the human hand. In addition to skill, the hand frequently functions in support postures. Sensation is another major function of the hand. The hand is richly supplied with sensory-nerve endings mediating touch, temperature, pain, and position. Large areas of the cerebral cortex represent the complex sensory and motor function of the hand. Boivin<a></a> advocates investigation into the prehension patterns and sequences commonly used in activities of daily living. Stabilization of the wrist in various positions aids prehension. For example, the wrist assumes an angle of 145° when very strong prehension is required.<a></a> Finley, Wirta, and Cody <a></a> studied the synergic action of muscles of the upper extremity resulting in a better understanding of the relationship between central and peripheral control of movement. The three major components of the response phenomenon that they noted were: cognitive, ballistic-type physical displacement, and apparent sensing to compare, confirm, or adjust to assure successful accomplishment of the desired act. The information regarding time sequences is useful as reference material in studying pathomechanics.</p> <p>Finger and hand movement, wrist flexion and extension, and varying degrees of pronation and supination are lacking in the congenital below-elbow amputee. Prosthetic replacement of the wrist and hand is poor, only crude prehension and positioning are possible, and there is no substitution for the lack of sensory feedback. Maximum utilization of the residual biomechanics is essential in prosthetic replacement.<a></a> The biggest challenge is to design an upper-extremity prosthesis that (1) can be powered by and controlled with little effort, (2) can perform through the almost spherical range of a normal arm, (3) has a terminal device that can achieve prehension, (4) will respond to sensation, and (5) is cosmetically acceptable.<a></a> Upper-extremity prosthetics are significantly deficient in all of these areas. Because of the fixed prehension pattern of the terminal device and the fixed wrist, nearly all fine orientation movements must be made at levels higher than the forearm by compensatory motions of the elbow, hand, and shoulder .<a></a> Prosthetic controls permit only the simplest motions decomposed into their basic elements and executed slowly, in series, one at a time.</p> <p>Stoner<a></a> notes that no prosthesis accomplishes any of the wrist-flexion movements. The reasons for this neglect of wrist replacement are: (1) usually no controls from the harness are available to furnish the power, (2) wrist motions are used in fine movement of the hand and are not essential to bring the hand into the major spheres of action about the body, and (3) loss of wrist flexion can be compensated for grossly by other arm motions. Preposition flexion devices are available and are useful for activity close to the body.</p> <p>Pronation and supination are functions of forearm length. Wrist joints allow passive positioning for the most advantageous angle of terminal-device operation. With shorter forearm stumps, the mechanical advantage of flexion is decreased, in addition to the loss of pronation and supination.</p> <p>Joint motions in congenital amputees are often bizarre<a></a>. Kruger and Breyan<a></a> report that, in an X-ray evaluation of 16 extremities with terminal transverse partial hemimelia, 13 showed dislocation of the head of the radius. Of these, 77% showed dislocation before prescription of the initial prosthesis. It is therefore concluded that the phenomenon is inherent in the disability itself. The dislocation is asymptomatic. The authors offer two possible explanations for the phenomenon: deficiency of the ligamentous structures, or unopposed action of the biceps brach-ialis muscle. They consider the latter explanation the more likely. In short stumps, the pronator teres muscle is absent, and the biceps in flexing and supinating meets no opposition, thereby dislocating the radial head.</p> <h3>Harnessing</h3> <p>Harnessing techniques for upper-extremity prostheses must be based on bio-mechanical analyses of the remaining movements. Successful use of the prosthesis requires a harness that allows the most efficient use of those movements that are available. The socket limits some of the residual motion of the stump itself, and the harness limits the motion of the sound extremity to some extent. The harness should distribute the weight of the prosthesis evenly over a wide area and be functional in as many positions of normal use as possible. It should transmit power with a minimum of interference and be operable by relatively inconspicuous body motions. Power is provided by the stump itself (elbow flexion) or by the relative motion between two body parts (glenohumeral flexion and/or scapular abduction). Control-cable systems transmit this power from the amputee's body to the prosthesis. The suspension system may use a figure-of-eight, figure-of-nine, or shoulder-saddle chest-strap type of harness. The most common suspension is a figure-of-eight harness with a Northwestern ring-type cross.<a></a> The Northwestern ring allows adjustment of individual harness straps. The figure-of-nine harness is often used for power transmission with Munster-type sockets, which do not require a great deal of additional suspension. The chest strap is useful in spreading the load in heavy work<a></a> and maintaining the prosthesis in the proper position in the presence of baby fat. The harness provides some degree of feedback from the environment. O'Shea<a></a> has described a shoulder-saddle chest-strap harness with the primary advantage of increased comfort. Hile<a></a> described the adaptation and reinforcement of a brassiere to replace the chest-strap harness when breast development occurred.</p> <p>Requirements for suspension and harnessing vary from individual to individual, and skillful use of the available power sources is essential to good prosthetic use. Rapid rate of growth and limited power are critical factors in designing harnesses for congenital amputees.<a></a> Frequent adjustment by the prosthetist assures optimum harness and prosthetic function.</p> <h3>Components of the Prosthesis</h3> <h4>Terminal Devices</h4> <p>Two major considerations in the design of a prosthesis for a child are the continual neuromuscular and skeletal changes due to growth and the child's limited sources for power and control. Linear growth is more rapid than circumferential growth. The prosthesis can be fabricated to allow for later adjustments for growth, thus extending the functional life of the device. The components must be sturdy enough to withstand vigorous use, yet must be light enough to be controlled by the child. Some of the problems involved in the prosthetic replacement of human body parts are control, feedback, reliability, size, and appearance.<a></a> Upper-extremity prostheses for children are essentially scaled-down models of adult types. However, Hall<a></a> and Wilson<a></a> note that recent advances in children's prosthetics include improved design and function of terminal devices, lightweight plastic sockets and shells, and more efficient harnessing methods. There are a large number of mechanical components available that can be combined to best meet the needs of the individual child. Split mechanical hooks stress the restoration of function at the expense of abnormal appearance, while artificial hands with cosmetic gloves attempt to combine modest levels of function with near-normal static appearance. Both hooks and artificial hands should be given the same care as the normal hand; since sensation is absent, they are more prone to damage.</p> <p>There are two mechanisms of terminal-device operation: voluntary opening and voluntary closing. In the voluntary-opening type, tension on the control cable opens against a variable spring force, while in the voluntary-closing type, control-cable tension closes against the spring force. Hooks and hands are available with either mechanism. Voluntary opening is the simplest form of prehension mechanism: the prehension force is provided by special heavy rubber bands. Among the disadvantages of this type are the inability to handle delicate or heavy objects, and the fact that this mechanism is opposite to the prehension of the normal hand. An advantage of the voluntary-closing terminal device is that it more accurately simulates normal prehension, and pressure can more easily be graded to the object to be grasped. Formerly, manually controlled locks were employed, but now automatic locking is available. The fact that, to release the lock, the cable pull must be greater than the pull that closes the terminal device may be a disadvantage. Neither mechanism has been proved superior in a wide range of activities,<a></a> but research to improve both types for juvenile amputees is continuing.</p> <p>Ritter and Sammons<a></a> have elaborated on the advantages of voluntary-closing devices for children's prostheses. The fact that normal prehension is simulated is especially relevant in bilateral grasping. Performing different hand patterns simultaneously, as is necessary with voluntary-opening devices, is particularly difficult for the preschool child to learn, since he is still developing refinement of prehension. A description of the Army Prosthetics Research Laboratories (APRL) voluntary-closing hand, which provides palmar prehension of the three-jaw-chuck type, has been presented by Stoner.<a></a> Teska and Swinyard<a></a> have described a test to evaluate its functional capacity, versatility, and durability. Research is also being conducted concerning the Robins-Aid voluntary-opening hand.<a></a> The concept of cosmesis, or the appearance of the prosthesis, is difficult to define, but is very important. It is a very individualized concept, having varying importance for different people. Function, cosmesis, and acceptance are almost inextricably allied.<a></a> The area of compromise between function and cosmesis is a delicate and crucial one. Those professionals vitally concerned with function must be careful not to look down on the parents who may seem to be overly concerned with cosmesis. Several new plastics have been reported<a></a> that, while not identical to the color and texture of the human skin, do convey an idea of softness and warmth. These new terminal-device designs represent an attempt to combine improved function with an aesthetically satisfactory appearance, but without trying to imitate representationally the characteristics of the missing part.</p> <p>It was formerly common practice to provide the congenital amputee with a plastic mitt or wafer as the initial terminal device. Dean,<a></a> Lineberger,<a></a> and Watkins and Ford <a></a> have presented arguments supporting this practice. Among the major reasons given are: cosmetic appeal, flexibility, support without slipping in creeping, avoidance of injury to the child himself or others during play, and other factors supporting early fitting in general.</p> <p>The infant passive hook is now considered the better choice as an initial terminal device. Some of the reasons for its preferred function are listed by Blakeslee<a></a>: (1) it provides for gross palmar prehension and body-support activities with skill equal to the mitt, (2) it allows the infant to hook over objects for support in pulling to a standing position, (3) it provides a holder for small objects that are placed in it, (4) it helps the infant to develop bilateral prehensile awareness, being recognized as a device to hold objects, and (5) parents who were willing to accept a prosthesis for their child readily accepted the passive hook. Shaperman<a></a> reported the results of an evaluation of the passive mitt and the passive hook with similar results. She also noted improved skill and increased speed of learning when the control cable was added to the passive hook. Initially, the hook presented a slightly greater safety hazard, but the injuries that did occur were minor. Shaperman noted that the hook was one ounce heavier than the mitt, but it appeared to be well within the limits of the infant's ability to lift and manipulate it easily.</p> <p>Hooks are available in a variety of sizes, shapes, and weights. The Dorrance 12P or 10P hook are commonly provided for the unilateral juvenile amputee. They are canted and plastic-covered. Proponents of prescribing hooks cite the advantages of greater prehensile function, with greater visibility and facility available. Numerous authors <a></a> have expressed a preference for the use of the hook rather than the hand. Edelstein maintains that the cosmetic appeal of a skillfully used hook is greater than that of a cadaverous-looking glove. The idea that the hook can only be accepted as a tool, and that therefore it is hard to see the need for a more cosmetic socket, has been expressed by Boivin .<a></a> Research toward improved hook design and function is being carried out. The literature reveals progress reports in the development of the Sumida hook,<a></a> the Northwestern University Center control hook,<a></a> the Steeper split hook no. 65,<a></a> and other more recent advances in prosthetics.<a></a> Carroll<a></a> conducted a study to analyze the prehension force needed by child amputees. The test items were related to function and varied with the age of the child. Most items tested static prehension only; the individual could either hold the object, or it slipped out of the hook because of insufficient prehension force. Dynamic prehension, or the child's ability to control the prehension force, was tested by the ability to hold a paper cup with water in it. The results of this study showed that more children were fitted adequately in regard to the size of the terminal device than in relation to the prehension force. None of the children were found to be wearing an excessive number of rubber bands. With the exception of the toddler group, the prehension force was found to be inadequate for performance of one or more of the test items. One result of this study was a set of suggested pinch forces for below-elbow amputees:</p> <table> <tbody> <tr> <td> <p><b><i>Age (years)</i></b>   </p> </td> <td> <p><b><i>Pounds of force</i></b>   </p> </td> </tr> <tr> <td> 2-4</td> <td>2.25 </td> </tr> <tr> <td> 3-9</td> <td>3.5 </td> </tr> <tr> <td> 5-9</td> <td>4 </td> </tr> <tr> <td> 8-17</td> <td>5 </td> </tr> <tr> <td> 15-20</td> <td>6 </td> </tr></tbody></table> <p>Greater consideration needs to be given to the adequacy of prehension forces for the functional activities of congenital amputees.</p> <p>Cosmetic hands are often prescribed when the juvenile amputee reaches adolescence. Interlocking wrist-unit mechanisms are available that permit the use of a hook for functional activities and a more cosmetic hand for social occasions. These hands usually provide a modified three-jaw-chuck prehension between movable index and middle fingers and a thumb that can lock in position. Hands available for children include the Dorrance no. 2 hand<a></a> and the APRL-Sierra child-size no. 1 hand.<a></a> One disadvantage that must be considered is the greater weight of the hand as compared to the hook. The APRL-Sierra no. 1 hand weighs 170 grams, while the Dorrance 10x hook weighs 60 grams.<a></a> This is especially important, considering that this additional weight has the mechanical advantage of a long forearm lever and the congenital amputee does not possess a great deal of muscle power.</p> <p>The APRL-Sierra no. 1 hand was developed to meet the need for a functional and cosmetically acceptable hand for juvenile amputees. It is a voluntary-opening mechanism with a hand shell of cast aluminum, articulated index and middle fingers, a two-position thumb, and nonarticulated but flexible ring and little fingers.<a></a> In this field study, only 7 of 77 children rejected the hand completely. The remaining participants fell into four groups: those that used the hand exclusively, those that used the hand predominantly, those that used both equally, and those that used the hook predominantly. The authors suggest that the age of the child is a major factor regarding hook or hand preference. Younger children may experience difficulty with hand weight and opening forces, may be more careless in their use of the hand, and may be less subject to social pressures toward cosme-sis. Sex appeared to be an even greater consideration than age. Girls of all ages appear to be potentially the best candidates for the Sierra-APRL no. 1 hand, while younger boys would seem least likely to accept the device. Fishman and Kay <a></a> performed a study to delineate the relative usefulness of the hook and the hand. The results were at variance with previous clinical impressions, which indicate that a hand is a significantly less functional terminal device than a hook. In an extensive evaluation of the Dorrance no. 2 hand in 72 bimanual activities, Gorton<a></a> found that no definite trends emerged to indicate that the hook was measurably more functional than the hand or that the hand was significantly more functional. The test employed by Fish-man and Kay analyzed general and specific patterns of grasp by means of functional activities. The rating scale for performance of activities was somewhat subjective, but the detailed analysis of the results was excellent. From this study, the authors concluded that: (1) the APRL-Sierra no. 1 hand was heavier and, in most cases, more difficult to operate than the previously used hook, but these were not serious drawbacks for the majority of subjects; and (2) the hand provided somewhat less pinch force than most of the hooks and a less precise grasp. While the majority of children reported that they could perform more activities better with the hook, they also were able to specify a number of activities that were performed better with the hand, such as picking up a pencil, grasping paper, and holding silverware for eating.</p> <p>Constant research and re-evaluation of prostheses is essential.<a></a> Boivin<a></a> has written an excellent article criticizing present artificial-hand design. He maintains that an inherent belief exists that the refinement of the normal hand cannot presently be reproduced, leading to the assumption that it can never be reproduced. He cites the apparent lack of coordination and integration in biomedical engineering research, and proposes that a reason for this is that the goal is providing normal hand function, but that this is being attempted without sufficient consideration for the actual anatomical and physiological functions of the hand according to the kinesiological data presently available. One example is the fact that artificial hands flex only at the metacarpophalangeal joint, while the flexor digitorum profundus, the most active finger flexor, flexes at the interphalangeal joints as well. Boivin presents two suggestions for modification of artificial-hand design: first, that the normal transverse arch be reproduced in artificial hands, adding to cosmesis and function; and second, that artificial hands be made smaller and covered with a soft subcutaneous tissue-like material under the glove. Besides improved cosmesis, this would improve grasp by allowing better molding of the fingers over the object to be grasped. This second approach is presently being used by the Otto Bock Orthopedic Industry, Incorporated, in their new modular arm. The catalogues illustrate an above-elbow arm, but it is quite possible to employ this system for below-elbow amputees by fabricating the socket, attaching the proper length tube and the terminal device. This "System Arm" can be used for every level of upper-extremity amputation except wrist disarticulation and extremely long below-elbow amputations. Child-size systems are available. (This information was received from personal communication with Otto Bock Orthopedic Industry, Incorporated.)</p> <h4>Wrist Units, Elbow Hinges, and Sockets</h4> <p>Wrist units perform the dual function of attaching the terminal device to the prosthetic forearm and providing terminal-device rotation for manual preposi-tioning. There are manual-friction, manual-lock, and active-rotation units. Manual-friction is the most commonly used type. A rubber washer and a metal washer are compressed as the terminal device is screwed into place. Behavior of the unit is unpredictable because of the uneven compression and the easy accumulation of dirt, but it has the advantages of simplicity and easy maintenance. Manual-lock units allow rotation and locking of the terminal device by separate steps through the use of cylindrical inserts that have index teeth around their circumference.<a></a> The inserts are threaded to fit the terminal-devicestud. Active-rotation devices use stump rotation to produce rotation of the terminal device and are able to amplify residual stump rotation.<a></a> Wrist-flexion units that provide partial replacement for lost palmar and dorsal flexion of the wrist are available. By adding the extra degree of freedom, they can minimize the need for compensatory motions at higher levels. These units are presently only suitable for light duty.<a></a> Clarke, Kral, and Shaperman <a></a> evaluated wrist-flexion units for children. The advantages of the addition of a wrist-flexion unit to an upper-extremity prosthesis include: (1) the ability to bring the arms close to the body for self-care activities,(2) the ability to bring the arms together in the midline for bimanual activities, and(3) less need for body exertion and bending to accomplish these activities. The authors found that one angle of flexion or flexion and radial deviation is sufficient for all activities. Wrist flexion of 25° or less is comfortable and useful, and there is no advantage above 25°. They advocate that the conventional wrist unit be laminated into the forearm unit in a flexed position, after careful evaluation to determine the most advantageous angle. This overcomes the disadvantages of wrist-flexion units for children, such as added weight of the terminal device, an additional component to preposition, and mechanical unreliability. It would seem that the need for dorsiflexion at the wrist for functional activities should be further evaluated, since this study only considered variable degrees of palmar flexion.</p> <p>Flexion of below-elbow prostheses is provided by hinges of various types; the main classes are "rigid," "semirigid," and "flexible." They can be made of metal, leather, or metal cable. Some elbow hinges are polycentric and have a step-up ratio to provide a greater range of motion for a short below-elbow amputation. This is useful if adequate power is available, since flexion strength is lost through this mechanism. When both power and range are insufficient, it is possible to utilize the stump power to activate a locking hinge. Flexion of the forearm is then provided by humeral flexion.</p> <p>Most below-elbow prostheses require an upper-arm cuff made of leather to help to stabilize the connection between the amputee and the prosthesis necessary to adequate control.<a></a> The most common types are the very light triceps pad and the open cuff. These would be the most useful for congenital amputees; the heavy-duty closed cuff would not usually be necessary.</p> <p>The socket is the foundation of all upper-extremity prostheses. The standard socket designs are used for juvenile amputees, but they may fit poorly because of the large amount of soft tissues in the child and the lack of well-developed bony prominences. It is through the socket that power and control are transmitted from the stump to the prosthesis and some degree of feedback is received. Double-wall construction allows a stump-fitted inner wall with an outer wall designed for structural uniformity and cosmesis. Retention of pronation and supination in short and very short below-elbow amputees is usually not a consideration, since pronation and supination are factors of forearm length. Another important matter is stability in flexion. In short and very short stumps, a single-axis hinge helps to provide this stability.</p> <p>Among the types of sockets available are single-socket, split-socket, preflexed socket, and Munster-socket designs. Single sockets are often lacking in the necessary flexion stability for congenital amputees. Because of limited range of motion, a short or very short stump may require a split socket with a step-up hinge. One degree of stump movement gives 2° or 3° of prosthesis movement, thereby increasing the range of motion, but two or three times normal force is needed to accomplish this. VanDer-werker and Rosenberger<a></a> described the mechanism and installation of a flexor assist for use with the step-up split socket. Pellicore <a></a> noted the unfavorable cosmesis of the split socket, which was later largely replaced by the use of a preflexed forearm. This improved the cosmesis somewhat and increased the functional forearm power, but the range of motion was limited to 100°-110° instead of the normal 135°.</p> <p>A great deal of the recent literature is devoted to a description and discussion of the Munster-type socket. The technique, involving intimate encapsulation of the stump, was developed by Dr. O. Hepp and Dr. G. G. Kuhn of Munster, Germany, and introduced into the United States in 1958. Short below-elbow stumps present a small attachment area, poor leverage, and a decreased useful range of motion. Some of the characteristics of the Munster technique that help to overcome these deficiencies are: (1) the elbow is set in a preflexed position yielding the most useful range of motion, usually about 35 deg., (2) a channel is provided at the antecubital space for the biceps tendon to avoid interference between the socket and biceps tendon during flexion, and (3) the posterior aspect of the socket is fitted high around the olecranon and the epicondyles, taking advantage of these bony prominences to provide attachment and stability to the socket.<a></a> These characteristics eliminate the need for split sockets with step-up hinges, giving improved prosthetic control and feedback, and often eliminate the need for a harness for suspension purposes. Younger congenital amputees may require more harnessing to maintain the prosthesis in place.</p> <p>Epps and Hile<a></a> described the fabrication techniques and evaluated the Munster prosthesis. Among the favorable points they found were: simplified harnessing, light weight, no perspiration problem, and excellent stability under axial-load testing. They also noted the elbow hyperextension characteristic of the individual with terminal transverse partial hemimelia. They concluded that the Munster-type prosthesis is the fitting choice for the child with a unilateral short or very short below-elbow amputation. In their investigation of the applicability of Munster-type fittings, Fishman and Kay<a></a> found that all of the subjects were definitely in favor of this type of prosthesis. The decrease in flexion range had no appreciable effect on prosthetic function for unilateral amputees. (Some modifications, such as lowering the anterior trim line and provision of a wrist-flexion device, may be necessary for the bilateral amputee.) Among the advantages cited are the facts that the stump does not slip out while performing overhead activities, and that less energy is required in operation of the prosthesis. They suggest that this type of fitting is functionally advantageous for amputees with very short to medium below-elbow stumps. Two factors limit the applicability of this technique for stumps of longer lengths: (1) the pronation and supination in these stumps cannot be harnessed with a Mun-ster prosthesis, and (2) the proximal socket opening at a sharp angle to the shaft presents increasing difficulty in donning and doffing the prosthesis as stump length increases.</p> <p>Gazeley, Ey, and Sampson<a></a> reviewed four cases of fitting children with Munster sockets and concluded that the technique is not satisfactory for bilateral amputees, because of the limited flexion. Except for that, they were very pleased with its use. Gorton,<a></a> Kay and Fishman, <a></a> and Pellicore<a></a> have all cited the usefulness of the Munster-type prostheses in fitting short and very short below-elbow stumps. Gorton found the positive factors to be: increased stability and socket retention, socket comfort with minimal stump motion within the socket, harness comfort with the elimination of the triceps pad and front support strap, and improved cosme-sis due to the minimization of the harnessing system. The negative features listed were: decreased range of motion (limited to about 70°), limited elbow flexion, and harness discomfort due to the control strap riding low across the back. The other authors discovered similar findings. With the limited range of motion, it is necessary to make this the most functional range. Partial flexion is necessary to keep the prosthesis on the stump. Complete extension is not as essential to functional activity as an adequate flexion range.</p> <p>The use of sockets that do not completely enclose the stump is more extensive in Germany than in the United States. With this type of prosthetic fitting, the end of the stump remains free for gripping and touching. According to Fletcher <a></a> and an article in the <i>British Medical Journal, </i><a></a> in congenital limb deficiency the end of the limb has a tactile sensation equivalent to that of a normal fingertip, even when the distal two-thirds of the forearm is missing. He attributes the prosthetic rejection by many children to the fact that standard prostheses rob them of this important sense of touch. He feels that fitting such an individual with an artificial limb is, in effect, performing a physiological amputation. Kuhn<a></a> and Jentschura, Marquardt, and Rudel<a></a> have described an open-end socket that enables the patient to use the sensory surface of his stump as well as the terminal device. The socket is provided with a friction joint on the dorsum of the prosthesis so that the terminal device can be bent away from the end of the stump. The economic advantage of an increased "life span" of the prosthesis, as well as the functional advantages of the open socket, have been presented by Jaramillo and Lehneis.<a></a> The preservation of tactile sensation is an important consideration in upper-extremity prosthetic design. Increased research on open sockets is indicated, since they seem to provide a critical advantage over the standard prostheses, especially for the bilateral amputee.</p> <h3>Prosthetic Prescription and Fitting</h3> <p>The prescription of a prosthesis for a congenital amputee, as for any amputee, is best achieved by a team approach. The child's functional needs and developmental status must be ascertained in order to provide the optimum combination of components. Actual fabrication is followed by a final check-out of the compatibility of the amputee and the prosthesis.</p> <p>The physician, prosthetist, and physical and occupational therapists are the main members of the prosthetic-clinic team.<a></a> The physician, in writing the prescription, must combine his knowledge of the individual with the results of evaluations performed by other members of the team. The prosthetist advises about possible solutions to the case, measures the patient, fabricates the prosthesis and harness, and evaluates the functional results of fitting. The physical and occupational therapists evaluate motor development, range of motion, and muscle strength, advise the physician and pros-thetist of available body power for control, suggest possible solutions to fitting problems, and perform the final checkout evaluation.</p> <p>As a functional replacement for the missing limb, the prosthesis must be a simple, lightweight device that will enable the child to perform certain tasks, but not necessarily all tasks. Stamp, Mahon, and Morgan<a></a> found that, with the unilateral below-elbow amputee, the use of a prosthesis improves the function of the opposite, normal extremity. The combination of a normal extremity and a prosthesis is much more functionally efficient than is the combination of a normal extremity and a stump.</p> <p>The functional needs of the child must be determined in order to provide a prosthesis that will fill these needs. Self-care needs are an important part of the functional evaluation. Observing the compensatory patterns that the child has naturally developed for holding or reaching yield an indication of his specific functional needs. One approach to functional evaluation<a></a> has been to observe which parts are missing and to formulate a prescription on the theory that these are the parts that need to be replaced prosthetically. This theory assumes that, once these are provided, the child will meet all of his activity needs. It is important that the total effect of the prosthesis is a significant gain in function. The advantages and disadvantages for each individual must be carefully considered.</p> <p>It is necessary in the early examination to determine the developmental status of the child.<a></a> This evaluation bears a significant relationship to the timing and type of prosthetic fitting. In much of the literature, the achievement of a secure sitting balance is designated as an important criterion to upper-extremity prosthetic fitting. (The criteria for fitting are discussed more completely in the section on the trend toward early fitting.) An important part of the evaluation is the observation of the infant's prehension patterns. The infant's ability to control and relate his various arm, hand, and body movements predicts his pattern of prosthesis operation and use <a></a>. The development of compensatory prehension patterns is one of the positive indications for fitting the child with a cable-operated hook. The child's interest, attention span, and coordination must also be determined. All of this information aids in prescribing a prosthesis and planning a training program.</p> <p>In addition to this evaluation of neuromuscular development, the therapist must also determine muscle strength and range of motion. The prosthetist needs to know which structures are present and which are absent, and what sources of power are available. Muscle defects may accompany skeletal defects, as pectoral agenesis occasionally accompanies below-elbow deficiency.<a></a> Some of the abnormalities of neuromuscular-system function to notice are: involuntary motion, deviations in the speed of motion, resistance to passive movement, atrophy, fatigue, and static or dynamic postural deviations.<a></a> Functional muscle testing as described by Daniels, Williams, and Worthingham<a></a> provides valuable information. Range-of-motion tests are useful in noting any contractures or other factors limiting the range and in determining the scapular movement available to operate the devices prescribed. Sequential testing and accurate recording are necessary in functional, motor-developmental, muscle-strength, and range-of-motion evaluations.</p> <p>Exact body measurements, both longitudinal and circumferential, are often made by the prosthetist at the time of fitting. In the unilateral amputee, the epicondyle-to-thumb length is important as a sizing reference for the total length of the finished prosthesis.</p> <p>The choice of the components for the prosthesis is based on a thorough knowledge of the functional needs and the potentials of the individual. It was formerly accepted practice to prescribe a passive mitt, but this practice has been replaced by the use of a passive, plastic-covered hook. The hook gives the child the opportunity to incorporate the concept of a prehensile device from the start. The manual-friction wrist unit is often useful for congenital amputees. At first it can be positioned by the parents, and later by the child himself. Sockets that permit rotation are not usually indicated in short below-elbow stumps, since residual pronation and supination is minimal. The Munster-type socket, or modifications of it, as well as conventional below-elbow double-walled laminated sockets, seem to be successful in fitting the individual with terminal transverse partial hemimelia. Harnessing and suspension are highly individualized and can make the difference between successful and unsuccessful prosthetic prescription. Some of the greatest problems in prescribing and fitting the congenital amputee arise from his rapid, uneven rate of growth, the presence of baby fat, the lack of well-defined bony prominences, and the almost constant mobility of all young children. It must be emphasized that good prescription of prosthetic components must be based on a thorough knowledge of the individual. The prosthesis should allow him to function at his highest level in his environment. For the congenital amputee, this may mean providing him with the opportunity to assume a normal pattern of development of bimanual activity. In unilateral amputees, the prosthesis functions as a helper, not as the dominant hand.</p> <p>Fabrication and interim fittings are performed by the prosthetist. After careful initial measurements, a plaster cast of the stump is made. This is used to make a mold of the stump. A full description of the techniques for fabricating the prosthesis is beyond the scope of this paper; however, a step-by-step account of fabrication is given in the <i>Manual of Upper Extremity Prosthetics.</i><a></a> There is no universally acceptable check-out procedure for the child amputee. The standardized adult forms are not useful, because child prosthetics is a relatively new field in which improvements in techniques are constantly being made<a></a>. Additional contraindications to a standardized form are the varied ages and developmental levels of the children, philosophies of case management and prescription which may vary from clinic to clinic, and the fact that so many modifications of the prostheses for congenital amputees are needed. The standard check-out forms must be adapted if they are to be used for child amputees. The clinic team must evaluate the fit and function. The pros-thetist's primary interest is the mechanical aspects, the therapist's is the child's functional benefit. The physician must coordinate the efforts of all of the paramedical personnel. Blakeslee<a></a> has presented some of the important considerations regarding check-out for the juvenile amputee.</p> <p><i>Prosthesis fit</i></p> <ol> <li>Is the prosthesis cosmetically acceptable? Is it well made, and does the workmanship follow all of the specifications of the prescription?</li><li>Is the prosthesis of the proper length, and is the socket fit satisfactory? Do bony prominences have sufficient space? Do the component controls appear to be within reach of the amputee?</li><li>In the upper-extremity prosthesis, is the harness adjusted properly and is it comfortable?</li><li>When the prosthesis is removed, are there any excessive pressure points in the socket area? </li></ol> <p><i>Functional considerations</i><br />All components must be checked to make certain they are in good working order, and must be adjusted for efficient operation by the child and/or adult. Some of the primary functional considerations are:</p> <ol> <li>Is the prosthesis properly aligned?</li><li>If it is an upper-extremity device, is the control system appropriate for this child? Will he be able to control the arm and operate the controls in the desired range of motion? Is the terminal device in good condition and does it operate smoothly? Does the harness appear to be correctly positioned and in balance?</li><li>Can the prosthesis be applied with ease? Is the amputee comfortable in the standing, sitting, and walking positions and while performing functional activities?</li></ol> <p>These check-out procedures emphasize the points to consider in preprosthetic evaluations, prescription of components, and fabrication. The prosthesis must be made to fit the needs of the child; the child should not be expected to adapt to the prosthesis.</p> <h3>The Trend Toward Early Fitting</h3> <p>A great deal has been written concerning the advantages of early fitting, and a variety of developmental criteria for fitting have been described. This section deals with the advantages of early prosthetic fitting for the upper-extremity juvenile amputee, a brief discussion of normal motor development, and a discussion of fitting at various ages. The age levels can be roughly grouped as follows: before school age, nine to twelve months, six to eight months, four to six months, and three months or younger. This grouping is the distribution that occurred naturally in the literature. The concept of prosthetic acceptance or rejection is also discussed in this section.</p> <p>The philosophy of early fitting is the dominant theme of much of the literature. The difference exists in the definition of the term <i>early. </i>Before this concept was accepted, prescription of an artificial limb was not advised until the patient reached the middle or late teens,<a></a> in order to avoid the expense of purchasing a device that soon would be outgrown. More recently, the child was fitted just prior to school age,<a></a> but still after the child had become oriented to one-handed function. Frantz<a></a> has presented a brief history of the management of the juvenile amputee during the past twenty years.</p> <p>Mongeau and others<a></a> recommend that the habilitation of congenitally deformed children be initiated at an early age. Many other authors have proposed reasons for early fitting. Friedmann<a></a> lists the following advantages: (1) to stimulate bilateral function, (2) to help the child and parents to accept the prosthesis for function or cosmesis, (3) to incorporate the prosthesis into the child's body image, (4) to improve balance, (5) to get the child accustomed to the normal length of the limb, (6) to prevent scoliosis and other skeletal abnormalities due to asymmetry, (7) to make the child aware of prehensile function, and (8) to promote eye/hand control. In addition to the advantage of greater acceptance, Blakeslee<a></a> cites the fact that early fitting leads to a more normal development of the residual parts and diminishes atrophy caused by disuse and hypogenesis. The prosthesis encourages physical activity, which increases growth and strength. The avoidance of substitute patterns of grasp, such as holding objects in the axilla or elbow-bend and working in an awkward or energy-consuming position, was noted as an advantage by Blakeslee<a></a>, Brooks and others,<a></a> Gillis,<a></a> and Klopsteg, and Wilson et al..<a></a> More of the movement patterns of the upper extremity are acquired than in the lower extremity, thus increasing the importance of early fitting. Gillis maintains that the movement patterns necessary to control the prosthesis are most perfectly developed at the same time as those for the natural limb. The possibilities of atrophy through disuse and the development of contractures are greater with later prosthetic fitting.<a></a> As the result of a study conducted at the Rehabilitation Institute of Montreal, Gingras and others<a></a> found that in a majority of cases there was hypotrophy of the deficient limb. They found an average difference of one centimeter between the lengths of the humeri. The hypotrophy was attributed to disuse because it had been observed that patients who had early prosthetic training were enabled to put their muscles to greater use and therefore they showed less limb-length inequality. An additional advantage of early fitting mentioned by Edelstein<a></a> is that it aids the limb-deficient child in crawling. Children learn to use the upper-extremity prosthesis as well as, if not better than, adults.<a></a> The advantages of skill in prosthetic use resulting from early fitting have been cited by Brooks and others,<a></a> Dean,<a></a> and Mayo.<a></a> Some of the favorable results of early prosthetic fitting for the unilateral below-elbow amputee presented by Brooks and Shaperman<a></a> include: (1) full-time wearing of the prosthesis, (2) skillful operation of the prosthesis, (3) natural and spontaneous patterns using the prosthesis and including it in normal activities, (4) good habits of prosthesis maintenance, and (5) good acceptance of the prosthesis by the child, family, and community.</p> <p>In reviewing the literature, the author noted that earlier fitting was advocated more often for children with bilateral and multiple limb deficiencies than for those with unilateral deficiencies. One possible explanation for this may be the comparatively greater need for sensory input for development and function by the former group. The supposition of earlier fitting was substantiated in a census study by Kay and Fishman.<a></a> They suggested that this may be related to the greater need by multiple limb-deficient individuals for prosthetic assistance.</p> <p>The developmental norms of Gesell and Amatruda<a></a> form the basis of much developmental evaluation. They are especially relevant to the unilateral congenital amputee. For instance, he may first be aware of his missing limb at about three months of age, when he attempts two-handed grasp. Vitali<a></a> cautions that a limb-deficient child should not be expected to achieve standards of developmental performance before others in his age group.</p> <p>In an analysis of data collected over a two-year period ending on June 30, 1967, Davies, Friz, and Clippinger<a></a> noted that a relatively high percentage (32%) of congenital amputees were not fitted until after their eleventh birthday. Since the current philosophy is to fit congenital amputees at a very early age, it would be interesting to know the reason for this delay. The authors could not determine whether the fault lay with the amputee clinics or with parents who were reluctant to take their children to clinics or ignorant of the prosthetic opportunities available to them.</p> <p>In discussing the advantages of early fitting, there is variability in the definition of <i>early. </i>Brooks and Shaperman,<a></a> Kay and Fishman,<a></a> and Watkins and Ford <a></a> support the idea of fitting the unilateral below-elbow amputee before school age, at the latest. Of those authors advocating fitting when sitting balance has been achieved, some are referring to independent sitting without support (about ten months of age) and others to sitting with support (about six months). In either case, this leaves the upper extremities free in a functional position. The group of proponents includes Aitken,<a></a> Brooks and others<a></a>, Caine and Reeder,<a></a> Catto and MacNaughtan, <a></a> Jansen,<a></a> Shaperman,<a></a> and Wilson.<a></a> Several authors indicate a preference for fitting at six to eight months of age. Among these are Blakeslee<a></a>, Gillis,<a></a> Hall,<a></a> Kempner,<a></a> Lineberger,<a></a> and Vitali.<a></a> Lineberger and Gillis have cited the benefit of having a prosthesis to aid in crawling and pulling to a standing position.</p> <p>Encouraging bilateral movement patterns and establishing familiarity with and tolerance for the limb are advantages of prosthetic fitting between four and six months of age. This is considered the best age for fitting by Edelstein,<a></a> MacNaughtan,<a></a> Martin,<a></a> and Mayo.<a></a> Lambert and others<a></a> maintain that the congenital amputee should be fitted with a prosthesis as soon as he needs it. For the unilateral upper-extremity amputee, this may be as early as three months. According to Gingras and others,<a></a> fitting this early is based not only on considerations of function, but also on the idea of helping the child incorporate the presence of an artificial arm into his body image and to accept it better. Tolerance and adaptation to the prosthesis as well as aid in developing sitting balance has been stressed by Nichols and others.<a></a> Prosthetic acceptance or rejection is a very complex concept. It is an accepted psychological principle that an individual is better able to achieve adequate adjustment to a total loss of function than to a partial one, yet prosthetic devices restore partial function. The relationship of the amputee to his prosthesis is that of man to machine. It is an intimate and long-term contact between a human being and a mechanical device. The gadget tolerance of the individual is of great importance, especially as the child grows older and develops greater skill in using the prosthesis. Both the visual consideration of cosmesis and the auditory factors of a mechanical device, such as the sound of a terminal device closing on an object, play major roles in the formation of the individual's attitude toward his prosthesis. If the prosthesis is regarded as a tool that makes him less different and gives him a better opportunity for integration into his peer group, then the child is more likely to wear and use his prosthesis. If he believes that the prosthesis accentuates the difference between himself and others, it is likely that he will reject it.<a></a> Throughout the literature, it has been emphasized that children usually accept a prosthesis without too much difficulty .<a></a> It helps if the individual can gain immediate satisfaction from its use, rather than feeling that it is a deterrent to his activity. A child can be helped to appreciate the usefulness of the prosthesis by providing him with toys and chores that require two hands. Both a full-time wearing pattern and the ability to talk freely and openly about the prosthesis are good indicators of acceptance.</p> <p>Several authors have emphasized the positive relationship between early fitting and good prosthetic acceptance. A patient most easily accepts a prosthesis if he obtains it before becoming accustomed to one-handed activity.<a></a> Kempner,<a></a> Mongeau and others,<a></a> and Wilson <a></a> believe that early fittings lead to complete patient and family acceptance. In evaluations by Brooks and Shaperman<a></a>, children with short below-elbow stumps fitted before two years of age received the best scores for "acceptance." Gingras and others<a></a> found that rejection is a common occurrence if prosthetic fitting takes place after adolescence, while Blakeslee<a></a> found excellent acceptance and utilization if the child was fitted before four years of age, and increased rejection after that age.</p> <p>Congenital amputees experience the same structuring process in regard to body image as do normal children. If a child is presented with a prosthesis during the critical stage when his body image is forming,, he will incorporate the limb into his pattern of activity and self-image.<a></a> Centers and Centers<a></a> note that modern prostheses are functionally adequate for many of the activities engaged in by children. This may be a factor <i>in </i>the incorporation of the prostheses into their body images. Personality factors are directly related to acceptance of a prosthesis.</p> <p>In the case of the congenital amputee, his parents' attitudes affect his personality and his acceptance or rejection of a prosthesis. Parental influence cannot be overemphasized. It is within the family structure that all of the child's attitudes are developed. A clear view of parental influence is presented by Brooks and Shaperman<a></a> in their discussion of a group of children who had rejected their prostheses. The group was characterized by a lack of parental support and guidance in the child's general behavior. There was a great deal of emphasis on the child's accomplishments without the prosthesis. These parents expected less of their children than their potential, openly expressed dislike for the appearance of the prosthesis, and had a limited ability to communicate feelings and problems. One review<a></a> indicated that the better-educated middle-class families are most likely to help their children accept prosthetic appliances.</p> <p>All of these considerations regarding acceptance and rejection are interrelated.</p> <h3>Questionnaire Survey Concerning Age at Initial Fitting</h3> <p>The questionnaire survey sought to document a trend toward earlier initial fitting of upper-extremity prostheses in the congenital amputee. As the most frequently occurring limb deficiency, unilateral terminal transverse partial hemimelia was selected as the focus of consideration. An extensive review of the literature had seemed to indicate a trend toward earlier fitting. While children were formerly fitted just prior to school age or even during the middle or late teens, the achievement of independent sitting balance is now a widely accepted criterion for prosthetic prescription. According to Gesell and Amatruda's studies of motor development,<a></a> the norm for the achievement of this maturational level is nine months (36 weeks).</p> <p>It was the belief of the author that (1) even earlier fittings are being performed in significant numbers, (2) a passive hook is most frequently prescribed, and (3) the development of the Münster-type socket has played a role in the trend toward earlier fitting.</p> <p>Questionnaires were mailed to the 28 clinics participating in the Child Prosthetics Research Program, a cooperative endeavor conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development. The information requested was of three types: age at time of initial fitting, type of socket and terminal device most frequently prescribed, and basic developmental levels considered essential for fitting the prosthesis.</p> <p>The sample consisted of 40 new patients with upper-extremity terminal transverse partial hemimelia who were initially fitted between March 1, 1969, and approximately March 1, 1971. The frequency of fittings is indicated in <b>Table 1.</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One clinic whose data arrived too late to be included in the chart reported fitting more than 200 cases. A relatively small number (between 15 and 20) were fitted between the ages of 6 and 9 months, and a much larger number (50 or 60) were fitted after the age of 12 months. Two other clinics indicated that the information needed to complete the questionnaire was not readily available. (One of these stated that all of their children were fitted after the age of 12 months.) In requesting the data, no upper limit was set on the last interval (later than 12 months). For this reason, no statistical analysis of the central tendency (mean or median) was possible. The return on this survey was 43%, the low response level being partly attributable to the fact that no date was designated for the return of the questionnaire.</p> <p>The frequency distribution indicated that 65% of the children were fitted under one year of age. Using nine months as the age for reaching the developmental level of independent sitting, the data indicates that 37.5% were fitted before that age. It is also interesting to note that 20% of the sample was fitted before six months and 7.5% before three months. This information indicates a trend toward fitting earlier than the widely accepted criterion of independent sitting balance. The very important concept of parental attitudes and other intangible factors were not considered, nor was the age when the child was first seen at the clinic taken into account in this study. If it were, perhaps an even stronger trend toward earlier fitting would be noticed.</p> <p>Regarding the type of terminal device, seven clinics prescribed a Dorrance 10P or 12P passive hook most frequently. One fitted a nonfunctioning hand (mitten) initially and changed to a hook at about two years of age. The other clinic listed both the passive hook and the passive hand in their response. Five of the clinics prescribed a conventional double-walled plastic-laminate socket most frequently, and four clinics most often prescribed a Münster or modified Münster socket.</p> <p>An interesting outcome of this survey was the compilation of the developmental criteria for fitting employed by the various clinics. In the following chart, the list of criteria is paired with the developmental norms described by Gesell and Amatruda.<a></a> </p> <table> <tbody> <tr> <td> <p><b><i>Developmental Criteria</i>      </b></p> </td> <td> <p>      <b><i>G and A Norms (mo)</i>  </b></p> </td> </tr> <tr> <td> <p>Beginning to prop on elbows</p> </td> <td>      3 </td> </tr> <tr> <td> <p>Readiness for bimanual activity</p> </td> <td>      4 </td> </tr> <tr> <td> <p>Head control</p> </td> <td>      5 </td> </tr> <tr> <td> <p>Object transfer</p> </td> <td>      7 </td> </tr> <tr> <td> <p>Beginning sitting</p> </td> <td>      8 </td> </tr> <tr> <td> <p>Independent sitting balance</p> </td> <td>      9 </td> </tr> <tr> <td> <p>Controlled voluntary grasp and release</p> </td> <td>      9-12</td> </tr></tbody></table> <p>One clinic responded that they did not adhere to any developmental criteria, but felt that as soon as the child was three or four months old, a prosthesis could be fabricated with adequate socket fit. It was their belief that the earlier the socket was fitted, the better.</p> <p>The data collected on this sample did not establish a relationship between the development of the Münster-type socket and the trend toward earlier fitting.</p> <p>It is hoped that persons responsible for prescribing prostheses might consider the criteria proposed by other clinics for fitting of prostheses for congenital upper-limb amputees. The advantages that prompted the change from pre-school-age fitting to fitting at the developmental level of independent sitting continue to exert an influence toward still earlier fitting. The greatest advantage claimed is that of acceptance of the prosthesis. Logically, if the artificial limb is provided before a one-handed activity pattern is developed, changes for acceptance are increased. It would further seem logical that, when the capacity for two-handed grasp in the midline develops (at approximately four months), a prosthetic limb should be there to oppose the normal limb. The proximal stability necessary for control is developed previously in the on-elbows position. Many factors interact to affect the age of initial fitting. The age at which the limb-deficient child is referred to the clinic is certainly a significant one. Parental attitudes are closely associated with this consideration. The development of prosthetic parts specifically designed for children is important, as is the increase in knowledge in the entire field of prosthetic management of the juvenile amputee. Dissemination of this knowledge to the related health fields, especially to those individuals in contact with the mother of the newborn child with limb deficiencies, may promote earlier referral to the appropriate prosthetic team.</p> <p>It is believed that the trend toward earlier fitting is advantageous. A difference in the practice of various clinics has been noted. A polarity exists with a tendency for some clinics to fit predominantly at a very early age range and others only later. Three of the clinics indicated fitting only after 12 months. It would be useful for all the clinics that participate in the management of congenital amputees to carefully evaluate their criteria for prosthetic fitting and training.</p> <h3>Preprosthetic Therapy</h3> <p>Preprosthetic care should begin as early as possible. Hall<a></a> believes that physical and occupational therapy should be started as soon as the child begins to take part in his environment. A highly individualized treatment program to correct the deficiencies in range of motion, posture, and muscle strength is an important goal of preprosthetic therapy. The evaluations described earlier as prerequisites to prescription are also a part of the preprosthetic therapy program. Jaramillo and Lehneis<a></a> suggest that the child's poor attention span or negativism may be due to the lack of preprosthetic training by means of a good exercise program, rather than to poor family cooperation.</p> <p>Several authors have emphasized the important role the mother plays as the therapist.<a></a> She can be the best therapist for her child, since she spends more time with him than anyone else. She must understand the purposes of the therapy program and carry out the program at home. A good home program will facilitate prosthetic training. A well-informed mother can help to prevent contractures and postural deviations and to correct existing problems. It is a significant psychological asset for the mother to be an active member of the prosthetic team. An additional consideration that is the mother's responsibility in the early stages of habilitation is stump hygiene. The stump should be washed, rinsed, and dried thoroughly and inspected daily for any minor irritation or abrasion. The limb-deficient child perspires more than normal because of reduced body area. <a></a> He should be dressed in light, unrestrictive clothing for cooling and to allow freedom of movement.</p> <p>Limitations of range of motion do not occur as often in the upper extremity, and when they do occur, they do not as markedly affect its use.<a></a>The best treatment is prevention. This can be accomplished by instructing the parents in positioning and active exercises to prevent contractures and build strength and endurance. Extreme caution should be used in stretching any joints in the congenital limb-deficient child. The elbow is especially vulnerable, and passive stretching is contraindicated. (The tendency for radial-head dislocation has already been discussed.) The best techniques for increasing range of motion are those that achieve relaxation of the shortened group by heavy resistance to the antagonist muscle group. The PNF techniques of repeated contractions, slow reversal, slow reversal-hold, rhythmic stabilization, hold-relax, or slow reversal-hold-relax, as described by Knott and Voss would be appropriate. Since the young child is more flexible in his muscular structure, it is easier to reverse the adaptive shortening of the muscles than it would be in adults. Blakeslee<a></a> also notes the use of passive stretching, casts, and braces for the correction of flexion contractures.</p> <p>The delay in the early neuromuscular development of children with congenital skeletal limb deficiencies has been noted by Blakeslee<a></a>, Hall <a></a>, Jaramillo and Lehneis <a></a>, and Steele.<a></a> The child may be delayed in the development of head and neck control, rolling over, creeping, and sitting. He may need assistance in achieving developmental tasks. For example, if the child lacks head and neck stability, placing a small pillow under his chest allows development of the trunk and neck extensors. During this early period, assistance may be needed to help strengthen the neck and trunk flexors, extensors, and rotators. Later, it may be necessary to stimulate bimanual activity, especially gross grasp, by providing large objects for the child to hold. The upper-extremity amputee may need help in pulling to a standing position so that he can adequately develop his lower-extremity musculature.</p> <p>Essential muscle groups are exercised to maintain mobility and increase strength. Specific muscle groups must be strengthened in order to provide sufficient power to operate the prosthesis. Bates and Honet<a></a> and Montero <a></a>advocate the use of isometric exercises for this purpose. Exercises for neck and back extensors, flexors, and rotators are best accomplished through play activity. Catto and MacNaughtan <a></a> suggest using mirrors to stimulate the desired movement. The sound side should be included in the exercise program. Emphasis on strengthening the shoulder-girdle musculature for elevation, depression, scapular abduction and adduction, and general chest expansion (respiratory exercises) is important, since these muscles are needed to operate the prosthesis.<a></a> For the below-elbow amputee, strengthening elbow flexion and extension and any available pronation and supination is of prime importance.<a></a> Blakeslee<a></a> has emphasized the importance of general conditioning. Limb-deficient children tend to have a low energy output. This was observed even in below-elbow amputees who were otherwise normal in appearance and physiognomy. Greater than average endurance and output are required to operate a prosthesis. He also mentions that individual and group sports and other group activities have been successful in increasing energy output and improving general physical condition. Swimming has been found particularly advantageous.</p> <p>A preprosthetic therapy program provides a good foundation for later training of the child in the use of the prosthesis.</p> <h3>Prosthetic Training</h3> <p>Prosthetic training begins when the congenital amputee receives his prosthesis and continues periodically through vocational training. The initial training and orientation with a passive terminal device is essentially the same as that with an active terminal device, so both are considered together in this section.</p> <p>Training is one of the most difficult and important phases in the management of the congenital amputee. It is essential that the child is enabled to handle his environment rather than adapting the environment to his needs. Training a congenital amputee is very different than training a traumatic juvenile or an adult amputee who once had a functional extremity. The functional level of a normal child of the same age should be the basis of achievement goals.<a></a> The program progresses naturally from gross bimanual grasp to skilled functional activity. Factors affecting training are the child's neuromuscular development, attention span, functional requirements, and parental cooperation.</p> <p>The parents play an important role in the training of the juvenile amputee. The care and function of the prosthesis must be carefully explained to the parents, and they must be very aware of what it can and cannot do. The importance of the parents in prosthetic training has been emphasized by many authors.<a></a> Unless contraindicated by medical or other reasons, full-time wearing of the prosthesis from the first application should be the aim. According to Blakeslee,<a></a> one advantage to achieving a full-time wearing pattern as early as possible is the avoidance of the habit of removing the prosthesis for little or no reason. Later in childhood, the wearing pattern will be interrupted for repairs and refitting, so a stable pattern is desirable. Infants accept prosthesis-wearing easily, unless there is discomfort or the parents do not allow the prosthesis to be worn all day. Mac-Naughtan, <a></a> Shaperman, <a></a> Steele,<a></a> and Watkins and Ford<a></a> advise a gradual increase in tolerance leading to full-time wear except for sleeping, bathing, and rough contact sports. This seems to be a more logical approach than to expect immediate full-time wearing after the child has become accustomed to complete freedom of movement. During the period when the child has a passive prosthesis, he should be encouraged to use it as a "helper" in bimanual grasp, crawling, and pulling to a standing position. Toys are an excellent medium for encouraging bimanual activity. The infant amputee who receives his prosthesis during the first year of life shows remarkably early proficiency in gross arm movements; he develops habits of including the arm as a total unit rather than any specific part of the arm such as the hook, tip, or elbow.<a></a> An awareness of the hook's holding function should be developed as early as possible.</p> <p>In response to the questionnaire survey conducted by the author, the University of California at Los Angeles included a discussion of the criteria for the addition of a cable. Some of the factors proposed as prerequisites for terminal-device activation are: the readiness for bimanual activity, a reasonable attention span (approximately five minutes), the ability to follow two-step directions, tolerance of handling by the therapist, the presence of sufficient neuromuscular development to operate the cable, a full-time prosthesis-wearing pattern, and an awareness of the hook's holding function. At UCLA, the cable is usually added at a developmental age of two or two and one-half years.</p> <p>Like the variations observed in the age of choice for initial fitting, similar variability occurs in the age at which the terminal device is activated. The usual age seems to be about two years. Mac-Naughtan<a></a> has expressed the opinion that training should be conducted at the 14-to-20-month age. Depending on the ability of the child and the nature of his deformity, active control can be accomplished at 16 to 24 months, according to Hall<a></a> and Kempner. <a></a> Edelstein<a></a> cites 18 months, and Lambert<a></a> cites 18 to 24 months for the below-elbow amputee. By the age of 21 to 24 months, the child has developed a two-handed functional pattern, and he shows signs of a need to develop a pinch grasp as opposed to purely palmar prehension. <a></a> By two years of age, according to Blakeslee<a></a>, the child is ready for effective terminal-device activation, although this is typically a period of profound negativism. Dean <a></a> and Mayo<a></a> suggest that a single control cable be activated at 24 to 30 months, while Gingras and others<a></a> believe that, if active prosthesis training is begun by age two or three years, control can be achieved by four years of age.</p> <p>A study by Trefler<a></a> reveals the drawbacks of normally fitting around two years of age. Some of these considerations are that the child is ready for bilateral grasp before that age; he may be difficult to work with at the "terrible twos" stage of hyperactivity and negativism, and he may have already developed compensatory patterns, which are more easily prevented than broken. The advantages of terminal device activation at 15 months of age with a goal of spontaneous terminal-device use are: (1) the child is easy to work with for short periods of time (he has an attention span of one to two minutes), (2) when the cable system is applied to the child's prosthesis, it often helps to eliminate the problem of excessive external rotation of the socket, and (3) the availability of active grasp can enhance the activity pattern of an intelligent child. No disadvantages of early terminal-device activation were discovered. The cable did not restrict the child's movement during play at all.</p> <p>Wendt and Shaperman<a></a> conducted an interesting study to determine whether an infant amputee with unilateral below-elbow deficiency who was fitted initially with a prosthesis that included a cable would achieve purposeful control of the terminal device as part of his normal developmental progression without formal training. The results indicated that only a minority of the patients (approximately 25%) did achieve spontaneously the degree of skill usually acquired after formal training. Some patients partially learned skills, and others remained unaware of the function of the hook. It is possible that some children were negatively conditioned by the experience of trying to operate the terminal device and finding that they were unable to do so because of a lack of skill and guidance and concluding that the hook was a poor and unreliable tool. An alternative method of case management that has been suggested is to add the cable when manual hook-opening appears and then to allow natural development of terminal-device control. If the skill does not develop spontaneously, the therapist should intervene with the training program. This emphasizes manual hook-opening as a relevant step toward the eventual development of active opening. It was found that children who do learn terminal-device operation without training develop good skill and use patterns. If they are going to do so independently, they give evidence of this well before two years of age and achieve a well-established pattern by that time. It seems that, if a child is ready to develop the skill for terminal-device operation naturally, he should be allowed to do so.</p> <p>Prosthetic training once the control cable has been added is composed of two parts: training in the control of the terminal device and later functional training in activities of daily living. The child's ability to operate a hook relates primarily to his maturity.<a></a> Because of the child's short attention span, brief, frequent training sessions are desirable. Patients may sometimes be required to enter the hospital for the initial training sessions and occasional retraining later. At home, the mother can encourage these brief, frequent practice sessions. The child can best learn the correct control operations and realize the potentials of this prosthesis through play. There is a tendency for the child to continue to use his prosthesis as a passive device even after active control has been added.<a></a> Early training before the control cable is added should establish the concept of the prehensile function of the prosthesis. Manual hook-opening, at first by the parent and later by the child, and placing toys into the hook, should be encouraged. Flexion of the humerus opens the terminal device. The child must be helped to achieve the awareness of the relationship of these two incidents. The concept of stabilizing the sound shoulder in order to operate the terminal device is a difficult one to grasp. Having the child reach toward the terminal device with his sound arm may be helpful, or the therapist may need to stabilize the harness. The technique of immobilization seems to be mastered abruptly and inexplicably<a></a>, but it may take a great deal of time. The important objective is to get the child to open the hook, no matter how awkwardly it is accomplished. It may be necessary to cut down on the number of rubber bands on the hook to enable the child to open it; at this point in training, a large prehension force is not needed. The therapist can help hy offering objects to the child and placing them so that the hook will open when he reaches for them. One of the most difficult things for a child to learn is to pick up objects from a horizontal surface.</p> <p>The sequence of learning grasp and release with the prosthesis has been described by Blakeslee<a></a>, Richardson and Lund,<a></a> Shaperman,<a></a> and Wendt and Shaperman.<a></a> Although there may be variations in the pattern among individuals, it is agreed that a pattern does exist for learning terminal-device operation. A brief summary of the patterns observed by the above authors is presented here.</p> <p>Children learn first to actively maintain the hook in an open position and then to initiate hook-opening actively. Early opening is often accomplished by abducting and internally rotating the arm rather than by flexing the shoulder. This closely resembles grasp by the normal infant. The child finds it easier to open the terminal device with the elbow extended than in any other position. There is a tendency for the child to place objects into the hook with the sound hand. The ability to actively close the hook around an object develops before active release. At first, release of objects is accomplished by pulling them out of the hook with the sound hand. The child seems to be unaware that he can open and close the hook for release and that this requires the same motions that were used for grasp. It takes a long time and a great deal of practice for a child to become proficient in the use of the prosthesis. He must learn how far to open the hook to accommodate objects of different sizes and shapes, to position the hook accurately, and to properly time the release of an object. The child must also learn to extend the prosthetic arm and still maintain grasp on an object by releasing his sound shoulder so it no longer acts as the reaction point for control. The younger child cannot be expected to learn these more complex skills.</p> <p>Training hints have been offered by many therapists. The most frequent suggestion is the use of toys that require bimanual activity.<a></a> A lengthy list of toys suitable to each age group and each desired activity can be compiled. It was also mentioned that feeding time has been found to be one of the most successful training periods. Drill activities cannot be neglected, but relating them to functional play activities as soon as possible is desirable. <i>The Limb-Deficient Child</i><a></a> contains an excellent and extensive section on prosthetic training.</p> <p>Three prime functions that require prosthetic training are feeding, toilet care, and dressing. Other functional patterns that add to patient independence and satisfaction are: playground, household, and schoolroom activities, sports, musical instruments, card playing, and any other activities commensurate with the child's age. Special assistive devices are available commercially or can be fabricated when necessary.<a></a> Vocational training and preparation is a major consideration as the child grows older. For the unilateral amputee, the prosthesis is a helping or assisting device, and the sound arm is the dominant one in all activities. The part of functional training described in this paper is donning and removing the prosthesis. It is not practical to expect the very young amputee to be able to put on his prosthesis independently from the beginning. This is in contrast to the training procedure in adults, which would begin with this skill. Application is accomplished in the same manner as putting on a coat.<a></a> The socket is grasped with the sound arm and the stump is slipped under the inverted-Y strap. If the prosthesis is raised above the head so that the harness hangs down, the sound arm can reach back through the axilla loop, and the harness then can be properly placed. To remove the prosthesis, the child raises both arms over his head and grasps the socket with his sound arm. He can withdraw the stump while pulling up on the socket and then remove the axilla loop. Although a stump sock is usually worn to absorb perspiration, prevent suction, and allow greater comfort in the socket, it is a matter of individual preference. Some children with below-elbow deficiencies prefer not to wear a stump sock.<a></a> It is recommended that a T-shirt be worn under the harness to decrease local pressure and irritation, especially in the axilla, and to absorb perspiration.</p> <p>Successful training will permit the child to function freely and independently in his environment. Additional training may be required when the needs of the individual change.</p> <p>Follow-up studies of juvenile amputees after long-range treatment from infancy to adulthood have been conducted by Davies, Friz, and Clippinger,<a></a> Hamilton,<a></a> and Lambert, Hamilton, and Pellicore.<a></a> All three indicate the excellent results of long-term prosthetic management as indicated by good social adjustment, excellent prosthetic utilization, high employment rates, and high levels of educational achievement. Increases in these favorable results can be expected as children with congenital limb deformities are referred to prosthetic centers for treatment earlier and earlier.</p> <h3>Conclusion</h3> <p>This paper has discussed the prosthetic management of the congenital amputee with upper-extremity terminal transverse partial hemimelia. Psychological aspects, components of the prosthesis, prescription and fitting, the trend toward early fitting, preprosthetic therapy, and prosthetic training have been considered. A review of the literature and a questionnaire survey were completed. Several questions are raised and areas for further research are suggested as a result of this study.</p> <p>Research concerning the etiology of congenital limb deficiencies is indicated, including the unexplained phenomenon that the highest incidence of these deficiencies involve terminal transverse partial hemimelia of the left upper extremity in females.</p> <p>Information regarding phantom sensation in the congenital amputee is lacking. Study in this area might help to explain the phenomena of phantom pain and sensation in traumatic amputees.</p> <p>Reports regarding peer attitudes toward juvenile amputees show some disagreement. Some authors maintain that the attitude exhibited is one of healthy curiosity easily satisfied by an explanation, while a study by Centers and Centers showed more covert rejecting attitudes toward this group of individuals. It would be interesting to retest this hypothesis of social discrimination in the light of recent changes in attitudes toward many minority groups, since this study was conducted nearly ten years ago.</p> <p>A great deal of research is indicated and is being conducted in the area of prosthetic design. The results of biomechanical and kinesiological studies must be incorporated in the design of components. Analysis of the forces used in prehension and the most frequent types of prehension employed would be beneficial in improving terminal-device design. Further evaluation of the hooks and hands presently available and the voluntary-opening and voluntary-closing mechanisms are needed to determine which is most efficient and to delineate areas for further research. Some work has been done regarding optimum wrist-flexion (palmar) angles for functional activity close to the body. However, no consideration has been made as to the need for dorsiflexion, which is used very frequently in functional activity of the normal hand. The field of plastics offer a great source for improvements in fabrication of prostheses. Durable hooks with improved cosmesis may be a possibility with the new plastic materials available, as it has already aided in light weight and durable socket design and fabrication. The open-ended sockets that permit the use of the sensation at the tip of the stump seem to be an excellent development, especially for the bilateral amputee. Investigation into the advisability of increased use in the United States is indicated.</p> <p>Some disagreement exists concerning the development of prosthetic tolerance by the juvenile upper-extremity amputee. It is not, however, a significant controversy, since the goal of full-time wear is agreed upon, with differing opinions only concerning the rate at which this goal is reached.</p> <p>The results of the questionnaire survey indicate a trend toward earlier prosthetic fitting of the congenital amputee. Among the most interesting and valuable of all the information received was the developmental criteria for fitting. This information should be made available to the clinics participating in the Child Prosthetics Research Program, thereby enabling each of them to re-evaluate their criteria in light of this newly accumulated knowledge. Perhaps this can be accomplished through the <i>Inter-Clinic Information Bulletin.</i>The survey conducted did not consider the important factors of parental attitudes and age at time of referral to the prosthetic center. Any future study should incorporate these factors. Another study might better be able to establish or negate a relationship between the development of the Münster-type socket and the trend toward early fitting.</p> <p>Additional information concerning activation of the terminal device is needed. The proposal by Wendt and Shaperman of allowing natural development of the terminal device control once manual opening occurs, then intervening with formal training if control is not established by two years of age, merits consideration.</p> <p>Prosthetics for congenital amputees is a relatively new area, largely developed since the thalidomide tragedy of a few years ago. It has many areas requiring further research, such as the need for lightweight prostheses that can be operated with the available muscle power and the constant consideration of rapid growth. Research in this specific field of prosthetics for congenital amputees will contribute to and continue to benefit from the ongoing research in prosthetics in general. The goal of this research is improved functional ability for individuals with congenital skeletal limb deficiencies of varying degrees of severity and for all amputees.</p> <h3>Addendum</h3> <p>Three additional responses from the questionnaire survey were received after the statistical analysis had been completed and the article had been prepared. These brought the total return to 53.5%. A summary of the information received is presented here.</p> <p>The results were generally similar to those previously reported, with a number of individuals fitted at each interval except the first (less than three months).</p> <p>The developmental criteria presented were: bilateral gross grasp, beginning to sit, independent sitting, and (not previously mentioned) initiation of hand-eye coordination, as with holding a bottle, blocks, and general grasp for objects.</p> <p>Two of the clinics indicated that they usually fit a first prosthesis at six months of age if the developmental level allows it. Those fitted later in the statistics returned were not referred to the clinics until after that age.</p> <h3>Acknowledgments</h3> <p>I would like to thank Miss Dorothy Page, my advisor, for her help and guidance during this project. I would especially like to thank Miss Mildred C. Ey, O.T.R., Director of Occupational Therapy at Sunnyview Rehabilitation Center Hospital; and Mr. Klaus H. Lohman, C.P., of LaTorre Orthopedics Laboratory. I also extend my appreciation to Dr. Sidney Fishman, Mr. Hector W. Kay, the A. J. Hosmer Corporation, the Dorrance Company, the Otto Bock Company, and the clinics answering the questionnaire.</p> <p><b>References:</b></p> <ol> <li>Aitken, George T., Management of severe bilateral upper limb deficiencies, <i>Clin. Orthop. </i>no. 37:53-60, 1964.</li> <li>Amputations and substitutes for limbs, <i>Brit. Med. J. </i>2:195-196, Apr. 22, 1967.</li> <li>Bates, Marion D., and Joseph C. 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Dolan, <i>Patient Census at Child Amputee Clinics</i>— <i>1967, </i>Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968. </li> <li>Murphy, Eugene F., The challenge of replacing human parts and functions, <i>Bull. Pros. Res. </i>10-3:4-19, Spring 1965. </li> <li>Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, <i>Artif. Limbs </i>12:1:13, Spring 1968. </li> <li>O'Shea, Barbara, A chest strap harness for the below-elbow child amputee, <i>Inter-Clinic Inform. Bull. </i>6:7:1-4, 18, 1967. </li> <li>Peizer, Edward, Veterans Administration Prosthetics Center research, <i>Bull. Pros. Res. </i>10-6:257-260, Fall 1966. </li> <li>---------, Veterans Administration Prosthetics Center research, <i>Bull. Pros. Res. </i>10-10:270, Fall 1968. </li> <li>Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, <i>Inter-Clinic Inform. Bull. </i>3:11: 1-8, 1964. </li> <li>Richardson, Geraldine, and Aida Lund, Upper extremity prosthetic training for the young amputee, <i>Amer. J. Occup. Ther. </i>13:2:57-63, Mar.-Apr. 1959. </li> <li>Ritter, Diane, and Fred Sammons, An interesting terminal device modification, <i>Inter-Clinic Inform. Bull. </i>4:9:7-10,19, 1965. </li> <li>Santschi, William R., (Ed.), <i>Manual of Upper Extremity Prosthetics, </i>2nd ed. rev., University of California, Los Angeles, 1958. </li> <li>Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, <i>Amer. J. Occup. Ther. </i>14:1:17-23,26, 1960. </li> <li>---------, Learning techniques applied to prehension, <i>Amer. J. Occup. Ther. </i>14:70-74, Mar.-Apr. 1960. </li> <li>---------, A comparison of two infant terminal devices, <i>Inter-Clinic Inform. Bull. </i>3:7:1-6, 1964. </li> <li>Simmel, Marianne L., The absence of phantoms for congenitally missing limbs, <i>Amer. J. Psychol. </i>74:467-470, Sept. 1961. </li> <li>Sokolow, Jack, Management of the amputee in practice, <i>Med. Clin. N. Amer. </i>53:3:659-664, May 1969. </li> <li>Spring, John M., and Charles H. Epps, Jr., The juvenile amputee: some observations and considerations, <i>Clin. Pediat. </i>7:76-79, Feb. 1968. </li> <li>Stamp, Warren G., Sharon Mahon, and Harry C. Morgan, Problems of management of the child with multiple amputations, <i>Arch. Phys. Med. Rehabil. </i>46:354-368, May 1965. </li> <li>Stanek, William F., Orthopedic service at children's hospital: the amputee center, <i>Rocky Mountain Med. J. </i>63:54, Oct. 1966. </li> <li>Staros, Anthony, and Edward Peizer, Veterans Administration Prosthetics Center research report, <i>Bull. Pros. Res. </i>10-12:331-333, Fall 1969. </li> <li>Steele, Shirley, Children with amputations, <i>Nurs. Forum </i>7:411-423, 1968. </li> <li>Stoner, Emery K., Functional evaluation of the upper extremity, in <i>Handbook of Physical Medicine and Rehabilitation, </i>ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </li> <li>Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, <i>Clin. Orthop. </i>no. 37:82-97, Nov.-Dec. 1964. </li> <li>Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, <i>Amer. J. Surg. </i>109:294-299, Mar. 1965. </li> <li>Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, <i>Inter-Clinic Inform. Bull. </i>3:6:1-4, 1964. </li> <li>Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in <i>Selected Articles from Artificial Limbs, </i>Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </li> <li>Taylor, Isabelle Wagner, Psychological needs of the handicapped child, <i>Inter-Clinic Inform. Bull. </i>9:8:9-17, 1970. </li> <li>Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, <i>Amer. J. Occup. Ther. </i>15: 17-18, Jan.-Feb. 1961. </li> <li>Trefler, Elaine, Terminal device activation for infant amputees, <i>Inter-Clinic Inform. Bull. </i>9:9: 11,14, 1970. </li> <li>VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, <i>Inter-Clinic Inform. Bull. </i>3:1:1-3, 1963. </li> <li>Veterans Administration Prosthetics Center, Semiannual report, <i>Bull. Pros. Res. </i>10-3:135-136, Spring 1965. </li> <li>---------, Semiannual report, <i>Bull. Pros. Res.</i> 10-4:157-159, Fall 1965. </li> <li>Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, <i>Inter-Clinic Inform. Bull. </i>2:7:7-12, 1963. </li> <li>Wallace, Maxine T., Group therapy for parents of congenital amputees, <i>Inter-Clinic Inform. Bull. </i>5:2:10-14, 1965. </li> <li>Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, <i>Arch. Phys. Med. Rehabil. </i>43:293-296, June 1962. </li> <li>Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, <i>Neurology </i>11:905-911, Oct. 1961. </li> <li>Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, <i>Amer. J. Occup. Ther. </i>24:393-402, Sept. 1970. </li> <li>Wilson, A. Bennett, Jr., Limb prosthetics— 1967, <i>Artif. Limbs </i>11:1:1-46, Spring 1965. </li> <li>---------, Limb prosthetics —1970, <i>Artif. Limbs</i> 14:1:1-52, Spring 1970. </li> <li>---------, The prosthetics and orthotics program, <i>Artif. Limbs </i>14:2:1-18, Autumn 1970. </li> <li>For an Additional Bibliography, please refer to the PDF at the top of this page.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Hamilton, Robert C, A vocational evaluation of juvenile amputees who have attained the age of twenty-one years: a preliminary report, Inter-Clinic Inform. Bull. 3:7:8-9, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Spring, John M., and Charles H. Epps, Jr., The juvenile amputee: some observations and considerations, Clin. Pediat. 7:76-79, Feb. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">---------, Learning techniques applied to prehension, Amer. J. Occup. Ther. 14:70-74, Mar.-Apr. 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Richardson, Geraldine, and Aida Lund, Upper extremity prosthetic training for the young amputee, Amer. J. Occup. Ther. 13:2:57-63, Mar.-Apr. 1959. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>118.</b> </td><td class="clsTextSmall">Wendt, Jeannine D., and Julie Shaperman, A study of development of prehension patterns: the infant with a cable-controlled hook, Amer. J. Occup. Ther. 24:393-402, Sept. 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">Trefler, Elaine, Terminal device activation for infant amputees, Inter-Clinic Inform. Bull. 9:9: 11,14, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Artif. Limbs 9:2:26-33, Autumn 1965. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr><tr><td class="clsTextSmall"><b> 93.</b> </td><td class="clsTextSmall">Shaperman, Julie Werner, Orientation to prosthesis use for the child amputee, Amer. J. Occup. Ther. 14:1:17-23,26, 1960. </td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bates, Marion D., and Joseph C. Honet, Isometric exercises for the upper-extremity stump, Journal of the American Physical Therapy Association 44:1093-1094, Dec. 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Kyllonen, Ronald R., Body image and reaction to amputations, Conn. Med. 28:19-23, Jan. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Knapp, Miland E., Upper-extremity amputations: surgical considerations, Postgrad. Med. 45:2:237-240, Feb. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Nichols, P. J. R, E. E. Rogers, M. S. Clark, and W. G. Stamp, The acceptance and rejection of prostheses by children with multiple congenital limb deformities, Artif. Limbs 12:1:13, Spring 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Lambert, Claude N., Robert C. Hamilton, and Raymond J. Pellicore, The juvenile amputee program: its social and economic value: a follow-up study after the age of twenty-one, J. Bone Joint Surg. (Amer.) 51-A:6:1135-1138, Sept. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Martin, J. K., Congenital malformations associated with thalidomide and their management, Amer. Heart J. 67:284-285, Feb. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Jansen, Knud, Amputation: principles and methods, Bull. Pros. Res. 10-4:5-41, Fall 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Catto, A. M., and A. MacNaughtan, Physiotherapy and occupational therapy in the management of the upper-limb amputee, Physiotherapy 52:186-188, June 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Caine, Donald, and A. J. Reeder, The problem of the congenital amputee, Med. J. Aust. 50: 1:301-305, Mar. 2, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Management of severe bilateral upper limb deficiencies, Clin. Orthop. no. 37:53-60, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116 .</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall"> ---------, Amputees and their prostheses, Artif.Limbs 14:2:19-48, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Gingras, G., M. Mongeau, P. Moreault, M. Dupuis, B. Hebert, and C. Corriveau, Congenital anomalies of the limbs: part I, medical aspects, Canad. Med. Assoc. J. 91:2:67-73, July 11, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr><tr><td class="clsTextSmall"><b> 79.</b> </td><td class="clsTextSmall">Mayo, Eileen J., Upper extremity prostheses for children, Canad. Nurse 58:145-148, Feb. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies: management of limb defects, Brit. Med. J. 2:5305:647-651, Sept. 8, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Frantz, Charles H., An evolution in the care of the child amputee, Artif. Limbs 10:1:1-4, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b> 119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Daniels, Lucille, Marian Williams, and Catherine Worthingham, Muscle Testing: Techniques of Manual Examination, 2nd ed., W. B. Saunders, Philadelphia, 1956. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Epps, Charles H., Jr., Upper extremity limb deficiency with concomitant infantile structural scoliosis, Inter-Clinic Inform. Bull. 5:2:1-9, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">McGraw, Myrtle B., Neuromuscular Maturation of the Human Infant, Columbia University Press, New York, 1943. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Stamp, Warren G., Sharon Mahon, and Harry C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med. Rehabil. 46:354-368, May 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Jaramillo, Selene, and Hans R. Lehneis, A therapeutic program for children with limb deformities—preservation of rudimentary appendices and prosthetic design, Inter-Clinic Inform. Bull. 9:4:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Jentschura, G., B. Marquardt, and E. M. Ru-del, Inter-Clinic Inform. Bull. 4:9:11-14, 1965. (Reprinted from Behandlung und Vorsorgung bei Fehlbildungen und Amputationen der oberen Extremitdt, Georg Thieme Verlag, Stuttgart, 1963.) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">Kuhn, Gotz Gerd, Treatment of the child with severe limb deficiencies, Inter-Clinic Inform. Bull 10:3-S:l-26, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Amputations and substitutes for limbs, Brit. Med. J. 2:195-196, Apr. 22, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">---------, Malformations of the upper limb, Proc. Roy. Soc. Med. 62:1:55-56, Jan. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">---------, Dorrance model 2 hand field study, Inter-Clinic Inform. Bull. 6:8:11-13, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gazeley, William E., Mildred C. Ey, and William Sampson, Follow-up experiences with Muenster prostheses, Inter-Clinic Inform. Bull. 7:10:7-11, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Epps, Charles H., Jr., and John H. Hile, Experience with the Muenster-type below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 7:10:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">---------, The Münster-type below-elbow socket, an evaluation, Artif. Limbs 8:2:4-14, Autumn 1964. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hart-mann, and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs 9:2:4-25, Autumn 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Pellicore, Raymond J., Experiences with the Hepp-Kuhn below-elbow prosthesis: a preliminary report, Inter-Clinic Inform. Bull. 3:11: 1-8, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Sammons, Independent-control harnessing in upper-extremity prosthetics, Artif. Limbs 7:1:11-16, Spring 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Clarke, Susan, Carole Kral, and Julie Shaperman, Built-in wrist flexion for children's prostheses, Inter-Clinic Inform. Bull. 9:5:1-7, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Santschi, William R., (Ed.), Manual of Upper Extremity Prosthetics, 2nd ed. rev., University of California, Los Angeles, 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">McWilliam, R., and S. R. Montgomery, Artificial arms—are they practical?, Med. Biol. Illus. 19:4:200-201, 1969. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Mitchell, C. Leslie, Amputation and prosthesis: past research and future needs, Clin. Orthop. no. 37:110-112, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">VanDerwerker, Earl E., Jr., and Josef Rosen-berger, A simple flexor assist for below-elbow prostheses, Inter-Clinic Inform. Bull. 3:1:1-3, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, part I, Artif. Limbs 8:1:28-43, Spring 1964. </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">---------, Acceptability of a functional-cosmetic artificial hand for young children, part u, Artif. Limbs 8:2:15-27, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Gorton, Ann, Field study of the Muenster-type below-elbow prosthesis, Inter-Clinic Inform. Bull. 6:8:8-10, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Carroll, Leila, Sizing and prehension forces of Dorrance voluntary opening devices, Inter-Clinic Inform. Bull. 2:9:7-10, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Contini, Renato, Engineering in medicine, Bull. Pros. Res. 10-8:4-19, Fall 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Veterans Administration Prosthetics Center research report, Bull. Pros. Res. 10-12:331-333, Fall 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Peizer, Edward, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-6:257-260, Fall 1966. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Semiannual report, Bull. Pros. Res. 10-3:135-136, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 113.</b> </td><td class="clsTextSmall">---------, Semiannual report, Bull. Pros. Res. 10-4:157-159, Fall 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brooks, Milo B., and Julie Shaperman, Infant prosthetic fitting: a study of the results, Amer. J. Occup. Ther. 19:6:329-334, Nov.-Dec. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Edelstein, Joan E., News notes, Inter-Clinic Inform. Bull. 9:4:15-16, 1970. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">MacNaughtan, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy 52:201-203, June 1966. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">Swanson, Alfred B., Phocomelia and congenital limb malformations: reconstruction and prosthetic replacement, Amer. J. Surg. 109:294-299, Mar. 1965. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">---------, A comparison of two infant terminal devices, Inter-Clinic Inform. Bull. 3:7:1-6, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>116.</b> </td><td class="clsTextSmall">Watkins, Arthur L., and Dorothy E. Ford, Rehabilitation after amputation of an upper extremity: a ten year study, Arch. Phys. Med. Rehabil. 43:293-296, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Dean, Carleton, Prosthetic Devices for Children with Emphasis on Fitting Upper Extremity Amputees, Michigan Crippled Children Commission, Lansing, Mich., ca. 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, Cosmesis: can it be defined?, Inter-Clinic Inform. Bull. 5:10:4-9, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">---------, Veterans Administration Prosthetics Center research, Bull. Pros. Res. 10-10:270, Fall 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">Teska, Ann, and Chester A. Swinyard, Evaluation of a standardized test for child's APRL-Sierra no. 1 hand, Amer. J. Occup. Ther. 15: 17-18, Jan.-Feb. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ritter, Diane, and Fred Sammons, An interesting terminal device modification, Inter-Clinic Inform. Bull. 4:9:7-10,19, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b> 120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>121.</b> </td><td class="clsTextSmall">---------, The prosthetics and orthotics program, Artif. Limbs 14:2:1-18, Autumn 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The challenge of replacing human parts and functions, Bull. Pros. Res. 10-3:4-19, Spring 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Hile, John, Below-elbow harness without axillary loop, Inter-Clinic Inform. Bull. 6:5:7-8, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">O'Shea, Barbara, A chest strap harness for the below-elbow child amputee, Inter-Clinic Inform. Bull. 6:7:1-4, 18, 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Friedmann, Lawrence W., Rehabilitation of amputees, in Rehabilitation and Medicine— 1968, ed. Sidney Licht, Waverly Press, Baltimore, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Kruger, Leon M., and Nicholas R. Breyan, A study of radial-head dislocation in children with transverse partial hemimelia of the upper limb, Inter-Clinic Inform.Bull.10:1:1-4, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, in Selected Articles from Artificial Limbs, Robert E. Krieger Publishing Co., Huntington, N.Y., 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Finley, F. Ray, Roy W. Wirta, and Kevin A. Cody, Muscle synergies in motor performance, Arch. Phys. Med. Rehabil. 49:655-660, Nov. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">Stoner, Emery K., Functional evaluation of the upper extremity, in Handbook of Physical Medicine and Rehabilitation, ed. Frank H. Krusen, Frederick J. Kottke, and Paul M. Ellwood, Jr., W. B. Saunders, Philadelphia, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Boivin, G., Nothing like the human hand, Inter-Clinic Inform. Bull. 7:4:17-19, 22, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">---------, Peer group attitudes toward the amputee child, J. Soc. Psychol. 61:127-132, Oct. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>117.</b> </td><td class="clsTextSmall">Weinstein, Sidney, and Eugene A. Sersen, Phantoms in cases of congenital absence of limbs, Neurology 11:905-911, Oct. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Simmel, Marianne L., The absence of phantoms for congenitally missing limbs, Amer. J. Psychol. 74:467-470, Sept. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Centers, Louise, and Richard Centers, A comparison of the body images of amputee and non-amputee children as revealed in figure drawings, J. Project. Techn. 27:158-165, June 1963. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">---------, Congenital anomalies of the limbs: part u, psychological and educational aspects, Canad. Med. Assoc. J. 91:3:115-119, July 18, 1964. </td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Hebert, Bernard, the psychological implications of traumatic amputation in children, Inter-Clinic Inform. Bull. 7:4:7-10, 21, 1968. </td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Hoover, Roy M., Problems and complications of amputees, Clin. Orthop. no. 37:47-52, Nov.-Dec. 1964. </td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human Limbs and Their Substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">Taylor, Isabelle Wagner, Psychological needs of the handicapped child, Inter-Clinic Inform. Bull. 9:8:9-17, 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">McCollough, Newton C., Interpersonal problems of the handicapped child, Inter-Clinic Inform. Bull. 4:11:1-4, 16, 1965. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">Steele, Shirley, Children with amputations, Nurs. Forum 7:411-423, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Observations and findings concerning upper-extremity prosthesis wearers, Inter-Clinic Inform. Bull. 3:8:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Gesell, Arnold, and Catherine S. Amatruda, Developmental Diagnosis: Normal and Abnormal Child Development, 2nd ed. rev., Harper and Row, New York, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Mongeau, M., G. Gingras, E. D. Sherman, B. Hebert, J. Hutchison, and C. Corriveau, Medical and psychosocial aspects of the habilitation of thalidomide children, Canad. Med. Assoc. J. 95:390-395, Aug. 27, 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Janelle, Claire, The role of the social service worker in the rehabilitation of the juvenile amputee, Inter-Clinic Inform. Bull. 7:4:20-21, 1968. </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Stanek, William F., Orthopedic service at children's hospital: the amputee center, Rocky Mountain Med. J. 63:54, Oct. 1966. </td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Brooks, Milo B., Lila L. Beal, H. Lorraine Ogg, and Berton Blakeslee, The child with deformed or missing limbs: his problems and prostheses, Amer. J. Nurs. 62:11:88-92, Nov. 1962. </td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Brooks, Milo B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Inform. Bull. 4:11:7-15, 1965. </td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Cohen, Pauline C, Impact of the handicapped child on the family, Social Casework 43:137-142, Mar. 1962. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Wallace, Maxine T., Group therapy for parents of congenital amputees, Inter-Clinic Inform. Bull. 5:2:10-14, 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">Swinyard, Chester A., Kay Perfect, George G. Deaver, and Leon Greenspan, Counseling parents of children with congenital deformities of the limbs, Inter-Clinic Inform. Bull. 3:6:1-4, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputation, in Psychological Practices with the Physically Disabled, ed. James F. Garrett and Edna S. Levine, Columbia University Press, New York, 1962. </td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Gouin-Decarie, Therese, The mental and emotional development of the thalidomide children and the psychological reactions of the mothers: a follow-up study, Inter-Clinic Inform. Bull. 7:4:1-6, 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Lineberger, Mildred I., Habilitation of child amputees, Journal of the American Physical Therapy Association 42:6:397-401, June 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Campbell, Harry E., and Julie Shaperman, Prosthesis costs for the unilateral below-elbow child amputee, Rehab. Lit. 26:305-307, Oct. 1965. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Epps, Charles J., Jr„ and Frances E. Bren-necke, Juvenile amputee program, Med. Ann. D. C. 31:295-297, May 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Sokolow, Jack, Management of the amputee in practice, Med. Clin. N. Amer. 53:3:659-664, May 1969. </td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Vitali, Miroslaw, Management of congenital deformities, including thalidomide children, in Great Britain, Inter-Clinic Inform. Bull. 2:7:7-12, 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>119.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., Limb prosthetics— 1967, Artif. Limbs 11:1:1-46, Spring 1965. </td></tr><tr><td class="clsTextSmall"><b>120.</b> </td><td class="clsTextSmall">---------, Limb prosthetics —1970, Artif. Limbs 14:1:1-52, Spring 1970. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Kay, Hector W., and Sidney Fishman, 1018 Children with Skeletal Limb Deficiencies, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Mar. 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Gehant, Barbara A., Patient Census at Child Amputee Clinics—1968, Prosthetics and Orthotics, New York University Post-Graduate Medical School, Oct. 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Munson, Nancy K., and Clyde M. E. Dolan, Patient Census at Child Amputee Clinics— 1967, Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Davies, Elizabeth J., Barbara R. Friz, and Frank W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull. 9:3:6-19, 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bergholtz, Susan G., Patient Census at Child Amputee Clinics—1969, Prosthetics and Orthotics, New York University Post-Gradu-ate Medical School, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Fletcher, Ian, Artificial limbs, Physiotherapy 52:182-186, June 1966.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Lambert, Claude N., The juvenile amputee, Illinois Med. J. 123:514-517, May 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">Street, Dana M., and Frank Cunningham, Congenital anomalies caused by intra.-uterine bands, Clin. Orthop. no. 37:82-97, Nov.-Dec. 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Glessner, James R., Jr., Spontaneous intrauterine amputation, J. Bone Joint Surg. (Amer.) 45-A:2:351-355, Mar. 1963. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Kempner, Shirlee, Recent articles of interest, Inter-Clinic Inform. Bull. 5:2:19-20, 1965. (Abstract, Recent concepts in the treatment of the limb-deficient child, Cameron B. Hall, Manitoba Med. Rev. 44:552-557, 1964. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton (ed.), The Limb-Deficient Child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Hall, Cameron B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs 10:1:36-51, Spring 1966. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Montero, Jose C, Rehabilitation of the amputee, Mod. Treatm. 5:5:1047-1056, Sept. 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Gingras, G., and C. Corriveau, Modern amputations and prosthetics, Appl. Ther. 9:537, June 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Burtch, Robert L., A study of congenital skeletal limb deficiencies, Inter-Clinic Inform. Bull. 2:7:1-6, 1963. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">---------, The classification of congenital skeletal limb deficiencies: a preliminary report, Inter-Clinic Inform. Bull. 3:1:4-9, 1963. </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Frantz, Charles H., and Ronan O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.) 43-A:8:1202-1224, Dec. 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Barbara L. Sypniewski </b></td></tr><tr><td class="clsTextSmall">This article was prepared as part of an honors project at Russell Sage College - Albany Medical College SChool of Physical Therapy, Troy, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1972_01_020/1972_01_020-01.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management Creator An entity primarily responsible for making the resource Barbara L. Sypniewski * https://staging.drfop.org/files/original/cdc95b02cc47b6ac5a555a1046cadadf.pdf 34ed2a18f8f3439ef880701f80f81b2e https://staging.drfop.org/files/original/ce7a2b7ad0810f0b02370d41250efccc.jpg 3a4c39847e4ec3b9bf8261686abda3a1 https://staging.drfop.org/files/original/634cb539af8eab5253faddc40f6e9d0b.jpg 37149e5deb28bbdda74066f00fe6e09d https://staging.drfop.org/files/original/ea53ec98f51b6dce71f7a77727448ef3.jpg c7ecfa8c1488b9d239aaf61306016d21 https://staging.drfop.org/files/original/679f4b61888358a86e8bf53ae8458619.jpg a163b30fed74ee555cf603bcc30ef8cd https://staging.drfop.org/files/original/9ba53dc99c34b34ebbcf6445256aaa41.jpg 3bf51c3620d99120850d76f06e54d498 https://staging.drfop.org/files/original/b9ce20332f3ef2c5febd1df36e326169.jpg a27393f6213633786a241d9f9c92ce4f 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 http://www.oandplibrary.org/cpo/pdf/1986_02_093.pdf Text Any textual data included in the document <h2>Below-Knee Prosthesis with Total Flexible Socket (T.F.S.): A Preliminary Report</h2> <h5>John Sabolich, B.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Thomas Guth, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Recent efforts in Oklahoma City, and San Diego have borne fruit to a promising new way to fit below-knee amputees. The basic design consists of a thin walled thermo-plastic socket secured in a frame by nylon strapping tape so that most of the socket is left exposed and unsupported (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg"><b>Fig. 1</b></a>). This design, named the Total Flexible Socket (T.F.S.), was conceived out of necessity with a few patients that were so difficult to fit that even aggressive techniques such as multiple transparent diagnostic sockets, alginate injections, total surface bearing modifications, and silicone gel inserts failed to provide a measure of comfort acceptable to them. It was felt that a more unconventional method would have to be implemented. Currently, this technique is being used with most of the geriatric population seen, and with time and experience it is being applied to an ever increasing proportion of the total below-knee amputee population served. Forty or more of these sockets have been fitted over the past five months to patients ranging in age from ten to 89 years with results that were beyond initial expectations. Patient reaction has been extremely positive. Plans are to submit an up-dated article when over 100 documented fittings with the described technique have been accomplished.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg">Figure 1. Medial and lateral views of T.F.S. in an exoskeletal version. Suspension sleeve and cosmetic hose rolled down for clear view of socket secured in place with band of fiberglass tape.</a></strong><br /> <p>The idea for the T.F.S. design was prompted during the course of fitting a patient with a flexible diagnostic test socket. The patient was comfortable in this socket even when bearing his full weight on a padded fitting stool. Subsequently, when a full socket receptacle for the test socket was laminated and it was rigidly contained, this comfort was lost. The patient still complained of pressure even when holes were cut out over bony prominences.</p> <p>Finally, when the maximum amount of material was cut away and the former socket receptacle was reduced simply to a means of attaching the socket to the rest of the prosthesis, thus allowing the socket to return to its former measure of flexibility, comfort was regained.</p> <p>Several interesting phenomenons were noted:</p> <ol> <li> <p>Since the T.F.S. design is totally flexible, allowing ML as well as AP expansion and retraction, the socket finds and seeks its own level of pressure distribution. If the AP is too tight, it automatically expands, causing the ML to tighten up, wrapping around the tibial flare and the fibula. This, of course, is not true when a receptacle is only opened up over bony areas allowing no reciprocal ML-AP displacement and minimal flexibility, even over bony areas. With the T.F.S., if the ML is too tight, then the AP automatically tightens as the ML loosens, and vice-versa if the AP is too tight (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg"><strong>Figure 2. Transverse view of a socket cross section showing, in an exaggerated fashion, the reciprocal AP-ML displacement.</strong></a></li> <li> <p>The AP-ML "Milking" action seems to have a positive effect on circulation since the residual limb seems palpably warmer when a T.F.S. is removed, as compared to when a rigid socket is used. In the case of flexible sockets thinner than 3/32 inches thick, the entire socket moves with the residual limb, seeming to expand and contract due to the open nature of the frame. This phenomenon can be felt better than seen by holding the socket as the patient alternately places weight on the prosthesis and removes it, especially after the socket warms up to body temperature. This dynamic socket movement and improved circulation could be very significant for the geriatric P. V.D. patient. This action also seems to enhance atmospheric suspension: when the patient removes weight, the socket collapses and grips the residual limb like the familiar childhood toy, a Chinese fingertrap.</p> </li> <li> <p>Atmospheric Suspension (A.S.) assorted methods of achieving suction suspension for the below-knee amputee have been tried for years, with varying degrees of success. The main reason behind this effort is the desire to solve the number one problem of the below-knee amputee, that of skin shearing and pistoning between the residual limb and socket. Another major problem has been that of the patient wanting a lighter weight, more responsive prosthesis. With the T.F.S.A.S. combination, most patients have been responding favorably with such comments as "It feels like my own leg!" and "It feels like part of me!" With atmospheric suspension, the patient no longer needs to wear a suspension sleeve to maintain full suction. The Total Flexible Socket holds suction better than a rigid socket because the socket can move and conform to the changing contours of the residual limb, through all phases of gait and sitting. A loose elastic knee cage is recommended to enhance proximal brim seal during knee flexion past 90°. For sports prostheses, use of a rubberized sleeve of choice is recommended. Cosmesis is also enhanced since the patient no longer has the extra bulk of socks or inserts increasing calf circumference. It's a little too early to tell, but it is felt that atmospheric suspension may well become the standard below-knee fitting technique for all types of patients.</p> </li> <li> <p>Use of a cuff suspension strap is improved since the cuff and socket brim can contour in about the patella (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg"><b>Fig. 3</b></a>). Use of a suspension sleeve with the T.F.S. is also possible, and if anything, enhances the function of a T.F.S. since the suspension sleeve supports the socket brim and soft tissues, holding the two in close conformity through the full range of knee motion.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg"><strong>Figure 3.</strong></a></li> <li> <p>Flexibility allows greater containment posteriorally in the popliteal region. The posterior wall can be higher since it flexes away during sitting. Little posterior flare is needed. In fact, this area could be rolled in slightly, similar to how the cubital fold is contained in myoelectric below-elbow arms (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg"><b>Fig. 4</b></a>). If the practitioner desires, the socket can be made flexible all the way down to the distal tibia. This is accomplished by building a thick distal end pad (with or without an insert) inside the socket, or an extension on the exterior of the socket which extends the trimline of the frame distally, allowing total flexibility in the distal regions of socket.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg"><strong>Figure 4. Lateral view of T.F.S. showing suggested modified contour.</strong></a></li> <li> <p>The ML measurement of the knee becomes wider as the knee flexes. This can be demonstrated by placing an ML gauge on the knee and watching the gauge as one puts the knee through its range of motion. The T.F.S. design allows for this dynamic variance.</p> </li> </ol> <p>Last but not least, overall hygiene and circulation seem to be dramatically improved. Especially impressive is the absence of red marks on the skin following doffing of the T.F.S. There are none of the usual red marks left by conventional sockets. Patients who had to have many reliefs before in their rigid sockets now require none.</p> <p>Since several prosthetists have been fitting these sockets successfully, using various modification techniques, it has been concluded that it is irrelevant which particular modification technique is used. Results from all modification techniques have been improved utilizing the Total Flexible Socket. The use of negative modifications only is recommended. One simply does not need to add positive build-ups to the model since the reciprocal AP-ML displacement dynamically accommodates the patient's anatomy. The bony areas are accommodated automatically (most of the time) as the patient ambulates. It is, of course, most exact to use multiple transparent diagnostic sockets, alignate, or oil injection procedures (as well as other means) to obtain the best fit possible.</p> <p>The flexible socket seems to work so well that it is tempting to skip the check socket stage. Do not succumb to this temptation, or you will never know just how comfortable the socket can be once you get the patient fairly comfortable in the rigid transparent socket and clone it to the T.F.S.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg"><b>Diagram</b></a></p> <br /> <p>After the hard socket is fit, it is necessary to remove an additional 1/4" to 3/8" of plaster from the positive model around the superior brim, close to the patella, to allow a flexible clamping action about the proximal brim. Use of this extra modification can not be emphasized enough for final comfort and stability. An intimate fit must be maintained around the proximal brim with the T.F.S. design. No other additions or modifications are necessary.</p> <p>If a liner or insert is used, it is fabricated over the positive model with a thick distal end pad to provide extra distance distally. This extra length is necessary if one desires to make the distal tibia area flexible since the frame can be trimmed more distal, even past the end of the distal tibia. Alternately, as mentioned, an extension can be added to the socket following vacuum forming.</p> <p>One can use any of four materials for the flexible part of the socket: The first is Surlyn,® which is preferred in most cases. This material can be molded fairly thin, and yet it provides excellent structural strength and integrity. Surlyn® stock material of 1/8"-3/16" thick is used (depending on the degree of flexibility) for vacuum forming. A final thickness of about 1/16" or less is adequate. It is not necessary for this socket to be extremely flexible, as with a fenestrated socket, since the majority of the socket is open and flexible in all directions with two adjacent sides being able to move relative to the frame.</p> <p>The second material is polyethylene, which is more flexible and sometimes more desirable for children or geriatrics who are somewhat inactive. The third is Streifylast, which is a material that is being utilized more and more lately since it has a high level of flexibility while maintaining its structural integrity, and is especially resistant to tearing and breakage. A fourth material called Polyethylene Plus® (available through Maramed) seems to be superior even to Streifylast and has an extremely good tear resistance.</p> <p>Once the socket is vacuum formed, a fiberglass nylon polyester frame is fabricated. Carbon fiber and acrylic resin can be used, if one desires greater strength and less weight, but is not necessary in most cases. The thickness of this frame depends on the activity level of the patient, but usually ranges in thickness from 1/16" to 1/8".</p> <p>As in<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg"> <b>Fig. 5</b></a><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg"><b></b></a>, there are two basic frame designs: one for geriatrics, and one for active or sports oriented patients. The geriatric type extends proximally to the medial tibial flare and is cut away everywhere else except around the distal end pad (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg"><b>Fig. 6</b></a>). The sports type frame for younger patients comes more proximal pos-teriorally, lending more strength. It maintains total AP-ML flexibility since it still has only two sides adjacent to each other. As long as one does not place a third wall on the frame, reciprocal AP-ML flexibility is preserved and provides for automatic pressure distribution. It must be emphasized that these are only guidelines and the actual trimlines of the frame are variable and modified as the patient's needs dictate.<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg"><strong>Figure 5. Four views of the T.F.S. showing sports and geriatric trimlines and distal end pad or buildup. Distal buildup is especially useful when it is desired to cut the anterior trimline below the distal tibia.</strong></a></p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg"><strong>Figure 6. T.F.S. showing geriatric trimline. Ultralite construction.</strong></a><br /> <p>The flexible socket can be attached to the rest of the prosthesis by using two or three bands of nylon fiber tape wrapped circumferen-tially about the frame and socket to provide strength, while not affecting flexibility. If one desires even more strength, pressure sensitive tape can be wrapped over the nylon tape or even over the whole frame and socket. The socket can be riveted or fastened with Chicago screws in addition to the tape, for additional security.</p> <p>The final finishing of the prosthesis is relatively simple. If an endoskeletal approach is used, the soft foam cover hides the socket frame interface as well as the nylon strapping tape and results in a very cosmetic prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg"><b>Fig. 7</b></a>). The T.F.S. prosthesis finishes especially well as an endoskeletal since it feels more life-like all the way up the prosthesis. If one desires an exoskeletal finish, one can easily use polyurethane foam for shape, laminate the outer covering, remove the flexible socket, and grind the foam away from around the frame and cosmetic shell as desired. This leaves a void or hollow of about 1/8" (all that is necessary) between the flexible socket and cosmetic shell. Alternately, the prosthesis can be shaped and finished about the socket in the same fashion as an endoskeletal prosthesis. The proximal external contours can then be established with a soft fairing of PE-LITE® or Plastazote glued to the flexible socket and frame.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg"><strong>Figure 7. T.F.S. with soft cosmetic covering.</strong></a><br /> <p>Fabrication of an Atmospheric Suspension Socket is the same as for any T.F.S., except for the placement of either an expulsion valve or a small suction valve on a 45° angle at the distal posterior of the total flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg"><b>Fig. 8</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg">Figure 8. T.F.S.-A.S. showing placement of valve distally</a>.</strong><br /> <p>Modification on the other hand, is a little different than a non-atmospheric suspension T.F.S. The socket must be a little snugger to accommodate total self-suspension. After achieving the "perfect skin fit" with a clear diagnostic socket and the alginating procedures, the model is poured and modified the same as any T.F.S. by slightly tightening it about the patella area. The technician then takes the modified model and laminates a two layer cotton rigid socket over it, which is rolled or slushed twice with promoted liquid polyester resin to tighten all areas of the socket equally. This socket, with reduced internal dimensions, is then poured with plaster of Paris and the T.F.S. socket is subsequently vacuum formed over the resulting positive model. It is felt that this extra tightening is necessary to compensate for the fact that a rigid diagnostic socket cannot be donned as easily as a T.F.S. of equal or greater tightness.</p> <p>In conclusion, a new concept for the fabrication of a below-knee prosthesis has been described, as well as the preliminary results of fitting some 40 patients for up to five months. It is sincerely hoped that other prosthetists will find it as beneficial to their patients as it has been found to be in both Oklahoma City and San Diego.</p> <h3>Acknowledgments</h3> <p>We would like to thank one of our own prosthetists, Bill Etheridge in Oklahoma City for forcing John out of conventional thinking so we could aggressively research this interesting phenomenon.</p> <p>We would like to thank Mary Healy, San Diego, for her help in Atmospheric Suspension Technique.</p> <p>We also wish to thank Alan Finnieston, CPO for materials research and for finding an appropriate tear resistant thermoplastic.</p> <b><b>Thomas Guth, CP.<br /></b></b><em>Thomas Guth, CP is Secretary Treasurer at RGP Orthopedic Appliance Company, 6147 University Avenue, San Diego, California 92115.</em><b><b><br /><br /></b></b><b>John Sabolich, B.S., C.P.O.</b><br /><em>John Sabolich, B.S., CPO is with Sabolich, Inc. at 1017 N.W. 10th Street in Oklahoma City, Oklahoma 73106.</em> Page Number(s) 93 - 99 Year 1986 Volume 2 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_02_093/1986_02_093-09.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review 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 Below-Knee Prosthesis with Total Flexible Socket (T.F.S.): A Preliminary Report Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * Thomas Guth, CP. * https://staging.drfop.org/files/original/465b011652d5a340194157a65a7ec6cc.pdf 058afa0a050515ba9cadcbbbe5bbdcbc https://staging.drfop.org/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg fb35416caeea9a249029aa892a41fa14 https://staging.drfop.org/files/original/f48d51f3218c758f4338e50f0b689234.jpg fabaf7cea0b1796ff8316615aabb3e95 https://staging.drfop.org/files/original/812c173d343ffad067c6c208af011518.jpg e1dad0e0174b7d66a96d04ede66f5469 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 http://www.oandplibrary.org/cpo/pdf/1984_04_024.pdf Text Any textual data included in the document <h2>Rochester Parapodium</h2> <h5>Edwin Kinnen, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Martha Gram, P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Kenneth V. Jackman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Franklin V. Peale, M.D., P.C.&nbsp;<a style="text-decoration: none;">*</a><br />P.W. Haake, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Gerald A. Tindali, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />James A. Brown, O.P.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The Biomechanics Team at the University of Rochester Medical Center has been developing and testing design modifications to the Toronto parapodium since 1975. Early in 1983, these design modifications had stabilized, and prototypes of the new design were offered to medical centers and orthopedic laboratories in the United States and Canada. The Rochester parapodium has now been fitted to over 80 young children of ages 17 months to 14 years. Most of these children have flaccid paralysis due to spina bifida or spinal injury from L5 to T12.</p> <p>The Rochester parapodium differs from the Toronto design in the hip and knee hinge and locking mechanisms. The hip joints unlock together with a single lever release and lock automatically on extension. The hip joints unlock with a forward motion and have no lateral projections, which allows ease in releasing hip lock in a confined space such as a wheelchair. The knee joints also unlock independent of the hip joints with a second single lever release and lock automatically on extension with the aid of an extension assist bar.</p> <p><b><a href="/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg">Figure 1</a>: The hip joints unlock independent of the knee joints.</b></p> <p>Without lateral projections, rolling is easier for the child who applies the orthosis sitting or in the supine position on floor, then rolls to prone position in order to elevate to a standing posture. This separated locking and unlocking action has simplified many everyday activities for the paraplegic child.</p> <p>With increased control, the child can become independent in sitting and standing from a chair with arms. He can also bend over to pick up objects from the floor with hips flexed and knees locked. These are important functions for a preschooler exploring his or her surroundings and participating in peer group activities.</p> <p><b><a href="/files/original/f48d51f3218c758f4338e50f0b689234.jpg">Figure 2</a>: Both joints unlock with a pull of a lanyard.</b></p> <p>Previously, children wearing the parapodium had to get up from a prone position on the floor by pulling to standing with fully extended knee and hip joints. Now a child can use jackknife-like movements to stand. These movements appear to require much less energy and open the activity to children with higher levels of paralysis.</p> <p>The lateral supports have also been redesigned for the Rochester parapodium, using bar stock instead of tubular sections. These flat lateral supports facilitate rolling, a very important movement for a child who is independent in dressing and changing positions. The new side bar design, a more rigid construction, also improves the child's momentum during swivel walking. With polypropylene added to the bottom of the base, many children can learn to swivel-walk at functional speeds, with hands free.</p> <p><b><a href="/files/original/812c173d343ffad067c6c208af011518.jpg">Figure 3</a>: A child can bend over to pick up objects with hips flexed and knees locked.</b></p> <p>The activities now possible with the new design allow the paraplegic child to function at home and in school with relatively little need for adult supervision or assistance.</p> <p><i>Partial support for this work has been provided by the J.M. McDonald Foundation, Cortland, New York.</i></p> <em><b>James A. Brown, O.P.A. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em><br /> <div style="width: 400px;"><em><b><br />Gerald A. Tindali, C.P.O. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em></div> <div style="width: 400px;"></div> <div style="width: 400px;"><em><br /><b>P.W. Haake, M.D. </b> 220 Alexander Street, Rochester, New York 14610</em></div> <div style="width: 400px;"><em><b><br />Franklin V. Peale, M.D., P.C. </b> 220 Alexander Street, Rochester, New York 14610.</em></div> <div style="width: 400px;"><br /><em><b>Kenneth V. Jackman, Ph.D. </b> Associate Professor of Pediatric Orthopedics, University of Rochester, Rochester, New York 14642.</em><br /><br /></div> <div style="width: 400px;"><em><b>Martha Gram, P.T. </b> Dept. of Pediatrics, University of Rochester, Rochester, New York 14627.</em></div> <div style="width: 400px;"><br /><em><b>Edwin Kinnen, Ph.D. </b> Dept. of Electrical Engn, University of Rochester, Rochester, New York 14627.<br /><br /><br /></em></div> Page Number(s) 24 - 25 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-3.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 Rochester Parapodium Creator An entity primarily responsible for making the resource Edwin Kinnen, Ph.D. * Martha Gram, P.T. * Kenneth V. Jackman, Ph.D. * Franklin V. Peale, M.D., P.C. * P.W. Haake, M.D. * Gerald A. Tindali, C.P.O. * James A. Brown, O.P.A. * https://staging.drfop.org/files/original/b3bb30209b6e347e141d9887fbe0dd84.pdf 8fe2d7fe613164fa18efa52b86f36da9 https://staging.drfop.org/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg 0fe31995eb047f4d749816ffeec36e4c https://staging.drfop.org/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg a27208224d59514e3a6eaab581dc3c90 https://staging.drfop.org/files/original/4af954f59f49c76eabdab685dc5eab40.jpg 319799db788cc6ab393c7443e79399a0 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 http://www.oandplibrary.org/cpo/pdf/1984_04_026.pdf Text Any textual data included in the document <h2>Orthotic Pelvis Control in Spina Bifida</h2> <h5>H.R. Lehneis, Ph.D., C.P.O.&nbsp;</h5> <p>Control of the pelvis has been typically problematic in high level spina bifida patients due to the imbalance of motor power around the hip joint. This can be readily appreciated when one considers the differential innervation particularly of the hip flexors versus the hip extensors (<b>Table 1</b>). Note that the hip flexors are at least partially innervated at the L2 and L3 level, whereas the hip extensors are innervated below the L3 level. Such imbalance at the L2 and L3 level of involvement is the cause of lordosis so often seen in these patients, which is often aggravated by hip flexion contractures. Control of the pelvis and thus lordosis has been difficult with conventional designs.</p> <strong>Table 1. Innervation of the Lower Limb</strong><br /><img src="/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg" p="" width="469" height="684" /><br />In analyzing the force system required to prevent hip flexion and thus lordosis, it becomes clear that the rigid portion of the pelvic band needs to be reversed from the conventional location (<a href="/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg"><b>Fig. 1</b></a>). It should be noted that this consists of a plastic molded Subortholen panel which extends superiorly to the level of the xyphoid process. The uprights of the hip joints are attached to this panel. An anteriorly directed force is provided by a leather hammock covering the buttocks (<a href="/files/original/4af954f59f49c76eabdab685dc5eab40.jpg"><b>Fig. 2</b></a>). Straps attached on each of the four corners of the hammock run through D rings, attached equi-distant above and below the orthotic hip joint center. This system has worked quite effectively in controlling lordosis since first initiated approximately five years ago. <p>In cases where the patient presents a relatively severe hip flexion contracture, the hip joint uprights are attached to the panel by means of a single pivot placed approximately 5 cm. below the lateral trim line of the panel. By gradually tightening the straps of the buttock pad, some correction can often be achieved. The pivot allows the anterior panel to adapt to the changing angulation as correction is attempted.</p> <p>It should also be noted that in our practice, patients up to the age of approximately six years old are provided with solid ankles and knees since their legs are still short enough to sit through hip flexion without obstructing much of the space in front of the chair. The purpose of this is to provide the patient with maximum stability and lightweight orthoses. As the patient gains upper limb strength and mobility, knee joints with drop locks are added, usually of the lateral single bar type. Double bars are only used when the patient is relatively heavy and when there is a torsional problem in the orthosis. The ankle-foot portion of the orthosis remains of the solid ankle type to provide the largest possible base of support over which the patient's center of gravity can be maintained with a greater degree of latitude than is possible if orthotic ankle joints were to be used.</p> <h3>Acknowledgment</h3> <p>The assistance of Barry Gosthnian, CPO in developing the system described is gratefully acknowledged.</p> Page Number(s) 26 - 28 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-3.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-2.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 Orthotic Pelvis Control in Spina Bifida Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., C.P.O.  https://staging.drfop.org/files/original/1bc3249b9871bf77d6deaebeec0f9573.pdf 062b6087654766cc1458acca6e7a8016 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 http://www.oandplibrary.org/cpo/pdf/1984_04_028.pdf Text Any textual data included in the document <h2>Technical Note: Rigid A.F.O. - Another Choice</h2> <h5>Robert E. Doran, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>When an orthotic prescription calls for an ankle/foot orthosis to provide rigid ankle/foot stabilization, the two basic choices have been (1) a double bar metal orthosis or (2) a thick and/or reinforced thermoplastic orthosis. We are all familiar with the advantages and disadvantages each has to offer.</p> <p>It was this author's goal to design a rigid A.F.O. that would combine the advantages of both. The features of such an orthosis should include light-weight construction; provide rigid ankle stabilization; provide adjustable plantar and dorsiflexion in order to dynamically align the orthosis; fit inside the shoe; be cosmetically acceptable; be easily donned; and maintain alignment while changing heel heights.</p> <p>With the above in mind, the following orthosis was designed. The orthosis consists of "pre-preg" (the resin is impregnated in the matrix in an uncatalyzed form prior to lay-up, generally at the factory. Once the desired lay-up is achieved, the structure is exposed to a catalyzing agent so that it hardens), carbon-fiber and fiberglass fabric. Epoxy and polyester resin have been used as bonding agents and the orthosis is formed over a plaster model of the patient's leg. Such pressure applying agents as vacuum bags and pressure wraps have been used. The carbon fiber and fiberglass fabric are properly oriented to resist the stresses imposed upon the orthosis and comprise a structure that provides a high strength to weight ratio.</p> <p>The orthosis has a foot section which begins on the plantar aspect of the foot and extends proximally on the medial and lateral sides of the leg. The "uprights" are connected by adjustable velcro-closing calf straps. Plantar and dorsiflexion adjustments are independently achieved by adjusting the anterior and posterior velcro-closing calf straps.</p> <p>In some cases, donning is simplified by removing the posterior strap, thus allowing for a posterior entry of the foot and leg into the orthosis and shoe.</p> <p>Over the past eighteen months, nine patients with diagnoses that include low level paraplegic, C.V.A., and neuromuscular disease have been fitted with the graphite composite A.F.O. as a successful alternative to "traditional" orthoses.</p> <p>Orthotists now have another choice when designing a rigid ankle foot orthosis for their patients. The graphite composite A.F.O. combines some of the advantages of the standard metal and thermoplastic constructed A.F.O.</p> <b>Robert E. Doran, C.P.O. </b> Thousand Oaks Prosthetic Orthotics, 253 Lombard Street, Suite C, Thousand Oaks, California 91360.<br /><br /><br /> <div style="width: 400px;"></div> Page Number(s) 28 - 28 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Rigid A.F.O. - Another Choice Creator An entity primarily responsible for making the resource Robert E. Doran, C.P.O. *