4 20 371 https://staging.drfop.org/files/original/a962e11e32431a447a3ce708cbc2efbd.pdf e6d793879e49c2715fac7901c9ab48ab DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_034.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 34 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_034.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_034.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Review of Visual Aids for Prosthetics and Orthotics</h2> <h5></h5> <h4>Prosthetics (General)</h4> <p><i><strong>"A Day in the Life of the Amputee," Hosmer-Dorrance, 1955, 26 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents a bilateral upper-extremity amputee as he performs a number of activities related to self-care, work, and recreation. These include fishing, bowling, gardening, dressing, eating, playing pool, driving a car, and lighting a cigarette.</p> <p><i>Evaluation: </i>A technically well-executed film of a man who has acquired unusual skill in the use of the prostheses. It is recommended for upper-extremity amputees and for professional groups who wish to become familiar with the potential accomplishments of this type of amputee. Essentially, its purpose appears to be to encourage upper-extremity amputees to use prostheses and to develop maximal skill in their use.</p> <p><i>Distributor: </i>A. J. Hosmer Corporation, P. O. Box 37, Campbell, Calif. 95008.</p> <p><i><strong>"A Triple Amputee Steps Out," U.S. Veterans Administration, 1964, 25 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Shows the rehabilitation of a male adult with an above-knee amputation on one side, a below-knee amputation on the other, and a unilateral above-elbow amputation. The patient also suffers from heart and kidney complications that add to the difficulty of rehabilitation. Preprosthetic exercises and balancing activities are followed by ambulation with stubbies and, finally, with permanent prostheses and crutches.</p> <p><i>Evaluation: </i>The level of rehabilitation for this severely involved patient appears unrealistic; and, although he finally ambulates, the gait is labored and unsteady. Use of the upper-extremity prosthesis, which would seem a more useful activity for this patient, is not discussed. This film has little place in paramedical teaching and would be of interest only to note the accomplishments of this unusual and highly motivated amputee.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Diary of a Sergeant," U.S. War Department, 1945, 22 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>The story of a soldier (Harold Russell) who, having lost both arms during World War II, wages a determined and successful fight to achieve success in the use of artificial limbs and to establish himself as a useful member of society.</p> <p><i>Evaluation: </i>An excellent film for its era. It has lost much of its value, however, through the passage of time and today is primarily of historical interest. It deals with the emotional trauma involved in loss of arms and portrays the courage required by an amputee to achieve his rehabilitation goals. For these reasons, the film may still serve a purpose when used to motivate discouraged upper-extremity amputees or when shown to groups concerned with the emotional impact caused by crippling disease or injury.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Dynamic Exercises for Lower-Extremity Amputees," U.S. Veterans Administration, 1959, 10 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Reviews normal gait and the relationships of body segments during walking. Following the physician's examination of the above-knee stump, the amputee patient demonstrates a series of dynamic exercises to develop balance, coordination, and strength. These exercises are part of a physical-therapy program that prepares the amputee to meet daily functional demands. Several amputee gaits are demonstrated.</p> <p><i>Evaluation: </i>This is a large order for a ten-minute film, particularly since it goes beyond the scope of the title. The exercises <i>per se </i>are excellent, but the rate at which they are presented limits the use of the film as a teaching device. A patient-to-patient type of teaching contributes to some worthwhile scenes. The film is considered useful for those who are previously oriented in the techniques of dynamic exercises and who are experienced in working with amputees.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Gait Analysis," Northwestern University Medical School, 1961, 27 min., color, sound, 16 mm.</strong></i> <a style="text-decoration:none;">*</a></p> <p><i>Summary: </i>Demonstrates the most common gait defects that may be seen in an above-knee amputee, including circumduction, abduction, vaulting, medial and lateral whips, instability of the knee, long prosthetic step, and others. The defects are shown on a subject wearing an adjustable above-knee prosthesis and are described in detail, then discussed as to possible causes, considering the amputee, the stump, and the prosthesis. Demonstrates a normal gait so that comparison between normal and abnormal gait can be made. The narration is conducted by a physician, a prosthetist, and a physical therapist, all faculty members of the Prosthetic-Orthotic Education Program at Northwestern University Medical School. A pocket-size folder that summarizes the material presented has been prepared for use as a handout at showings.</p> <p><i>Evaluation: </i>This is a valuable teaching film. Ample time is allowed for the viewer to observe each gait deviation, making it possible for him to correlate the movie sequence with the material presented in the booklet that accompanies the film. Recommended for all medical groups concerned with the management of the lower-extremity amputee, including physicians, physical and occupational therapists, nurses, and prosthetists, at both the student and the graduate levels. The amputee patient would also benefit from seeing this film.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00.</p> <p><i><strong>"New Geriatric Prostheses Adaptable to Bilateral Amputees," Waterbury Hospital, Waterbury, Conn., 1964, 10 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes an above-knee prosthesis designed for use by the geriatric patient and points out the advantages of certain modifications over the more conventional "temporary" prosthesis. Demonstrates the use of these prostheses as fitted to a bilateral amputee, a 64-year-old woman.</p> <p><i>Evaluation: </i>This film would be of interest only to those who are dealing with the problems of prescribing, designing, or fabricating prostheses for the geriatric patient. The graphic description of the prosthesis is well presented.</p> <p><i>Distributor: </i>Dr. Sung J. Liao, Director, Department of Physical Medicine and Rehabilitation, Waterbury Hospital, Waterbury, Conn.</p> <p><i><strong>"New Legs," National Council for Care of Cripples, South Africa, 1960, 18 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the case history of a young railway plate-layer who suffered an accident that ultimately resulted in a bilateral hip disarticulation. He is fitted with a pair of prostheses that incorporate double-action hip joints. Following a training program, he is shown walking with prostheses and crutches and participating in many physical activities with and without the prostheses.</p> <p><i>Evaluation: </i>The purpose of this film is to encourage people living in South Africa to support rehabilitation through the purchase of Easter Seal stamps. Perhaps this accounts for the optimistic tone of this technically excellent picture. The amputee is unusually cheerful, physically agile, and well motivated, and his well-planned rehabilitation program is highly successful. This film might be of interest to the patient and family. For paramedical groups it is of interest only to show the potential achievement of one amputee with a bilateral hip disarticulation.</p> <p><i>Distributor: </i>Film Library, International Society for Rehabilitation of the Disabled, 219 East 44th St., New York, N. Y. 10017.</p> <p><i>Rental Fee: </i>$10.00. (No rental fee for members in good standing with the International Society.)</p> <p><i><strong>"Normal Human Locomotion," University of California at Los Angeles, 1965, 3 hr., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>This seven-reel film reproduces a classroom lecture as presented by Cameron B. Hall, M.D., in the UCLA courses in lower-extremity prosthetics. In his presentation, Dr. Hall graphically describes the normal pattern of human locomotion and explains it in terms of pertinent basic principles, including determinants of gait and mechanical forces. The film is printed at a contrast level that permits it to be shown in a partially lighted room, thereby allowing viewers to write on the illustrated lesson sheets provided with the film.</p> <p><i>Evaluation: </i>The film is of special value. It encompasses a difficult subject on the basis of research from voluminous literature, and it is organized in a clear, concise, and understandable manner.</p> <p>No attempt is made to achieve a technically perfect film; it comes "as is" from the classroom. Dr. Hall's teaching methods, which include skillful execution of illustrations, a keen sense of timing, and--most important-a sequential, organized presentation of materials, combine to make this film an excellent teaching device for both students and instructors.</p> <p>The film is highly recommended for any professional person engaged in gait training or concerned with any aspect of human locomotion. Its use in undergraduate programs will vary according to the teaching talents of the faculty members and the curriculum content. If the length precludes showing it in one session, it can be shown in two or three sessions. It is recommended that instructors review the film in order to strengthen their own teaching methods and to determine in what way it can supplement or reinforce instruction in their own particular situation.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00. (The film may be retained by the borrower for a maximum time of two weeks. Requests for the film should indicate the number of lesson sheets desired.)</p> <p><i><strong>"One Step at a Time," Rehabilitation Institute of Montreal, 1963, 15 min., black and white. sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Portrays a unilateral above-knee amputee who is first seen walking with crutches but without an artificial limb. After considerable introspection, this young male decides to be prosthetically fitted. As the story unfolds, it depicts his reaction to the various steps in the rehabilitation program. The three key people responsible for the program-the physician, the physical therapist, and the prosthetist-are presented, and their roles are briefly explained. The prosthetist plays the major role in this film.</p> <p><i>Evaluation: </i>The close-ups, the music, and the general tone of this picture are designed to show the emotional impact on the amputee of the various situations that evolve during the rehabilitation process. The movie is photographically artistic and technically good. Its use to professional people is limited, however, because of the superficial manner in which the material is handled. It appears to be directed toward the layman and especially toward the unfitted amputee.</p> <p><i>Distributor: </i>National Film Board of Canada, 690 Fifth Ave., New York, N. Y. 10019.</p> <p><i>Purchase Cost: </i>$75.00. (Available for review if viewer is interested in purchasing the film.)</p> <p><i><strong>"Physical Therapy Management of a Bilateral Lower-Extremity Amputee," U.S. Army, (PMF 5382), 1964, 32 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Illustrates the progression of physical-therapy procedures in the management of the amputee, following the program from the day preprosthetic stump exercises are initiated until the time skillful use of the prostheses is achieved and the amputee-a military officer-is returned to duty as an instructor. The various procedures include bandaging of the above-knee and below-knee stump, joint measurement, stump exercises, stump hygiene, care of the suction socket, body-strengthening and balancing exercises, gait training and analysis, and advanced functional activities. Also, briefly presented are the principles involved in fitting two types of prostheses, the suction socket and the patellar-tendon-bearing socket.</p> <p><i>Evaluation: </i>The film is technically superior and professionally sound. Of particular interest and worthy of mention are the well-presented progression of exercises, the clear graphic descriptions, the inclusion of training with the patellar-tendon-bearing prosthesis, and the portrayal of the exacting self-discipline required by the patient.</p> <p>Although the rehabilitation team is acknowledged, the film is presented entirely from the physical therapist's point of view. Because of the extensive amount of material in this film, its primary value lies in an orientation to a good physical-therapy program rather than its use in teaching skills. It is recommended for viewing by physical therapists and students, and also by any of the allied medical professions who have an interest in the management of the amputee. New amputees would also appreciate this preview of the treatment program.</p> <p><i>Distributor: </i>Requests for Army Medical Service motion pictures should be directed to the Commanding General, Attn.: Audio-Visual Communication Center, of the Army Area in which the requesting individual or institution is located, as follows: First U.S. Army, Governors Island, N. Y. (includes Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont); Second U.S. Army, Fort George Meade, Md. (includes Delaware, Kentucky, Maryland, Ohio, Pennsylvania, Virginia, and West Virginia); Third U.S. Army, Atlanta, Ga. (includes Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, and Tennessee); Fourth U.S. Army, Fort Sam Houston, Tex. (includes Arkansas, Louisiana, New Mexico, Oklahoma, and Texas); Fifth U.S. Army, 1660 East Hyde Park Blvd., Chicago, Ill. (includes Colorado, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming); Sixth U.S. Army, Presidio of San Francisco, Calif. (includes Arizona, California, Idaho, Montana, Nevada, Oregon, Utah, and Washington).</p> <p><i><strong>"Some Biomechanical Methods for Evaluating Activities," VA Prosthetics Center, 1956, 18 min., color, magnetic sound {requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Shows some of the biomechanical methods used in the laboratory to measure the effectiveness with which both normal and handicapped people can perform various activities. Various photographic, mechanical, and electrical techniques are demonstrated.</p> <p><i>Evaluation: </i>This interesting film deals with research methodology and is, therefore, of interest primarily to individuals engaged or interested in research.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <p><i><strong>"Suction Socket Artificial Limb," U. S. Veterans Administration, 1951, 24 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes the suction-socket prosthesis in terms of the anatomical principles involved in its fabrication and fitting. Presents the indications and contraindications for its prescription, emphasizing the importance of the emotional maturity of the patient. Demonstrates briefly gait abnormalities and training. Also illustrates check-out procedures.</p> <p><i>Evaluation: </i>Although made in 1951, this excellent film is valuable in its presentation of a type of above-knee prosthesis that continues to be widely used. This film is of greatest value to physicians, prosthetists, and physical therapists, both staff and students. As background information, it could be useful for anyone concerned with the management of the above-knee amputee.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <p><i><strong>"The Urban Maes Amputation for Peripheral Vascular Disease," U. S. Veterans Administration, 1956, 14 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates the Urban Maes operative technique of below-knee amputation in a patient with disease of compromised circulations. Shows the healed stump and joint range of motion some weeks later. Also presented are several other patients whose treatment management is similar. Several views of stumps are shown, and the patients are seen ambulating on a temporary pylon as well as on the permanent prosthesis.</p> <p><i>Evaluation: </i>Primarily of value to physicians. Because of its relative simplicity, however, the film would be a good selection to illustrate a well-defined surgical procedure to individuals who have not observed actual surgery.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D.C. 20420.</p> <p><i><strong>"Total Rehabilitation of a Bilateral High Upper-Extremity Amputee" U. S. Veterans Administration, 1959, 30 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Stresses the roles of all members of the rehabilitation team in the management of this amputee. Illustrates the team approach in establishment of the program-examination and supervision by the physician; preprosthetic preparation of the stump and an exercise program by the physical therapist; prosthetic training by the occupational therapist; and vocational guidance by the counselor. Most of the time in this film is devoted to occupational therapy, and the amputee is shown in several learning situations involving functional activities.</p> <p><i>Evaluation: </i>The scenes that show how the patient encounters difficulty in performing normally simple chores and how the patient and the therapist work together to find an efficient method of performance are well presented. Although the film does not attempt to present a step-by-step prosthetic training program, the omission of any reference to solving toilet problems, a real concern with this type of amputee, is unfortunate. The team approach is somewhat overemphasized in the film, particularly insofar as the meetings are concerned. This film has teaching value for occupational therapy students and for occupational therapists who have had limited experience in working with patients with upper-extremity amputations. It may also be useful as an orientation for any paramedical group whose members are concerned with the management of the high upper-extremity amputee.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C, 20420.</p> <p><i><strong>"Upper-Extremity Prosthetics," U. S. Veterans Administration, 1952, 23 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents two veterans, both of whom are upper-extremity amputees. One wears his prosthesis successfully; the other keeps his device in his desk. The film explains the dynamics leading to this difference. The successful patient is portrayed as the recipient of services offered in a well-planned amputee management program. The absence of such a program, together with other deterrent factors, is presented as the cause for the second patient's rejection of his original prosthesis. A program designed to correct his reluctance to wear the prosthesis is outlined.</p> <p><i>Evaluation: </i>This film succeeds in achieving its objectives, as it clearly demonstrates the importance of good technical and psychological management of the amputee patient. It is not recommended as a teaching film, for it is lacking in its portrayal of the ideal training program. It is recommended as a general type film for paramedical groups and for patients who might be resistant to the intensive effort needed to obtain maximal use of the prosthesis.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C. 20420.</p> <p><i><strong>"Upper-Extremity Prosthetic Principles," U. S. Veterans Administration, 1955, 29 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates several interesting activities that were part of a research program aimed at improving upper-extremity prosthetic devices. Of special interest are the demonstration of normal movements of the human hand in a variety of grasping and gripping activities, an analysis of lost movements at various levels of upper-extremity amputation, and the types of upper-extremity prostheses appropriate for specific levels of amputation.</p> <p><i>Evaluation: </i>As far as paramedical groups are concerned, this film is of interest to those who would like to be better informed about the development of prosthetic devices. It could be used to illustrate components of prostheses when these are not available, although it should be remembered that only those prosthetic devices in use prior to 1955 are included.</p> <p><i>Distributor: </i>Central Office Film Library, Veterans Administration, Vermont Ave. and H St., N.W., Washington, D. C. 20420.</p> <h3>Child Prosthetics</h3> <p><i><strong>"Adaptation of Children to Prosthetic Limbs," Michigan Crippled Children Commission, 1960, 20 min., color, optical and magnetic sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents five children, including upper- and lower-extremity amputees, each of whom demonstrates a wide range of physical activities while wearing his prosthesis. The disability of the child and the indicated prosthetic fitting are also presented.</p> <p><i>Evaluation: </i>This film demonstrates well how the artificial limb becomes an integral part of the body image at an early age. The remarkable skill and agility with which these children perform various physical activities are impressive. Some scenes are unnecessarily prolonged and repetitious. The technical quality of the film is not good, and prosthetically it is primarily of historical interest. Of possible interest to parents in demonstrating potential achievement.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Child Upper-Extremity Amputee," University of Michigan Medical Center, 1964, 19 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents ten child amputees and portrays their accomplishments in use of an upper-extremity prosthesis at specified ages, covering a span of several years in some instances. The x-rays of the involved extremities are shown, and a pictorial description of the amputation or limb deficiency is given. In cases of congenital amputees, diagnoses are given in terms of roentgenographical appearance. The type of prosthesis prescribed for each child and the changes necessitated by his growth and development are shown.</p> <p><i>Evaluation: </i>A well-presented, informative film that graphically portrays the accomplishments that may be expected of the child amputee who has the advantage of an early treatment program. It points out clearly the disadvantage to the child when prosthetic fitting is delayed. An orientation film of a specialized nature, it should be of interest to any professional person involved in the care of the child amputee. Parents of child amputees could also benefit by seeing this film. It is recommended for public health nurses who are in a position to refer the young amputee to the amputee clinic.</p> <p><i>Distributor: </i>Audio-Visual Education Center, University of Michigan, Frieze Building, 720 East Huron St., Ann Arbor, Mich. 48104.</p> <p><i><strong>"Child Prosthetics Project: A Report," University of California at Los A ngeles, 1958, 22 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Explains the role of each member of a large prosthetics team, which includes the family physician, pediatrician, orthopaedic surgeon, social worker, psychologist, engineer, prosthetist, physical therapist, occupational therapist, and project administrator. Portrays proceedings of a prosthetics conference, during which the patient and parent are presented. The contributions of the social worker, the psychologist, and the engineer are emphasized. At the conclusion of the film, it is explained that one of the principal purposes of the team is to collect research data with a view toward improving training and prosthetic devices and procedures.</p> <p><i>Evaluation: </i>At the time the film was made, it undoubtedly served the purpose of showing the UCLA program as well as presenting the concepts of the prosthetics team and the early fitting of the child amputee. Although it might be of some value in demonstrating a research approach, its outdated quality relegates it, for the most part, to the category of "historical interest."</p> <p><i>Distributor: </i>Paul L. Brand and Son, 2153 K St., N.W., Washington, D. C. 20001.</p> <p><i>Rental Fee: </i>S7.60 plus shipping charges.</p> <p><i><strong>"Early Development of Ambulation-Unilateral Below-Knee Amputee," University of California at Los Angeles, 1965, 18 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Depicts the progress of the child amputee from the time he attempts to stand until he walks independently with the prosthesis, which has become an integral part of his body image. Shown are the changing patterns of rhythm, the gradual narrowing of the base of support, and the increasing stability as motor-kinesthetic development takes place and the child participates in increasingly complex skills and play activities.</p> <p><i>Evaluation: </i>Presents well the concept of early fitting, as the child is shown wearing and using the prothesis as effectively as a normal leg. The film should be shown in conjunction with <i>Infant to School-Age Child - Unilateral Below-Elbow Amputee.</i></p> <p><i>Distributors: </i>Child Amputee Prosthetics Project, UCLA Rehabilitation Center, 1000 Veteran Ave., Los Angeles, Calif. 90024. Also available for loan from the crippled children's services in all 50 states and in the District of Columbia, the Virgin Islands, Puerto Rico, and Guam through funds supplied by the Children's Bureau, Department of Health, Education, and Welfare.</p> <p><i><strong>"Infant to School-Age Child - Unilateral Below-Elbow Amputee," University of California at Los Angeles, 1964, 10 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the various stages in the motor-kinesthetic development of the child and relates them to the specific times at which the child amputee is ready for initial prosthetic fitting as well as for increasingly complex devices. As skills and physical activities develop in response to demands of daily living, devices are provided that are appropriate to the level of function. The cooperation of the parents in the teaching process is stressed.</p> <p><i>Evaluation: </i>The concept of fitting the child amputee with the appropriate device at a specific time in his motor-kinesthetic development is well presented. The film has value, not only in demonstrating the progress of the child amputee, but also in teaching the basic principles of growth and development in the young child. Although the film is specialized in nature, it is recommended for undergraduate students in paramedical fields to present the principles of growth and development. It is highly recommended for professional groups working with child amputees. It should be shown in conjunction with the film <i>Early Development of Ambulation</i>-<i>Unilateral Below-Knee Amputee.</i></p> <p><i>Distributor: </i>Child Amputee Prosthetics Project, UCLA Rehabilitation Center, 1000</p> <p>Veteran Ave., Los Angeles, Calif. 90024. Also available for loan from the crippled children's services in all 50 states and in the District of Columbia, the Virgin Islands, Puerto Rico, and Guam through funds supplied by the Children's Bureau, Department of Health, Education, and Welfare.</p> <p><i><strong>"Juvenile Amputee with Congenital Skeletal Limb Deficiencies," Tulane University School of Medicine, 1964, 20 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents ten patients treated at a child-amputee clinic. As each case is presented, the limb deficiency is described on the screen in the terminology of the recently developed roentgenographic classification. The deficiency is further described by x-ray plates and by pictures of the child before surgical procedures. Scenes filmed at a later date show the patient wearing and using a prosthesis fitted to the surgically revised limb. The history of the child is outlined rather fully and, in some instances, the history is pictorially depicted at intervals over a number of years.</p> <p><i>Evaluation: </i>This film would be helpful in reinforcing use of the classification of limb deficiencies as developed by O'Rahilly and Frantz. The results obtained in fitting severely involved children are impressive. The information presented is too extensive for the time allotted, making it difficult to stay with the narrator and detracting from the technical quality of the film. This film is recommended for professional groups interested in orientation to this particular type of patient and program. It could also benefit parents of the congenital child amputee.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>S3.00.</p> <p><i><strong>"Lower-Extremity Amputees - Toddlers," Michigan Crippled Children Commission, 1957, 22 min., color, magnetic sound {requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Presents briefly the motor development of the child as it relates to the upright position and ambulatory progress. Describes anomalies and stumps, both pictorially and roentgenographically. Discusses the prosthetic fitting and the child's ambulatory program. Changes in gait patterns over a number of years are demonstrated.</p> <p><i>Evaluation: </i>The development of the gait pattern over the years is especially interesting. Because of advances in design, fabrication, and the fitting of prostheses since the film was made, it has outlived its period of optimal value.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Prosthetic Training of the Very Young Child Amputee - Upper Extremity,'" Michigan Crippled Children Commission, 1959, 20 min., color, optical and magnetic sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Demonstrates the training technique used in teaching three upper-extremity child amputees to use their prostheses. It shows a child-sized APRL hand that was in the experimental stage at that time.</p> <p><i>Evaluation: </i>This film shows good beginning training technique, outlining three different areas of training-basic body-control motions, development of prosthetic control, and functional prosthetic use. The training situations shift abruptly, causing the film to lose continuity. Technically, it is not a high-quality film. Occupational therapists might find this film of value because some of the techniques of training are still acceptable, although the prostheses are outdated.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <p><i><strong>"Upper-Extremity Amputees - Toddlers," Michigan Crippled Children Commission, 1956, 22 min., color, magnetic sound (requires special projector), 16 mm.</strong></i></p> <p><i>Summary: </i>Presents type, diagnosis, and prosthetic fitting of several upper-extremity child amputees. Demonstrates the performance of skills and activities while wearing the prosthesis.</p> <p><i>Evaluation: </i>This film, made at the Mary Free Bed Guild Children's Hospital in Grand</p> <p>Rapids during the earlier years of the child-amputee program, serves to demonstrate how readily children adapt to early prosthetic fitting. Advancements in the prosthetic field, however, cause the film to be outdated. It should be noted that the sound, which is magnetic, is cut off for about the last ten minutes.</p> <p><i>Distributor: </i>Michigan Crippled Children Commission, The Area Child Amputee Program, 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</p> <h3>Orthotics</h3> <p><i><strong>"Assistive Devices for the Physically Handicapped," National Foundation for Infantile Paralysis, 1951, 12 min., sound, color, 16 mm.</strong></i></p> <p><i>Summary: </i>Illustrates many assistive devices and their use by postpoliomyelitis patients. The devices include mouth sticks, overhead slings, feeders of various types, automatic page turners, hydraulic lifts, and several others.</p> <p><i>Evaluation: </i>This very comprehensive film is useful to show the kinds of devices used to increase the functional capacity of the post-poliomyelitis patient with severe residual paralysis. Credit is due those whose ingenuity resulted in the improvised equipment demonstrated here. While the film is photographically excellent, its content in terms of emphasis on certain devices, such as the mouth stick, is questionable. The film, made prior to the poliomyelitis vaccines, is necessarily outdated in some aspects, but the devices shown would still be of interest to personnel working with the severely disabled.</p> <p><i>Distributor: </i>Film Library, International Society for Rehabilitation of the Disabled, 219 East 44th St., New York, N. Y. 10017.</p> <p><i>Rental Fee: </i>$10.00. (No rental fee for members in good standing with the International Society.)</p> <p><i><strong>"Kinetics and Orthotics for Function," Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 1963, 25 min., black and white, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Presents the basic principles in the selection and the use of orthotic devices to achieve as normal function as possible in the presence of upper-extremity weaknesses. The basic normal motions of the upper extremity in the performance of several everyday activities are carefully depicted. The subject, a quadriplegic patient, is introduced as he is undergoing a manual muscle test. The test, which reveals severe weakness in the musculature of the upper extremities, also serves as a basis for determining the degree and nature of the mechanical assistance required to supplement the existing strength. Periodic evaluations are made; and, as strength increases, the appliances are adjusted or replaced. Finally, the amount of assistance is reduced to the minimum required by the patient, who is shown performing a number of activities. Before discharge from the hospital, the patient is equipped with a flexor-hinge hand and is planning to return to his former occupation.</p> <p><i>Evaluation: </i>An excellent analytical presentation of the prescription and use of orthotic devices for severely involved upper-extremity patients. Outstanding in this picture is its adherence to the practice of sound teaching principles. As each new step is presented, the principle underlying the selection of orthotic devices is applied and illustrated. The analysis of normal motion serves as a basic approach to the problem. The film gives a feeling for the long time involved and is realistically hopeful in terms of patient accomplishment. This film is highly recommended for all paramedical groups; for occupational therapists it is of value in teaching specific techniques of training.</p> <p><i>Distributor: </i>Film Library, New York University Medical Center, 342 East 26th St., New York, N. Y. 10016.</p> <p><i>Rental Fee: </i>$5.00.</p> <p><i><strong>"Spinal Cord Injury" Rancho Los Amigos Hospital, 1961, 25 min., color, sound, 16 mm.</strong></i></p> <p><i>Summary: </i>Depicts eight levels of spinal-cord injury and demonstrates the degree of independence that the average patient can attain after injury. Independence is accomplished through a program of maximum strengthening of the remaining active muscles, combined with appropriate assistive devices, such as short leg braces, long leg braces, overhead slings, artificial muscles, special splints, crutches, hydraulic lifts, etc., and training.</p> <p><i>Evaluation: </i>This well-organized film discusses clearly and precisely each level of injury in terms of specific pertinent information, such as key muscle groups involved, functional loss, and orthotic devices. It points out that the prognosis of the patient is not constant with the level of injury, but is based on demonstrable muscle function. Limitations are carefully noted, and goals are realistic. The film is highly recommended for any professional person working with the paraplegic or quadriplegic patient and for inclusion in the undergraduate curriculum for therapists and nurses. Patient and family would benefit from seeing this film, provided they have accepted a realistic attitude toward rehabilitation.</p> <p><i>Distributor: </i>American Academy of Orthopaedic Surgeons, 29 East Madison St., Chicago, Ill. 60602.</p> <p><i>Rental Fee: </i>$3.00.</p> <p><i><strong>"The Heather Hand," U. S. Veterans Administration, 1960, 10 min., color, silent, 16 mm.</strong></i></p> <p><i>Summary: </i>Describes a light-weight, wrist-extension, hydraulic orthosis. Shows the patient putting it on himself and performing several activities.</p> <p><i>Evaluation: </i>Although this film illustrates the device very well and graphically demonstrates its function, it is of practically no value for paramedical groups because it is not accompanied by any explanation, either written or auditory.</p> <p><i>Distributor: </i>Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</p> <h3>Amputation Surgery and Fabrication of Prostheses</h3> <p>The compilers of this review did not consider themselves qualified to evaluate films on amputation surgery or the fabrication of prostheses.</p> <p>Titles of films on surgery may be found in the <i>Film Reference Guide for Medicine and Allied Sciences, </i>U. S. Department of Health, Education, and Welfare, Public Health Service, Communicable Disease Center, Atlanta, Ga. 30333.</p> <p>For those interested, the following films on the fabrication of prostheses are listed.</p> <p>Available from the Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001: <i>Above-Knee Prosthetics</i>-<i>Stump Casting with the Use of a Casting Stand; Below-Knee Prosthetics</i>-<i>Stump Casting with the Use of a Casting Stand; Fabrication Technique for Medial Opening, Polyester Nylon, Syme Prosthesis; Plastic Finishing of an Above-Knee Socket; The Total-Contact, Soft-End, Plastic Laminate Above-Knee Socket.</i></p> <p>Available from Hydra-Cadence, Inc., 623 South Central Ave., P. O. Box 110, Glendale, Calif.: <i>Hydra-Cadence, Reel 1; Hydra-Cadence, Reel 2.</i></p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Enhancing the value of this film and intended to be used in conjunction with it are 16 loop films, each of which depicts one gait deviation. These loops are 7 ft. in length and can be rerun an indefinite number of times on standard projectors. The set may be purchased for $25.00. When the film is ordered, a check in this amount should be made payable to the distributor: Ideal Picture Co., 417 North State St., Chicago, Ill. 60610.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Review of Visual Aids for Prosthetics and Orthotics https://staging.drfop.org/files/original/64eb48831c842d569b969a8c4023b43a.pdf 23a3264fbd43cb19735d1394ea4628b9 https://staging.drfop.org/files/original/457d0569478cb47d506c23642463165c.jpg 45eb3dbafd54e0d668f2f3bfc95c21f2 https://staging.drfop.org/files/original/f273ddd8f2d9ddf2bcefdc00fecea5cd.jpg 32d7ead140275fb07cd1b5fb68f0d23c https://staging.drfop.org/files/original/926a3decfb9da45446674f936ec89f91.jpg a5f732da60ea27eaccc3b5f8030bb28a https://staging.drfop.org/files/original/1ed3a83ad57a832a54252e4a0737039f.jpg 74e042f3b878ccf644a029e6c7863bd2 https://staging.drfop.org/files/original/e646eb1d8492cc5ba623391e15c6cad5.jpg dcd12710088de3f157db636bb403595c https://staging.drfop.org/files/original/826147443b433df462696387b01d80a1.jpg a3dd7046d03c6312c1783e053e286e89 https://staging.drfop.org/files/original/6db35e73e1a625e17d758c9c372e668b.jpg 3d9d018b29c5258b24e6459783cdfe87 https://staging.drfop.org/files/original/2b3975ce6719b0edcd6b0152b38e1452.jpg 87afc6aa558904540e7d54714b7c124c https://staging.drfop.org/files/original/6f94b060664d6dee12584cfafd9dfb42.jpg e8c575c8db2e62e393094a9bf8f896e4 https://staging.drfop.org/files/original/6a71bd9c057c8ce272a912840c6bdcdb.jpg 27624130c2456841ffa292e8b25b333c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_005.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 5 - 9 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Evolution of the Georgia Warm Springs Foundation Feeder</h2> <h5>Robert L. Bennett, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Thirty years ago (March 1936) a young lady rom Crawfordsville, Ga., was fitted at the Georgia Warm Springs Foundation with what was referred to in her medical record as "an ingenious device" (<b>Fig. 1</b>). This apparatus was later called a "foot-operated feeder" because it required voluntary extension of her foot against a movable footboard on her wheelchair to bring about tilting of the seesaw cradle supporting her forearm. In this manner, she was able to feed herself. She used this device for twenty years and then returned to Warm Springs and was fitted with a far more efficient type with the imposing name "balanced forearm orthesis."<a style="text-decoration:none;">*</a> <!--Page 6--> The "ingenious device" just mentioned appears to have been the first feeder ever used at Warm Springs, and perhaps the first ever used anywhere.<a style="text-decoration:none;">*</a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "An ingenious device" supplied in 1936 to a patient at Georgia Warm Springs Foundation; also known as a "foot-operated feeder." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1936 is found what appears to be the first feeder used at Warm Springs that required shoulder depression to bring the hands toward the head, and perhaps this feeder should be thought of as the true ancestor of our present-day device. As can be seen in <b>Fig. 2</b>, the 1936 device consisted of a metal yoke bolted to the lapboard of a wheelchair but free to revolve horizontally. A metal forearm cradle fastened to the yoke by a wooden block moved vertically in a seesaw fashion. This was called a "Barker feeder," since Edward H. Barker was the first patient to use the device. Over the next few years, at least three patients were fitted with this type of feeder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the "Barker feeder" of June 1936. Perhaps the true ancestor of the present-day device, it required shoulder depression to bring the hand toward the head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Reviewing the literature to determine the first feeder and then tracing the development of the feeder at Warm Springs has been an unexpectedly difficult and time-consuming job. It has been most difficult to separate mobile supportive devices used in the treatment of the paralyzed upper extremity from the functional seesaw devices used to assist the patient with a paralyzed biceps to flex his elbow.</p> <p>Looking back over the years, one is rather amazed to find that it took so long to develop the <!--Page 7--> present-day balanced forearm orthesis. The excuse must be that the development of truly efficient orthetic devices comes only with persistent patient demands and long usage. Extensive patient demand for this type of apparatus did not come until the mid-1940's. Records indicate that perhaps as few as 20 feeders were made at Warm Springs between 1936 and 1946. It should be remembered that prior to the occurrence of large epidemics of poliomyelitis in the early 1940's there were really very few patients who survived the acute attack of poliomyelitis with massive involvement of upper extremities. As the incidence of acute poliomyelitis increased, the medical profession learned how to keep these patients alive. Rather suddenly, in the mid-1940's, Warm Springs was faced for the first time with the problem of large numbers of patients who had such weakness in their upper extremities that they could not bring their hands toward their head.</p> <p>In May 1943 the bulky base of the "Barker feeder" was replaced by a simple rod and collar, the rod passing through a hole in the lapboard of the wheelchair and held in position by a simple collar (<b>Fig. 3</b>). Several holes were placed in <!--Page 8--> the lapboard to determine the proper position for attaching the feeder. In March 1945 the feeder was placed on a simple aluminum base (<b>Fig. 4</b>). This allowed the patient to move the feeder horizontally across the lap-board by body movements for best position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The feeder of May 1943. The base of the "Barker feeder" has been replaced by a simple rod and collar. Several holes placed in the lapboard helped to determine the proper position for attaching the feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The stand feeder of March 1945. The aluminum base permitted the patient to move the feeder horizontally across the lapboard by body movements for best position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first real change in the design of feeders occurred in April 1946. The feeder was suspended from the upright of an overhead sling! Originally, it was called a "bird-cage feeder," simply because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages (<b>Fig. 5</b>). At this time, the Warm Springs treatment program dictated that no patient with severe upper-extremity involvement should use a feeder until late in the convalescent phase of care. Hence there was a natural transition from the use of overhead slings to protect the weakened shoulder girdle to the suspension feeder to develop functional capacity in the upper extremity. For the next ten years, there is record of 326 suspension feeders being fitted to a total of 197 patients. Only seven of this type were used after 1956, and none after 1961.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The "bird-cage feeder" of April 1946-so called because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was not until December 1949 that segmented feeder arms were used (<b>Fig. 6</b>). These arms were attached directly to the vertical tubing of the back of the wheelchair. Insofar as can be determined, hinged-spring control of the proximal link-seen in <b>Fig. 6</b>-was used in this instance only, and no further use of the mobile arms was made until October 1952.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Segmented-arm feeder used in December 1949. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The light and mobile C-clamp feeder that could be easily attached to the edge of a table, to the lapboard, or to a wheelchair arm rest was developed in the spring of 1950 (<b>Fig. 7</b>). Between 1950 and 1960, 61 were used on 45 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. C-clamp feeder developed in May 1950. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In October 1952 the segmented-arm feeder was again used but without the spring hinge at the attachment of the proximal link to the back of the wheelchair. The proximal link was rigidly clamped to the upright (<b>Fig. 8</b>), allowing horizontal motion only. This feeder was followed in 1953 (<b>Fig. 9</b>) by one to which ball bearings had been added to the base and to the moving joints of the arms. The base could also be <!--Page 9--> tilted to assist movement of the proximal link. This was really the first of the present-day Georgia Warm Springs Foundation feeders. Between 1952 and 1964, 786 of these feeders were applied to 427 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Segmented-arm feeder of October 1952. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Present-day Georgia Warm Springs Foundation feeder, the balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In September 1953 it was found that many patients with severe upper-extremity weakness had good musculature in the lower extremities and trunk; therefore, while they needed a feeder, they did not require a wheelchair. It was at this time that feeders were fitted directly to the trunk of the patient, either attached to a corset (<b>Fig. 10</b>) or to a belt. Between 1953 and 1961, 100 such feeders were fitted to a total of 53 individual patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Two views of a patient fitted with a corset-based feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the years 1946 through 1964, for which the record is quite detailed and complete, a total of 1,334 feeders were applied to 773 patients. Some patients had several different kinds of feeders, and so the latter number does not indicate that there were 773 different patients. In 1961 questionnaires were sent to 488 patients who had been fitted with feeders and who had returned to their homes with feeders. Two hundred nine replies were received; of this number, 139 (66.5 per cent) were still using their feeders.</p> <p>The feeder, or balanced forearm orthesis, was developed primarily for patients with paralyzed upper extremities following acute anterior poliomyelitis; however, it is being used for many neuromuscular problems that result in lack of sufficient voluntary strength to bring the hand toward the head. More recently it has been used in conjunction with externally powered orthetic devices that activate elbow, forearm, and hand.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1966_01_005/sp66-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_005/sp66-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_005/sp66-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_005/sp66-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_005/sp66-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_01_005/sp66-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_01_005/sp66-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_01_005/sp66-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_01_005/sp66-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_01_005/sp66-010.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Evolution of the Georgia Warm Springs Foundation Feeder Creator An entity primarily responsible for making the resource Robert L. Bennett, M.D. * https://staging.drfop.org/files/original/a6215b76e14080dd6c7ca38556f64bd7.pdf 4e4651dcdc97cadd4a5eb1206df0da68 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_001.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>An Evolution in the Care of the Child Amputee</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past twenty years the child amputee has emerged as a clinical entity requiring specialized medical and paramedical services. Prior to World War II, no precise methods of management existed. Common practice in fitting a child amputee with a prosthesis involved procrastination. </p> <p>The extent of the change that has occurred is well illustrated by two articles appearing in this issue of <i>Artificial Limbs: Recent Concepts in the Treatment of the Limb-Deficient Child</i>, by Cameron B. Hall, M.D., and the report of the Consultants to the Subcommittee on Child Prosthetics Problems on <i>Nomenclature for Congenital Skeletal Limb Deficiencies</i>. Dr. Hall's article presents an overview of current thinking on the subject, while the nomenclature focuses attention on the precise identification of congenital limb malformations. Many events have contributed to this evolution in thinking and practice. </p> <p>In September 1946, under the aegis of the Michigan Crippled Children Commission, an amputee training center was inaugurated at the Mary Free Bed Guild Children's Hospital and Orthopaedic Center in Grand Rapids, Mich. This project was inspired by the late Carleton Dean, M.D., who was then Director of the Michigan Crippled Children Commission. In the early 1940's, Dr. Dean had recognized that something was amiss in the habilitation of child amputees. He was vitally interested in the amputee program that had been developed by the Armed Services and the Veterans Administration. The science of prosthetics was advancing at a phenomenal pace. New mechanical components were being developed and were proving to be superior to anything heretofore available. Plastic protheses were supplanting the old conventional wooden limbs. Dr. Dean argued that there was no reason why these advances could not be used for child amputees. </p> <p>Little (if any) literature on the management of the child amputee was available, although Dr. Atha Thomas, of Denver, had written a very interesting and instructive chapter entitled "Prostheses for Children" in his book, <i>Amputation Prosthesis</i> <a></a>. In this chapter he advocated amputation in tibial hemimelia, foot removal in proximal femoral focal deficiency, and in pseudoarthrosis of the tibia. Dr. Thomas discussed overgrowth of the fibula as a complication of the child amputee and advocated osteoplastic procedures as described by Nikitin<a></a> and Barber.<a></a> Of singular significance is the fact that Thomas advocated "early fitting." </p> <p>Four years after the opening of the child amputee center in Grand Rapids, the professional personnel presented a formal paper on <i>The Juvenile Amputee</i> at the annual meeting of the American Academy of Orthopaedic Surgeons in February 1950. One hundred ninety-two cases were analyzed in detail. In addition to this presentation, a 28-minute motion picture depicted the problems of the child amputee and demonstrated fitting and training techniques. A scientific exhibit outlining the methods utilized in the care of the child amputee through the team approach was also displayed. Thus, for the first time, the child amputee was identified as an entity to the medical community. Five principles of treatment were stressed: </p> <ol> <li>Physical examination and stump evaluation. </li><li>Utilization of physical and occupational therapeutic methods. </li><li>Detailed coordination of prosthetic fabrication and fitting. </li><li>Inpatient prosthetic training. </li><li>Regularly scheduled outpatient follow-up in an organized child amputee clinic. </li></ol> <p>In January 1954 a workshop was held in Grand Rapids to review the total child amputee problem. Representatives of the Children's Bureau of the Department of Health, Education, and Welfare, the University of California at Los Angeles, New York University, and the Army Prosthetics Research Laboratory (now the Army Medical Biomechanical Research Laboratory) attended. The individual members of the conference enthusiastically endorsed the proposition that an organized program of treatment for child amputees in the United States was definitely indicated. An attempt was made to define the child amputee as compared to the adult amputee. It was agreed that the child amputee could be described as a growing, immature, dependent individual whose long bone epiphyses were still "open." </p> <p>In December 1955, in formal session, the Prosthetics Research Board appointed an <i>ad hoc</i> committee of seven members charged with developing recommendations relative to child amputees in the United States. The outcome of this effort was the formation of the Subcommittee on Child Prosthetics Problems. Its mission was to develop information, and to advise the Prosthetics Research Board on all aspects of the child amputee situation in the United States. </p> <p>During March 1956 the Subcommittee on Child Prosthetics Problems mailed questionnaires to 84 prosthetists and 25 orthopaedic clinics throughout the United States. The response was prompt and enlightening. Analysis of the returns indicated universal interest in child amputee treatment procedures. Shop practices were sharply individualized, and no precise criteria for training existed. At this time there appeared to be only four specialized juvenile amputee clinics in the United States.<a style="text-decoration:none;">*</a></p> <p>With this background of information, the Subcommittee proceeded to encourage the development of child-sized prosthetic components. This endeavor involved not only the miniaturization of adult-sized components but also the introduction of specially designed features so that the devices could be operated by young children. With the assistance of the Army Prosthetics Research Laboratory under the direction of Colonel M. J. Fletcher, the Child Amputee Prosthetics Project at UCLA under the direction of Drs. Craig Taylor and Milo Brooks, and the sound evaluation services of New York University under the direction of Dr. Sidney Fishman, components were gradually developed, fitted, and evaluated relative to their efficiency on child amputees. </p> <p>Stimulated by Dr. Arthur J. Lesser of the Children's Bureau (who was then a member of the Subcommittee on Child Prosthetics Problems), significant steps were taken to encourage the formation of specialized child amputee clinics as a means of standardizing practices in the management of juvenile amputees throughout the country. With the ultimate goal of having a clinic within reach of every child amputee in the nation, definite criteria outlining the requirements for the operation of a satisfactory amputee clinic were formulated. As qualified clinics were established, the cooperative investigation of difficult clinical problems was undertaken. Since these clinics were devoting their efforts exclusively to the child amputee, techniques, appliances, and practices could be introduced and critically evaluated through New York University. Over the years the findings of these studies, which have been analyzed and published, have resulted in the evolution of standards of management never before attained. The fruitfulness of these endeavors is well illustrated by the fact that the Committee for Care of the Handicapped Child of the American Academy of Orthopaedic Surgeons, in conjunction with the Children's Bureau, recently published a document entitled <i>Standards for the Care of the Juvenile Amputee</i>. These standards, which have had nationwide distribution, are essentially the same as those that have evolved through the cooperative research program. </p> <p>The growth in the number of child amputee clinics has been most gratifying. As of January 1966 they numbered twenty in the United States and two in the Dominion of Canada. </p> <p>During the early years of the child amputee program, clinical statistics indicated a ratio of two post-traumatic or postsurgical amputees to one congenital amputee. However, in a period of eight to ten years, a dramatic change has occurred: First, because of the publicity given to the treatment program, children began to appear in clinics at a much younger age than previously. At this very young age, the majority of patients have limb deficiencies that are congenital in nature. <i>Second</i>, the logical consequence was a tipping of the scales of etiological incidence to the congenital type. At present, the majority of clinics report a ratio of five congenital types of deficiencies to two acquired types. </p> <p>Thus the meaning of the term "juvenile amputee" has broadened to encompass post-traumatic amputees, postsurgical amputees, and congenital limb deficiencies and malformations. </p> <p>In 1961 another significant step was taken by the Subcommittee on Child Prosthetics Problems. In that year it initiated publication of the <i>Inter-Clinic Information Bulletin</i>. The first issue was published in October 1961, and the <i>Bulletin</i> has appeared monthly ever since with articles written by the clinic chiefs pertinent to the child amputee. The success of this project is attested by the figures of March 1966 when 1,700 copies were printed and 1,565 were distributed; 351 individuals and institutions received 630 copies. In addition 400 copies were sent to the World Rehabilitation Fund for distribution to its members and 535 to the American Orthotics and Prosthetics Association for distribution to its membership. </p> <p>The impact of the thalidomide tragedy in Europe (West Germany and England) in 1959-1962 focused attention again on the need to improve prostheses, especially when malformed limbs or the complete absence thereof made it difficult to fit conventional suspension and power and cable systems. </p> <p>Heidelberg University had worked with pneumatic power and applied its principles very successfully to these children. Since then there has been a concerted effort in the United States to exploit external power, utilizing compressed carbon dioxide and electricity as power sources. At the present time, a significant number of children throughout the country are wearing externally powered prostheses on an experimental basis. </p> <p>Laboratories are continuing to develop devices in an effort to decrease weight, provide easier application, and improve power sources. There is good reason to believe that as time goes on these endeavors will bear fruit in improved, practical prosthetic function. Interest in child amputees is growing steadily in all parts of the world. These children—many of them multihandicapped—now have a much greater hope for better appliances and services than they ever had in the past. </p> <p>In retrospect, it is evident that much has been achieved by the Subcommittee on Child Prosthetics Problems during the past ten years, but also that much remains to be done. Hopefully, the foundations have been laid for further advances. </p> <p><b>References:</b></p> <ol> <li>Barber, G. C. P., <i>Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia</i>, J. Bone and Joint Surg., 13:68, 1939.</li> <li>Nikitin, A. A., <i>Comparative evaluation of late results of various amputations of lower extremities in children</i>, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B. Lippincott, Philadelphia, 1945.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich., George T. Aitken, M.D., and Charles H. Frantz, M.D. (1946); Kessler Institute for Rehabilitation, West Orange, N.J., Henry H. Kessler, M.D. (1949); University of Illinois Amputee Clinic, Chicago, Ill., Claude N. Lambert, M.D. (1952); Child Amputee Prosthetics Project, University of California, Los Angeles, Calif., Milo B. Brooks, M.D. (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barber, G. C. P., Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia, J. Bone and Joint Surg., 13:68, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Nikitin, A. A., Comparative evaluation of late results of various amputations of lower extremities in children, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, J. B. Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Subcommittee on Child Prosthetics Problems, December 5, 1955-June 30, 1966. When the Subcommittee was formed in 1955 it was a part of the Prosthetics Research Board, the predecessor of the present Committee on Prosthetics Research and Development. The Subcommittee became a standing subcommittee of CPRD when CPRD was formed in 1959. Dr. Frantz, an orthopaedic surgeon in Grand Rapids, Mich., is Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission. On July 1, 1966, Dr. George T. Aitken, who also is an orthopaedic surgeon in Grand Rapids and Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission, became Chairman of the Subcommittee on Child Prosthetics Problems.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Evolution in the Care of the Child Amputee Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/6d21fba44b4c02b4c004bf63e1f63831.pdf cfe971bc146b39e11e97c79118b1a01c https://staging.drfop.org/files/original/b6e1c2c759ed57d301d37d5ab4b5dac1.jpg 1c533dccdbe487d7d7d5d410dad1110b https://staging.drfop.org/files/original/c4a8c9195afad4e3ca03898f003dee7a.jpg daa3d984879549cbfc42159eb222089a https://staging.drfop.org/files/original/9f6daaddd1106d9cbe983c2033775d25.jpg becab7587312a262eb82597586a55b32 https://staging.drfop.org/files/original/362bb85952cc606295a9d63a6b958884.jpg bc9f5510398c4a397e38835cfa659c6b https://staging.drfop.org/files/original/3df3d00f10722335a631d5d506bce3e9.jpg 1438d406cb4650e0b21cc5cd159ab4d4 https://staging.drfop.org/files/original/3c515a6e746ee9da332077965f79f130.jpg eeaa58e7d94c89adda2a30a56fce67e6 https://staging.drfop.org/files/original/c14f2585925462148b4dc438c9c27a32.jpg d44e67466a5e9abea7791e13cea64868 https://staging.drfop.org/files/original/f76954679dfd8b87f5df527a3c7d892b.jpg 7ac7d32a7aec4d1aec8fd653c346fbc1 https://staging.drfop.org/files/original/1993fdd6c16310f6c51fb0a4ac52babe.jpg 3404b478edcf7b6daea295ec18b64db0 https://staging.drfop.org/files/original/5699bab2e0bc22f0d0c338f1fe253c49.jpg dd7be1022a55d231aecf0c0506683d10 https://staging.drfop.org/files/original/7edc77d5b01a38b55dc8a930df01f1a9.jpg d1de7bf09a288dccc2a1dbaa6f857c5e https://staging.drfop.org/files/original/19b07e847745ca927903c374fcdd08b3.jpg 329601d54d376428eddccdf1c99743e2 https://staging.drfop.org/files/original/35cb88c8107f12d1e13e4f66aeb734d0.jpg 50819e7dac33551723a15d6e26c1d066 https://staging.drfop.org/files/original/1cb6915c5fcaae6c2d352544442ba21e.jpg 0bcc34a21662a964b18d6bcb72c0e2ed https://staging.drfop.org/files/original/4ac29010338a64c8712eb4fcef376384.jpg ae72774766d287aff0fe5353562f75a3 https://staging.drfop.org/files/original/e7e2686a60c6518befb80b03771e5f80.jpg 9f8d304788a8729cacce1bfeb40979a6 https://staging.drfop.org/files/original/affd9f9bd75a9a20f20ca57f8be4e3c3.jpg 4a1273b17bd7fa3518107c0cfa7fe4de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_026.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 26 - 33 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_026.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee</h2> <h5>Liesl Friedmann, O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Considerable information is available concerning the treatment philosophy, prosthetic prescription, and training of the child with a unilateral upper-limb deficiency<a></a>. However, there are few published data on adapted equipment for the child with a bilateral upper-extremity deficit. To help remedy this lack, this article presents a brief discussion of the current treatment philosophy at the Institute of Physical Medicine and Rehabilitation in the New York University Medical Center and describes some of the adapted equipment and training procedures that have been found useful for children with congenital bilateral upper-limb deficiencies.</p> <p>The presentation is essentially confined to children fitted with conventional prostheses. Experience with unilateral and a few bilateral amelic children at the Institute of Physical Medicine and Rehabilitation has led to the conclusion that these patients obtain inadequate benefit from conventional fitting and might do better with externally powered prostheses. However, these prostheses pose their own unique training problems which are not considered here.</p> <p>Bilateral Fitting Recommended The child is fitted as soon as he sits independently. If there are lower-limb deficiencies or other conditions which delay the achievement of sitting balance, assistive devices and training programs are used to facilitate this accomplishment.</p> <p>It is believed that all children with bilateral upper-limb deficiencies should be fitted bilaterally at the outset for the following reasons:</p> <ol> <li>To encourage the performance of bimanual activities and, hopefully, to assist in the development of an appropriate body concept by providing bilateral extremities of equal length.</li><li>To aid balance and prevent scoliosis.</li><li>To increase prosthetic tolerance.</li><li>To prepare for later bilateral prehensile function.</li><li>To promote eye-hand control of the prostheses.</li></ol> <p>The considerations listed above outweigh the disadvantages of lack of sensory input from the covered stumps. Since the prostheses are not worn full time by any of these children, ample sensory stimulation of the deficient limbs can be achieved.</p> <h3>Training Considerations</h3> <p>In the training program, the longer stump is developed as the dominant member unless the child shows a strong preference for the shorter limb. If both sides are equal in length, the child's preference is determined by observation.</p> <p>If the child has lower extremities which can assist in the performance of activities of daily living, use of the feet is encouraged, with loafer-type shoes recommended for easy removal.<a></a> However, exclusive use of the feet should be discouraged. Pedal skills should be used to assist prosthetic function or in emergencies when the prostheses are not available. Thus, the feet should be used primarily for activities that cannot be performed with prostheses, although strict rules cannot be applied. The degree to which the lower extremities are used must be a matter of judgment based on the individual case. It should be remembered, however, that if the child becomes too dependent on his lower extremities he will have to learn to reduce foot usage when he reaches the age of social consciousness.</p> <h3>Fitting Modifications</h3> <p>In general, the same standard fitting procedures are used for the bilateral limb-deficient child as are used for the unilateral patient with the following modifications:</p> <ol> <li>A 12P hook is fitted immediately but is not activated . Passive mitts are not used.</li><li>During the passive phase of training (inactive terminal device), a figure-eight harness is used, with a chest strap connecting the two axilla loops added for retention. To prevent the harness from riding up in the back, a vertical strap from the cross of the figure-eight is attached to a waist belt.</li><li>The usual developmental sequence in a child's perception of the prehensile function of a hook is well known<a></a>. In bilateral amputees, the developmental sequence is the same, but is sometimes extended over a longer period. The therapist will usually be able to detect the child's readiness for cable attachment and active use by noting the typical signs of frustration arising from inability to function independently; for example, a sudden, sustained increase in crying, temper tantrums, refusal to wear the prostheses, and similar otherwise unexplainable manifestations. Occasionally, the child will verbalize the desire to do things independently without the prostheses. A reasonable attention span is an imperative requisite.</li><li>When the child reaches the age of four or five years, bilateral wrist-flexion units are provided.</li><li>For the very young above-elbow amputee, friction-lock elbow units, which have recently become available, are useful.</li></ol> <h3>Training Procedures</h3> <p>Patients with bilateral limb deficiencies below the mid-humeral level present less of a fitting and training problem than bilateral amelic patients. Nevertheless, they still require specialized training. It is recommended that they be taught the use of one hook at a time and learn pre-positioning of the terminal device by use of the opposite hook, the knee, elbow, chin, or any available hard surface. Training in changing the position of wrist-flexion units by pushing against a hard surface or the opposite prosthesis needs to be given. These patients must also learn to don and remove their prostheses <a></a> and perform the activities of daily living.</p> <h3>Assistive Devices</h3> <p>The pattern of the training program in the New York University Medical Center follows the developmental scale of the normal child as far as possible.<a></a> However, it must be remembered that the "child amputee" will eventually become a teen-ager and then an adult. Thus both the physical and psychological aspects of growth should be taken into account in special training programs.</p> <p>Most of the special training devices used by adults for independence in activities of daily living can also be used by the young teenager. However, since training must start at a very early age if independence is to be obtained, devices specifically designed for the very young child must be used initially. The items described in this article are some that have been developed for the patients at the Institute of Physical Medicine and Rehabilitation.</p> <h3>Self-Feeding Aids</h3> <p>The first level of activity training is self-feeding. A swivel spoon<a style="text-decoration:none;">*</a> possibly with a flat, built-up handle to prevent slipping (<b>Fig. 1</b>) is useful. Initially, the therapist places the spoon into the hook. Later, the child learns to pick up the spoon from the rim of the plate or from the table without assistance. Usually, the child can push the food against the rim of a bowl or against a plateguard. At about four years of age, the child is introduced to the use of a "pusher," a utensil (<b>Fig. 2</b>) commonly used by normal children in Europe. The pusher has been found to be a good pre-knife-and-fork feeding aid. The pusher, which can be made from a flattened and re-shaped teaspoon, is placed behind the "thumb" of the hook on the nondominant side by the therapist. At this stage it is also likely that the child will be able to use a regular teaspoon with a flat handle, bent at an angle which is a compromise between that needed for scooping and the angle needed to get the food to the mouth without spilling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Straight spoons. The one on the right illustrates a method of building up the handle to prevent slipping when grasped by a prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Top, metal pusher formed from flattened spoon. Bottom, spoon flattened to make pusher. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At six to seven years of age, knife-and-fork usage can be started (<b>Fig. 3</b> and <b>Fig. 4</b>). At first, both utensils are placed behind the "thumbs" by the therapist, but with practice the child learns to do this independently. Bilateral wrist-flexion units are very useful for proper positioning of the utensils as they are maneuvered for insertion into the terminal devices and then for cutting. To prevent plate movement, it is frequenth" helpful at this stage to use a damp, flat foam-rubber sponge, wet paper towel, or adhesive foam rubber attached to the bottom of the plate. Correct table height is important in reducing shoulder abduction during eating. With the prostheses in complete abduction, the elbows should barely touch the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of knife and fork for cutting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Use of knife and fork for peas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When teaching drinking with a cup, a plastic, flat-handled cup<a style="text-decoration:none;">*</a> should be used initially. If necessary to prevent spilling when the cup is placed on the table, a lid (<b>Fig. 5</b>) may be provided. At this stage, the child can grasp and release actively but has not yet learned to pre-position the hook. This must be done by the therapist. When the child is able to preposition the hook (three to four years of age), a regular plastic or paper cup can be introduced. Such cups must be held by the upper rim from above (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cup equipped with cover to avoid spilling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Plastic cup held at rim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the public schools of New York City, children are provided soup and a sandwich for lunch. These items are most difficult to handle with a prosthesis. Soup should be sipped from the cup or through a straw, but the child cannot control his prosthesis well enough to prevent mutilation of a sandwich. At the Institute of Physical Medicine and Rehabilitation, a sandwich holder has been devised which is used successfully by some children. The teacher or a parent must insert the sandwich, but the child can then eat it from the holder (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Sandwich holder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Dressing Aids and Adapted Clothing</h4> <p>The amount and type of dressing activities performed by the bilateral upper-extremity amputee vary greatly from one child to the next. For these patients the combined use of feet and teeth may be required.</p> <p>To don his prostheses the child must first put on his stump socks and then maintain them in position as he maneuvers his stumps into the sockets. This feat is not very difficult for the bilateral below-elbow amputee, but if one or both of the limbs are deficient above the elbows, the socks tend to fall off. Others<a></a> have described a bilateral stump sock which is useful. At the Institute of Physical Medicine and Rehabilitation, a connecting piece has been added to this bilateral stump sock to protect the back and axillary skin from irritation (<b>Fig. 8</b>). There is no commercial source for this item at present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Bilateral stump socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Adolescent girls frequently find a front-opening brassiere useful. The standard item can be easily converted into a front-opening type by sewing up the back, opening the front and fastening it with a long Velcro strap and D-ring (<b>Fig. 9</b>). To close the top, a supplementary smaller strap with Velcro or a large hook on an elastic strap may be used. Sleeveless dresses split below the waist and with an open back are helpful.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Front-opening brassiere. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major training problem is toileting, which is particularly difficult for females. If a female child does not have normal lower extremities or at least toes able to function sufficiently in grasping clothing or toilet paper at the proper body level, life-long dependency in this function may have to be accepted. In using bilateral upper-extremity prostheses for assistance in toileting, it is a problem to get the prostheses close enough to the body to adjust the underpants while wearing a dress, even with elbow turntables and bilateral wrist-flexion units.</p> <p>Some children have successfully used modified underpants which do not have to be removed. The crotch of the undergarment is split and refinished with binding (<b>Fig. 10</b>). The opening should close when the child is in the erect position. When the patient sits on the toilet seat, with the trunk flexed on the thighs and the lower limbs abducted, the opening is sufficiently wide to prevent soiling of the garment. With practice, the use of toilet paper can usually be mastered without special devices. Sometimes, however, the solution of this problem requires the development of special reaching devices which are highly individualized. Female patients usually find tampons much superior to sanitary napkins.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Modified underpants. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Schoolwork Aids</h3> <p>For the bilateral amputee to function effectively in school, adaptation of equipment is required in many activities. For example, cutting with scissors is an impossible task with the standard item. <b>Fig. 11</b> illustrates a simple and very satisfactory adaptation in which one handle of the child's scissors is embedded in a small piece of wood 1-1/2 in. X 1 in. X 1/2). The lower handle of the scissors is placed in a groove made with an X-acto knife and held in place with plastic wood. When the scissors are positioned in the wood block, the tip should touch the table. The axis of the two blades should not be tight and the blades should fall open with ease. The child holds the upper handle of the scissors with the hook tines pointing downward. As the handle of the scissors is pulled up and down, the block of wood rides flat on the table surface. In learning to use the adapted scissors, the child should start with straight lines on paper and then include gentle curves and corners and, finally, complex figures. Such scissors are effective only with paper; cloth cutting requires the use of electric scissors (<b>Fig. 12</b>). For cutting thread on a sewing project, a seam ripper is verv useful (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Scissors with one handle embedded in wood. Plastic wood holds the handle in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Electric scissors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Seam ripper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Writing can be facilitated by the use of a clipboard or attaching the paper to the table with masking tape, rather than letting the child struggle to hold the paper steady with his non-dominant prosthesis. Chalk holders which prevent the chalk from breaking and improve blackboard writing efficiency are available commercially<a></a>. A pencil holder has also been described<a></a>. A simpler crayon-holding device has been used for very young patients at the Institute of Physical Medicine and Rehabilitation (<b>Fig. 14</b>). This holder consists of a wood block (6 in. X 2 in. X 2 in.) with a series of holes drilled at angles to enable the child to withdraw and reinsert the cravon without having to pre-position the crayon. Unless the child presses down very hard, the crayon will not slip from the hook. If a thin layer of foam rubber is glued to the bottom of the wood block, it will not slip on the table. Some older children cannot use their other hook to insert a pencil behind the ''thumb" for stability. When clamped to the edge of the table, a simple block of wood with a single deep hole (<b>Fig. 15</b>) is effective in holding the pencil so that it may be properly grasped. In time, the child learns to pick up and position the pencil without special devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Crayon holder fashioned from wooden block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pencil holder clamped to edge of tray. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Sewing and Knitting Aids</h3> <p>It is possible for a bilateral upper-extremity amputee to learn knitting and sewing. One needle with the knitting on it can be inserted in a vise (<b>Fig. 16</b>), while the other needle is held behind the "thumb" in the dominant prosthesis. The wool is laced around the needle by the nondominant hook. Thick needles and wool should be used. Sewing can be made easier by use of a frame mounted on a pivot with ball bearings (<b>Fig. 17</b>). Many four- and five-year-old children enjoy sewing cards or doing simple cross-stitch work. This is an excellent activity for training the child to achieve minimal opening of one hook at a time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Small vise used to hold knitting needle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Frame to hold sewing card, mounted on ball bearings to swing freely on pivot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Constant Modification Necessary It is hoped that other therapists will find these suggestions useful and that they will report special devices that they have used successfully. Finally, it should be emphasized that, although a variety of assistive devices, including the feet, are used by young children with bilateral upper-extremity deficiencies in performing the activities of daily living, the problem changes as the child grows older. The physical growth and social consciousness characteristic of the teen-ager may preclude the use of techniques that were acceptable in the younger child. Constant alertness to the need for modification of techniques is required to meet the changing physical and psychosocial needs of the developing child.</p> <p><b>References:</b></p> <ol> <li>Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</li> <li>Deutsche Vereinigung fur die Rehabilitation Behinderter (Heidelberg-Schlierbach), Information on measures for rehabilitation of children with dysmelia, 1962.</li> <li>Friedmann, Liesl, Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bulletin, April 1965, pp. 7-16.</li> <li>Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</li> <li>Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</li> <li>University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Calef, P. L., A pencil holder for the bilateral upper-extremity amputee fitted unilaterally, Inter-Clinic Information Bulletin, September 1964, pp. 15-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Baby Cup, KT5, with flat double handle and lock lid (50 cents); Kayware Corp., 2731 North Crawford Ave., Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sta-Lcvel Baby Training Spoon ($1.00); Price Industries, Ltd., 815 East Talmadge Ave., Akron, Ohio.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Jentschura, G., E. Marquardt, and M. Rudel, Behandlung und Versorgung bei Fehlbildungen und Amputationen der oberen Extremitaet, George Thieme Verlag, Stuttgart, 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California Press (Berkeley and Los Angeles), The limb-deficient child, Berton Blakes-lee, ed., 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Shaperman, J. W., Orientation to prosthesis use for the child amputee, Am. J. Occup. Ther., XIV:1, pp. 17-23, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Liesl Friedmann, O.T.R. </b></td></tr><tr><td class="clsTextSmall">Therapist-in-Charge, Children's Division, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, 400 East 34th St., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_026/autum65-53.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_026/autum65-54.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_026/autum65-55.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_026/autum65-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_026/autum65-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_026/autum65-58.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_026/autum65-59.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_026/autum65-60.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_026/autum65-61.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_026/autum65-62.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_026/autum65-63.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_026/autum65-64.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_026/autum65-65.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_026/autum65-66.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_026/autum65-67.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_026/autum65-68.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_026/autum65-69.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Special Equipment and Aids for the Young Bilateral Upper-Extremity Amputee Creator An entity primarily responsible for making the resource Liesl Friedmann, O.T.R. * https://staging.drfop.org/files/original/ade32438fe78cc76b9983a4b8b03a966.pdf 24729f77c1e834d976420985feac692f https://staging.drfop.org/files/original/d92a7eff2668b5c4ae4ad1304d095fa8.jpg 835435b1ece19459b1ac8d1a17c66508 https://staging.drfop.org/files/original/b5aae5c48c7c5d7cb3451ea33d46ca35.jpg 7f2c8261672b992d5e23edec9c77f155 https://staging.drfop.org/files/original/c23813c8338bfd0e458ded21a75e5f4e.jpg 0f0b8b3e72dd2046648a7cd419c0d7a3 https://staging.drfop.org/files/original/05f26b792282c85b48f580e1eae102ec.jpg 99d0cf43ee5a531ada3afac54450494f https://staging.drfop.org/files/original/ce9fd6c6b75b551158c3744e94f094b7.jpg 73c12aa3dbf0a65f1f4fa64ac9dd6213 https://staging.drfop.org/files/original/07ee80f09471576171407de72fa75dd5.jpg 4f76e5e9d6715c10b86b5cb853ec87a4 https://staging.drfop.org/files/original/97a5dc6f83c442defa0fe8ace990f196.jpg e8575a35f4234f2cacbfae587bae4e43 https://staging.drfop.org/files/original/97b8c915a4b3c287a6f6d8da7f49a69a.jpg cbc601a2e8329c86d4569281990ed01c https://staging.drfop.org/files/original/06006f97bc193b21a924aebb7cc5e327.jpg 90544b8e8968a5c9e75adc9c7dca2a85 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_027.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 27 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Orthopaedic Shoes for Bilateral Partial Foot Amputations</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Most physicians and competent orthotists recommend the use of orthopaedic shoes in cases requiring shoe modifications or braces. However, in practice, the term "orthopaedic" is loosely applied to a variety of shoes of widely different cost, construction, function, durability, and appearance. Orthopaedic shoes are distinguished from stock or nonorthopaedic shoes by a steel shank, a long, high, reinforced counter and internal corrections; prescribed modifications are incorporated as elements of the shoe construction rather than added externally. These are clear differences, and the superiority of orthopaedic shoes is generally recognized.</p> <p>Although related, there are two vastly different types of shoes labeled "orthopaedic." One is the kind of shoe described above, which is usually referred to as the <i>custom </i>orthopaedic shoe; the other is the <i>stock </i>orthopaedic shoe. The latter usually contains a steel shank, and in certain instances it also includes a long medial counter and Thomas heel. At this point, however, the similarity to custom orthopaedic shoes ends. Additional corrections which are prescribed must be added externally. They do not include the reinforcement required to prevent "breaking" of the sole at undesirable points and to prevent lateral bulging of the uppers.</p> <p>Despite these disadvantages, stock orthopaedic shoes are frequently prescribed or selected by patients. Cost is probably a significant if not decisive factor since typical costs for stock orthopaedic shoes average half or less than half the cost of custom orthopaedic shoes. On analysis, however, cost differences tend to narrow, as the useful life of custom orthopaedic shoes is longer. In our opinion, the functional and cosmetic advantages of custom orthopaedic shoes far outweigh the cost differential.</p> <p>Apart from considerations of cost, stock orthopaedic shoes may be selected because the appearance to the untutored eye of a new pair seems adequate, and because the patient may seem initially to walk in much the same manner when wearing equally new custom orthopaedic and stock orthopaedic shoes. Not immediately apparent are the quick deterioration and shorter life of the stock orthopaedic shoe and the functional value of the custom orthopaedic shoe. Because of adaptive measures employed by the patient to overcome deficiencies in the stock shoe and to present a normal appearing gait, the external appearance of the gait pattern with the custom shoe may not always be superior. Adjustments made by the patient to adapt himself to the shoes are revealed in the interaction of forces between the foot and the ground during the stance phase of walking. It is primarily to these forces that the wearer of custom shoes reacts when expressing a preference for the function of one shoe over another, even though improvements by a reduction in gait deviations may go undetected during visual observation.</p> <p>A recent experience illustrates these points. A young man with congenital deformities of the feet, for whom orthopaedic shoes had been prescribed, was tested in our laboratory. (He also had congenital deformities of the hands.)</p> <p>He was considered an excellent subject for this type of analysis because of the remarkable adaptations he had made to his deformities. Despite their severity, he was an extremely adept walker with a nearly normal gait whether he wore shoes or not. We believed that his high adaptability would tend to mask, to an unusual extent, any gross differences in his gait and that, therefore, detectable differences could be attributed to the function offered by the shoe.</p> <h3>The Subject</h3> <p>The subject for this study was a 19-year-old congenital amputee with partial hands and feet (<b>Fig. 1</b>). At the initial examination he was wearing previously prescribed stock orthopaedic shoes with steel shanks as the only special feature. Added externally were sole and heel extensions (<b>Fig. 2</b>). After approximately 12 months of wear a severe break in the tarsal region of the right shoe and another, though less severe, of the left shoe were exhibited. The lateral walls of both shoes bulged excessively, resulting in permanent deformation and reduction of support. The short steel shank protruded through the sole at a point corresponding to the break, and the wear of the soles revealed a pattern of little or no support anterior to the shank which terminated at a point corresponding to the tarsometatarsal joint line (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Congenital bilateral amputations with absence of tarsals in the right foot and presence of tarsals in the left. A, Lateral view; B, frontal view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stock shoes showing deformation after 12 months' wear. A, B, Externally added heel and sole extensions can be seen. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stock shoes showing: A, break in tarsal region; B, uncosmetic external corrections; C, protruding short steel shank and a wear pattern indicative of lack of support in the metatarsal and toe areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He was fitted at a commercial establishment with a prescription for custom orthopaedic shoes recommended by the Veterans Administration Prosthetics Center (<b>Fig. 4</b>). These shoes were specially reinforced with long, flat steel springs and steel shanks installed between inner and outer soles to increase the resistance to dorsiflexion after mid-stance and to shift the "toe break" further forward. They also featured stiff, high, long counters and a wider heel base with a reversed Thomas heel on the right shoe to increase lateral support. An inside cork extension was prescribed to accommodate leg shortening. After four months of use the wear pattern of the soles indicated that the patient was receiving support; that is, resistance to dorsiflexion or "shoe break" extended all the way out to the toe (Fig. <i>4B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Custom shoes after four months' wear showing: A, cosmetic advantage; B, reversed Thomas heel and an even wear pattern indicative of support provided over entire surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <p>To record the gait performance of the patient as completely as possible, several methods were employed. Thirty-five mm. motion pictures were taken in both the anteroposterior and the mediolateral planes as the patient walked with his old shoes and with his new shoes. Similarly, cyclographic recordings were made of angular and linear displacements at the hip, knee, and ankle. Force plates were used to record the ground reaction forces during stance phase. Finally the patient's opinions were recorded.</p> <h3>Results</h3> <p>A motion-picture analysis showed that the subject walked very well with both stock and custom orthopaedic shoes. He was able to make small but significant compensations in his body alignment and in the timing of his movements with the result that the total body center of gravity maintained a smooth translatory path.</p> <p>In general, the more detailed cyclographic recordings clearly demonstrated a remarkable ability on the part of the patient to maintain a reasonably normal gait pattern despite differences in functional losses between right and left leg and substantial differences in the height and functional character of the shoes.</p> <p>As shown in <b>Fig. 5</b> and <b>Fig. 6</b>, displacement patterns-that is, the motions of the hip, knee, and ankle in space-were essentially similar with both stock and custom shoes. The consistently higher elevation of each of the major joints with the custom shoe was due simply to differences in the elevation of the shoes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Horizontal displacement of targeted points on the subject's right lower extremity during ambulation, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Horizontal displacement of targeted points on the subject's left lower extremity during ambulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although knee-flexion patterns with custom and stock orthopaedic shoes were generally similar, flexion of the left knee during the early stance phase was reduced substantially with the custom shoes (<b>Fig. 7</b>). This was attributed to the increased support provided by the custom shoes in the tarsometatarsal region with a consequent reduction of the "drop off" on the right leg during late stance. As a result of the excessive "drop off" due to the "break" of the stock orthopaedic shoes, the hip remained at a lower elevation than it would otherwise have attained. The lower hip elevation necessitated additional compensatory flexion of the left knee by the patient in order to walk in a reasonably symmetrical manner. Reducing the "drop off" maintained the hip at a higher elevation and made this additional knee flexion unnecessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A computation of the actual forces applied to the ground was made by resolving both vertical and horizontal force components. Indicated in the following tabulation are the peak forces applied to the ground during the period of heel contact to foot flat and between the instant of heel off and push off in two trial runs with the stock shoes and in two trial runs with the custom shoes. (<b>Table 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As the patient weighed 196 lb., it may be seen that the differences between the first and second peaks were substantially lowered on the right foot and somewhat less diminished on the left foot when the custom shoes were worn, demonstrating a more nearly equal application of forces to the ground. These differences were due primarily to his ability to maintain higher fractions of his body weight on the supporting foot after heel off.</p> <p><b>Fig. 8</b> graphically illustrates, for comparative purposes, the average peak magnitudes of the axial load during heel contact to foot flat, and during heel off to push off. The most significant effect on gait of the custom shoes was to diminish the magnitude of the force with which the heel was initially applied to the ground and to increase the force applied to the ground during the portion of stance corresponding to the period between heel off and push off. Although the absolute values of these changes are small, they had highly significant effects in reducing the patient's adaptive efforts and in reducing shoe wear. As might be expected in the complete absence of plantar-flexion in the right foot, the effects were greater on the right side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Subject's Opinion</h3> <p>The subject stated unequivocally that the custom orthopaedic shoes were far superior to the stock shoes that he had previously worn.</p> <p>They were more comfortable, they provided better support, and the inside buildup was more cosmetically desirable. The subject wore the custom shoes home and refused to take the stock shoes with him, discarding them on the spot.</p> <h3>Summary</h3> <p>There is very little question in our minds of the superiority of custom orthopaedic shoes over stock orthopaedic shoes. Even in the case described in this article when, at first glance, the need might be considered minimal, clear advantages were provided. On this functional basis alone preference should go to custom orthopaedic shoes. Further study of the life expectancy of custom and stock orthopaedic shoes should serve to clarify objectively where real economy in this matter lies.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_027/spring65-27.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_027/spring65-28.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_027/spring65-29.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_027/spring65-30.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_027/spring65-31.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_027/spring65-32.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_027/spring65-33.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_027/spring65-99.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_027/spring65-34.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthopaedic Shoes for Bilateral Partial Foot Amputations Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/1bcf24533393a270e599124c79df627d.pdf 60d27e744f0e910fb5a36973e948eeb2 https://staging.drfop.org/files/original/f3330c73f6253b5091be2b01f531b140.jpg dc38c24c7179bb4effb3aae915ea79b5 https://staging.drfop.org/files/original/3bfbe6e6b7b7ca08a21d8a48c3f7aa45.jpg c78a26b9dc50869149e455dbeeb47f7a https://staging.drfop.org/files/original/65d4cca945fc77e2edf91de00c4620ee.jpg 059f9b70cc153445dd52ad38f1197c7a https://staging.drfop.org/files/original/6d57408b37f4a7b475d3206c69df9017.jpg 5054831ea0e4ec721daa3a4edd6360df https://staging.drfop.org/files/original/a0c55a5151b7c247a981368ea9bb74e3.jpg 56e078026c6bd5e04cc4d7a4a7644338 https://staging.drfop.org/files/original/d82cddd653af422dee248f52593085c6.jpg a9098af669adf8d1ac1861e371694404 https://staging.drfop.org/files/original/0d4a99f5d93c2bbb9b5ad821b8208825.jpg 67a7d08af08aa01f3f67a3ba4b200d7b https://staging.drfop.org/files/original/ab25a84fa2da308c0909dc1329c9f9a4.jpg eaf49a7130edc6d667abd9ce0349e04e https://staging.drfop.org/files/original/3ada30036b5b486eab3687d8874e56c2.jpg c89eb22bef8bad2e22f39b8d41c49a39 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_023.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 23 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_023.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_023.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Inverted V-Strap Suspension for PTB Prosthesis</h2> <h5>Jack L Caldwell, C. P. <a style="text-decoration:none;">*</a><br /></h5> <p>The leather cuff-suspension strap described in <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis <a></a> </i> and in the June 1962 issue of <i>Artificial Limbs </i>has been found satisfactory in the majority of cases (<b>Fig. 1</b>). However, in certain cases with short stumps suspension problems have arisen. One particular case (<b>Fig. 2</b>), a patient having a very short stump (2 3/4 in.), presented such a critical suspension problem that other means of achieving suspension were attempted. The first approach was a figure-eight dacron strap with Velcro for adjustment (<b>Fig. 3</b>). A continuous strap encircling the thigh was crossed over the patella. The ends of the strap were attached to the socket. Socket retention was improved, but some disadvantages were noted. When tightened sufficiently to provide good suspension, the strap caused a circumferential constriction above the knee impairing stump circulation (<b>Fig. 4</b>). Furthermore, this type of suspension did not provide an adequate extension stop for the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior and posterior views of typical cuff-suspension system for PTB prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Very short below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Continuous-strap suspension arranged in a figure-eight with Velcro for adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Effect of circumferential constriction above the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Continued experimentation led to the use of the present suspension system using two straps looped through a ring for socket suspension (<b>Fig. 5</b>). The suspension system consists of two straps 1 in. wide and approximately 16 in. in length. When looped through a stainless steel ring, these straps form two inverted V's with the apex of each inverted V passing through the ring. The ends of the V-straps are attached to the socket. Each strap has one end anteriorly and one end posteriorly attached to the proximal socket, thereby providing a four-point suspension. The ring joins both straps and is attached to a flexible waist belt by an elastic thigh strap. No circumferential strap is used about the thigh; a waist belt and a thigh suspension strap, plus the free-sliding characteristics of the two V-straps through the ring, provide firm suspension in all positions of knee extension or flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The strap attachments to the socket should be placed so as to prevent knee hyperextension. The proper sites for strap attachment to the socket are related to the length of the stump. Usually, the shorter the stump the more anterior and proximal are the sites for attachment of the anterior suspension strap. The average short stump of 3 to 4 in. requires that the anterior attachments be located approximately 1 in. above the patellar-tendon contour of the socket and at each side of the patella, with sufficient space for the patella to pass between the straps as the knee is flexed. The posterior socket attachments may be located in the popliteal section of the posterior socket as shown in Figure 6. If the socket wall is thick, the posterior straps should be permitted to pass between the stump and the inner socket walls as illustrated in <b>Fig. 5</b>, <b>Fig. 6</b>, <b>Fig. 7</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Posterior view showing a common attachment point for the posterior straps. The attachment points may be either together or separate, and the straps may be attached either inside the socket or outside. Care must be taken to prevent the strap from rubbing against the (iliotibial) tendons on the lateral side of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Top view of the V-straps with the knee extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The V-straps must be sufficiently short to hold the ring down firmly against the superior margin of the patella. The elastic thigh strap may be adjusted for proper tension above the knee to prevent the ring from slipping down upon the patella.</p> <p>The ring must be sufficiently large to permit two 1-in. dacron webbing straps to slide through it without overlapping one another (<b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>). The ring shown in the illustrations accompanying this article is the Northwestern University upper-extremity harness ring described in the June 1962 issue of <i>Artificial Limbs. </i>It is an O-ring. If a D-ring is used, the flat side should be turned upward. A quick-disconnect snap fastener as illustrated may be used to connect the elastic thigh strap to the ring.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Top view of the V-straps with the knee flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Posterior-oblique view showing retention of the prosthesis to the slump while the knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As the knee is flexed, the suspension straps remain comfortable, and strap tension does not change regardless of knee position. <b>Fig. 8</b> and <b>Fig. 9</b> show a knee in full flexion. The dark areas on the V-straps demonstrate the amount of their excursion through the ring as the knee is flexed. When the knee is extended, the ring will slip forward over the shadowed areas, returning to the position shown in <b>Fig. 5</b> and <b>Fig. 7</b>.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-hearing below-knee prosthesis, </i>University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-hearing below-knee prosthesis, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jack L Caldwell, C. P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_023/spring65-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_023/spring65-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_023/spring65-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_023/spring65-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_023/spring65-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_023/spring65-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_023/spring65-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_023/spring65-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_023/spring65-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Inverted V-Strap Suspension for PTB Prosthesis Creator An entity primarily responsible for making the resource Jack L Caldwell, C. P. * https://staging.drfop.org/files/original/88bef5d62a14398fc3a18bca7131f8d8.pdf 86d59bbde4b62c325ee0ebad480c4e5f https://staging.drfop.org/files/original/a84e8ce4eb14a01f0ef2b2853a788184.jpg 0a6c5befd14aa80990442ce44b52ab3b https://staging.drfop.org/files/original/086c58dc00817fa00adcb9085b4887ee.jpg 3c6699b65e4f90cf65ce688efeef8135 https://staging.drfop.org/files/original/9b7bcc17ba2e80fbdba893a929d85938.jpg 9ed6bb7ee61966d89d7987f935e7b034 https://staging.drfop.org/files/original/16080d78a84c16864ec113cd9ecacdf5.jpg b392c89f1756f04fe19a3ad6250113e2 https://staging.drfop.org/files/original/29997ac6960eedc1a118bddad0b95f7c.jpg 6c9a31a9af5ba3831ccdbeb8f4936c57 https://staging.drfop.org/files/original/5786b706e7e673ea58f74136b2873bd9.jpg 0cd440682c88a020c34584737b244d7d https://staging.drfop.org/files/original/9619f95ba15af83f199f79659e870183.jpg b4c873ee734251f9760a68756ee81e23 https://staging.drfop.org/files/original/98848e3c786b553e83ab938453172bb8.jpg 0c8c38b091e2db04fca212e6d969202b https://staging.drfop.org/files/original/156b8585b39aa6c343505e1dbb2319eb.jpg 473d661cc1700725a11f2a0801e2f0b4 https://staging.drfop.org/files/original/180831d52019c33f425c4abef213436c.jpg cb53f48a3e0b0aadd418c3f302efb8c8 https://staging.drfop.org/files/original/00d9d63023a6fe1b224f4e65f8f427d8.jpg d19eb70180882f9be9283cfe7c9fad7c https://staging.drfop.org/files/original/92cc21d0b179a43c17c8e2601b36face.jpg ef09bcbd71c9a5ab1946affdd2d3a1fb https://staging.drfop.org/files/original/84ed9b79ed6c37a2442937152385a670.jpg 96cc057c0c3752fe06400aaef020bf31 https://staging.drfop.org/files/original/02800ee7d2bcaf59054a58fa1a76f5f9.jpg bcd50bad74ee70aedc0c9fdd43ae2b78 https://staging.drfop.org/files/original/e83e8ff373a7a2161bce8c4e4b469c59.jpg e0815425b9120a70904cb54f6db154c4 https://staging.drfop.org/files/original/13e717b3a2917a1f960b337b564c1a2c.jpg 95b5a4e637a9579f4f7f1262bd8f9f93 https://staging.drfop.org/files/original/c7761c10dee8f20eb5989c636532dd48.jpg 16a76ccbb32f47d32cc0636dfe8b849c https://staging.drfop.org/files/original/de8c25414b9f0dc535a4ece8c2a3bc3c.jpg e42c82f4b353b2d82db9be8e58647298 https://staging.drfop.org/files/original/aae1935446e932da0d197817ff316667.jpg cdfce01bb2a2f3d62f09803a4399a4cd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_004.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 4 - 25 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Munster-Type Below-Elbow Socket, a Fabrication Technique</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Kevin A. Cody, M.A. <a style="text-decoration:none;">*</a><br />George Hartmann, C.P.O. <a style="text-decoration:none;">*</a><br />Dominick E. Casella <a style="text-decoration:none;">*</a><br /></h5> <p>The introduction of the Munster technique into the United States in 1958 generated considerable interest in the prosthetics profession, particularly for the management of amputees with short and very short below-elbow stumps. However, in spite of the enthusiasm for this technique, its application has met with varying success in this country. The dearth of precise instructional material has undoubtedly contributed to the lack of consistent results. Each prosthetist has improvised from the limited information available, sometimes successfully, sometimes unsuccessfully.</p> <p>The purpose of this article and the manual upon which it is based<a></a> is to present a detailed description of the Munster technique based upon the procedures utilized in the successful fittings performed in the New York University evaluations of 1963-1964.<a></a> But there can be no substitute for formal instruction and demonstration in the technique. This point is stressed because at least one critical procedure in the fabrication technique, that of cast taking, is quite difficult to learn by the written word and pictures alone.</p> <p>The procedures presented do not conform in every respect to those promulgated by the developers, Drs. Oskar Hepp and G. G. Kuhn.<a></a> However, it is believed they are a close approximation. For this reason the technique is referred to as the "Munster-type" fabrication technique. In choosing this title, it is intended to give appropriate credit to Drs. Hepp and Kuhn for the original development of the technique, without implying identity with their procedures.</p> <p>Short below-elbow stumps have always presented fitting problems for the obvious reasons of small attachment area, poor leverage, and a decreased range of useful motion. Split sockets and step-up hinges have commonly been used to provide a full range of elbow flexion (135 deg.) to amputees having very short below-elbow stumps. However, this system is characterized by several features which tend to reduce its over-all acceptability. Step-up hinges decrease the lifting power available to the amputee, increase the bulk of the prosthesis at the elbow and proximal forearm, and historically have lacked durability. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior-oblique and posterior-oblique views of the Munster-type prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the middle 1950's, Drs. Hepp and Kuhn of Munster, Germany, formulated a new approach to the prosthetic management of short upper-extremity stumps. They developed a technique for fabricating sockets for below-elbow and above-elbow amputations which provides a more intimate encapsulation of short slumps.<a></a> </p> <h3>Evaluation of Munster Fabrication Technique</h3> <p>New York University Adult Prosthetic Studies became interested in the Munster technique for amputees having short and very short be-low-elbow stumps, following the favorable experiences reported by amputee clinics in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children.<a></a> Under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development, New York University conducted an evaluation of what was considered the Munster technique in applications to adult amputees.<a></a> The general characteristics of the below-elbow sockets fabricated in this study were:</p> <ol> <li>The forearm was set in a position of initial flexion (average 35 deg.) in relation to the humerus. Because of the reduced range of useful motion, the socket was flexed to position the terminal device in the most generally useful area.</li><li>The anterior trim line extended to the level of the antecubital fold, with a channel provided for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket enclosed the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket. The trim line was just above the level of the epicondyles.</li></ol> <p>Because of the high anterior and posterior walls of the sockets, the range of motion for the average amputee was limited to approximately 70 deg. (from 35 deg. to 105 deg. flexion). The limited range of motion characteristic of Munster-type sockets bears emphasis (<b>Fig. 2</b> and <b>Fig. 3</b>). In current practice, the acceptable checkout standard for maximum elbow flexion with the prosthesis is that it should be within 10 deg. of stump flexion without the prosthesis. This standard is not applicable to the Munster-type prosthesis. Nevertheless, the decreased range of motion available has been found acceptable by unilateral amputees who typically use their prostheses as assistive devices and perform very few activities at the extremes of the flexion-extension range.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Maximum extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Maximum flexion, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results of the New York University study of Munster-type fittings cited earlier indicated that:</p> <ol> <li>Amputees reacted positively to the comfort and security of the socket.</li><li>The decrease in flexion range had no appreciable effect on the prosthetic functions of unilateral amputees. However, for bilateral subjects, modification of the anterior trim line and the provision of a wrist-flexion device were necessary for the performance of tasks close to the body.</li><li>Lifting and holding forces available to the amputee were generally superior.</li></ol> <p>(<b>Fig. 4</b> and <b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Live lift"-resisting vertical downward force while maintaining the elbow flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Axial load"-resisting vertical downward force with the elbow extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following the favorable results obtained in fitting adult amputees, New York University Child Prosthetic Studies initiated a study of the applicability of these procedures to children with very short, short, and long below-elbow deficiencies. As of March 1965, ten successfully fitted children ranging in age from 20 months to 10 years had worn their prostheses for periods ranging from 4 to 14 months.</p> <p>Although the study of the children's fittings had not been completed at this writing, the indications are that fabrication procedures for adults, as described in this article, would be equally applicable to children.</p> <h3>Prescription Considerations</h3> <p><i>A priori, </i>this method of socket fabrication would appear to be of greatest potential benefit to amputees with stumps of the short and very short types. These are patients who, under current practice, would typically be fitted with metal elbow hinges-step-up, polycentric, or, at the longer limits of the range, single-pivot or flexible hinges. Prime beneficiaries might be amputees who normally would be fitted with split sockets and step-up hinges because of the inherent disadvantages in this type of fitting.</p> <p>In general, this hypothesis has been verified by fitting experience to date. In the NYU evaluations approximately 90 per cent of the stumps fitted fell into the short and very short below-elbow categories. Specifically, nine adults (including one bilateral amputee) with stump lengths ranging from l-1/2 in. to 5-1/2 in. (18 to 52 per cent) and eight children with stumps 2 in. to 3 in. long (25 to 40 per cent) were successfully fitted with Munster-type prostheses.</p> <p>The precise limits of applicability of the Munster-type prosthesis (that is, the minimum and maximum stump lengths) must be determined individually for each patient. However, based upon a somewhat limited investigation of these considerations, the following guidelines are offered:</p> <p><i>Minimum length: </i>Very short stumps virtually disappear at 90 deg. of elbow flexion. Hence, the maximum prosthetic flexion angle obtainable with stumps in this category is limited accordingly. The shortest stump fitted at NYU was 1-1/2 in. (18 per cent) in length. The maximum flexion angle obtained (with prosthesis) was 80 deg.</p> <p>Thus, fitting of Munster-type sockets to stumps as short as 1-1/2 in. depends upon the acceptability of a very limited amount of elbow flexion (usually less than 90 deg.).</p> <p><i>Maximum length: </i>With regard to maximum stump length, two limiting factors must be considered:</p> <ol> <li>Depending on the extent of the anatomical deficiency, stumps of mid-length and longer usually have some degree of residual pronation-supination which may be harnessed in a conventional below-elbow socket with flexible hinges. This active pronation-supination of the prosthesis is eliminated with the Munster-type fitting. The question to be decided is whether other advantages of the Munster-type prosthesis adequately compensate for the loss of rotation in a given case.</li><li>The configuration of the Munster-type socket (proximal opening at an angle to the socket) presents progressively increasing difficulty in donning and doffing the prosthesis as stump length increases. Absolute stump length rather than proportion of sound side remaining appears to be the prime determinant. The difficulties can be reduced by socket modifications, such as a looser fit or lowered trim line. Such modifications, however, progressively reduce control and retention of the prosthesis.</li></ol> <p>NYU has fitted several adult and juvenile amputees whose stumps fell into the long classification; that is, 55 per cent of sound side or longer. One adult at the borderline of the long classification (5-1/2 in.-56 per cent) and a child well within this category (4 in.-66 per cent) were not affected by the considerations mentioned above. In both cases residual pronation and supination were minimal, and no difficulty was experienced in putting on and taking off the prosthesis.</p> <p>However, an adult with a 7-in. stump (66 per cent) required considerable modifications to the proximal brim before the prosthesis could be delivered successfully. The anterior trim line was reduced approximately 1/2 in. below the cubital fold to facilitate passage of the stump. The subject had about 55 per cent of residual stump rotation; but, since this rotation had not been utilized in the previous prosthesis, no deprivation was imposed by the Munster-type arm.</p> <p>One child with a 6-in. (92 per cent) stump was also successfully fitted with two different modifications of the Munster-type prosthesis. In the initial prosthesis, the posterior trim line was reduced to just above the olecranon for manageable donning and doffing. In a second fitting, the standard trim lines were maintained, but the socket was made somewhat looser than usual. Both modifications produced sockets with slightly reduced but still very acceptable retention.</p> <p>Thus, the Munster-type prostheses can apparently be fitted without difficulty to stumps up to the limit of the short below-elbow classification (55 per cent). The fitting of longer stumps involves consideration on an individual basis of the factors discussed.</p> <h3>Bilateral Fittings</h3> <p>The question of fitting Munster-type prostheses bilaterally is not fully resolved. Two problems are inherent in such fittings:</p> <ol> <li>The difficulty in donning two closely fitting prostheses without assistance.</li><li>The limitation imposed by restricted elbow flexion, particularly on the dominant side.</li></ol> <p>NYU has had no experience in fitting children bilaterally but has successfully fitted one bilateral adult amputee (4-in. and 5-1/2-in. stumps). The inherent problems were resolved by:</p> <ol> <li>Fitting the sockets less snugly than usual to facilitate donning.</li><li>Lowering the anterior trim line and providing a wrist-flexion unit on the dominant side for activities close to the body.</li></ol> <p>It is probable that selected juvenile bilateral amputees might be successfully fitted with similar modifications.</p> <h3>Procedures</h3> <h4>Stump Eexamination and Measurements</h4> <p>Materials required for stump examination and measurements are:</p> <ul> <li>Measuring tape</li> <li>Ruler</li> <li>Goniometer</li> <li>Measurement form (<b>Fig. 6</b>)</li> </ul> <p>A thorough stump examination is an important prerequisite to any prosthetic fitting procedure. In the Munster-type fitting, a stump examination is even more critical than usual because of the intimate socket encapsulation of the stump. Skin irritations, painful scars, abrasions, and sensitive areas must be identified so that necessary socket reliefs maybe anticipated and provided.</p> <p>Consistent with sound prosthetics practice, it is advisable to follow the conventional measurement procedures described in the<i>Manual of Upper Extremity Prosthetics</i><a></a> so that a comprehensive record will be available for future reference. The appropriate below-elbow measurements are recorded on the modified Upper-Extremity Measurement Chart shown as <b>Fig. 6</b>. However, it should be noted that, since the plaster-wrap casts are used as check sockets in this technique and stump molds made from the wrap casts are not corrected to measurements, the only measure essential for fabrication is the length of the normal forearm to wrist and thumb tip.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Measurement form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should also be noted that stump and sound forearm lengths are pleasured from the olecranon rather than from the epicondvles, since the olecranon is more convenient to use as a reference point on the cast and socket. These measurements are described below.</p> <p><i>Stump length: </i>The stump length is measured from the posterior aspect of the olecranon (<b>Fig. 7</b>). If distal redundant tissue is present, the measurement should include the redundancy.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Measuring stump length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Forearm length: </i>With the patient's sound forearm flexed at approximately 90 deg., and held midway between pronation and supination, measurements are made from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid, and from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Measuring forearm length. A, Measuring from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid; B, measuring from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Wrap Cast</h4> <p>Materials required to take the wrap cast are:</p> <ul> <li>Cotton stockinette (appropriate size for stump)</li> <li>Dacron tape for temporary harness</li> <li>Yates clamps</li> <li>Indelible marking pencil</li> <li>Three rolls of plaster-of-Paris bandage (6 or 8 cm. elastic-type preferred)</li> <li>Pail of water</li> </ul> <p>A snug, form-fitting cotton stockinette is placed over the stump to insulate the skin and hair from plaster. The assistance of the amputee or a temporary figure-eight harness may be used to keep the stockinette free from wrinkles. The harness method is generally preferable for children.</p> <p>Application of the proper molding grip is essential to the success of the wrap cast and hence to the final outcome of the fitting. It is important, therefore, that the prosthetist practice this procedure on each amputee prior to the application of the cast. He will thus become familiar with the individual characteristics of each amputee's stump, and the possibility of erroneous molding once the stump is wrapped will consequently be reduced. Furthermore, the amputee will know what to expect during the casting procedure and be better able to cooperate.</p> <p>It is important to note that the prosthetist will be able to apply the molding grip more conveniently when his arms and those of the amputee are at the same level. It is suggested, therefore, that child amputees sit on a table or stand on a raised platform.</p> <p>In this article, the specific steps to be followed are described for a right below-elbow amputee (the hand positions are reversed for a left amputee). Because of the fundamental importance of the correct molding grip, this aspect of the fabrication procedure is illustrated with both photographs and drawings.</p> <p>With the amputee's stump flexed to 90 deg., the index and middle fingers of the pros-thetist's right hand are placed on the anterior surface of the stump. The prosthetist's right wrist should be in a neutral or slightly extended position. The two fingers should rest on either side of the biceps tendon and along the anterior surface of the slump. Moderate pressure is exerted (to the point of firm resistance) simultaneously into the cubital fold and downward on the anterior surface of the stump, but am concentration of pressure distally is avoided (<b>Fig. 9</b> and <b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Practicing the molding grip. The prosthetist exerts moderate pressure on either side of the biceps tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Another view of the prosthetist exerting pressure on either side of the biceps tendon, simultaneously into the cubital fold and downward on the anterior surface of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The dorsal aspect of the proximal ulna is distinctly wedge-shaped. The prosthetist's left hand is shaped so that the thenar and hypo-thenar eminences form a channel into which this wedge will fit (<b>Fig. 11</b>). The grooved hand is then positioned against the underside of the stump to provide stability and support without distortion. The metacarpal joints of the prosthetist's left hand should be located just below the amputee's olecranon (<b>Fig. 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Practicing the molding grip. A, The wedge-shaped ulna as viewed from the rear; B, channel formed in the prosthetist's hand; C, the ulna fitted into the channel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Practicing the molding grip; positioning the grooved left hand of the prosthetist against the underside of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The index, middle, and ring fingers of the prosthetist's left hand are cupped and positioned on the distal posterior surface of the humerus just above the level of the epicondyles (<b>Fig. 13</b>). Gentle downward pressure is applied with the pads of the fingers. Care must be taken to avoid pressure between the palm of the hand and the olecranon. Thus relief is automatically provided for the olecranon. The little finger and the thumb may be curled to make contact with the medial and lateral epicondyles, respectively. However, these digits should <i>not </i>exert any pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Practicing the molding grip; gentle downward pressure being applied by the pads of the index. middle, and ring fingers of the prosthetist's left hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In view of the intimate fit which characterizes the Munster-type socket, tender areas and bony prominences such as the olecranon and the epicondyles must be clearly defined for the provision of the necessary reliefs. While the stump is flexed at 90 deg., these areas are marked with an indelible pencil so that thev may be easilv identified on the wrap cast (<b>Fig. 14</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Marking tender areas and bony prominences </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A preliminary trim line is marked on the cast sock by drawing a line posteriorly connecting two points 1 in. superior to the medial and the lateral epicondyle, respectively; and the line is continued anteriorly so that it passes through a point 1/2 in. above the mid-cubital space (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Marking the preliminary trim line on the cast sock. A, A line is drawn posteriorly connecting two points 1 in. superior to the medial and the lateral condyles; B, the line is continued to pass anteriorly 1/2 in. above the mid-cubital space. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The critical relationship between the stump and the Munster-type socket cannot be overemphasized. Every effort should be made, therefore, to obtain a properly fitting cast. To this end, it is recommended that at least two, and preferably three, casts be taken so that the prosthetist and the patient together may choose the best of the series. Elastic or non-elastic plaster-of-Paris bandages may be used, but the elastic is preferable since it results in a more accurate configuration.</p> <p>While the stump is flexed at 90 deg. and the humerus is held midway between internal and external rotation, the wrap is commenced with two circular turns above the elbow joint (over the olecranon and the cubital fold). Only very slight tension should be applied to the plaster-of-Paris bandage (either elastic or nonelastic) in the process (<b>Fig. 16</b><i>A</i>). The wrapping proceeds to the distal end of the stump in a figure-eight or a spiral pattern (<b>Fig. 16</b><i>B). </i>The wrap is continued at least 1/4 in. above the reference marks made earlier.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Wrapping the stump. A, The wrap is begun with two circular turns around the elbow joint-over the olecranon and the cubital fold; B, the distal end of the stump is included in either a figure-eight or a spiral pattern; C, the wrap is continued at least 34 in. above the reference marks made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the wrapping has been completed, the molding grip practiced earlier is applied (<b>Fig. 17</b>). Finger pressure should be sufficient to displace all loose tissue (to the point where firm resistance is reached). Pressure is maintained until the plaster has set.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Application of the molding grip to the wrap cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened, the proximal end of the wrap cast is reinforced with several turns of nonelastic plaster-of-Paris bandage in order to minimize distortion. Then the stockinette is pulled down over the cast (<b>Fig. 18</b><i>A</i>). As the cast is gently worked off the stump, upward pressure is applied to the arm to increase skin tension at the proximal end of the cast in order to break the vacuum seal (<b>Fig. 18</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Removal of wrap cast. A, Pulling the stockinette down over the cast; B, applying upward pressure on the arm as the cast is gently worked off the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The stockinette is removed from the cast, and the indelible markings which have been transferred from the stockinette to the inner wall of the cast are accentuated (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Accentuating the indelible markings transferred from the stockinette to the inner wall of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These procedures should be repeated until a minimum of two, and preferably three, casts have been taken.</p> <h4>The Check Socket</h4> <p>Materials required to prepare the check socket are:</p> <ul> <li>Knife</li> <li>Scissors</li> <li>Fresh plaster</li> <li>Water</li> </ul> <p>All of the wrap casts taken should be prepared in accordance with the procedures described below and used as check sockets. The one agreed upon by both the prosthetist and the patient as providing the most comfortable fit and the greatest range of motion and maximum security is selected for use in the preparation of the positive plaster model.</p> <p>A hole is cut in the cast, just large enough to allow the passage of a stump pulling sock and as close to the distal end as possible so that shortening of the cast is minimized (<b>Fig. 20</b><i>A</i>). The final trim lines for every socket must be determined individually for each amputee. However, as an initial step, the proximal end of the cast is trimmed to the level of the reference line made earlier (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Trimming the cast. A, The hole cut in the distal end should be just large enough to permit passage of a stump pulling sock; B, trimming the proximal end at the level of the reference line made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is then moistened, and the inside of the cast is smoothed with fresh plaster to remove all gauze marks, except in the area of the epicondyles and the olecranon (<b>Fig. 21</b>). <i>No </i>plaster should be added in these critical areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Smoothing the inside of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting The Check Socket</h4> <p>Materials required for fitting the check socket are:</p> <ul> <li>Cotton stockinette (stump pulling sock)</li> <li>Indelible marking pencil</li> </ul> <p>A length of stockinette is placed on the amputee's stump, and the distal end of the stockinette is drawn through the hole in the check socket. The stump is pulled into the socket, care being taken that all flesh is drawn inside the cast (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pulling the stump into the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the check socket on the amputee, the usual tests are made for adequacy of fit, comfort, and range of motion by having the amputee exert force against resistance in elbow flexion, extension, and rotation (<b>Fig. 23</b>). Although the stump cannot rotate the socket, there may be some undesirable rotation of the stump within the socket. If the fit of the check socket is not satisfactory, the socket should be rejected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Determining the adequacy of the fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the check socket causes any pain or discomfort, the appropriate area should be marked on the outside of the socket so that relief can be provided (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Marking an area which requires relief. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The same procedures are repeated with the other check sockets and the best socket is selected for use in completion of the prosthesis.</p> <h4>Establishing The Range of Motion in Check Sockets</h4> <p>The maximum forearm flexion and extension positions attainable with the Munster-type prosthesis will be significantly less than those achieved in conventional prostheses. Experience has shown that the maximum flexion range for the typical short below-elbow stump fitted with a Munster-type socket is approximately 70 deg. (from 35 deg. initial flexion to 105 deg. maximum flexion).<a></a> A range of motion of this magnitude is not always achievable but should be the initial goal of the fitting.</p> <p>The principal factors limiting the range of motion are:</p> <ol> <li>Restriction in the maximum flexion angle obtained attributable to one or more of the following conditions: <ul> <li>Insufficient relief for the olecranon</li> <li>Too small a channel for the biceps tendon</li> <li>Too high an anterior wall</li> </ul> </li><li>Restriction in extension attributable to too high a posterior trim line.</li></ol> <p>However, it must be emphasized that lowered trim lines or loose fit will adversely affect the retention of the socket on the stump. Hence, the initial trim lines need to be closely maintained in order to provide maximum socket retention. They should be reduced only when absolutely necessary to provide greater comfort or increased range of motion, or both.</p> <p>Materials required in establishing the range of motion are:</p> <ul> <li>Indelible pencil</li> <li>Scissors or knife</li> <li>Goniometer</li> <li>Ruler</li> </ul> <p>A line is drawn on the lateral side of the check socket coincident with its long axis (from the lateral epicondyle to the mid-distal end) to serve as a guide in measuring flexion and extension (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Drawing a line on the check socket coincident with its long axis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The center of the goniometer is placed on the lateral epicondyle. The lower arm of the goniometer is placed on the long axis line, and the upper arm of the goniometer is lined up with the acromion (<b>Fig. 26</b>). Maximum flexion and extension angles are measured from these points of reference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Placement of goniometer to measure maximum flexion and extension angles </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If motion is restricted, the specific cause for the restriction should be determined and corrective action should be taken (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Trimming the check socket to provide increased range of motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee cannot achieve the proposed 35 deg. of initial flexion in the check socket, the discrepancy is compensated for in the alignment of the forearm shell. Therefore, while the stump is maintained in an actively extended position, a second line is drawn on the check socket at an angle of 35 deg. between the humerus and the stump (<b>Fig. 28</b>). This line will serve as a guide in aligning the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Drawing a second line at a 35-deg. angle between the humerus and the stump to serve as a guide in aligning the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The adequacy of the proposed initial flexion angle is tested by placing a ruler along the <i>35 </i>deg. line drawn on the check socket (<b>Fig. 29</b>). The ruler is placed to correspond to the intended length of the finished prosthesis; that is, the olecranon-to-thumb-tip measurement recorded on the Upper-Extremity Measurement Form (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Placing a ruler along the 35-deg. line to test the adequacy of the proposed angle of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee should flex and extend this improvised forearm composed of the check socket and the ruler (<b>Fig. 30</b>). Maximum flexion should be about 105 deg., except for very-short stumps, where it probably may not exceed 90 deg. Because of the inherent limitation of motion associated with the Munster-type prosthesis, the usual test of having the amputee bring his terminal device to his mouth is not applicable. The goal is to provide the maximum flexion angle possible compatible with a cosmetically acceptable initial flexion position and socket retention.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Checking the flexion and extension of the improvised forearm composed of check socket and ruler. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the maximum flexion angle obtained with 35 deg. of initial flexion is not acceptable, the angle of the ruler is adjusted to provide greater initial flexion. Initial flexion angles to a maximum of 45 deg. have been used, but at the expense of decreased cosmesis (<b>Fig. 31</b>). If less than 35 deg. of initial flexion is desired for cosmetic or other reasons, the angle is decreased accordingly. Such reduction also decreases the maximum flexion angle obtainable. The selected angle of initial flexion is indicated on the check socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Alternative angles of initial flexion: 30 deg., increased extension, decreased flexion; 40 deg., increased flexion, decreased extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Preparation of the Positive Model</h4> <p>Materials required for the preparation of the positive model are:</p> <ul> <li>Plaster-of-Paris bandage</li> <li>Talcum powder</li> <li>Hollow pipe (approximately 12 in. in length and 1/2 in. in diameter)</li> <li>Awl</li> <li>Two roundhead screws</li> <li>Fresh plaster</li> <li>Water</li> <li>Sanding screen</li> <li>Indelible marking pencil</li> <li>Vaseline or other parting agent</li> </ul> <p>The distal end of the check socket is closed with plaster-of-Paris bandage or with masking tape (<b>Fig. 32</b>) and a small extension (approximately 1 in.) is constructed at the proximal end of the check socket (<b>Fig. 33</b>), again with plaster-of-Paris bandage or with masking tape. This extension will provide the prosthetist with a margin of safety in smoothing the positive stump model without disturbing the desired trim line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Closing the distal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Construction of extension at proximal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the inner surface of the check socket has been sprinkled with talcum powder, the check socket is filled with liquid plaster of Paris (<b>Fig. 34</b>). Before the plaster hardens, a hollow pipe is inserted into the plaster. A recess approximately 1 in. to 1-1/2 in. deep is made in the plaster at the proximal end of the mold. A small hole, approximately 1/4in. in diameter, should be drilled in the pipe toward the bottom of the recess to facilitate vacuum lamination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Check socket filled with liquid plaster of Paris and a hollow pipe inserted into the plaster. The small hole drilled in the pipe will facilitate vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the positive model has hardened, the check socket is punctured with an awl at the proximal and distal ends of the forearm-extension reference line (<b>Fig. 35</b>). The punctures should penetrate into the positive stump model. An indelible pencil is inserted into the holes to mark the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Puncturing the check socket with an awl in order to mark on the positive model the proximal and distal ends of the forearm extension reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster wrap (check socket) is removed, and major irregularities, for example, superfluous plaster, are trimmed from the positive model (<b>Fig. 36</b>). All reference marks should be accentuated on the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trimming irregularities from the positive stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The junction between the positive model of the stump and the mold extension is faired with liquid plaster of Paris to provide a smoothly curved radius (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Fairing the juncture between the positive model and the mold extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The olecranon area on the positive stump model is built up approximately 1/16 in. with liquid plaster of Paris (<b>Fig. 38</b>). This build-up will provide additional relief for this bony prominence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Building up the olecranon area on the positive model to provide relief for this bony prominence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal end of the positive stump model is built approximately 1/2 in. with liquid plaster of Paris. This build-up will increase the length of the socket slightly and provide space for the hole through which the stump sock is pulled (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Building up the distal end of the positive model to increase the length of the socket slightly and to provide space for the hole through which the stump sock is pulled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The positive model is sanded smooth, and roundhead screws are inserted into the two reference holes made on the lateral side of the model. These screws will produce projections on the laminated socket through which a line will be drawn to align the forearm extension cone.</p> <h4>Lamination</h4> <p>Materials required for lamination are:</p> <ul> <li>Drill with 1/8-in. bit</li> <li>PVA sheets</li> <li>Dacron blanketing</li> <li>Nylon stockinette</li> <li>Polyester resin</li> <li>Promoter</li> <li>Masking tape</li> <li>Vacuum pump</li> <li>Wrist unit</li> <li>Manila paper</li> </ul> <p>The socket and forearm shell are laminated in accordance with standard procedures.<a></a> Vacuum lamination<a></a> is recommended to provide a truer reproduction of the model.</p> <p>Holes 1/8 in. in diameter, are drilled through the undercut areas at the proximal end of the positive model in order to draw the PVA bag into those areas during vacuum lamination (<b>Fig. 40</b>). The holes should exit in the vicinity of the previously mentioned hole in the pipe.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Drilling 1/8-in. holes through undercut areas at proximal end of the positive model to draw in PVA bag during vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the stump model has been lubricated, the inner PVA bag, dacron blanketing (for a smoother inner surface), the nylon stockinette, and the outer PVA bag are applied in the usual manner<a></a>, under a vacuum pressure of 12 in. of mercury (<b>Fig. 41</b>). (This is equivalent to 5.9 psi.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Inner PVA bag, dacron blanketing, nylon stockinette, and outer PVA bag ready for lamination on lubricated stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Polyester resin is applied in the standard manner.<a></a> Special attention should be paid to working the resin into the undercut areas (<b>Fig. 42</b>). The layup is oven-cured as usual.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Working resin into undercut areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has cured, an opening is cut in the extreme distal end of the socket (<b>Fig. 43</b>). The hole should be of sufficient diameter to allow the passage of the stump pulling sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Cutting an opening in the distal end of the socket to allow passage of the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A reference line is drawn on the outer wall of the socket by connecting the two screwhead projections. A forearm extension cone is applied in the usual manner, with the long axis of the cone coincident with the reference line (<b>Fig. 44</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Forearm extension cone aligned with reference line established by screwheads on socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lamination procedure for the forearm is the same as for the socket, except that dacron blanketing is not used (<b>Fig. 45</b>). The forearm extension may be laminated as a separate section or directly over the socket, using a wax melt-out. Both procedures work satisfactorily. After the forearm laminate has been cured, the prosthesis is cut along the proximal socket brim and the mold is broken out.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Forearm extension laminated over socket and cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting of the Prosthesis</h4> <p>A 1-in. hole is drilled through the medial wall of the forearm shell close to the distal end of the inner socket to permit passage of the stump pulling sock. The edges of the hole are polished with a grinding cone (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Polishing the edges of the hole tor the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Wearing a length of stockinette (approximately 8 to 10 in.) as a stump sock, the amputee inserts his stump into the socket and pulls the distal end of the sock through the hole (<b>Fig. 47</b>). The application of tension on the stump sock facilitates the complete insertion of the stump into the socket. The sock is left on the stump and the end of the sock is tucked into the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Application of tension on the stump sock facilitates the complete insertion of the stump into the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is checked for the adequacy of its fit. Reliefs are provided and trim lines are modified (<b>Fig. 48</b>) where necessary for comfort and range of motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Checking the adequacy of socket fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnessing</h4> <p>Three different harness arrangements have been used successfully at New York University with the Munster-type sockets.</p> <p>Initially, the arms were fitted with a conventional figure-eight harness with triceps pad, flexible hinges, and inverted Y-strap. However, the intimate stump encapsulation, flexion attitude, and high trim lines of the Munster sockets provide excellent retention and security, and in most cases obviate the need for suspensory apparatus to maintain the socket on the stump. Without harness, the majority of subjects in the Xew York University stud}' with adult amputees were able to resist high axial loads (in the order of 50 lb.) with negligible socket displacement. In the fitting of child amputees, the same results obtained with axial loads up to one-third of body weight. Hence, the two simplified axilla-loop harness systems which will be described have proved adequate for most patients.</p> <p>The conventional harness is fabricated according to standard prosthetics practice.<a></a> However, because of the integral security of the socket, the size of the triceps pad may be reduced.</p> <p>In the New York University fittings a triangular triceps pad constructed of light-gauge aluminum covered with leather was used exclusively (<b>Fig. 49</b>). The general pattern of the templates used as a guide in shaping this pad is shown in <b>Fig. 50</b>. The exact size of the template for each subject is determined as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. View of conventional harness showing triceps pad fabricated of light-gauge aluminum covered with leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Pattern of template for triceps pad (not actual size). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The width is equal to one-half the circumference of the arm measured just above the epicondyles.</li><li>The length is three-quarters of the width.</li></ol> <p>There is no significant functional difference in the two simplified axilla-loop harness systems. In one system the reaction point is located at the proximal socket, while in the other it is located over the triceps. The choice between the two systems depends upon the amputees' preferences regarding the position of their control cables.</p> <p>To locate the reaction point on the proximal socket, a standard housing crossbar assembly is riveted to the <i>midline </i>of the posterior wall of the socket approximately 1/2 to 3/4 in. distal to the proximal brim (<b>Fig. 51</b>). The crossbar portion of the loop is directed upward.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Simplified axilla-loop harness with reaction point on proximal socket. Upper, standard housing crossbar assembly riveted to the midline of the posterior wall of the socket. Lower, harness completed with an axilla-loop arrangement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal retainer base plate is located on the lateral side of the forearm in the usual manner so that it produces as direct a line of pull as possible between the crossbar and the terminal device.</p> <p>The cable-housing assembly is attached in the usual manner. The cable should be maintained as short as possible without interfering with function in order to reduce the incidence of the cable rubbing on the flesh or clothing.</p> <p>The harness is completed with an axilla-loop arrangement (<b>Fig. 51</b>). An additional suspensory strap (that is, a front-support strap) or flexible hinges are not needed.</p> <p>The simplified axilla-loop system is appropriate for most patients. But some patients will object to the low position of the control cable, which may interfere with the sleeves of shirts or blouses. To meet such objection, the reaction point may be located on a small leather triceps pad (3 in. x 3 in.)(<b>Fig. 52</b>). A small strap, preferably Velcro, is sewn across the middle of the posterior surface of the triceps pad to provide a means of securing the pad to the arm. A standard housing crossbar assembly is attached over the strap and centered on the triceps pad. The distal retainer base plate is placed on the forearm in the same manner as described in the previous system. The cable housing assembly is attached in the usual manner. The harness is complete with an axilla-loop arrangement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Reaction point on small triceps pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Checkout Procedures</h4> <p>Standard below-elbow checkout procedures<a></a> are applied to the Munster-type prosthesis and the usual requirements should be met except for the following:</p> <ol> <li>Since prosthetic forearm rotation is eliminated, the pronation-supination measure is not applicable.</li><li>Since a decreased flexion range is an integral feature of the socket, the checkout standard of a 10-deg. loss of flexion with prosthesis does not apply. Maximum flexion for most amputees will range between 100 deg. and 115 deg., which may be approximately 30 deg. less than stump flexion with the prosthesis off.</li><li>Because of the decreased elbow flexion, the requirement for opening of the terminal device at the mouth may not apply. However, full opening of the terminal device should be available at maximum flexion of the elbow.</li></ol> <p>In following the checkout procedures, particular attention should be paid to the unique features of these sockets; namely, the critical importance of the fit of the socket around the epicondyles and olecranon and the built-in suspension of the sockets. The application of compression and torque forces (particularly a vertical downward force at the terminal device with the elbow flexed at 90 deg.) should indicate the presence of any pressure areas around the elbow. Additionally the axial-load test<a></a> -application of a vertical downward force at the terminal device with the elbow fully extended-should reveal any deficiencies in the suspension feature of the sockets.</p> <p>It must be recognized, however, that, because of the close fit of the socket over the epicondyles and olecranon, some adults will not be able to tolerate the accepted axial-load standard of 50 lb. (or, for children, one-third of the body weight). Special caution to avoid injury to the amputee should be taken when applying the axial-load force. Failure to meet the 50-lb. standard should not in itself be sufficient cause to reject the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</li> <li>Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The "Muenster" type fabrication technique for below-elbow prostheses, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the "Muenster-type" below-elbow prosthesis, April 1965.</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</li> <li>University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster-type' below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Dominick E. Casella </b></td></tr><tr><td class="clsTextSmall">Research Administrative Assistant, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>George Hartmann, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Kevin A. Cody, M.A. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N. W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_004/autum65-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_004/autum65-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_004/autum65-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_004/autum65-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_004/autum65-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_004/autum65-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_004/autum65-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_004/autum65-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_004/autum65-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_004/autum65-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_004/autum65-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_004/autum65-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_004/autum65-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_004/autum65-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_004/autum65-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_004/autum65-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_004/autum65-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1965_02_004/autum65-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1965_02_004/autum65-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Munster-Type Below-Elbow Socket, a Fabrication Technique Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Kevin A. Cody, M.A. * George Hartmann, C.P.O. * Dominick E. Casella * https://staging.drfop.org/files/original/300fec58bb900f1c7824dd89bd4bbaae.pdf 76815d70cedf1bca701b131c7ff7e1e3 https://staging.drfop.org/files/original/900377a01eea06be7f175e196b90925d.jpg f2357efa66a29ce5c62e4d968a6ccfa9 https://staging.drfop.org/files/original/9f83d9cea044e7f3c97f76b921831c78.jpg 7eebd4fbeda2d03e63a1e5aa08d4ee8c https://staging.drfop.org/files/original/210a566f2d7906636a17a4da061ba64f.jpg a9a6af01b0842bab00a8484934d9b946 https://staging.drfop.org/files/original/1576a7cdca5985ca39b8dfd73643a26d.jpg cd929d3b6f4cf06461d5d6085b38b978 https://staging.drfop.org/files/original/7f40b03606f628d72d01f42ac743588c.jpg 7d7945a45ce4611bc7826c5b4eb56bac https://staging.drfop.org/files/original/60fd60e81e861bcade3d43e96948c6ed.jpg 616e1eafc83246f42671d97fe4d7cb35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_014.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 14 - 22 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_014.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Experiences with the PTB Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The original patellar-tendon-bearing (PTB) prosthesis was constructed at the Biomechanics Laboratory of the University of California. For details regarding the anatomical and physiological considerations<a></a>, the biomechanics<a></a>, and the construction<a></a>, the reader is referred to the June 1962 issue of <i>Artificial Limbs.</i></p> <p>In Finland about 1,000 PTB prostheses have been manufactured since 1959. Although the name of these prostheses and the main principle of their construction imply that weight is borne on the lower patellar ligament (<b>Fig. 1</b>), this is not the only weight-bearing area. Both tibial condyles and, to some extent, the distal end of the stump share the weight. The distribution of weight in these areas necessitates truly individual fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Vertical cross section of anterior portion of PTB socket. The supporting force, as shown by the arrow, acts on the lower patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For technical details of fabrication of PTB prostheses, the reader is referred to the issue of <i>Artificial Limbs </i>which has been cited. Here it is sufficient to say that a plaster cast of the stump is taken first. Then an intimately fitting, distally closed socket of hard plastic and a socket insert of sponge rubber are made. Distally, the socket is joined to a wooden shank, to which a SACH foot is attached (see <b>Fig. 2</b> for views of a finished prosthesis). It is not essential that the socket be made of plastic, but at present this seems to be the best material available. It is relatively easy to laminate a plastic shell from a plaster model. The plastic socket withstands moisture and is, therefore, relatively resistant to perspiration, and it is readily cleaned. The drawbacks are the airtightness of the material, the risk of its causing allergic reactions, and, perhaps, the poorer heat insulation in cold weather compared with materials previously used. These points will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with PTB prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. After three weeks the patients and their prostheses are examined at the Department of the State Supervisor, where either the prostheses are approved, or some modification, correction, or repair is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their PTB prostheses a questionnaire is sent to them. At the Department of the State Supervisor, record cards are kept for all amputees, on which are entered notations concerning modifications and repairs. Thus it is easy to check on what happens to the various prostheses.</p> <p>This article is based on the examinations of the amputees and their prostheses three weeks after the initial issue, data obtained from the questionnaires distributed to the amputees when they have worn their prostheses for six months, and data obtained from the record cards.</p> <p>The study covers 228 amputees fitted with PTB prostheses. Prostheses from different workshops differ somewhat from each other, since standardization of the products is a problem in Finland, as it is elsewhere, perhaps. Therefore, only genuine PTB prostheses have been included in this study.</p> <p><b>Fig. 3</b> shows the ages of the amputees, disclosing that the age group of 40-54 years is the largest. The youngest patient was 20, while the oldest was 75. Ex-servicemen account for 94.3 per cent of the series. The remainder are insured civilians. Only one of the cases in the series was a recent amputee whose initial fitting was with a PTB prosthesis. This does not imply that recent amputees are fitted for theoretical reasons with so-called "conventional" prostheses. On the contrary, it should be an advantage to be fitted from the outset with a PTB prosthesis, although it goes without saying that recent amputees offer special problems because of the longer duration of stump changes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Ages of the amputees when they were fitted with PTB prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. From the standpoint of prescription, it is of major interest to ascertain whether the PTB prosthesis can be worn while performing heavy labor, considering the absence of a thigh corset and the greater stress on the knee joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> discloses that the series includes 59 farmers or smallholders, 21 industrial workers, two lumbermen, and 7 painters. It stands to reason that amputees, whenever possible, choose labor that is not very heavy. Many farmers admitted that they had abandoned the heaviest tasks. However, others in the series mentioned lumbering as a part-time occupation. It was learned that some amputees had worn the PTB prosthesis without a thigh corset while walking on soft, uneven ground and on snow; in other cases, a short above-knee corset had been added almost immediately or when the PTB prosthesis had been worn for some time. It is apparent that stump length and the stability of the knee are important factors.</p> <p><b>Fig. 4</b> shows the lengths of the stumps in the series. In general, cases with a stump length of less than 12 cm. required a thigh corset, the length of which was about one-half or one-third the length of the thigh corset of a conventional prosthesis. The shortest stump in the series measured 6 cm., and the longest 35 cm. The series includes nine bilateral amputees (3.9 per cent).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn it? </i>According to the replies, 210 amputees (92.1 per cent) had worn their prostheses regularly from the outset.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>When the replies were compared with the record cards, it appeared that 18 (7.9 per cent) had not been able to wear their prostheses regularly. In three cases the cause could not be elicited. In 15 cases the causes were as follows:</li></ol> <ul> <li>The skin became irritated in three cases, and in one case an allergy set in.</li> <li>In two cases the socket became too loose.</li> <li>The stump did not tolerate the pressure; it became tender.</li> <li>There was pressure on the stump when the patient drove his car.</li> <li>Ulceration of the stump occurred in three cases.</li> <li>The prosthesis was cold in the winter, and it slipped off when the patient walked in the snow.</li> <li>The stump swelled when the patient was riding a bicycle.</li> <li>Stairs were a problem.</li> <li>The closed socket caused excessive perspiration of the stump.</li> </ul> <p>3. <i>Have you worn your prosthesis </i>(a) <i>when working indoors, (b) when working outdoors, (c) when working outdoors in very cold weather? </i>A total of 223 (97.8 per cent) had worn their prostheses while working indoors; 208 (91.2 per cent), while working outdoors; and 140 (61.4 per cent), while working outdoors in very cold weather.</p> <p>4. <i>Have you worn your prosthesis in some additional</i>- <i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only 21 replies were obtained on this point. One patient was a chauffeur, two were building their own houses, one was building a summer cottage, two fished, five were doing agricultural work, three did lumbering, six did gardening, and one was a night watchman.</p> <p>5. <i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>The majority had used conventional prostheses of wood or leather. Only a few had worn prostheses of light metal. Some amputees had had prostheses of all three materials in the course of years.</p> <p>6. <i>Have you been satisfied with your prosthesis? </i>There were 206 (90.4 per cent) satisfied wearers. Only 22 (9.6 per cent) complained.</p> <p>7. <i>Do you think this prosthesis is {a) better than, (b) just as good as, (c) not as good as your previous limb? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   207 ( 90.8 per cent)</p> </td> </tr> <tr> <td> <p>Just as good as previous prostheses</p> </td> <td> <p>   8 ( 3.5 per cent)</p> </td> </tr> <tr> <td> <p>Not as good as previous prostheses</p> </td> <td> <p>   12 ( 5.3 per cent)</p> </td> </tr> <tr> <td> <p>First prosthesis (recent amputee)</p> </td> <td> <p>   1 ( 0.4 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>The great majority were satisfied with the PTB prosthesis. What appealed to them most was its lightness and the freedom from a thigh corset. This enabled the development of the thigh muscles in a short time. However, not all the amputees were able to manage without a thigh corset.</p> <p>8. <i>What defects or drawbacks have you observed in your PTB prosthesis? </i>Listed below are the complaints of 26 amputees (12.3 per cent). In eight cases the complaints apply mainly to the stump, and in 18 to the prosthesis, but it is not always possible to distinguish sharply between the two.</p> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p><b>Prosthesis</b></p> </td> </tr> <tr> <td> <p>Allergic reaction</p> </td> <td> <p>Cold in the winter (two cases)</p> </td> </tr> <tr> <td> <p>Circulatory disturbance</p> </td> <td> <p>Socket closed and too warm (three cases)</p> </td> </tr> <tr> <td> <p>Ulceration</p> </td> <td> <p>Socket became too loose (two cases)</p> </td> </tr> <tr> <td> <p>Itching</p> </td> <td> <p>Socket pressed on the stump</p> </td> </tr> <tr> <td> <p>Stump shrinkage</p> </td> <td> <p>Flexion of the knee during work impossible because socket extends above knee</p> </td> </tr> <tr> <td> <p>Perspiration</p> </td> <td> <p>Unstable on slippery ground and without a thigh corset</p> </td> </tr> <tr> <td> <p>Edema</p> </td> <td> <p>Unstable in soft snow</p> </td> </tr> <tr> <td> <p>Fatigue</p> </td> <td> <p>Unstable on soft ground </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Excessive strain on the knee without a thigh corset</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Insert wears out too rapidly </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Heel of the SACH foot is too soft</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe of the SACH foot gradually bends upward</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe wears out too rapidly</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Difficult to ski</p> </td> </tr> </tbody></table> <p>9. <i>Has perspiration in the amputation stump constituted a problem? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Perspiration a problem</p> </td> <td> <p>   161 (70.6 per cent)</p> </td> </tr> <tr> <td> <p>Perspiration not a problem</p> </td> <td> <p>   39 (17.1 per cent)</p> </td> </tr> <tr> <td> <p>Initially excessive perspiration, later not</p> </td> <td> <p>   19 (8.3 percent)</p> </td> </tr> <tr> <td> <p>Less perspiration than with other prostheses</p> </td> <td> <p>   9 (4.0 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>Owing to the closed, air-tight socket, perspiration was a major problem, particularly in the summer. It should be borne in mind, however, that this problem also occurs with conventional prostheses, although perhaps not to the same degree. The possibilities for reducing the perspiration problem are discussed later.</p> <p><i>10. Has the skin on the stump tolerated the prosthesis? </i>The skin tolerated the prosthesis well in <b>190 </b>cases (83.9 per cent), better than with other types of prostheses in 14 cases (6.5 per cent), and not so well as with others in 24 cases (9.2 per cent).</p> <p><i>11. Have reddening of the skin and eczema occurred? </i>A total of 75 amputees complained of reddening and eczema, while 153 had no such symptoms.</p> <p><i>12. Did reddening, eczema, or ulceration of the stump occur before you started using a PTB prosthesis, and, if so, for how long? </i>In 157 cases (68.9 per cent) such symptoms had arisen from the use of conventional prostheses of wood, leather, or light metal.</p> <p><i>13. What are your experiences with the new prosthesis outdoors in cold weather? </i>A total of 142 amputees had worn their prostheses outdoors during the winter, and temperatures of -20 to -40 deg. C had caused no problem. Many had skied as much as 30 km. Only five (3.5 per cent) had found the new prosthesis too cold. Replies were as follows:</p> <table> <tbody><tr> <td> <p>No complaints</p> </td> <td> <p>   111 ( 78.2 per cent)</p> </td> </tr> <tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p>Somewhat colder than previous prostheses</p> </td> <td> <p>   21 (14.8 per cent)</p> </td> </tr> <tr> <td> <p>Very cold</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p><b>   142 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>It developed from the replies that the vast majority of the patients had been able to wear their PTB prostheses regularly from the outset. Eighteen amputees had experienced discomfort of various kinds. In many cases there were only minor complaints, and the source of the trouble was readily dealt with. Sometimes the complaints related to phenomena always associated with the manufacture and fitting of prostheses.</p> <p>It is noteworthy, too, that the patients wore their prostheses while performing hard labor.</p> <p>The vast majority of the patients were satisfied. The dissatisfied wearers numbered 22 (9.6 per cent). The causes for complaint are specified in <b>Table 2</b>. The ages and stump lengths of these patients are indicated in the tabulation to permit evaluation of their possible influence. Data regarding all the modifications needed to make the prostheses fit for use, even the smallest repairs, were obtainable from the amputee cards.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is a characteristic feature of the PTB prosthesis that it immediately starts remodeling the stump, because of the intimate fit of the socket. During the first few weeks the stump shrinks, so that the socket becomes too loose. It can be seen in <b>Table 2</b> that this occurred in 11 cases, or 50 per cent of the dissatisfied wearers. These patients were fitted with a new socket insert, and occasionally also with a new socket shell, which implies that a large part of the prosthesis had to be rebuilt. In many cases the insert had to be modified several times. These possibilities must be reckoned with when this type of prosthesis is prescribed.</p> <p>The regeneration of the thigh muscles in those who managed without a thigh corset has already been mentioned. This phenomenon results from the greater muscular activity required to control the movements and the stability of the knee with the PTB prosthesis. After three weeks none of the wearers was able to use his old prosthesis with a thigh corset, because the corset had become too tight.</p> <p>The genuine PTB prosthesis is furnished with only a narrow strap fixing it above the knee. In six cases it was necessary later to provide a thigh corset with sidebars, but the length of the corset was one-third to one-half of what is usual for conventional prostheses. These amputees had stumps which measured 12,13,15,19, 22, and 25 cm., respectively. Only half of these can be said to be particularly short. Obviously, the need for a thigh corset depends not only upon the length and shape of the stump, but also upon the stability of the knee. In three of the cases the knee had been strained. In one case the PTB prosthesis, even after being furnished with a thigh corset and sidebars, had to be replaced with a conventional prosthesis, but this was an exceptional case.</p> <p>Excessive perspiration in the stump, particularly during the summer, constituted a major problem. The closed socket insert and the airtight material are its main causes, but the muscular atrophy because of inactivity and the resultant poor circulation contribute. A gradual decrease in perspiration might be expected to occur, considering the development of the musculature and improved circulation resulting in all amputees who manage without a thigh corset, and considering also the pump effect exerted on the stump by the tight-fitting socket. A similar effect has been observed as a result of placing a sponge-rubber pad at the bottom of conventional prostheses of patients with chronic eczema and ulceration of the stump (<i>1</i>). In the present series, however, a later decrease of perspiration was observed in only 8.3 per cent of the cases. In addition, four per cent reported that perspiration has all the time been less of a problem with the new prostheses.</p> <p>When perspiration of the stump is excessive, skin complications-eczema and ulceration- are likely to occur. Data on skin symptoms in the present series were compared with corresponding data relating to the use of conventional prostheses. The comparison is hampered by the fact that the observation time is shorter for the PTB prostheses than for the older types. Results of the comparison were as follows:</p> <table> <tbody><tr> <th><p></p> </th> <th><p>PTB</p> </th> <th><p>Conventional Prostheses</p> </th> </tr> <tr> <td> <p>Reddening, eczema, ulceration</p> </td> <td> <p>   75 (32.9 percent)</p> </td> <td> <p>   157 (68.9 percent)</p> </td> </tr> <tr> <td> <p>No complications</p> </td> <td> <p>   153 (67.1 per cent)</p> </td> <td> <p>   71 (31.1 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   228 (100.0 per cent)</p> </td> <td> <p>   228 (100.0 per cent)</p> </td> </tr> </tbody></table> <p>It appears that with the PTB prosthesis skin complications were about half as common as with conventional prostheses.</p> <p>In cold winter weather, the PTB prosthesis is somewhat colder than prostheses made of leather or wood, but nonetheless satisfactory and fit for use.</p> <p>In general, the difficulties arising in the present series were due mainly to reduction in the volume of the amputation stump, instability of the knee, and, in some cases, shortness of the stump, which necessitated the construction of a thigh corset. Also, skin complications sometimes occurred as a result of the excessive perspiration caused by the closed-socket insert. The first-mentioned circumstances were easy to cope with, while the skin changes constituted a real problem. In some cases, an opening was made in the distal end of the socket insert, or a number of small holes were drilled in the socket. In certain cases, a sponge-rubber pad was utilized, partly to exert a continuous light pressure on the stump and partly to absorb the moisture accumulating in the bottom of the socket insert.</p> <p>When the PTB prosthesis was first introduced into Finland, we hesitated to prescribe it to amputees who move about much outdoors on soft ground; for instance, on fields and meadows, in the forest, and on snow. This group of persons consists mainly of farmers and lumbermen and the population of northernmost Finland. Our apprehensions have been confirmed only in occasional cases, and the general impression of the PTB prosthesis is favorable. The advantages far outweigh the drawbacks. In particular, the lightness of this prosthesis, the hygienic properties of the plastic material, and the regeneration of the thigh muscles should be emphasized.</p> <p>Reference to the literature shows that others have encountered the same problems that are described here. Frank A. Witteck <a></a>, writing in the June 1962 issue of <i>Artificial Limbs, </i>warned against prescribing the PTB prosthesis in cases with instability of the knee, to very heavy amputees, and in bilateral cases. However, if the stumps have been satisfactory, we have even fitted bilateral cases with PTB prostheses, and no special problems have occurred.</p> <p>In our experience, the PTB prosthesis is con-traindicated only in cases with instability of the knee and with very short stumps or with stumps of unsatisfactory shape.</p> <p>Because numerous, careful fittings are required in these cases, it is desirable that a prosthetist's shop be within easy reach. The PTB prosthesis makes heavy demands on the skill of the manufacturer.</p> <h3>Summary</h3> <p>This study was carried out on 228 amputees fitted with PTB prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans comprise 94.3 per cent of the series, the remainder being insured civilians. In some cases the prostheses were worn by amputees engaged in heavy labor under difficult conditions. Of the amputees, 92.1 per cent were able to wear their prostheses regularly from the outset, and 90.4 per cent were very satisfied. In particular, they emphasized the lightness of the prostheses and the absence of tight thigh corsets, resulting in a sense of ease and freedom.</p> <p>In some cases, complications were caused by a decrease in stump volume, a result of the intimate fit of the socket. This necessitated a change of socket insert, which is readily accomplished, and sometimes of the socket shell as well, which in effect amounts to making a new prosthesis. In certain cases, instability of the knee, the shape of the stump, and a stump length less than the optimum gave rise to symptoms which could be alleviated only by giving the amputee a thigh corset. The series includes four such cases (1.8 per cent).</p> <p>PTB prostheses were also prescribed in bilateral cases, of which there were nine (3.9 per cent).</p> <p>The study shows that the PTB prosthesis has been successfully worn in cold winter weather, although it is somewhat colder than prostheses made of wood or leather.</p> <p>In all the amputees the thigh muscles developed enormously within a few weeks.</p> <p>Excessive perspiration in the stump was a problem in many cases. This phenomenon is due to the intimate fit of the plastic socket. A gradual decrease of the perspiration was noted in 8.3 per cent. However, four per cent stated that, from the outset, perspiration had been less of a problem than with their previous prostheses. It should be borne in mind that during the warm season perspiration tends to be a problem with all prostheses.</p> <p>The PTB prosthesis without a thigh corset is contraindicated in cases with instability of the knee and in cases with a very short stump or with a stump of unsatisfactory shape. Furthermore, caution is indicated in the prescription of this prosthesis to farmers, lumbermen, and others who move on soft and slippery ground.</p> <p>The PTB prosthesis requires very careful fitting, and extreme care must be exercised in its manufacture. In cases where there is a long distance between the place of residence and the prosthetics facility, this is not perhaps the most appropriate type of prosthesis.</p> <p><b>References:</b></p> <ol> <li>Bakalim, Georg, Sponge rubber pad in the prosthesis in cases of chronic dermatitis and ulceration in the stump, Acta orthop. scandinav., 1:117, 1964.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</li> <li>Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</li> <li>Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-16.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-17.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experiences with the PTB Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/4762f350fbaca4d7dceedcfd3c7d363e.pdf 7281217b29c631bcd7ebf10f4c376c5e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_001.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Score</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The past twenty years of the Artificial Limb Program comprise predominantly a series of wins, a few losses, and some ties awaiting replays. Participants, coaches, and managers in this prolonged struggle against nature and ignorance have enjoyed some spectacular seasons, but they also have endured grueling practice and frustrating defeats. </p> <p>Wide interest in artificial limbs accompanies major wars. Ancient armorers made cleverly articulated limbs. The Napoleonic and Crimean Wars stimulated active development in Europe. The American Civil War led to numerous private inventions of prostheses. During World War I vigorous and systematic programs were conducted on both sides. These ended soon after the war, partly because of inflation and other disturbances, and partly because of confidence that limbs had been substantially improved. Everywhere there was a return to "normalcy," but the general impression that amputations are infrequent in peacetime is erroneous. Dr. Glattly's recent survey <i>(Artificial Limbs, </i>Spring 1963) corroborates the claim that for a variety of reasons very substantial numbers of civilians face this major operation in peacetime. </p> <p>In World War II both the Army and the Navy of the United States set up large amputation centers to provide definitive surgery, artificial limbs, and other rehabilitation. Both Services introduced some new materials and mechanisms. To combat severe shortages they used prefabricated, standardized parts and division of labor for fitting and assembling instead of the slow, painstaking custom craftsmanship in very small shops typical of the American limb industry. Dramatic successes occurred. Nevertheless, Service Centers, amputees, commercial limb shops, and, increasingly, the general public were made conscious of the severe limitations of even the best prostheses. </p> <p>The Surgeon General of the Army, therefore, called a conference in January 1945 which was supposed to agree upon the best available prosthetic components. The principal conclusion was that <i>none </i>of the available limbs was really adequate, so research was needed. </p> <p>The Surgeon General then asked the National Research Council to set up a committee to conduct a research and development program. The resulting committee and its descendants have had a variety of designations, membership, organizational structures, and sponsors. Originally the work was supported by the wartime Office of Scientific Research and Development, then by the Army. The Veterans Administration, for many years the sole sponsor of contractual research in prosthetics, still continues important support, but in recent years various agencies within the Department of Health, Education, and Welfare have assumed major financial responsibility. </p> <p>When the original Committee on Prosthetic Devices asked its surgeons to appraise the artificial limbs available in the summer of 1945, the two chief demands to its engineers were for development of a functional artificial hand that looked normal and for stance-phase stability for above-knee artificial legs, presumably from a lock released during swing phase. Patent files and technical literature were littered with descriptions of inadequate attempts by several generations of inventors. </p> <p>The surgeons' demands reflected a primary conception of the Committee's role to concentrate on <i>devices, </i>susceptible to engineering design. In an era when many orthopaedists still were active in military amputation centers and physical medicine was only emerging, the surgeons were not yet concerned with development of new surgical techniques or with prosthetics education. </p> <p>Neither were the surgeons primarily concerned with fitting, though its importance was realized. The second subcontract of the Committee, to develop further a saucer socket for the hip-disarticulation case, was with the Research Institute Foundation, a tiny laboratory which had been set up by the Artificial Limb Manufacturers Association. (This project incidentally initiated a number of ideas which later and independently were developed vigorously at larger laboratories.) Both Committee and limb industry a score of years ago considered the fitting of limbs to be a handicraft, often a sculpture-like art, learned by long experience but scarcely susceptible to systematic research. </p> <p>German studies of alignment principles in World War I had relatively little immediate impact on American practices. Alignment of the above-knee prosthesis in 1945 typically placed the artificial foot far out under the head of the femur "so the amputee would not fall over to the amputated side" and made the axis of the socket bore vertical "so as not to give in to flexion contracture." Thus, while standing on the prosthesis, the amputee leaned against his pelvic band and mechanical hip joint, stressing them severely, in an effort to shift his center of gravity nearer to the foot. Likewise, after exhausting the possibilities of lordosis and unsymmetrical gait in an effort to control a free knee joint after maximum hyperextension of a slightly flexed stump in a straight socket, the recent amputee demanded a mechanical knee lock; a stiff heel bumper or a "long" prosthetic step (caused by inadequate knee friction) only increased instability at heel contact and made the demand for a knee lock more insistent. </p> <p>The early years of the Artificial Limb Program were dramatic, in some senses wasteful, yet in others very fruitful. Some efforts were lost, but unquestionably the whole field of upper-extremity prosthetics was changed for the better by fundamental studies, development, and improved management of the individual amputee. Some unilateral amputees found the APRL hand adequately functional, and careful testing proved its cosmetic glove passed unrecognized in a wide variety of social situations. Thus one complaint was at least marginally resolved. </p> <p>Vigorous study of locomotion proceeded concurrently with numerous development projects. Reintroduction of the suction socket, almost a side activity, forced attention to principles of fitting and alignment, to fostering of cooperation among doctor, limb fitter, therapist, and amputee, and to prosthetics education. Improved alignment as well as added gait training reduced the clamor for knee locks for stance control, and attention shifted toward the swing phase. Several swing-phase mechanisms are now widely used. The Henschke-Mauch Model "A" hydraulic stance-plus-swing-control mechanism has finally been recommended after prolonged development and evaluation. If clinical application studies of the Henschke-Mauch Model "A," including application to recent amputees, prove as encouraging as now seems likely, this device will answer at last the second complaint of the surgeons back in 1945. </p> <p>But many problems remain. The Program has gradually spread its field of vision beyond the mere development of mechanical components. Fundamental research has provided data on locomotion, biomechanics, muscle action, pain, and other problems. Clinical studies have been made of amputation surgery, cineplasty, myoplasty, and early postsurgical fitting, though further studies of surgery and wound healing are needed. Fitting and alignment now can profit from better anatomical and biomechanical principles, new shop tools, improved materials, clearer analysis of defects, and greater insight into causes. The necessary skill and artistry of the increasingly professional prosthetist can be used more effectively. The team principle has become widely practiced, to the reassurance of all concerned. </p> <p>Continuing soul-searching has steadily spurred the participants in this battle against ignorance. The best artificial limbs are still crude. Very little has yet been done about orthotics, deliberately kept in abeyance because braces are worn for such a wide variety of conditions that analysis is difficult. The Subcommittee on Sensory Aids, resuming the tasks of the wartime Committee on Sensory Devices, is only beginning its task of reviewing the present VA projects on aids for the blind. CPRD is studying its possibilities and responsibilities in the broad field of bioengineering. </p> <p>The past score of years has given the Committee an intensive series of encounters, sometimes bruising-but often exhilarating-with problems of mechanisms, their human users, the man-machine interfaces, and the idio-syncracies of the professions concerned. </p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Member, Editorial Board, Artificial Limbs; Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Score Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/c8a6de84d03266c8bc9f6d6fbbd73688.pdf d1910921582f687b0864172e72031731 https://staging.drfop.org/files/original/1485e4d578f1b428ab1272868a562fc9.jpg 7f8190e7460853fcb6038029386ab1b8 https://staging.drfop.org/files/original/50626bc64a6c233af5c84abb7e6df06f.jpg cc5e165fe7160341865c6791ffbdf829 https://staging.drfop.org/files/original/a164e3f6134e5ced2d7e9cbcdad0579e.jpg 5901261c3142163ed97b63077e119af1 https://staging.drfop.org/files/original/3eb28fac21b5adb765e964436bd2f075.jpg aa6fff355b3e7a00e8413bfd9665f54c https://staging.drfop.org/files/original/f0969d5ad22c3d7d3386e1840992de54.jpg 40d2b29106fe4f7b4648d916a305851e https://staging.drfop.org/files/original/b8a15397236070a1928f734b01eb7ada.jpg aa0f0ea19415d3b62b627c9f367e717a https://staging.drfop.org/files/original/cb45f9034e87770a17262895139a95e2.jpg 0a2949048e4a5d562595657a3d9747e4 https://staging.drfop.org/files/original/ddfff8a45792bdbaff35b784cf009351.jpg ba30758487795821efba0587640fe3a8 https://staging.drfop.org/files/original/07ffd06b6d225ed567e2848bba985e83.jpg e3b152af1db7fd6c4894d6db133288ad https://staging.drfop.org/files/original/97f84bc7e3ced60be18d3ffe0df9cdca.jpg 2040d3bd5e41d0d2959bed152fa4c1cc https://staging.drfop.org/files/original/e57ff3235c3552832ed937f2e20f0f02.jpg 866160e477f752c327061c13dc0be413 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_004.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 4 - 13 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria</h2> <h5>James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p><i>At a recent meeting of the Workshop Panel on Lower-Extremity Fitting <a></a>, which is sponsored by the Subcommittee on Design and Development of the Committee on Prosthetics Research and Development, there was prolonged discussion of below-knee prostheses. Questions were raised concerning the adequacy of the PTB design for many patients, especially patients who were longtime users of the joint-corset, below-knee limb. The view was expressed that the expenditures of time and money in achieving a successful PTB fit did not justify the selection of the PTB prosthesis or a conversion to it, and that the use of a joint-corset prosthesis initially would shorten the prosthetic restoration process for most patients.</i></p> <p><i>It was recognized that the private practitioner is often forced to elect the simplest and least expensive procedure for his patient. Institutional facilities, on the other hand, can take more of the patient's time, without having the often-required succession of visits reflected in direct cost to the patient or to the sponsor. Yet, the panel was of the opinion that some prosthetists probably are still committing errors in fitting PTB prostheses, resulting in deterioration of the stump, excessive shrinkage, or edema. Moreover, criteria for use of the joint-corset prosthesis are still misunderstood.</i></p> <p><i>Fortunately, the Workshop Panel on Lower-Extremity Fitting had the benefit of the counsel of James Foort, formerly of the University of California (Berkeley) but now of the Prosthetics-Orthotics Research and Development Unit at Manitoba Rehabilitation Hospital, Winnipeg, Canada Mr. Fool spoke at length on the PTB design and then agreed to put his comments in writing for the benefit of clinicians the world over. Presented below is his helpful review of the subject.</i></p> <p><i>We are indeed indebted to Mr. Foort for his contribution. The clear expression of certain axioms will, hopefully, solve some of the problems experienced in the fitting of this very important prosthetic appliance.</i></p> <p><i>Anthony Staros <a style="text-decoration:none;">*</a> - Chairman, Workshop Panel on Lower-Extremity Fitting</i></p> <p>The patellar-tendon-bearing (PTB) prosthesis has been in use for more than five years. It was fully discussed in the June 1962 issue of <i>Artificial Limbs <a></a>. </i>Although experience suggests that approximately 90 per cent of all below-knee amputees can benefit from the use of the PTB prosthesis, a substantial number of prosthetists continue to fit joint-corset prostheses to a large proportion of their patients. Apparently, these prosthetists and their clients have found that maintenance and replacement costs outweighed the fabrication and functional advantages of PTB prostheses. Difficulties developing from the use of the PTB prosthesis are said to be edema, stump breakdown, and stump shrinkage. With these difficulties in mind, the purpose of this review is to examine the fitting technique for PTB's, emphasizing factors to be considered in avoiding or overcoming the difficulties and outlining criteria for use of joint-corset prostheses.</p> <h3>PTB Fitting Technique</h3> <p>The most common error made with a PTB socket is an excessively tight fit in the popliteal area of the stump. Too large a bulge in the popliteal area can be constrictive, affecting circulation, causing edema, and in turn leading to deterioration of the stump end. <i>Posterior pressure needed to balance the posteriorly directed force against the patellar tendon by the weight-bearing bar of the socket must be provided by the posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures, as well as by the popliteal area of the stump. (First factor.)</i></p> <p>Emphasis on the patellar tendon as a weight-bearing structure has contributed to constriction of the stump in the popliteal area. <i>The posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures are important weight-bearing surfaces of the stump. (Second factor.)</i></p> <p>In order to make the area for pressure against the popliteal surface of the stump larger, many prosthetists have extended the back of the socket up into the space between the hamstring tendons, cutting grooves to relieve the tendons during knee flexion. This design can contribute to constriction of circulation in the popliteal area when the amputee stands or sits. <i>The back brim of the socket should be formed into a broad, flared surface against which the hamstring tendons can rest when the amputee sits. (Third factor.) </i>So shaped, the back brim of the socket can be made sufficiently high to provide the large support area needed to minimize pressure while holding the patellar tendon in position on the weight-bearing bar and still ensure sitting comfort (<b>Fig. 1</b>). When the back brim is made higher, as for a short stump, the flare also lifts the stump out of the socket and supports it when the amputee sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two views of a temporary plastic PTB socket showing the flared posterior brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edema is also caused by constriction at the mid-stump level, and such constriction can result from the cumulative effects of modifying the plaster stump model. The least desirable modification is that made in the lateral fibula area. This modification is meant to help stabilize the stump mediolaterally in the socket, but the fibula is a poor structure against which to stabilize. <i>To achieve mediolateral stability of the stump in the socket, the socket should fit securely against either side of the tibial crest and against the medial and lateral surfaces of the knee joint. (Fourth factor.) </i>Mediolateral stability is a problem only if the foot is set in or out too far. <i>The socket should be placed over the foot so that there is little tendency for the prosthesis to tilt medially or laterally on the slump as the amputee walks. (Fifth factor)</i></p> <p>Although breakdown at the end of the stump is sometimes attributed to pressure on the end, a more likely cause is constriction at the mid-stump level. Tightness around the middle third of the stump gives the amputee the feeling that the end is contacting the bottom of the socket or that the tissues are being pulled up against the end of the bone. There are, however, circumstances in which end pressure is damaging and painful. <i>The socket should support distal tissues with sufficient pressure to aid venous and lymphatic return without pressing against the bone ends. (Sixth factor.) </i>If the stump has been amputated through cancellous bone, however, the bone end may be an important weight-bearing surface (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A very short stump which is capable of bearing considerable weight on the end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently, the anterodistal tibia area is painful because of the thin cutaneous covering; it is also vulnerable to excessive pressure because of poor circulation. Hollowing out the socket in this region usually does not give the expected relief. Foot alignment, as viewed from the side, and a stiff heel action can be the causes of difficulty. <i>The foot should be pliant and aligned to give a smooth rolling action as the amputee walks, as though the foot were a segment of a wheel run. (Seventh factor.) </i>If, so to speak, the "hub of the wheel" is too far back, the end of the stump is forced forward painfully against the socket as the amputee attempts to control the prosthesis at heel contact by active extension of the knee. This problem is especially pronounced with recent amputees who have not become skilled at regulating the forces against the stump by appropriate coordination of knee and body actions. A softer heel wedge, increased plantar-flexion of the foot (or extension of the socket), or moving the foot forward (least likely) can reduce discomfort at the anterodistal end of the stump resulting from these causes.</p> <p>General tightness is sometimes considered a source of trouble-and may be initially. But a socket should fit snugly, especially for a recent amputee or one who has not worn a PTB prosthesis before. The newly fitted amputee may have to remove the insert from the socket shell, put it on the stump, powder it, and force it back into the socket shell, even when he is wearing only a cast sock over the stump. One should be sure, however, that the socket bears weight evenly on the main support areas and that it also supports the distal tissues. If the socket does provide proper support, the imprint of the stump sock on the skin will be even in appearance, with the important support areas on the stump somewhat reddened. During the early phases of walking, the amputee should not use the prosthesis excessively. Soon his stump will become accommodated, and then he will be able to use a wool sock. <i>Tissues which are snugly pressed in a socket will shrink until pressures are reduced to suitable levels. (Eighth factor.) </i>Sometimes when the stump is fitted snugly, a vacuum develops during the swing phase and has a tendency to produce edema. To correct this problem, holes -sufficiently large to prevent hissing noises- may be drilled into the prosthesis, or the suspension system should be made more effective.</p> <p>All these factors must be kept in mind when an impression is made over the stump and the plaster model of the stump is shaped for use as a socket mold.</p> <h4>Taking The Plaster Impression</h4> <p>It is not easy to outline a specific procedure for taking a plaster cast of an amputee's stump. Stumps vary in the amount and resiliency of tissue covering the skeletal frame to be fitted. Moreover, the size, strength, and shape of prosthetists' hands and their sense of pressure-all unique to the individual-vary considerably. But if the impression is made tightly over the weight-bearing areas of the stump, these areas will be better defined than if the cast is made looser, regardless of these other differences.</p> <ol> <li>The impression should be started at the knee. The plaster-of-Paris bandage is wrapped tight, starting at the superior edge of the patella. As each pass is made around the knee, the plaster is formed up higher on either side of the knee by guiding it upward with the fingers of the left hand (<b>Fig. 3</b>). At the back, the cast should cover the knee crease by about two finger widths. Wrapping continues in this manner down to the level of the tibial tubercle.</li><li>Next, an effort must be made to obtain an accurate imprint of the medial flare of the tibia (<b>Fig. 4</b>). The plaster-of-Paris bandage is pulled up against the medial flare with even tension, and each turn is anchored to the lateral surface of the knee. Thus tissue tension is prevented from driving the plaster away from this important support area.</li><li>The rest of the stump is wrapped with less tension.</li><li>The plaster is smoothed over the entire stump and worked around the bony areas. As the plaster is worked, the stump is palpated to determine how it should be held for shaping.</li><li>Just before the plaster begins to set, the thumbtips are positioned on either side of the patellar tendon, close to its edges, so that the plaster-of-Paris bandage is pulled in against the tendon as pressure is applied. This position of the thumbs precludes intrusion into the spaces under the edge of the patella medially and laterally. The fingers are placed around the media] flare of the tibia and held flat against the back of the stump. It is important <i>not </i>to push into the popliteal space with the fingertips. Where the fingers encircle the lateral side of the stump, they are not in contact, Across the back of the stump, they are straight and exert pressure against the posterior aspects of the lateral tibial condyle and the popliteal area. Very little force should be used. The cast has been wrapped tight at the top to obtain an imprint of the stump close to the required shape, and the cast is held to ensure that the required support areas will be well defined when it sets (<b>Fig. 5</b>).</li><li>When the plaster impression can hold its shape, the thumbs are used to obtain a clear imprint of the anterior crest of the tibia by moderately caving in the semi-set plaster along a 3/4-in. strip on each side of the tibia to within an inch of the end (<b>Fig. 6</b>). The impression will now be wedge-shaped in front. Just before the plaster sets firmly, the hands are returned to the holding position, and the cast is held until it can be taken from the stump. This holding-squeezing action flattens the back and ensures retention of the required anteroposterior width.</li></ol> <p><b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Starting the plaster impression and guiding the plaster upward along the sides of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pulling the plaster-of-Paris bandage against the medial flare of the tibia to obtain an accurate impression of this important support area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Holding the cast with moderate pressure and with the fingers flat across the back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Caving in the plaster on either side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Modifying The Model</h4> <p>It is desirable to modify the plaster stump model as soon as possible after the impression is taken, while the recollection of details is still strong.</p> <ol> <li>A groove is carved in the patellar-tendon ridge with a 1/2-in. self-cleaning rasp to a depth of about 1/2 in. The groove is made halfway between the inferior edge of the patella and the tibial tubercle. The groove should be about 3/4-in. wide between the upper and lower edge, and the edges should be smoothly curved toward the patella and toward the tibial tubercle (see <b>Fig. 7</b>).</li><li>Modifications on either side of the crest of the tibia are made in the usual way. <a></a></li><li>The medial flare area is smoothed first with a curved self-cleaning rasp to make the flare blend in with lower sections of the model and then with wire screening, which should be swept around the natural contours of the flare extending into the posterior area and even over the hamstring tendons (see <b>Fig. 8</b>).</li><li>The back of the model is flattened and smoothed over the popliteal area; care must be taken <i>not </i>to indent this area.</li><li>The flattened surface at the back of the model is extended downward and blended in with the more distal parts of the model by shaving off small amounts of plaster.</li><li>The model is smoothed on either side of the knee. If necessary, material is carved away to reduce the model to the measured width of the knee. This area is important, because it contributes to stabilization of the stump in the socket. The lateral side of the socket stabilizes the medial flare of the tibia against its weight-bearing surface in the socket. Sometimes a very slender amputee will find that when he sits, the wide part of his femoral condyles binds against the socket at the top. To correct this, the socket should be heated in that area and forced outward to give relief.</li><li>Plaster is added to the model in bony areas such as the head of the fibula, the crest of the tibia (especially toward the distal end), and the ends of the fibula and tibia. If the crests of the tibial condyles are prominent, extra space should be provided for them in the socket. They and the tibial tubercle seldom present problems if the patellar-tendon shelf has the proper dimensions, because then the socket is forced away from those prominences.</li><li>Before constructing the posterior flare on the plaster model, it is necessary to mark the socket trim lines on the model. First, a line is drawn circumscribing the model at the mid-patellar-tendon level and perpendicular to the long axis of the model. This line defines the back brim for the average type of stump. <i>A </i>shorter stump will be fitted higher at the back, depending on how short it is. Next, a line drawn through the middle of the patella and upward on either side gives the shape of the medial and lateral extensions of the socket. On the lateral side, the line will pass straight down through the posterolateral corner of the model to cross the posterior reference line. The corner can be rounded so that the lines join with a 1/2-in. radius. On the medial side, the trim line should be further in from the side so that the posteromedial curve is retained in the socket to help provide posterior support to the stump. This is possible because the medial hamstring tendons are toward the midline of the stump. After the model has been secured in a vise with the popliteal area up and the long axis of the model horizontal, plaster is poured above the trim line at the back (<b>Fig. 9</b>). When the plaster has set slightly, a 3/4-in. flare is formed by smoothing the plaster with wet fingers and thumb. It is seldom necessary to adjust the fit of the flare for relief of the low-set medial hamstring tendons, even though the socket curves around to the back on that side, because the flare allows the tendons to support considerable pressure comfortably. (For a medial view of the modified model, see <b>Fig. 10</b>.)</li></ol> <p><b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>, <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The patellar-tenclon groove. A, Carving the groove in the patellar-tendon ridge on the plaster model; B, the finished form of the groove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The finished form of the medial flare area on the plaster model. A, An anterior view; B, a posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marking and forming the posterior flare on the plaster model, which has been secured in a vise with the popliteal area up. Top, the line circumscribing the model at mid-patellar-tendon level defines the level of the back brim of the socket. Center, plaster is poured onto the model above the trim line and allowed to set slightly. Bottom, wet fingers and thumb are used to form the posterior flare. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Medial view of the modified model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Shrinkage</h4> <p>Even the seasoned stump can shrink. To the prosthetist this is a problem of economic significance, because his guarantee provides for repair or replacement. The worst of it is that when the socket of a PTB prosthesis is no longer satisfactory and must be replaced, there is little the prosthetist can do but rebuild the prosthesis completely. The least that can be done is to lay in material between the socket shell and the insert or to cast RTV Silastic resin under the stump. This sometimes affects alignment, which then must be adjusted. If the weight-bearing area can be modified easily, it is good practice to take a new cast of the stump, prepare a new model, and make a new insert over it. The new insert will support the stump distally, while the modified brim area gives satisfactory weight support and stabilization.</p> <p>Actually, what is needed is a different approach to the provision of prostheses. The recent amputee should be provided with a well-fitted limb to which a series of sockets can be easily attached until the stump has become stable. Then a final fitting can be made. At present, the permanent limb is often fitted as soon as the shrinker bandage treatment has been completed. The forces imposed on the stump by the prosthesis are much greater than can be developed by the shrinker bandage. Also, the socket forces are different in location. In addition to the loss of control and harmful forces that develop between the stump and the prosthesis, the reduced bulk of distal tissues leaves them unsupported and prone to edema.</p> <p>When the stump is fitted tightly, as recommended here, the initial discomfort will diminish as the stump shrinks and molds into shape. Finally, the amputee will be able to don his prosthesis while wearing a wool stump sock.</p> <h4>Perspiration and Maceration of the Stump</h4> <p>There have always been amputees who have suffered maceration of the stump end as a result of accumulation of perspiration in their sockets. Contributing to the heat in a PTB prosthesis are the rubber-leather insert, the thick plastic shell and surrounding materials, the closed end of the socket, and the tightness of fit. Ventilation is poor, even when holes are drilled through the walls of the socket. Use of a valve system, such as that designed at the Navy Prosthetics Research Laboratory, which allows air to enter slowly and forces it to escape up through the sock, could be helpful provided noise is avoided; and porous plastic laminates, such as have been developed at the Army Medical Biomechanical Research Laboratory, may be of some use as a solution to the problem. The most likely immediate solution is to make the socket thin, somewhat pliable, perforated, and without an insert. Such a socket must be titled with care, since there is no soft insert to provide a margin for error and to permit easy modification of the socket. A socket constructed of four to six layers of stockinet laminated with two turns of glass-cloth covering from the top to the tibial tubercle will serve. The socket, supported in a plastic receptacle (<b>Fig. 11</b>), can easily be replaced without seriously affecting the entire prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Temporary plastic socket and the receptacle into which it fits. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Use of Joint-Corset Prostheses</h3> <p>Under ideal conditions, the percentage of amputees who use joint-corset prostheses might be as low as 10 per cent. There is no doubt that the joint-corset system can make up for deficiencies in the fit of the socket and thereby serve as a safety factor when the proper lit of a PTB prosthesis is not achieved or maintained. Hut there are definite criteria which can be used for the prescription of a joint-corset prosthesis.</p> <p>Sometimes the amputee's occupatjon requires him to use his prosthesis under heavy-duty conditions; he may be required to pry up or lift heavy objects. <i>When the amputee must place a force on his prosthesis which is considerably greater than the weight of his body, a joint-corset prosthesis aids him by permitting part of the weight to be borne on the thigh. (First criterion </i>) The joint-corset system is especially effective when the knee is slightly flexed so that forces are borne by the back of the thigh and are transmitted to the shank through the side joints. When the thrust on the prosthesis is along its axis, the amputee can prepare for it by temporarily tightening his thigh corset.</p> <p>Many amputees kneel, climb ladders, or climb stairs frequently. Such activities may be especially difficult or troublesome to the bilateral amputee because of rotation of the PTB prosthesis on the stump. <i>The joint-corset system prevents the prosthesis from rotating about the amputated leg when the joints are flexed. (Second criterion.)</i></p> <p>There is the rare amputee whose knee is unstable, or whose musculature is so weak that the joint-corset system is required. <i>The joint-corset system can stabilize an unstable knee against extreme mediolateral motions; against dislocations; and, when a back-check is used, against hyperextension of the knee. (Third criterion.)</i></p> <p>For the amputee with a stable knee, however, the corset is functionally limited as a mediolateral stabilizer because of the thinness of the joints, the fleshy nature of the thigh, and the pliability of the leather corset. Only if the amputee also bears weight on the corset", or has an extremely atrophied thigh against which he laces the corset tightly, or the corset extends to the peroneal level with cross braces between the side joints, will the corset be of much value as a mediolateral stabilizer.</p> <p>Also rare are amputees who cannot bear weight effectively either on the stump or through the femur. <i>An amputee who cannot bear weight on the stump should be fitted with a quadrilateral ischial-gluteal weight-bearing support and have straps connecting the thigh to the side joints above the knee for control of flexion and extension and for suspension of the prosthesis. (Fourth criterion.)</i></p> <p>Sometimes an amputee is mentally retarded or senile. In such an event, especially if there are no qualified helpers to ensure that the prosthesis is donned correctly, the joint-corset system should be used. <i>The joint-corset system is an aid in ensuring that a prosthesis is correctly placed on the amputated limb when the amputee's judgment is questionable. (Fifth criterion.)</i></p> <p>A problem often faced by the prosthetist fitting a PTB prosthesis to an experienced wearer of a joint-corset prosthesis is that the amputee is not prepared to make the change, either because he doubts that he can do so successfully or easily, or because he has a definite bias toward the joint-corset prosthesis. <i>The joint-corset system should be used when there are definite psychological pressures favoring it. (Sixth criterion.)</i></p> <h3>Conclusions</h3> <p>Probably many prosthetists who fit the PTB prosthesis successfully have discovered for themselves, or have learned from previous experience with other prostheses, how to deviate from established procedures. For those who have difficulties, this review may be of assistance. But it may be necessary to have those who are successful demonstrate to those who are not. Short-term or immediate success should not mislead those who are trying to establish improvements. Often it is only after a year or so that results can be judged. Meanwhile, encouragement should be given to those who seek to develop devices and techniques which will eliminate as many as possible of the craft-oriented tasks needed to fit amputees, thereby increasing reliability and uniformity.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, <i>Report of third workshop panel on lower-extremity fitting, November 4-6, 1964.</i></li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis, </i>Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, June 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, Report of third workshop panel on lower-extremity fitting, November 4-6, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria Creator An entity primarily responsible for making the resource James Foort, M.A.Sc. * https://staging.drfop.org/files/original/80c2672becb304a755607958b8b3c960.pdf f647e29523f0bb254a98b3e47c5cfca4 https://staging.drfop.org/files/original/f95345137c719c2af67d3301523b3afb.jpg d6fcf2d9d9b48a1a4abf9da786e34eaa https://staging.drfop.org/files/original/752ebfc3ea102a5175fc0fb02e645908.jpg 5350192b793bb2e68a1dbc04c7211858 https://staging.drfop.org/files/original/9c6d7cf4e0c09122676c79d5d6d61204.jpg 902056a0233b4f2c12423310fba95867 https://staging.drfop.org/files/original/fec489d1be2e1025db85614faa8ae709.jpg 0a36603eee31a4a2a19d429958545543 https://staging.drfop.org/files/original/cec2ebadd71bf2d6eaca13a56f774b7c.jpg 0c0ee61bafc622396bcac40f430d3bff DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_028.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 28 - 44 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Turntable Lock for Elbow Units</h2> <h5>Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>In the conventional elbow unit (Hosmer E 400) for above elbow and shoulder dis articulation amputees, manual control of humeral rotation is permitted by virtue of cork and teflon gaskets providing mechanical friction between the top of the main portion of the elbow unit and the turntable to which the upper arm shell or socket is fastened.<a></a> The amount of friction is determined by the tension maintained by the stud and attaching nut. Since humeral rotation great as to rule out easy adjustment. At the same time there must be enough resistance to rotation to accomplish most activities. </p> <p> There are times when a rigid arm is desirable; for example, when climbing ladders, using a shovel for long periods, carrying an object balanced on the forearm, or carrying an object held away from the body. To provide rigidity for such demanding tasks, the North Western University Prosthetics Research Center has developed a manually controlled lock which can be mounted on the area provided for a forearm lift assist on the Hosmer E 400 elbow unit. A spring forcefully engages the locking pin in one of three holes drilled through the turntable for this purpose. Since the turntable possesses enough friction for most activities, the locking pin need only be used to overcome the tendency of the forearm to rotate gradually when shoveling, to provide the extra margin of safety when climbing vertical ladders, or to supply the rigidity needed in certain other tasks. The amputee returns the locking pin to the disengaged position when the task is completed. </p> <p> Installation of the lock requires: first, drilling the indexing holes in the turntable; second, revising the plastic cap on the elbow unit and mounting the locking device; third, cutting a notch in the cork and teflon gasket to make room for the locking pin and regluing the gasket to the elbow unit. </p> <p><b>Fig. 1</b> and <b>Fig. 2</b> are views of the locking device, and <b>Fig. 3</b>, <b>Fig. 4</b>, and <b>Fig. 5</b> show details of its installation. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Installation of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. View of modification showing indexing holes in turntable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Drawing of base of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Drawing of lock components. A, Pin; B, Cap; C, Spring </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Drawings of modified turntable. The radius of the indexing holes may be determined by using a 1/8-in. diameter scriber in the lock base mounted on the elbow and scribing directly on the turntable. The amputee can best select the locking positions after completion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The first prototype (not shown) of the lock was fitted to DM, a 38 year old farmer who is a left above elbow amputee. The lock was mounted on the posterior rim of the elbow frame. A 3/16 in. locking pin was used and has proved to be very durable. The lever which latches and unlatches the lock has been replaced because of breakage. A disadvantage was the requirement for modification of the elbow frame and extensive modification of the cork and teflon gasket. Another disadvantage was the location of the lock lever at the back of the elbow rather than at the side. The device has been worn continuously for 20 months with no malfunction in the locking pin. One unit of the second prototype (as shown in the illustrations for this article) of the lock was fitted to EA, a 38 year old farmer and bulldozer operator who is a right above elbow amputee. The device has functioned well for a period of more than 16 months, and the amputee reports that he uses il several times daily. He is able to lock and unlock the device without removing winter clothing. </p> <p> Another unit of the second prototype of the lock was fitted to IS, a 40 year old farmer who is a right above elbow amputee. The device malfunctioned after six months when the elbow became free moving without the usual amount of friction. This caused excessive strain on the locking pin, which bent under the load. The pin was replaced, friction was restored, and the device has worked for 10 additional months. The amputee reports using the lock when holding materials to be butt welded, when climbing ladders, and in other situations where a static arm is required. </p> <p><b>References:</b></p> <ol> <li>Aitken, George T., T. J. Bushey, Edward R. Ford, and Fred Leonard, <i>Upper-extremily components</i>, Chap. 2 in <i>Orthopaedic Appliances Atlas</i>,Vol. 2, Edwards, Ann Arbor, Mich., 1960.</li> <li>Sammons, Fred, <i>Elbow rotation lock</i>, Northwestern University Prosthetics Research Center, July 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., T. J. Bushey, Edward R. Ford, and Fred Leonard, Upper-extremily components, Chap. 2 in Orthopaedic Appliances Atlas,Vol. 2, Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall"> Research Associate, Northwestern University Prosthetics Research Center, 401 E. Ohio St., Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-41.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-45.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Turntable Lock for Elbow Units Creator An entity primarily responsible for making the resource Fred Sammons, B.A. * https://staging.drfop.org/files/original/2ba44c5f9ec8c60d3a6423ce01cae5b9.pdf a43fa5236221ccee26a9e5f795227879 https://staging.drfop.org/files/original/9847a895cbb0e47c889cc46b60067737.jpg 174af1515ac8068d3ba651a0676237c2 https://staging.drfop.org/files/original/54cec80f0cecce2e15a82d15081386fa.jpg 268a5deb1dfa2e91ec39e0cda5df9553 https://staging.drfop.org/files/original/cfb040cf84ed9ddf06a4f4bd0d669e8e.jpg 03e8d28df85de2b168de9603bde28d7a https://staging.drfop.org/files/original/318951cdb08cfadc6743ddec4e2731bd.jpg b3cd9eccd9455a345c9ad40f33434a7b https://staging.drfop.org/files/original/62b69d04e8bccad2110030b6b195b6da.jpg c8cdc886c8007ff14e3b4a6fb297c18b https://staging.drfop.org/files/original/6e618a8e4eb7f870507fc74e9dee010f.jpg cccc1fb60da16baf073ba3b9ab9c9710 https://staging.drfop.org/files/original/cd1a4279ea6056e85574a9669843fcd4.jpg 2498b1a659d3ba96b364efe3b8d49b3e https://staging.drfop.org/files/original/bf816b1898815a58c6d64beee92479d4.jpg 8b9e0b5f10a159cb742c129c41ede96f https://staging.drfop.org/files/original/a897c85ba11ff91431544e7f1b757f99.jpg f74eb3b7381ab64121ff3a6577980d2e https://staging.drfop.org/files/original/798f29058b5c15bebdfda8ba6af5110d.jpg 3d0d619d882104d2335f773d7cd1d622 https://staging.drfop.org/files/original/46d27e76db81864a24330ff3846bd3c9.jpg 2b88d140aa0566a6759afdc3509eecac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_015.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 15 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> In the study of the APRL Sierra No. 1 right hand, which preceded that of the left, the results of comparative performance testing indicated that there was little difference between the hand and the hook on the various test activities. Statements of children participating in the study and of their parents indicated a relatively high level of performance with the experimental hand, but advantages and disadvantages were not clearly defined. </p> <p> These results appeared to be at variance with past clinical impressions, which indicated that a significantly less functional terminal device than a hook. Hence, in the Left Hand Study the performance tests were repeated to check the results of the earlier study. An attempt wa hand wasas also made to delineate more completely the relative usefulness of the two devices by obtaining data concerning their effectiveness in a wide variety of activities. </p> <h3> Performance Tests</h3> <p> As indicated in Part I of this two part series of articles, the child amputees participating in these studies were required to make four visits to the clinics servicing them, during a period of five months. The first visit was a screening session to select suiTable candidates; on the second visit the child was fitted with the experimental hand; the third visit, two months after the fitting, was for the purpose of making evaluative comparisons between the old and the new terminal devices; and the purpose of the fourth visit, four months after the fitting, was to make a final evaluation. </p> <p> A prosthetic performance test, utilizing the old terminal device, was given the child on the second visit. On the third visit the same performance test was administered, utilizing first the APRL Sierra hand and then the old terminal device. The prosthetic performance test required the child to perform six activities, upon each of which he was timed and rated. The activities were: </p> <ol> <li>Unscrewing and reassembling five small plastic barrels ("Kitty in the Kegs") (<b>Fig. 1</b>)</li><li>Drying a wet cup, saucer, and dinner plate, using a dish towel (<b>Fig. 2</b>). </li><li>Putting on a shirt or dress as appropriate and shoes and socks (<b>Fig. 3</b>). </li><li>Assembling a jointed doll ("Loony Links") (<b>Fig. 4</b>). </li><li>Cutting out a printed figure and pasting it to a piece of paper (<b>Fig. 5</b>). </li><li>Eating ice cream from a paper cup, using a metal spoon (<b>Fig. 6</b>). </li></ol> <p> Typically, the test was administered by an occupational therapist. The rating scale employed ranged downward from a score of 5 for performance approximating that of a nonamputee to 1 for performance in which the terminal device was not used, in accordance with the following subjective criteria: </p> <table> <tbody><tr><th><p>Rating</p> </th><th><p>Criteria</p> </th> </tr><tr><td> <p> </p><p>5</p> <p></p> </td> <td> <p> </p><p>A nearly normal bilateral performance in which the terminal device seems essential; that is, it is used to perform active functions in addition to and more advanced than holding, such as grasp and transportation and manipulation of the object. </p> <p></p> </td> </tr> <tr><td> <p> </p><p>4</p> <p></p> </td> <td> <p> </p><p>A bilateral pattern in which the terminal device is a significant aid in grasping or hooking.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>3</p> <p></p> </td> <td> <p> </p><p>The terminal device is used for occasional grasping only, alternating with passive use.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>2</p> <p></p> </td> <td> <p> </p><p>The terminal device is used passively for pushing, weighting, or support, but not for grasp.</p> <p></p> </td> </tr> <tr><td> <p> </p><p>1</p> <p></p> </td> <td> <p> </p><p>The terminal device is not used, although the elbow and forearm may be used as an aid. Ratings of 1.5, 2.5, 3.5, and 4.5 were interpolated to indicate performance whose quality was between two categories.</p> <p></p> </td> </tr> </tbody></table> <p> Each child's performances with hook and hand were compared on the basis of best scores obtained while utilizing each device. In the Left Hand Study performance times with each device were also obtained. The comparative data are presented in Tables <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There are obvious limitations to these data, in that the tests may have differed with individual children (the type of clothing donned, for example), and there were undoubtedly differences in the frames of reference employed by different therapists in rating a given performance. Since the data themselves are of doubtful precision, the application of tests of statistical precision is not indicated. Within these limitations, however, there is evidence that: </p> <ol> <li>Mean performance ratings in all activities were higher for the hook (<b>Table 1</b>), which clearly appeared to be the better device functionally. Its superiority was most evident in the test activities of "Put on Clothes" and "Cut and Paste." The smallest differences in mean ratings were found in the "Kitty in the Kegs" and "Loony Links" tests. Both of these latter activities involve the grasping of objects for which the active fingers and thumb of the hand are relatively well adapted.</li><li>In a total of 408 hook and hand performance comparisons shown in (<b>Table 2</b>) (68 children performing 6 activities with each device), hook performance was rated as superior in almost half the instances (189 times). Interestingly enough, however, hook and hand performances were rated as equal almost as frequently (184 times), although hand performance was considered better in only a relatively insignificant number of cases ²⁹. In this tabulation of the data also, the superiority of the hook appears less marked in the same two test items "Kitty in the Kegs" and "Loony Links." </li><li>The comparative time data (<b>Table 3</b>) indicate that in the majority of instances hook performance was faster as well as more effective than hand performance, although again the results are by no means unanimous.</li></ol> <p> It is interesting to note (<b>Table 1</b> and <b>Table 2</b>) that in the Left Hand Study the performance ratings more clearly reflected the functional superiority of the hook than was the case in the tests with the right hand. For example, only seven children of 32 were rated as performing the "Kitty in the Kegs" test better with the hook in the Right Hand Study. In contrast, 17 of 36 children had better ratings utilizing the hook in this activity in the Left Hand Study. A similar marked difference in comparative ratings is evident in the "Loony Links" task. In the other test activities, the differences diminished until in the "Eat Ice Cream" item the right and left hand data are almost identical. </p> <p> The reasons for these differences are not clear. The subjectivity of the rating scale may, of course, have been a consideration. However, since the trend of the data is consistent, that is, favoring higher comparative hook ratings in the Left Hand Study, it would appear that other than chance factors are operative. </p> <p> Handedness might possibly be a factor, but unfortunately data on this variable were not obtained in the study. It is also possible that in the earlier Right Hand Study the raters were affected by a "halo" factor which had diminished by the time of the later Left Hand Study. </p> <h3> Functional Preferences</h3> <p> In studying child and parent opinions concerning the function provided by the No. 1 hand in comparison to that available in standard hooks, the task is complicated by the strong emotional factors involved. In many instances the excellent acceptance of hand appearance clearly tended to influence the answers to questions concerning its function. In interpreting the responses of children and their parents, therefore, it must be borne in mind that the hand was almost three times as heavy as the hook previously worn by the children; and although operating forces to initiate opening were only somewhat higher than for the hook, the forces required to obtain full opening were significantly higher two factors which should make use of the hand more difficult.<a style="text-decoration:none;">*</a> Pertinent comparative data are presented in (<b>Table 4</b>). Thus, when children report, as some do, that the hand is lighter and easier to operate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The presentation which follows is based primarily on data from the Left Hand Study, but these are supplemented where appropriate by evidence from the preceding Right Hand Study. </p> <p> All 39 children and parents in the Left Hand Study were asked, "With which terminal device is the child able to perform more activities?" The answers were: </p> <table> <tbody><tr><td> <p> </p> </td> <td> <p>  | Hook |</p> </td> <td> <p>| Hand |</p> </td> <td> <p> | No Preference |</p> </td> </tr> <tr><td> <p>Children</p> </td> <td> <p>    18</p> </td> <td> <p>  14</p> </td> <td> <p>   7 </p> </td> </tr> <tr><td> <p>Parents</p> </td> <td> <p>    16</p> </td> <td> <p>  9</p> </td> <td> <p>  14</p> </td> </tr> </tbody></table> <p> However, two children and two parents in the no preference category added statements which suggested that the hook provided more function and that their no preference choice was motivated by a balance between hook function and the cosmetic appeal of the hand either to the child or to the parent. Furthermore, some children who rated the function of the hand as better than that of the hook made comments indicating the reverse. Joseph: "The hand is heavier and harder." Robin: "The hand can do a couple of things but not too many things." Linda: "The hand is heavier and harder but I like the way it works." The therapist said that this girl's answer was motivated by a strong desire to keep the hand. </p> <p> However, several children who preferred the function of the hand were able to back up their choice by specific examples. Susan, a young above elbow amputee, said the hand was easier to don, better for washing dishes, for holding paper, and to pick things up. Rodney, also an above elbow amputee with an unfitted paraxial hemimelia (ulnar) on the contralateral (right) side, said the hand was heavier but easier to operate. His therapist said the hand did not afford Rodney greater function but he was much more eager to use it. This greater enthusiasm was also noted in Susan, the above elbow amputee previously mentioned. The greater motivation to use the hand on the part of both these youngsters may have actually resulted in a higher level of functioning! </p> <p> Fourteen of the 39 children fitted with the No. 1 left hand reported it to be as heavy as or heavier than their hook, and 17 found it hard to open or otherwise more difficult to operate than their hook had been. There seemed to be a significant relationship here with age, as indicated by the fact that of 17 children, ages 3 to 5, eight found the hand heavy, while of 22 children, ages 6 to 10, only six reported that the hand was heavy. Of those who stated that the hand was difficult to operate, ten were in the 4 to 5 age bracket and only five were in the 6 to 10 age group. </p> <p> A relationship to amputation level was also apparent. The one shoulder disarticulation amputee found the weight accepTable but the hand too hard to operate. He retained the hand, nevertheless, for cosmetic reasons. Of the five above elbow amputees, four found the hand heavy and difficult to operate, and the remaining child rejected it after less than two months' wear. In contrast to these negative reports, two above elbow amputees, only 5 years old, were among those who were most highly motivated to use the prostheses with the hand device. </p> <p> The combination of youth and a higher level of amputation made the use of the hand much too difficult for the youngest child in the study, an elbow disarticulation case who was barely 4 years old when fitted. Consequently, at the conclusion of the study he was wearing the hand only for special occasions. Of the four wrist disarticulation amputees, the two 4 year olds found the hand a little heavy and difficult to operate, while two 8 year olds advised that both weight and operating forces were satisfactory. </p> <h3> Specific Types of Grasp </h3> <p> In the Right Hand Study a general comparison of the functional qualities of hand and hook, based on child and parent opinions, had yielded indecisive results. Therefore, in the Left Hand Study children and parents were requested to rate the suitability of both the old terminal device (hook) and the No. 1 hand, not only for grasping objects in general but also for eleven specific types of grasp or activity areas. Explanatory comments concerning terminal device use for each specific function were also solicited. The eleven activity areas were: </p> <ol> <li>Carrying objects, such as school bags, purses, lunch pails, etc.</li><li>Grasping or picking up very small elongated objects, such as pins, paper clips, etc,</li><li>Grasping or picking up small elongated objects, such as pencils, scissors, etc.</li><li>Grasping paper.</li><li>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</li><li>Grasping or holding a drinking glass.</li><li>Using silverware while eating.</li><li>Grasping large bulky objects, such as paste jars, books, balls, etc.</li><li>Grasping objects such as bicycle handles, swing chains or ropes, etc.</li><li>Putting on clothes, such as shirts, blouses, etc.</li><li>Putting on shoes and socks.</li></ol> <p> Many of these areas involve the performance of a number of discrete activities. Hence, the data obtained not only provide bases for comparison of hand and hook functions but also supply considerable general information concerning the activities of children with upper extremity prostheses. Since this information may be of significance to clinic personnel, especially to therapists and to persons concerned with the development of devices for children with arm amputations, the data relating to each of the activity areas are presented in some detail (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Carrying a school bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Carrying objects, such as school bags, purses, lunch pails, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   0</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   4</p> </td> <td> <p>   8</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   0</p> </td> <td> <p>   3</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p>Approximately four fifths of the children reported the hook as satisfactory for carrying objects with handles, while only half found the hand satisfactory. Parents, on the other hand, believed the hook and hand functioned about equally well for holding these objects. Where difficulty was experienced with the hand, it was usually because the objects carried were too heavy for the amount of "Bac Loc" provided. Illustrative comments follow. Betsy: "The hand doesn't let me hold heavy things." Linda's mother: "Buckets, lunch pails, and anything of metal or plastic that is heavy slip from her grasp." Gabriel's mother: "The hand is satisfactory provided the handle is not too thick and the object not too heavy." </p> <h5><i>Grasping or picking up very small elongated objects, such as pins, paper clips, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   23</p> </td> <td> <p>   4</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   13</p> </td> <td> <p>   6</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   10</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> More than half the subjects and parents rated the hook as satisfactory for picking up very small objects. The hand was considered adequate for this function by only about a third of the children and parents. Some children pointed out that the hand was satisfactory for holding very small objects but not for picking them up (<b>Fig. 8</b>). One parent suggested that the child's vision was blocked by the rest of the hand, another that the floating fingers were in the way. Some of the illustrative remarks are quoted. John: "Nails but not pins." Susanne: "I have to hold the object in the other hand to pick it up." Danny's mother: "Too much effort and concentration."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Holding a safety pin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or picking up small objects, such as pencils, scissors, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   26</p> </td> <td> <p>   7</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children and parents considered the hook satisfactory for this function, while a slightly smaller proportion also found the hand satisfactory. The objects given particular attention within this category of use were scissors, pencils, crayons, hammers, and put together toys. </p> <p> It was apparently impossible to cut with ordinary scissors held in either a hook or an artificial hand. Thus, unilateral amputees held scissors in their good hand, while bilaterally involved children could not use them at all unless the scissors were especially modified. </p> <p> Concerning pencils, the reports were mixed, with some children rating the hook better for picking up and holding pencils, but with more subjects preferring the hand (<b>Fig. 9</b>). Some illustrative comments follow. Jeff: "I can hold a pencil better with the hook." Danny: "The hand holds a pencil better for sharpening." Randy: "I can pick up pencils easier with the hand." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Holding a pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Only one or two of the children with unilateral amputations made reference to writing with the prosthesis, although this was, of course, necessary for bilateral amputees. In general, the hook was favored for writing. Gail: "I can write better with a hook." Randy's teacher: "He is more secure doing written work when he wears hooks." (Randy is a bilateral upper extremity amputee.) </p> <p> There were only two references to hammers, one favoring each terminal device. Concerning put together toys there were two statements, both favoring the hook. </p> <p> In summary, scissors appeared to be difficult, if not impossible, to grasp with either hook or hand, pencils somewhat easier to handle with the hand, and put together toys easier with the hook, and possibly writing also. </p> <h5><i>Grasping paper</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   37</p> </td> <td> <p>   0</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   34</p> </td> <td> <p>   2</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Nearly all children rated both the hook and hand as satisfactory, with only four rating the hand as unsatisfactory (<b>Fig. 10</b>). Almost all the parents considered both devices satisfactory. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Grasping paper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The comments indicated that grasping paper was not one function but several, each calling for a different application of the terminal device. Involved were such tasks as holding paper for cutting with scissors, holding paper on a desk for writing, picking up paper, selecting one sheet from many, holding playing cards for card games, etc. </p> <p> Two children cited holding paper to cut with scissors to explain their rating of the hook as satisfactory, but in both cases they considered the hand also suiTable for this purpose. The therapist of a third child (Susan) felt that the hand was less helpful: "When cutting paper, Susan usually places the paper in the hook. With the hand she seldom places the paper in the hand; it seems to crush the paper and hold it in an awkward position." Susan herself regarded both devices as satisfactory for grasping paper. </p> <p> The hand was considered better for holding paper on a Table or desk while writing (<b>Fig. 11</b>). Sean's mother: "With the hook the paper tends to slip resulting in ragged print." Danny: "The hand holds down paper better for writing." Gail's mother: "School paperwork seems to be neater with the hand because the paper doesn't slip." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Holding paper while writing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Several remarks seemed to indicate that the hand was better for picking up paper, but one bilateral amputee mentioned difficulty in selecting one sheet from many. </p> <p> Concerning holding playing cards for various games, Susan's therapist made the following comment: "Playing card games is an activity which is performed better with the hand. It is in a better holding position and the cards come out easier when she is taking them from the hand." </p> <h5><i>Grasping or holding soft objects, such as sandwiches, toothpaste tubes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   20</p> </td> <td> <p>   9</p> </td> <td> <p>   9</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   13</p> </td> <td> <p>   10</p> </td> <td> <p>   12</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   21</p> </td> <td> <p>   10</p> </td> <td> <p>   5</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   9</p> </td> <td> <p>   5</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Half the children rated the hook as satisfactory, but the number dropped to a third for the hand. Half the parents considered the hook as suiTable and a slightly greater number rated the hand as adequate. More children than parents reported that neither device was used for grasping soft objects. </p> <p>Picking up and holding a tube of toothpaste apparently presented no problem, but difficulties arose with sandwiches, cookies, candy bars, marshmallows, grapes, or raw eggs, all of which were usually held in the sound hand. The majority of the children experienced difficulty in holding soft objects with either device. Debra: "The hand squashes it and I can't eat it the hand squashes the sandwich." Joseph: "The hook might squash them; the hand can pick it up but I'll smash it." There were some children who made comments favoring the hand. Danny: "With the hand I can gel a sandwich better without squeezing it" (<b>Fig. 12</b>). Mother of Randy (triple amputee): "Eating sandwiches is a treat which he was unable to do with hooks." However, a larger number preferred the hook for this purpose. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Grasping a sandwich. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping or holding a drinking glass</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   8</p> </td> <td> <p>   8</p> </td> <td> <p>   18</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   7</p> </td> <td> <p>   12</p> </td> <td> <p>   16</p> </td> <td> <p>   4</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   8</p> </td> <td> <p>   13</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   12</p> </td> <td> <p>   11</p> </td> <td> <p>   15</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Less than a fourth of the subjects rated either hook or hand as satisfactory for holding a drinking glass. The parents were slightly more positive, a third of them rating both hook and hand as suitable. Several of the children who gave a rating of satisfactory explained that they would use a terminal device only to hold a glass by the rim when filling it with water or to carry it while setting the table. </p> <p> Comparisons between hook and hand were few. Some children stated that the hand did not open wide enough for available glasses or that the glass slipped. Two others, however, stated that the hand had a better grip and did not slip. Small opening and slippage were problems also reported with hooks. The general impression is that even children who rated a terminal device as satisfactory for holding a drinking glass were merely claiming they could hold a glass as a special feat, not as a commonly used skill (<b>Fig. 13</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Grasping a paper cup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Using silverware while eating</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   13</p> </td> <td> <p>   2</p> </td> <td> <p>   22</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   15</p> </td> <td> <p>   2</p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   14</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   2</p> </td> <td> <p>   16</p> </td> <td> <p>   0</p> </td> </tr> </tbody></table> <p> Approximately a third of the children and half of the parents rated both hook and hand as satisfactory for holding silverware, while half of the children and a third of the parents indicated that neither device was used for the purpose. The slight differences favored the hand. With the exception of three bilateral arm amputees, the children who answered this question were left arm amputees. It appears likely that they used the terminal device only for holding a fork while cutting meat (<b>Fig. 14</b>), although one or two held a spoon in the terminal device also. Many children, even some who regarded a terminal device as satisfactory, reported that the parents usually cut their meat for them. Particular mention was made of problems of slippage, of difficulty of positioning, the better appearance of the hand performance, and the need for practice.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Holding a fork. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping large bulky objects, such as paste jars, books, balls, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   30</p> </td> <td> <p>   4</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   18</p> </td> <td> <p>   12</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   32</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   6</p> </td> <td> <p>   4</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Three fourths of the children rated the hook as satisfactory, but only half found the hand so. The same proportion of parents rated both hand and hook as satisfactory. </p> <p> The intention of the question was to determine whether the smaller opening provided by the hand was a disadvantage in actual use. The specifications of the No. 1 hand require that a minimum full opening of 2 in. be attainable with the thumb in the wide opening position, but most hands exceeded the specification to a maximum of approximately 2 3/8 in. However, there were indications that several children utilized the small, 1 1/2 in. opening only and did not bother to change the thumb position. A Dorrance 10X hook, by comparison, provided a 3 in. opening and the Dorrance 99X hook a 3 1/2 in. opening. </p> <p> A number of children and parents specifically mentioned holding baseball bats, balls, paste jars, books, boxes, dolls, and a see saw. Curtis: "With the hand, I can hold the bat better when I play ball." Glenda's mother: "Bats the ball using both hands now." Comments indicated that the hook was superior for throwing balls, but the hand was satisfactory for catching them in two handed fashion. In general, though, the children found it difficult to grasp balls with either the hook or the hand (<b>Fig. 15</b>). The hook was somewhat better for holding paste jars. Books, boxes, paper cups, and dolls (<b>Fig. 16</b>) were better held with the hook, but one boy said riding a see saw was easier with the hand. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Holding a large ball. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Holding a doll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Grasping objects such as bicycle handles, swing chains or ropes, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   34</p> </td> <td> <p>   1</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   5</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   36</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   33</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> <td> <p>   2</p> </td> </tr> </tbody></table> <p> Most children and parents rated the hook as suitable, but some children stated that the hand was unsatisfactory or not used for these activities. Confusion may have existed because of the separate uses; several of the children played on swings but did not ride a bicycle or tricycle. The hook was more often preferred for holding a swing chain, but preference was evenly divided for riding a bicycle (<b>Fig. 17</b>). Several parents felt that the hand grasp appeared more natural. There was concern about the danger of tearing the glove or breaking the thumb of the hand on a swing chain. Other activities mentioned under this heading were climbing monkey bars and holding a jump rope, a broom and a hoe, or a bow for archery. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Holding a bicycle handle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Putting on clothes, such as shirt, blouse, etc.</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   27</p> </td> <td> <p>   1</p> </td> <td> <p>   8</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   21</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   2</p> </td> <td> <p>   6</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   30</p> </td> <td> <p>   1</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p>Two-thirds of the children and parents rated the hook as satisfactory, but only half the children considered the hand as satisfactory for this purpose. Several children who considered both devices as satisfactory commented that they were usually dressed, or were assisted in dressing, by their mothers. There were more comments favoring the hook than the hand; the glove tended to stick to cloth and there was glove discoloration attributed to contact with clothing, particularly from red dyes.</p> <h5><i>Putting on shoes and socks</i></h5> <table> <tbody><tr><th> </th><th><p>|Satisfactory|</p> </th><th><p>|Unsatisfactory|</p> </th><th><p>|Does Not Use|</p> </th><th><p>|Not Reported|</p> </th> </tr><tr><td> <p>Children</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   24</p> </td> <td> <p>   3</p> </td> <td> <p>   9</p> </td> <td> <p>   3</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   19</p> </td> <td> <p>   3</p> </td> <td> <p>   11</p> </td> <td> <p>   6</p> </td> </tr> <tr><td> <p>Parents</p> </td> </tr> <tr><td> <p><i>Hook</i></p> </td> <td> <p>   29</p> </td> <td> <p>   3</p> </td> <td> <p>   6</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p><i>Hand</i></p> </td> <td> <p>   28</p> </td> <td> <p>   3</p> </td> <td> <p>   7</p> </td> <td> <p>   1</p> </td> </tr> </tbody></table> <p> Two thirds of the children and the parents rated the hook as satisfactory, but less than half of the former considered the hand satisfactory (<b>Fig. 18</b>). A fourth of the children stated that they did not use either device to put on shoes and socks, and the number who did not tie shoelaces with prostheses was undoubtedly much higher. Timothy, for example, said that he did not know how to tie shoelaces and that his mother dressed him, but he and his mother rated both devices as suiTable for putting on shoes. Another reason given for parental assistance was that the child consumed too much time in dressing himself. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Putting on shoes and socks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusions</h3> <p> In spite of the wide differences in the opinions expressed by the children and parents participating in the study, it was apparent that: </p> <ol> <li>The APRL Sierra No 1 hand was heavier and in most instances more difficult to operate than the previously worn hook, but for the majority of subjects in the sample these were not serious drawbacks. Those with shoulder disarticulation amputations and to a lesser extent some of the younger children and above elbow amputees were most likely to have difficulty with weight and operating forces. It is obvious, of course, that if the hand were lighter and had a more efficient operating ratio, it would be more accepTable to all.</li><li>The hand provided somewhat less pinch force than most of the hooks and a less precise grasp. The majority of children reported that they could perform more activities better with the hook; however, many could also specify a number of activities that were performed better with the hand. The latter was preferred somewhat more often for tasks such as picking up a pencil, grasping paper, and holding silverware for eating. The majority of the children and their parents considered the hand as "adequate" to "very satisfactory" for a wide range of activities.</li></ol> <h3>Acknowledgments</h3> <p> In Part I of this series of articles, grateful acknowledgments were made to the clinics participating in the Child Amputee Research Program and to a number of persons for valuable cooperation and assistance in the conduct of these studies and in the preparation of the report. We again express our sincere appreciation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Kitty in the Kegs," a set of small plastic barrels, one inside the other. A picture of a kitten is in the innermost barre. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Drying Dishes </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Putting on clothes. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Loony Links." The child is asked to assemble a jointed doll and stand it on its feel, using a preassembled doll as a model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and pasting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Eating ice cream. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, </i>Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Actual pinch forces in the hooks worn by children in the study were not obtained. However, recommended forces for the age group are: below elbow, 3 1/2lb, above elbow, 3 lb. than the previously worn hook, the data must be questioned. Nevertheless, conservative interpretation of the available information does provide insight not only into hand usage but also into terminal device function in general.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St , New York, N.Y. 10010.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_015/AutTable64-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-08.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-10.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-11.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-12.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_02_015/Aut64-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Acceptability of Functional-Cosmetic Artificial Hand for Young Children, Part II Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/ff93388a2b326482cd23ab1fe7b0530f.pdf 56f90f8e21d338b8b528570d124e7f89 https://staging.drfop.org/files/original/dcdfac18ac5ac3022676315508cf5d48.jpg dbee38bac224a96a2c011cb17d7d6a9f https://staging.drfop.org/files/original/e19ee311b0e20a0019bbf64b23a2defd.jpg 709d5e732087fd5a57d43b48a0652c1c https://staging.drfop.org/files/original/ff5fb16a3b6eb4327a31bb1992c94add.jpg 634c592b76ea73a55e13cf93c72ae7ca https://staging.drfop.org/files/original/dd03140d20e3ea247047a03394d6be8f.jpg 9801ffc457b82c0e5e04953cb4376b90 https://staging.drfop.org/files/original/1c887547c6cbac99872483f954e8b43a.jpg 056339fc83108b1608ab7864990f343f https://staging.drfop.org/files/original/8c92a0c6606452d4426b8a44d4f4bff6.jpg 3f5ae3451b2192b7ea3f4231b3f169e8 https://staging.drfop.org/files/original/32fdad7b172199d9b720f189835bc3c9.jpg 9710e54f4022a14c41497f00812a7a4c https://staging.drfop.org/files/original/aa48e315ac77e0e2136d3931d68f5e2e.jpg f8768c064188a404312b028d7fff4829 https://staging.drfop.org/files/original/b5bef2c3795da5096649620616ab5554.jpg 7bf997809b8206a66916590c0d7b404b https://staging.drfop.org/files/original/b19587d2238d7d8b888d85da0d64eef4.jpg aeafbf39f3d3f61b596eddca5ba9ffaf https://staging.drfop.org/files/original/c1ce590718115f39e52684aee441de8f.jpg d5ae4663e0a01f258e869afed35cbd4a https://staging.drfop.org/files/original/c7a6dde19f351a434ecf52aabd0334d3.jpg 65cdb5dd9ad39d3da6951490f7ee16f8 https://staging.drfop.org/files/original/cf1809077913f566b86fa7e5199c3c20.jpg 4530478b27ca832a157266ebe524bb10 https://staging.drfop.org/files/original/37824783f3fe6a952766ec00f7dd01d9.jpg b11bbffa4e419db31441af1f803b4640 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_004.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 4 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Münster-Type Below-Elbow Socket, an Evaluation.</h2> <h5>Sidney Fishman, Ph. D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> Short stumps have always presented fitting problems in both upper- and lower-extremity amputation sites for the obvious reasons of small attachment area and a lack of useful range of motion. In an attempt to alleviate these problems for upper-extremity amputees, Drs. O. Hepp and G. G. Kuhn<a></a> of Münster, Germany, developed fitting techniques for the below-elbow and the above-elbow amputee, respectively, that provide a more intimate encapsulation of short stumps. </p> <p> For the below-elbow amputee, the general characteristics of this technique (<b>Fig. 1</b>) are: </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Münster-Type fitting for below-elbow ampute. A, Lateral view ondicating the preflexion angle; B, anterior view indicating high trim line; C, posterior view indicating olecraron fit and the small tricep pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The elbow is set in a preflexed position (average 35 deg.). Because of the reduced range of useful motion, the socket is flexed so as to position the terminal device in the most generally useful area.</li><li>A channel is provided at the antecubital space for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket is fitted high around the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket.</li></ol> <p>For the above-elbow amputee, the characteristics of the technique are: </p> <ol> <li>The socket is fitted high on the acromian, utilizing this bony structure to retain the socket in position and provide stability. </li><li>The axillary section of the socket conforms closely around the tendons of the pectoralis major and latis-simus dorsi muscles to enable the patient to exert the force of these major muscles in moving his prosthesis.</li></ol> <p> In an earlier study<a></a>, amputee clinics reported a favorable experience in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children with short and very short below-elbow stumps. Since the Hepp-Kuhn technique seemed to represent an improvement in fittings of the preflexed type, New York University initiated a preliminary investigation of the procedure for adult amputees of this type. This study took place in the early part of 1961 and was limited to two short-below-elbow subjects. This exploratory study yielded generally positive outcomes in terms of function and comfort. One short-above-elbow amputee was also fitted with encouraging results. </p> <p> The present evaluation is an extension of the initial study with major emphasis given to below-elbow fittings. Concurrently, further exploration of the above-elbow fitting technique was undertaken and is continuing, although not reported in this article. </p> <p> For lack of a better term, the fitting procedures employed in this study are referred to as the "Münster-type" techniques. It should be emphasized that no claim is made that the techniques are identical to those followed by Drs. Hepp and Kuhn. New York University personnel witnessed a demonstration of the techniques given by Dr. Kuhn in 1960 and had available the cited reference. However, none of the New York University fittings were either directly or indirectly supervised or checked by the developers. </p> <p> Both logic and prior experience suggest that the greatest benefit from the Münster-type below-elbow fitting technique may accrue to subjects with short and very short below-elbow amputations in that the step-up hinges and split sockets characteristic of typical United States fittings for these categories could be eliminated. Historically, step-up hinges have lacked durability. Moreover, a price is paid for the step-up characteristic by a corresponding decrease in lifting power. Contrariwise, it is apparent that the range of elbow flexion is reduced by the Münster-type fitting. This reduction may or may not be significant in terms of amputee function (<b>Fig. 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparison of split socket and Münster-type fitting of very short below-elbow case. A, Very short below-elbow stump-3-1/4 in.; B, split socket with step-up hinge provides 140 deg. of elbow flexion; C, Münster-type fitting permits less elbow flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Sample</h3> <p> The sample in this study consisted of eight adult below-elbow amputee subjects (including one bilateral amputee) whose stumps were relatively short-from 3-1/4 in. to 5-1/2<i> </i>in. measured from the medial epicondyle to the end of the stump. The physical characteristics of the sample and a description of their previously worn prostheses are given in <b>Table 1</b> and <b>Table 2</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Methodology</h3> <p> The Münster-type techniques for fitting below-elbow prostheses, as understood by New York University personnel, were followed in fabricating experimental arms for the eight subjects in the sample. In one case (WP), however, the anterior trim line (channel for biceps tendon) was reduced in order to provide this bilateral amputee with a greater range of elbow flexion. All prostheses incorporated triceps pads, leather hinges, and figure-eight harnesses. Six of the eight subjects (OB, PL, TM, WP, ES, and PW) were fitted with polyester porous sockets fabricated in accordance with the technique developed at the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory)<a></a>. The other two subjects (DC and QS) were fitted with nonporous plastic sockets. </p> <p> The evaluation consisted essentially of a "before" and "after" comparison of status. The prosthetic status of all subjects in this study was assessed prior to their fitting with the Münster-type prosthesis in order to obtain a basis for later comparison. At one month and at six months after delivery of the experimental prosthesis, the prosthetic status of the subjects was reevaluated and comparisons between the conventional and experimental prostheses were drawn. </p> <p> The stumps of all subjects were examined prior to the experimental fitting in order to identify their condition (scars, irritations, discolorations, etc.). This examination was repeated at the specified intervals to see what effect, if any, the experimental socket had had on the physical condition of the stump. </p> <p> Two self-administering rating scales completed by all subjects elicited their opinions regarding prosthetic comfort, function, and cosmesis. A questionnaire was administered prior to the experimental fitting to assess the amputees' opinions regarding their conventional prostheses. A comparative questionnaire was administered in the post-fitting evaluations to compare the experimental and the conventional prosthesis in the factors previously rated. </p> <p> A prosthetic-usefulness schedule<a></a> was applied to the six subjects who had previously worn a functional prosthesis to investigate their opinions concerning the relative value and comparative ease of performance of the conventional and experimental prostheses in the areas of work, home tasks, social life, dressing, and eating. </p> <p> Three evaluation procedures were administered to the six subjects who had previously worn functional prostheses, as follows: </p> <ol> <li>The angles of preflexion and maximum flexion were measured on both conventional and experimental prostheses, as well as the amount of vertical downward force the amputees could resist with their elbows flexed at 90 deg. (live lift) and fully extended (axial load). </li><li>The accuracy of positioning control exhibited by the amputees was measured with both conventional and experimental prostheses. Scoring of performance on the positioning control test<a></a> was in terms of accuracy and speed</li><li>The amputees' ability to perform a series of 12 bimanual practical activities was rated on a seven-point scale. For each activity, six factors were rated independently but simultaneously by two experienced examiners. This evaluation was administered initially to the amputees with their conventional prostheses and then repeated with the experimental prostheses at the one-month and at the six-month post-fitting evaluations.</li></ol> <h3>Results</h3> <h4>Stump Examinations</h4> <p>In all cases a period of two to three weeks was required for the subjects to become adjusted to the more intimate fit of the Münster-type socket. During this initial wear period, the usual complaint was of an irritation in the medial epicondylar area, which was corroborated by visual examination. However, after this adjustment period, the experimental socket had no observed or reported effects on the amputation stump, although amputees were generally aware of increased pressure on the olecranon when the forearm was flexed. </p> <h4>Amputee Reactions</h4> <p> Comparative reactions to the conventional and experimental prostheses were obtained from the eight subjects in the sample. The factors investigated and the amputees' ratings are presented in (<b>Table 3</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> It is clear from (<b>Table 3</b>) that, with few exceptions, the amputees reacted very favorably to the Münster-type prosthesis. Sixty per cent of the responses were favorable toward the experimental item while only five per cent were unfavorable. The two factors which brought forth negative reactions were comfort (two subjects) and adjustments (two subjects). These negative reactions reflect difficulties experienced by these two amputees in adjusting to the intimate fit of the Münster-type socket. However, all seven subjects in the sample who had previously worn rigid hinges of one type or another cited the elimination of these hinges as a definite contribution to comfort. </p> <p>No differences in reactions which could be attributed to socket porosity, or lack of it, were noted. The fact that the wear period for most of the subjects was confined to the winter months may explain this lack of difference. </p> <p>The data on effort and control are of particular interest. All subjects in the sample reported improvement in these factors as a result of wearing the experimental prosthesis. Further questioning revealed that the amputees' opinions regarding improved prosthetic control with less expenditure of effort appeared directly attributable to the more intimate fit of the Münster-type socket. This reaction was commonly expressed by such statements as: "The prosthesis feels a part of me" and "I feel right-handed again." Several subjects reported that the Münster-type sockets did not tend to slip off their stumps under load, as was the case with their conventional sockets. One subject cited the more secure fitting of the Münster-type socket to be particularly advantageous in performing overhead activities because his stump did not slip out of the socket when he performed a pulling motion with the prosthesis. </p> <p>The reactions of the two subjects (ES and PL) who had previously worn nonfunctional prostheses (for 15 and 20 years, respectively) are noteworthy. Neither became especially skillful prosthesis users in the course of the study, but both did come to use their terminal devices for grasp, which they had not previously done. Their highly positive responses to the experimental item and the fact that it changed their prosthetic status from that of nonusers to users after so long a period were considered quite unusual. Since both patients were fitted with porous laminate sockets, the role of the Münster-type fitting is not completely "pure" but, at least, must be regarded as contributory. </p> <p>Of the six subjects who had previously worn functional devices, five were able to perform the same number of activities with the experimental prostheses as with the conventional, while one subject reported increased prosthetic function with the Münster-type prosthesis (for example, he was able to carry a coat on his flexed forearm and was able to use his prosthesis in steering a car). However, all six amputees indicated that activities were easier to perform with the experimental prosthesis because the close-fitting socket afforded better control and the elimination of the rigid hinges provided greater freedom. </p> <p>In no case was there any evidence that the decreased range of motion with the experimental prostheses caused an appreciable decrease in prosthetic function. Since unilateral amputees routinely use their prostheses as assistive devices, there are few activities that are performed prosthetically at the extreme ends of the flexion-extension range. Bilateral subjects, however, are dependent on their prostheses for all upper-extremity functions and therefore require a greater range of motion. To provide the bilateral subject in our sample with an increased range of elbow flexion on his dominant side (40 deg. to 120 deg.), the anterior trim line was lowered. In addition, a wrist-flexion unit was provided to facilitate the performance of tasks close to his body. </p> <h4>Functional Evaluation</h4> <h5><i>Biomechanical Data</i></h5> <p> The Münster technique provides an intimate encapsulation of the amputated stump which results in a decreased range of motion. Forearm rotation is virtually eliminated, and the elbow flexion-extension range is significantly reduced. However, this type of fitting frequently increases the amputees' ability to resist moments about the elbow and to sustain axial loads. </p> <p> A comparison of the flexion ranges of the conventional and experimental prostheses is presented in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The preflexion angle of the Münster-type socket ranged from 20 deg. to 45 deg., with an average of 35 deg. The exact preflexion angle was planned for each subject contingent on such factors as stump length, natural elbow motion, and amputee preference. Maximum flexion of the experimental sockets ranged from 85 deg. to 120 deg. with an average of 105 deg. </p> <p> <b>Table 5</b> compares the maximum holding forces that amputees (the six who had previously worn functional prostheses) were able to maintain with both prostheses. "Live lift" refers to the amount of vertical downward force (applied at the terminal device) that an amputee can resist while maintaining his elbow at 90 deg. (<b>Fig. 3</b>). To allow for different forearm lengths, the data are expressed in foot-pounds. "Axial load" refers to the amount of vertical downward force applied at the terminal device that an amputee was able to resist with his elbow in an extended position. A complaint of pain or one-inch slippage of the socket on the stump was taken as the maximum tolerable load (<b>Fig. 4</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. live-lift test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. axial-load test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In all cases the amputees were able to resist a greater force in the live-lift test with their Münster-tvpe prostheses than with their conventional prostheses. For three subjects (DC, WP, and PW) the differences were very significant. In subject DCs case, this difference can be readily understood since he had previously worn a split socket and step-up hinge with an inherent mechanical disadvantage. For subjects WP and PW (prior single-pivot and flexible-hinge wearers, respectively), it is speculated that their improved lifting power was directly related to the more intimate fit of the experimental sockets. However, it is not clear why the same ratio of improvement did not obtain for the other subjects. </p> <p> Four of the six subjects were able to resist a greater axial load with the Mtinster-type prostheses than with their conventional prostheses. The maximum axial load on the experimental prosthesis for the other two subjects was limited by stump pain, particularly in the epicondylar area. </p> <h5> <i>Positioning Control Test</i> </h5> <p> The positioning control test investigated the amputees' ability to control their prostheses; that is, to bring the terminal device to a desired location in space with measured speed and accuracy. Specifically, it tested the skill of the amputees in striking designated targets in the vertical (on the wall) and horizontal (on a table) planes. Three different sequences were applied in the vertical plane and two in the horizontal. Accuracy was measured by the distance of a mark (made by a pencil held in the terminal device) from the target. Superior prosthetic performance therefore is indicated by the lower scores and performance times. <b>Table 6</b> and <b>Table 7</b> present the data for the three vertical and two horizontal sequences of the positioning control tests, respectivelv. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Analysis of the data of the positioning control test reveals minimal differences between the conventional and the experimental prostheses. In the vertical sequences, these differences favored the experimental prostheses slightly, with regard to accuracy, but the reverse is true regarding speed. In the horizontal sequences the experimental prostheses were slightly favored in both accuracy and speed. However, none of the differences proved statistically significant. </p> <h5> <i>Practical Activities Test</i> </h5> <p> Comparative performance data were obtained on five subjects in the sample. Two of the remaining three subjects were not tested because they had no prior experience with a functional prosthesis. The third subject (WP) had previously worn English-made components (terminal devices, wrist units) which it was not possible to duplicate in his experimental prosthesis. Since these different terminal devices would have introduced an extraneous variable into the experimental situation, the data from this subject are not included here. </p> <p> Performance data were obtained on a 12-item practical activities test. The activities were: using a pencil sharpener, tying a necktie, tying a shoelace, carrying several packages, filing a fingernail, hammering a nail, opening a jar, putting on a glove, using a can opener, using a paper clip, using a telephone and taking a message, and removing bills from a wallet. Six factors, each rated on a seven-point scale, were considered for each test activity. The factors were: position of the prosthesis for use, grasp of the object (secure or insecure), position of object for use (efficient or inefficient), maintenance of position of object during use (efficient or inefficient), appearance of performance (natural or unnatural), adequacy of general performance (efficient or inefficient). The average scores for each subject in these six factors are presented in (<b>Table 8</b>), with the higher scores reflecting better performance. The average performance times for each subject are shown in (<b>Table 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The data from (<b>Table 8</b>) indicate that there were apparently no significant differences in performance between the Münster-type and conventional prostheses, and the time comparisons in (<b>Table 9</b>) present no clearcut patterns. Two implications of these findings are of interest. First, the obvious and measurable decrease in range of forearm flexion imposed by the Münster-type fitting has no discernible effect on the bimanual performance of unilateral amputees. Second, the highly favorable reactions of subjects to the function and control aspects of the experimental arm were not corroborated by the performance-test data. This apparent lack of agreement may derive from two factors, either singly or in combination: some subtle but important differences in performance did exist but were not detectable by the observational testing procedures applied, or the more intimate and perhaps better fit of the experimental prosthesis (as compared to the conventional) created a "halo" effect which positively affected opinions concerning other aspects of the prosthesis. That is to say, since the prosthesis felt better, it must necessarily perform better. </p> <h3>Applicability of the Technique</h3> <p> Since it was hypothesized that the experimental item might have prime applicability to amputees whose stumps fell into the very short or short categories, attention was focused in the study on the fitting of such subjects. However, it was also of interest to investigate the range of stump lengths (or types) for which the Münster-type fitting might be suitable. </p> <p> In the New York University sample the shortest stump fitted was 3-1/4 in. To investigate the possibility of fitting stumps <i>shorter </i>than this, a cast and check socket were made for a bilateral amputee with a 2-1/2 in. below-elbow stump on one side (currently wearing a stump-actuated elbow lock) and an above-elbow stump on the other side. Since the below-elbow stump virtually disappeared at 90 deg. of flexion, it was thought that this was the absolute maximum flexion angle that might be obtained. This limitation was not considered acceptable for the dominant prosthesis of a bilateral amputee. It was also considered that this stump length was very near the lower limit for acceptable fitting, even for a unilateral amputee. </p> <p> With respect to maximum stump length, two limiting factors are observed: </p> <ol> <li>Stumps of mid-length and longer usually have some amount of pronation-supination which can be harnessed in a conventional below-elbow socket (with flexible hinges), but not in the Münster-type socket. </li><li>The configuration of the Münster-type socket (proximal opening at a sharp angle to the shaft) presents progressively increasing difficulty to donning and doffing as stump length increases (<b>Fig. 5</b>).</li></ol> <p> In the New York University series, in which the longest stumps fitted were <i>5-1/2 </i>in. (two subjects), neither of the above considerations was significant in either case. It is estimated, however, that the slumps of these two subjects were approaching the upper length limit to which the Münster-type socket could be applied without sacrifice of residual pronation-supination, or modification of the proximal socket to facilitate donning and doffing. </p> <p> Subject to further study, therefore, it appears that the Münster-type socket can be applied to the range of below-elbow-stump types for which rigid hinges (step-up, multiple action, and single-pivot) are typically prescribed at present. Some consideration probably should be given to the development of a prosthesis that will permit stump-actuated pronation and supination of the terminal device, yet retain the stability afforded by the Münster-type socket. </p> <h3> Summary and Conclusions</h3> <p> The applicability of Münster-type fittings was investigated by New York University. The sample for this study consisted of eight subjects with below-elbow amputations ranging from 3-1/4 in. to 5-1/2 in. (34 to 52 per cent). The results of the evaluative procedures, which included interview techniques and performance testing, indicated the following: </p> <ol> <li>A brief "breaking-in" period was required by all subjects to adjust to the more intimate fit of the Münster-type socket. After this initial period of adjustment, the experimental sockets had no observable or reported effects on the amputation stumps except a slight increase in pressure on the olecranon during lifting activities. The use of soft (Silastic) inserts over the epicondyles and olecranon to ameliorate these factors is under investigation at New York University.</li><li>The subjective opinions of all subjects were heavily in favor of the Münster-type prostheses.</li><li>The decrease in flexion range had no appreciable effect on prosthetic function for the unilateral amputees. For bilateral subjects, modification of the anterior trim line and provision of a wrist-flexion device may be necessary for performance of tasks close to the body. </li><li>The lifting and holding forces demonstrated by the amputees were generally better with the Münster-type prostheses.</li><li>The data from the positioning control and practical activities testing were inconclusive.</li></ol> <p> The evidence suggests, therefore, that the Münster-type prostheses are functionally advantageous with considerable cosmetic and comfort appeal for amputees with very short to medium below-elbow stumps. </p> <h3>Recommendations</h3> <p> Based on the results of this study, it is recommended that: </p> <ol> <li>The Münster fabrication technique be accepted as a satisfactory means of fitting below-elbow amputees. Prime applications would be for patients with unilateral losses whose stump lengths were classified in the short and very short categories.</li><li>Upon completion of the detailed fabrication manual now being prepared by New York University, the Münster below-elbow fabrication technique be introduced into the curricula of the Prosthetics Education Programs.</li></ol> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. View of Münster-type socket showing sharp angle of the proximal opening in relation to shaft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Hepp, O., and G. G. Kuhn, <i>Upper extremity prostheses</i>, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plastic laminates for upper-extremity prostheses</i>, Artificial Limbs, Spring 1963, pp. 17-30.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, <i>Preflexed arm study</i>, November 1960. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plastic laminates for upper-extremity prostheses, Artificial Limbs, Spring 1963, pp. 17-30.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, Preflexed arm study, November 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper extremity prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-01.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-02.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-03.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-05.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-3.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-4.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-06.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-07.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-08.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Münster-Type Below-Elbow Socket, an Evaluation. Creator An entity primarily responsible for making the resource Sidney Fishman, Ph. D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/feebebaa37399c3b95576ae8e7aa803a.pdf e216245824105b9041905d276496dc47 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_001.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Whither Prosthetics and Orthotics?</h2> <h5>George T. Aitken, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The publicity concerning scientific and technical advances keeps us constantly aware of man's increasing competence to master his environment. The technologies available make possible a wide variety of mechanisms that expand man's sphere of activity and make possible comfortable living in environments previously considered undesirable. Some of the modern techniques, when applied in the biological fields, have eliminated some diseases, controlled others, and have made possible medical and surgical procedures that extend the life expectancy of persons of all ages. Continuing research undoubtedly is going to demonstrate eventually the etiological factors in other disease entities and thus permit the development of a nonsymptomatic approach to therapy.</p> <p> Many of the current scientific advances have been the result of interdisciplinary effort, where two or more separate disciplines have worked together, hopefully synergistically. This interdisciplinary effort in prosthetics and orthotics has produced what is often described as a bioengineering effort. In the past twenty years increasing emphasis has been placed on the engineering aspects of this specific problem. These years have witnessed a rapid advance in the development of new industrial materials and hardware that have been readily applicable to artificial limbs and braces. Many improvements in previous fabrication techniques and components were facilitated by using these newly available industrial developments, and thus some advances were made in upgrading the quality of prosthetic and orthotic devices.</p> <p> There have been varying degrees of concurrent fundamental research in the biological aspects of this interdisciplinary approach.</p> <p> It seems at times, though, that the glamour of technology has overshadowed the purely biological problems. Research activities involving these glamour areas have been more attractive to many, and funds for such research have been more available in these sometimes esoteric areas.</p> <p> At times it would seem that many involved in prosthetics and orthotics research and development have failed to see the entire problem. Basically, it is the problem of achieving the optimum man-machine interface. The ultimate resolution of the problem is the production of designs that result in comfort, maximum function, and reasonable cosmetic restoration.</p> <p>There is little question that much has been accomplished. Certainly we have available currently biological and engineering techniques that are capable, in a high percentage of cases, of producing improved function and cosmesis. Continuing intelligent modification of techniques and components produces more and more improvement in all of these areas. It is fair to assume that amputees and others with orthopaedic impairments are now better served than ever before.</p> <p>Unfortunately, many in the field of prosthetics and orthotics research and development seem to have a tendency to relegate the patient to a secondary position. They appear to be bent on the perfection of the machine without due consideration to the education or alteration, or both, of the man to perfect the interface.</p> <p>It seems timely to give consideration to some of the areas in which continuing, accelerated investigation is desirable.</p> <p>Research in amputation surgery to provide more functional stumps and consequently more comfort to the patient has been significantly lacking. There is a multiplicity of amputation techniques. Myoplastic and osteoplastic techniques either alone or in combination have been recommended to promote comfort and improved function. In this country there has been no well-organized clinical evaluation of these claims made primarily from abroad. It seems logical that such procedures be investigated and evaluated thoroughly. There are good theoretical reasons to justify consideration of these procedures so that they not be simply rejected because of dissimilar training and experience.</p> <p>Cineplastic procedures were critically investigated, and well-established criteria have been developed for their use. A similar review should be made of some of the other surgical problems.</p> <p>The immediate postsurgical fitting of sockets with or without early weightbearing currently is being investigated. Undoubtedly, the results of this wellorganized investigation will develop proper indications and techniques for this procedure. Hopefully, such techniques will be of positive value in influencing the man aspect of the man-machine interface.</p> <p>There are in addition many areas of basic biological research that need further investigation. The problem of biological signal sources for control of external power comes to mind immediately. Other, perhaps less exotic, problems, such as analysis of joint motions to permit more satisfactory alignment and construction of braces, or the metabolic problems incident to amputation and use of prostheses as well as analogous problems in the orthotics field, need further investigation. These are but a few of the many fundamental problems that need clarification.</p> <p>In the truly engineering area, there is a large volume of continuing research and development of systems, components, and techniques to produce better artificial limbs and better braces. Much of this work is in the newer areas of technology and has increasing emphasis on the problems related to the use of external power in prostheses and orthotic devices.</p> <p>There may be a need to review some of our accepted designs in the light of our recent progress and perhaps an effort should be made to determine whether previously acceptable items are really the best that can be developed in relation to some of our improvements in materials and techniques. It may be the time to review terminal-device design. It is possible that we now need (particularly in the light of external power) to redefine the functional requirements of a terminal device and arrive at some design criteria that will permit more efficient utilization of our technical improvements in power sources and transmission.</p> <p>With an increasing emphasis on prosthetic restoration in congenitally limbdeficient children, it may develop that there must be a redefinition of goals, in the case of the upper-extremity patient, as related to age, rather than as related to the needs of an adult. Possibly a careful analysis of the functional needs of pre-school and primary and secondary school children would permit us to develop components for a system that would be more effective than simply using scaled-down adult components and systems.</p> <p>An overall review of research and development in prosthetics and orthotics over the past twenty years cannot help but emphasize that people requiring prostheses and orthotic devices are being increasingly better served. There seems little question but that the efforts of our schools of prosthetics and orthotics education have produced a marked upgrading of the skills in prescribing and fitting these devices as well as greater competency in the training of the patient in the use of such devices.</p> <p>As a clinician, I am very pleased with the improvement of patient care in these areas. As an interested participant in research and development endeavors, I am increasingly aware that there is much more that remains to be done. There exist the technical facilities to do both better research and better development. What is needed is the wisdom to direct our efforts in such a way that we adequately explore all areas of this man-machine problem and so correlate our activities that the result—the functioning man-machine combine— is a continually improving biomechanical unit.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>George T. Aitken, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Committee on Prosthetics Research and Development, July 1, 1962-June 30, 1965. Upon completion of his term as Chairman of CPRD, Dr. Aitken will continue to serve as a member of CPRD.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Whither Prosthetics and Orthotics? Creator An entity primarily responsible for making the resource George T. Aitken, M.D. * https://staging.drfop.org/files/original/673830cf47fc4145408e60fb59c2e58e.pdf daa60cba2d873060d065a59d7d151976 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_001.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Collaboration for Rehabilitation</h2> <h5>Mary E. Switzer <a style="text-decoration:none;">*</a><br /></h5> <p>I welcome the opportunity to express my appreciation for the wonderful cooperation and assistance that the Vocational Rehabilitation Administration has enjoyed in our many close relationships with the National Academy of Sciences-National Research Council. Our associations with the Committee on Prosthetics Research and Development and the Committee on Prosthetic-Orthotic Education have been long and fruitful, and the contributions of these committees have been substantial in the development and coordination of the research and informational programs for the fields of prosthetics and orthotics. VRA is glad to be associated with the National Institutes of Health-which is another agency of the Department of Health, Education, and Welfare-and with the Veterans Administration in supporting the CPRD program; and, naturally, we look with special pride on the CPOE program since we are its primary support.</p> <p>In our search for the judgment of the most knowledgeable people in each field which we support, the members of our National Advisory Council on Vocational Rehabilitation and the consultants on our Medical Advisory Committee have come to respect the professional competencies of the engineers, physicians, therapists, prosthetists, and orthotists who serve on CPRD. The professional advice and recommendations available to the Academy-Research Council on this basis assure impartial excellence in judgment and accessibility to professional skills that are not readily available from any other source in this country.</p> <p>I have been particularly impressed with the extensive informational program that CPOE has developed, especially the brochures, films, and slides for use in schools of medicine, physical therapy, and occupational therapy and for the work that has been initiated in the development of new amputee clinics in several of our State programs.</p> <p>There are special reasons why the functions of the Committees continue to hold special significance to our total rehabilitation program: State-Federal, research and demonstrations, and training activities.</p> <p>A recent study was made of the 120,000 persons who were rehabilitated in the State-Federal program during 1964, and it was found that the classifications of amputations, absence of extremities or other orthopedic deformities, accounted for a total of 42,352 persons rehabilitated. Approximately 35% of the total group, therefore, were orthopedic rehabilitants. Thus, it is obvious that, even with the changing emphases in disability groups needing service, the thread of orthopedic disabilities runs through the entire program of rehabilitation, and orthopedic cases are almost four times as large as the next largest category of disability.</p> <p>The VRA program of research and demonstrations, which began with a trickle ten years ago, has broadened into a flow of new ideas, methods, and patterns of service to facilitate and improve the restoration of the disabled to worthwhile lives. There have been approximately 850 VRA research projects approved during the period 1955-1964, and about seven per cent of these projects have been for studies primarily concerned with problems caused by or related to orthopedic disability. Thirty-one universities, hospitals, or rehabilitation centers have sponsored 55 research projects relevant to this field of work. During fiscal year 1964, VRA awarded research grants to 13 new projects relating to the orthotic-prosthetic field and an additional 14 ongoing projects received continuation grants.</p> <p>Some of the most imaginative and creative work in our total program is going on in this field of research, and we are constantly aware of the dramatic advancements that are taking place. The collaboration of medical rehabilitation and engineering with some of the discoveries in the space program should bring a whole new dimension to the war on disability. So naturally we are pleased that CPRD has followed our recommendation to hold a conference on the Control of External Power in Upper-Extremity Rehabilitation so that leading engineers, physicians, and scientists can come together to formulate and coordinate their programs and assist us in developing future plans for support of their efforts.</p> <p>Our training program, which continues to pour a steady stream of new professional rehabilitation workers into the ranks, has expanded so that professional training in all of the fields that contribute to rehabilitation has been influenced by VRA training grants: medicine, nursing, physical therapy, occupational therapy, rehabilitation counseling, social work, speech pathology and audiology, rehabilitation of the blind and deaf, the mentally ill and the mentally retarded, and recreation for the ill and disabled.</p> <p>Since 1953, over 600 short-term courses in prosthetics and orthotics with a total enrollment of about 9,500 trainees have been attended by physicians, surgeons, therapists, counselors, prosthetists, orthotists, and related rehabilitation personnel. Last year alone, over 1,500 persons were enrolled in 90 courses which were a part of the extensive offerings in upper- and lower-extremity prosthetics and orthotics, management of the juvenile amputee, and general orientation courses for these fields. The work of the University Council on Orthotic-Prosthetic Education has done much to achieve a more uniform approach in curriculum offerings, teaching materials and methods, and evaluation procedures for the courses.</p> <p>The semester courses at UCLA and Northwestern, the Associate in Arts courses proposed at Cerritos College and Chicago City Junior College, and the undergraduate curriculum at New York University-all these attest to the professionalism that is developing in prosthetics and orthotics.</p> <p>CPRD's and CPOE's paramount asset to us is a technical proficiency while ours is a resource of public funds and a wealth of experience which we try to combine through the State-Federal partnership and our research and training projects into a comprehensive program for helping the disabled to reach their physical, economic, social, and personal goals. Our task, as public servants, is to administer these Federal funds as wisely as we can, always bearing in mind the true function of the law and purpose of our program: to convert dependency into competence and independence. As we work together along the paths of rehabilitation, exchanging our knowledge and our resources, perhaps we can all share in the conviction expressed on the seal of the Department of Health, Education, and Welfare which reminds us constantly that Hope is the Anchor of Life.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Mary E. Switzer </b></td></tr><tr><td class="clsTextSmall">Commissioner, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, Washington, D. C. 20201.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Collaboration for Rehabilitation Creator An entity primarily responsible for making the resource Mary E. Switzer * https://staging.drfop.org/files/original/2110d586443d4b19b7fc9536683bc8db.pdf b96a92130c9eedff024e88641dc2063c https://staging.drfop.org/files/original/fb9ebe60dff913d9135a2935bdf2deda.jpg d13d55f144121d2cfb8b9d4b730617e3 https://staging.drfop.org/files/original/ed52127592e5a7556ac833dfac1e096e.jpg 09b1f0c571cdcf62a95b58b49c7de006 https://staging.drfop.org/files/original/7b8faeb9f25f51fe5128b4495503c950.jpg 99db08c49eea3368263b0db1627f47c4 https://staging.drfop.org/files/original/30dace90d04426eb54982c1e6db41b48.jpg 1ed343a6460af0febbb1795bc6c12e7e https://staging.drfop.org/files/original/f9b5fe8693775eed4668606286075472.jpg a15b89b39232a09a39e2b982223cb10c https://staging.drfop.org/files/original/3b8587872e5cd2828bb2963b8d88dbc6.jpg 0de0585464dffd0d381b1074931ae52c https://staging.drfop.org/files/original/ed4b52ce5ac75f7406ab601d3bcedf30.jpg 587647562e5551eb1a9ab4f918a8d05b https://staging.drfop.org/files/original/9d684744fe2af745dd567f69072abe94.jpg 6a8c37f94d45cf2102a83e1ba04ba532 https://staging.drfop.org/files/original/f47f13f4f517be2c68e4885132255a73.jpg 7a973ac6c580a0cd23a1aad0da06345e https://staging.drfop.org/files/original/ee934e7d6260f4fe6b2d0b475480c0c7.jpg 6a87da86f9c77268e89c2920e54290a7 https://staging.drfop.org/files/original/9eb67fe346807f23eb9721e730181cf6.jpg 3d6338336fa57f8e45e0c104c8e44f29 https://staging.drfop.org/files/original/d03ce299f5faed1b04bd1cb5d511348a.jpg 30c15358ad729c1d1b4c7c63b57d6e8f https://staging.drfop.org/files/original/f40a73ddf7abbe1bc363584464f188a0.jpg 8d3a34e6604c20c0b27728cfb136b495 https://staging.drfop.org/files/original/5c007bf3a01c041d44b41f637e3b98dd.jpg a3fad156c8637c58e8b2c697edb9aa86 https://staging.drfop.org/files/original/bbd4c7da3293e56cd493f889704a4ed4.jpg 40069e7ae5876d1e96e3a89a733cbb52 https://staging.drfop.org/files/original/36c833299af80c7d07ced66aa833331a.jpg 34987d61eca54e9e03b1ed422ae2ff44 https://staging.drfop.org/files/original/a1b4f107929b70c2c1e7b1bd1d4e4dcf.jpg 2f4d617a5b5753ac4821f7d6b284cd9b https://staging.drfop.org/files/original/840c46b44786ace3aff7daeaa6ff78f5.jpg 7e7806eb8e3e875d3fd8986e218f9c24 https://staging.drfop.org/files/original/6cda4b12ad5be268580aae44a30a5534.jpg b09bb8952a15ec26af4db027bbfc3382 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_044.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 44 - 66 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Body Segment Parameters: A Survey of Measurement Techniques</h2> <h5>Rudolfs Drillis, Ph. D. <a style="text-decoration:none;">*</a><br />Renato Contini, B.S. <a style="text-decoration:none;">*</a><br />Maurice Bluestein, M.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Human motor activity is determined by the response of the subject to constantly changing external and internal stimuli. The motor response has a definite pattern which can be analyzed on the basis of temporal, kinematic and kinetic factors.</p> <p>Temporal factors are those related to time: cadence (tempo) or the number of movements per unit time (minute or second), the variability of successive durations of motion, and temporal pattern. The temporal pattern of each movement consists of two or more phases. The relative duration of these phases and their interrelationships are indicative characteristics of the movement under consideration. For example, in walking, two basic time phases may be noted, the stance phase when the leg is in contact with the ground and the swing phase. The ratio of swing-phase time to stance-phase time is one of the basic characteristics of gait.</p> <p>The kinematic analysis of movement can be accomplished by studying the linear and angular displacements of the entire body, the joints (neck, shoulder, elbow, wrist, hip, knee, ankle) and the segments (head, upper arm, forearm, hand, thigh, shank, foot). For the purpose of investigation, the most important kinematic characteristics are: the paths of motion, linear and angular displacement curves, amplitudes or ranges of motion, the instantaneous and average velocities and their directions, and finally the linear and angular accelerations of the body segments under investigation. Information on these criteria can be obtained readily from objective (optical or electrical) recordings of the movements of a subject.</p> <p>The kinetic analysis is concerned with the influence of different forces and moments acting on the body or a body segment during the performance of a given activity. To determine these forces and moments, accurate data on the mass (weight), location of mass centers (centers of gravity), and the mass moments of inertia of the subject's body segments are required.</p> <p>At present there are limited data on body segment parameters, especially those for American subjects. Such data available are based on studies made on a limited number of dissected male cadavers. This cannot be regarded as a representative sample for our normal population with its wide range of age and difference of body build. There are no data available on female subjects in the United States.</p> <p>A precise knowledge of these body segment parameters has many applications, such as in the design of work activities or the improvement of athletic performances. It has particular value in understanding orthopedic and prosthetic problems. It would result in a better design of braces and prosthetic devices and more reliable methods for their adjustment. From these data it would also be possible to develop more precise and effective procedures for the evaluation of braces and artificial limbs. These procedures would replace the use of subjective ratings on performance by an amputee or a disabled person.</p> <p>The information on body segment parameters obtained by simple clinical methods can be very useful in general medical practice. It would provide a tool for the determination of:</p> <ol> <li>body segment growth and decay in normal and abnormal conditions</li><li>body segment density changes in normal and pathological cases;</li><li>body mass distribution asymmetry;</li><li>more precise body composition (fat, bones, muscles).</li></ol> <p>The aim of this article is to give a brief review of the methods used by different investigators for the determination of body segment parameters. Since some of the first treatises and papers are no longer available, we include some tables and figures which summarize the data obtained by some of the earlier researchers.</p> <p>Early Efforts</p> <p>Since ancient times there has existed an intense curiosity about the mass distribution of the human body and the relative proportions of its various segments. Those professions which had to select or classify subjects of varying body build were particularly interested in the problem. In spite of individual differences between particular subjects there are many characteristics which are common to all normal human beings. Thus the lower extremities are longer and heavier than the upper extremities, the upper arm is larger than the forearm, the thigh is larger than the shank, and other similar relationships.</p> <p>Historically this interest was first directed to the length relationships between the body segments. To characterize these relationships certain rules and canons were promulgated. Each canon has its own standard unit of measure or module. Sometimes the dimension of a body segment or component parts of a body segment were used as modules and occasionally the module was based on some abstract deduction.</p> <p>The oldest known module is the distance measured between the floor (sole) and the ankle joint. This module was used in Egypt some time around the period 3000 b.c. On this basis, the height of the human figure was set equal to 21.25 units. Several centuries later in Egypt a new module, the length of the middle finger, was introduced. In this instance body height was set equal to 19 units. This standard was in use up until the time of Cleopatra.(<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Egyptian middle finger canon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the fifth century B.C., Polyclitus, a Greek sculptor, introduced as a module the width of the palm at the base of the fingers. He established the height of the body from the sole of the foot to the top of the head as 20 units, and on this basis the face was 1/10 of the total body height, the head 1/8, and the head and neck together 1/6 of the total body height. In the first century B.C., Vitruvius, a Roman architect, in his research on body proportions found that body height was equal to the arm spread-the distance between the tips of the middle fingers with arms outstretched. The horizontal lines tangent to the apex of the head and the sole of the foot and the two vertical lines at the finger tips formed the "square of the ancients." This square was adopted by Leonardo da Vinci. He later modified the square by changing the position of the extremities and scribing a circle around the human figure.</p> <p>Diirer (1470-1528) and Zeising (1810-1876) based their canons on mathematical abstracts which were not in accordance with any actual relationships.</p> <p>At the beginning of the twentieth century, Kollmann tried to introduce a decimal standard by dividing the body height into ten equal parts. Each of these in turn could be subdivided into ten subunits. According to this standard, the head height is equal to 13 of these smaller units: seated height, 52-53; leg length, 47; and the whole arm, 44 units.(<b>Fig. 2</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Kollmann's decimal canon </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Previous Studies in Body Parameters</p> <p>Starting with the early investigators, the idea has prevailed that volumetric methods are best for determining relationships between body segments. There were basically two methods which were used for the determination of the volume of the body segments: (1) body segment immersion, and (2) segment zone measurement or component method. In these methods it is assumed that the density or specific gravity of any one body segment is homogeneous along its length. Hence the mass of the segment can be found by multiplying its volume by its density.</p> <p>Immersion Method</p> <p>Harless in Germany first used the immersion method. In 1858 he published a text book on <i>Plastic Anatomy, </i>and in 1860 a treatise, <i>The Static Moments of the Human Body Limbs. </i>In his investigations, Harless dissected five male cadavers and three female cadavers. For his final report, however, he used only the data gathered on two of the subjects.</p> <p>The immersion method involves determining how much water is displaced by the submerged segment. Previous researchers, including Harless, have relied on the measurement of the overflow of a water tank to find the volume of water displaced.</p> <p>Harless started his studies with the determination of the absolute and relative lengths of the body and its segments. The absolute lengths were measured in centimeters. For determining the relative lengths, Harless used the hand as a standard unit. The standard hand measurement was equal to the distance from the wrist joint to the tip of the middle finger of the right hand. Later Harless also used the total height of the body as a relative unit of length. In the more recent studies on body parameters, this unit is accepted as the basis for the proportions of the various segment lengths. The results of Harless' studies are shown in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For obtaining the absolute weights of the body segments, Harless used the gram as the standard. As a unit for relative weights, he first decided to use the weight of the right hand, but later established as his unit the one thousandth part of the total body weight. His results are given in <b>Table 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a very careful way Harless determined the volume and density (specific gravity) of the body segments. The results of these measurements are presented in <b>Table 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To determine the location of mass centers (centers of gravity), Harless used a well-balanced board on which the segment was moved until it was in balance. The line coincident with the fulcrum axis of the board was marked on the segment and its distance from proximal and distal joints determined. The location of the mass center was then expressed as a ratio assuming the segment length to be equal to one. Harless also tried to determine the location of segment mass center from the apex of the head by assuming that the body height is equal to 1,000. The data for one subject are shown in <b>Table 4</b>. From the table, the asymmetry of the subject becomes evident.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To visualize the mass distribution of the human body, Harless constructed the model shown in <b>Fig. 3</b>. The linear dimensions of the links of the model are proportional to the segment lengths; the volumes of the spheres are proportional to segment masses. The centers of the spheres indicate the location of mass centers (centers of gravity) of the segments.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Body mass distribution (After E. Harless). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Modified models of the mass distribution of the human body and mass center location of the segments have been made by several other investigators. It is unfortunate that up to now a unified and universally accepted subdivision of the human body into segments does not exist.</p> <p>In 1884, C. Meeh investigated the body segment volumes of ten living subjects (8 males and 2 females), ranging in age from 12 to 56 years. In order to approximate the mass of the segments, he determined the specific gravity of the whole body. This was measured during quiet respiration and was found to vary between 0.946 and 1.071 and showed no definite variation with age. The segment subdivision used by Meeh is shown in <b>Fig. 4</b> and the results of the segment volume measurements are presented in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Body Segments (After C. Meeh). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>C. Spivak, in 1915, in the United States, measured the volumes of various segments and the whole body for 15 males. He found that the value of specific gravity of the whole body ranged from 0.916 to 1.049.</p> <p>D. Zook, in 1930, made a thorough study of how body segment volume changes with age. In making this study, he used the immersion method for determining segment volumes. These were expressed in per cent of whole body volume. His sample consisted of youngsters between the ages of 5 and 19 years. His immersion technique was unique, but his claim that it permitted the direct determination of the specific gravity of any particular body segment does not seem to have been established. Some of his results are shown in <b>Fig. 5</b> and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean head volume change with age (After D. Zook). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean leg volume change with age (After D. Zook and others). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the period from 1952 to 1954, W. Dempster at the University of Michigan made a very thorough study of human body segment measurements. His investigations were based on values obtained on eight cadavers. Besides volumes, he obtained values for mass, density, location of mass center, and mass moments of inertia. The immersion method was used to determine volume. However, these data have limited application since all of Dempster's subjects were over 50 years of age (52-83) and their average weight was only 131.4 lb. The immersion method was used in Russia by Ivanitzkiy (1956) and Salzgeber (1949).</p> <p>The immersion technique can be applied for the determination of the total segment volume or any portion thereof in a step-by-step sequence. It can be applied as well on living subjects as on cadavers. In this respect it is a useful technique.</p> <p>There is some evidence that for most practical purposes the density may be considered constant along the full length of a segment. According to O. Salzgeber (1949), this problem was studied by N. Bernstein in the 1930's before he started his extensive investigations on body segment parameters. By dividing the extremities of a frozen cadaver into zones of 2 cm. height, it was established that the volume centers and mass centers of the extremities were practically coincident. It would seem therefore that the density along the segment was fairly constant for the case studied. Accepting this, it follows that the extremity mass, center of mass, and mass moment of inertia may be determined from the volume data obtained by immersion. However, it should be noted that for the whole body, according to an investigation by Ivanitzkiy (1956), the mass center does not coincide with the volume center, due to the smaller density of the trunk.</p> <h4>Computational Methods</h4> <p>Harless was the first to introduce computational methods as alternatives to the immersion method for determining body volume and mass. He suggested that this would be better for specific trunk segments since no definite marks or anatomical limits need be applied.</p> <p>He considered the upper part of the trunk down to the iliac crest as the frustum of a right circular cone. The volume (<i>V1) </i>is then determined by the formula:<b>Eq. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He assumed that the volume of the lower (abdomino-pelvic) part of the trunk (<i>V2</i>) can be approximated as a body between two parallel, nonsimilar elliptical bases with a distance <i>h </i>between them. The volume <i>V2 </i>is determined by the formula:<b>Eq. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>On the basis of dimensions taken on one subject, using these formulas he arrived at a value for <i>V1 </i>of 21,000 cm cubed and 5,769 cm subed for <i>V2. </i>Using a value of 1.066 gr/cm cubed as the appropriate specific gravity of these parts, the total trunk weight was computed to be 28.515 kg. The actual weight of the trunk was determined (by weighing) to be 29.608 kg. The computed weight thus differed from the actual weight by 1.093 kg, or 3.69 per cent.</p> <p>Several subsequent investigators used this method subdividing the body into segments of equal height. For increased accuracy these zones should be as small as practically possible -a height of 2 cm is the practical lower limit. The zone markings are measured starting usually from the proximal joint of the body segment. The circumference of the zone is measured and it is assumed that the cross-section is circular. The volume may be computed and on the basis of accepted specific gravity values the mass may be found. From these values one may compute the center of mass and mass moment of inertia.</p> <p>Amar (1914) in order to compute the mass moment of inertia of various body segments made a number of assumptions. He assumed the trunk to be a cylinder, and that the extremities have the form of a frustum of a cone. The mass moment of inertia for the trunk about a lateral axis through the neck is determined from the formula:<b>Eq. 3</b><br /> and for the extremities by the formula:<b>Eq. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Weinbach (1938) proposed a modified zone method based on two assumptions: (1) that any cross-section of a human body segment is elliptical, and (2) that the specific gravity of the human body is uniform in all its segments and equal to 1.000 gr/cm cubed. The area <i>(A) </i>at any cross section is expressed by the equation:<b>Eq. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Plotting a graph showing how the equidistant cross-sectional areas change relative to their location from the proximal joint, it is possible to determine the total volume of the segment and hence its mass and location of center of mass. The mass moment of inertia (/) may be obtained by summing the products of the distances from the proximal joint to the zone center squared <i>(r squred) </i>and the corresponding zone mass:<b>Eq. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately both of Weinbach's assumptions are questionable since the cross sections of human body segments are not elliptical and the specific gravities of the different segments are not equal to 1.000 gr/cm cubed nor is density truly uniform in all segments.</p> <p>Bashkirew (1958) determined the specific gravity of the human body for the Russian population to be 1.044 gr/cm cubed with a standard deviation of ±0.0131 gr/cm cubed and the limits from 0.978 minimum to 1.109 maximum. Boyd (1933) determined further that specific gravity generally increases with age. Dempster (1955) showed that Weinbach's method was good for determining the volume of the head, neck, and trunk but not good for other body parts.</p> <p>It is evident that the determination of body segment parameters, based on the assumption that the segments can be represented by geometric solids, should not be used when great accuracy is desired. This method is useful only when an approximate value is adequate.</p> <p>Fischer introduced another approximate method of determining human body parameters by computation known as the "coefficient method." According to this procedure, it is assumed that fixed relations exist between body weight, segment length, and the segment parameters which we intend to find. There are three such relationships or ratios expressed as coefficients. For the body segment mass, the coefficient is identified as <i>C1</i> and represents the ratio of the segment mass to the total body mass. The second coefficient <i>C2 </i>is the ratio of the distance of the mass center from the proximal joint to the total length of the segment. The third coefficient <i>C3</i> is the ratio of the radius of gyration of the segment about the medio-lateral centroidal axis to the total segment length. Thus to determine the mass of a given segment for a new subject, it would be sufficient to multiply his total body mass by coefficient <i>C1 </i>corresponding segment mass. Similarly the location of mass center and radius of gyration can be determined by multiplying the segment length by the coefficients <i>C2 </i>and <i>C3</i> respectively.</p> <p><b>Table 6</b> compares the values of coefficient <i>C1</i>obtained by different investigators.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 6</b> shows that the differences between the coefficients obtained by different investigators for particular segment masses are great. The difference is highest for the trunk and head mass where the coefficients vary from 49.68 to 56.50 per cent of body mass. Next highest difference is in the thigh coefficients from 19.30 to 24.43 per cent of body mass. Since the number of subjects used in the studies, with the exception of that of Bernstein, is small and no anthropological information on body build is given, it is difficult to draw any definite conclusions about the scientific and practical value of these coefficients for body segment mass determination.</p> <p>As already mentioned, the data obtained by Harless are based on two decapitated male cadavers, and since the blood had been removed some errors are possible. The data of Meeh are based on volume measurements of eight living subjects. The large coefficient for the trunk is influenced by the assumption that all body segments have the same average density, where actually it is less for the trunk.</p> <p>Braune and Fischer (1889) made a very careful study of several cadavers. Their coefficients are based on data taken on three male cadavers whose weight and height were close to the data for the average German soldier. The relative masses (coefficients) of the segments were expressed in thousandths of the whole body mass. The positions of the mass center and radius of gyration (for determination of the segment mass moments of inertia) were expressed as proportional parts of the segment's total length. Fischer's coefficients have been accepted and used in most subsequent investigations to date.</p> <p>N. Bernstein and his co-workers (1936) at the Russian All-Union Institute of Experimental Medicine in Moscow carried out an extensive investigation on body segment parameters of living subjects. The study took care of anthropological typology of body build. The results of this investigation were published in a monograph, <i>Determination of Location of the Centers of Gravity and Mass (weight) of the Limbs of the Living Human Body </i>(in Russian). At present the monograph is not available in the United States. Excerpts of this investigation, which cover 76 male and 76 female subjects, 12 to 75 years old, were published by N. Bernstein in 1935 in his chapters on movement in the book, <i>Physiology of Work </i>(in Russian), by G. P. Konradi, A. D. Slonim, and V. C. Farfel.</p> <p><b>Table 7</b> shows data for the comparison of segment masses of living male and female subjects as established by Bernstein's investigation. The data are self-explanatory.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Determination of Mass Center Location</h4> <p>In the biomechanical analysis of movements it is necessary to know the location of the segment mass center which represents the point of application of the resultant force of gravity acting on the segment. The mass center location of a segment system such as an arm or a leg or the whole body determines the characteristics of the motion.</p> <p><b>Table 8</b> shows the relative location of the mass center for different segments. It is evident that the assumption that mass center of all segments is located 45 per cent from the proximal and 55 per cent from the distal end of the segment is not valid. Since the mass distribution of the body is related to body build it seems that the mass center location also depends on it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bernstein claims that he was able to locate the mass centers with an accuracy of ±1 mm. Hence the data of <b>Table 9</b> represent the result of very careful measurements. An analysis of these data shows that there is no definite trend of the coefficients differing with age or sex. The variance of the coefficients is very high and reaches nine per cent as maximum. Thus the use of the same coefficients for subjects with a wide range of body build is highly questionable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 7</b> and <b>Fig. 8</b> represent, in modification, Fischer's schemes for the indication of the mass center location of the extremities. The letters of the alphabet indicate the location levels of the mass centers on the human figure. The corresponding cross sections through the segments are shown separately. The letters designate the following:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Location of mass centers of the upper extremity (Redrawn from O. Fischer). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Location of mass centers of the lower extremity (Redrawn from O. Fischer). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>A</i>-mass center of upper arm</p> <p><i>B</i>-mass center of whole arm</p> <p>C-mass center of forearm</p> <p><i>D</i>-mass center of forearm and hand</p> <p><i>E</i>-mass center of hand</p> <p><i>F</i>-mass center of thigh</p> <p><i>G</i>-mass center of whole leg</p> <p><i>H</i>-mass center of shank</p> <p><i>I</i>-mass center of shank and foot <i>J</i>-mass center of foot</p> <p>The location of mass centers with respect to the proximal and distal joints as determined by W. Dempster (1955) is shown in <b>Fig. 9</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Location of mass centers of body segments (After W. Dempster). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is easy to find the equations for the determination of the coordinates of the mass center when the coordinates of the segment's proximal and distal joints are given.</p> <p>By using Fischer's coefficients for mass center of a particular segment the following formulas were developed:</p> <p>Coordinates of mass center of the:</p> <p>a. forearm:</p> <p><i>x = </i>0.42<i>xd</i> + 0.58<i>xp</i></p> <p><i>y = 0.42yd + </i>0.58<i>yp</i></p> <p>where <i>xd</i>, <i>yd </i>are coordinates of the distal (wrist) joint and <i>xp</i>, <i>yp </i>are coordinates of the proximal (elbow) joint.</p> <p>b. upper arm:</p> <p><i>x = </i>0.47<i>xd</i> + 0.53<i>xp</i> y <i>= </i>0.47<i>yd</i> + 0.53<i>xp</i></p> <p>where <i>xd, yd </i>are coordinates of the elbow joint and <i>xp, yp </i>are coordinates of the shoulder joint.</p> <p>c. shank:</p> <p><i>x = </i>0.42<i>dx</i> + 0.58<i>xpy = </i>0.42<i>yd</i> + 0.58<i>yp</i>where <i>xd, yd </i>are coordinates of the ankle</p> <p>joint and <i>xp, yp </i>are coordinates of</p> <p>the knee joint.</p> <p>d. thigh:</p> <p><i>x = </i>0.44<i>xd</i> + 0.56<i>xp</i> <i>y = </i>0.44<i>yd</i> + 0.56<i>yp</i></p> <p>where <i>xd, yd </i>are coordinates of the knee joint and <i>xp</i>, <i>yp </i>are coordinates of the hip joint.</p> <p>For the case of three-dimensional recordings of motion, similar equations for <i>z </i>are used. The coordinates of the mass center of trunk <i>(t) </i>are:</p> <p><i>xt = </i>0.235 <i>(xfr + xfl) + </i>0.265 <i>(xbr + xbl), </i>with similar equations for the <i>yt </i>and <i>zt</i> coordinates.</p> <p>Here <i>xfr </i>is the coordinate of the right hip and <i>xfl </i>is the coordinate of the left hip, and <i>xbr </i>is the coordinate of the right shoulder and <i>xbl </i>is the coordinate of the left shoulder.</p> <p>In the same manner the equations for segment systems are developed:</p> <p>a. entire arm:</p> <p>mass center <i>x </i>coordinate given by: <i>xac </i>= 0.130 <i>xgm + </i>0.148 <i>xm </i>+ 0.448 <i>xa + </i>0.27 <i>xb</i>, where</p> <p><i>xac</i>-entire arm mass center <i>x </i>coordinate <i>xgm</i>-mass center of the hand <i>xm</i>-wrist joint <i>xa</i>-elbow joint <i>xb</i>-shoulder joint</p> <p>Similar equations for <i>y </i>and <i>z </i>coordinates are used:</p> <p>b. entire leg:</p> <p>mass center <i>x </i>coordinate given by: <i>xlc = </i>0.096 <i>xgp</i>+ 0.119 <i>xp + </i>0.437 <i>xs + </i>0.348 <i>xf , </i>where</p> <p><i>xlc</i>-entire leg mass center <i>x </i>coordinate <i>xgp</i>-mass center of foot <i>xp</i>-ankle joint <i>xs</i>-knee joint <i>xf</i>-hip joint</p> <p>Similar equations are developed by the <i>y </i>and <i>z</i> coordinates.</p> <p>By analogy the formulas for coordinates determining the location of the mass center of the entire body in two or three dimensions can be developed.</p> <p>As regards the coefficient <i>C3, </i>it is known that the mass moment of inertia (<i>I</i>) is proportional to the segment's mass and to the square of the segment's radius of gyration <i>(p). </i>Fischer found that the radius of gyration for rotation about the axis through the mass center and perpendicular to the longitudinal axis of the segment can be established by multiplying the segment's length <i>(l) </i>by the coefficient <i>C3</i> = 0.3. Hence the mass moment of inertia with respect to the mass center is <i>Ig</i> = <i>mpp </i>= <i>m(0.3l)(0.31) </i>= <i>0.09ml squred.</i></p> <p>For the rotation of the segment about its longitudinal axis, Fischer found the coefficient <i>C4</i> = 0.35, so that the radius of gyration <i>p = </i>0.35 <i>d, </i>where <i>d </i>is the diameter of the segment.</p> <p>Since for living subjects the segment rotates about the proximal or distal joint and not the mass center, the mass moment of inertia that we are interested in is greater than <i>Ig </i>by the term <i>mee, </i>where <i>e </i>is the distance of mass center from the joint. It follows that the mass moment of inertia for segment rotation about the joint is equal to <i>Ij = mpp + mee = m(pp </i>+ <i>ee).</i></p> <h4>New York University Studies</h4> <p>At present the Biomechanics group of the Research Division of the School of Engineering and Science, New York University, is engaged in the determination of volume, mass, center of mass, and mass moment of inertia of living body segments. The methods employed will now be discussed. Some of these techniques are extensions of the methods used by previous researchers; others are procedures introduced by New York University.</p> <h4>Determination of Volume</h4> <p>The two methods being investigated by New York University to determine segment volumes are (1) immersion and (2) mono- and stereo-photogrammetry.</p> <p><i>Imersion Method</i></p> <p>The Biomechanics group at New York University uses water displacement as the basis for segment volume determination. However, the procedure differs from that used by previous researchers in that the subject does not submerge his segment into a full tank of water and have the overflow measured. Instead his segment is placed initially in an empty tank which is subsequently filled with water. In this way, the subject is more comfortable during the test, and the segment remains stationary to ensure the proper results.</p> <p>A variety of tanks for the various segments- hand, arm, foot, and leg-has been fabricated. It is desirable that the tank into which the segment is to be immersed be adequate for the extreme limits which may be encountered and yet not so large as to impair the accuracy of the experiments. A typical setup is shown in <b>Fig. 10</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Determination of the arm volume. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The arm is suspended into the lower tank and set in a fixed position for the duration of the test. The tank is then filled to successive predetermined levels at two-centimeter increments from the supply tank of water above. At each level, readings are taken of the height of the water in each tank, using the meter sticks shown. The volume occupied by water between any two levels is found by taking the difference between heights of water levels and applying suitable area factors. Thus to find the volume of the forearm the displacement volume is found for the wrist to elbow levels in the lower tank and between the corresponding levels in the upper tank. The difference between these two volumes is the desired forearm volume.</p> <p>To find the center of volume obtain volumes in the same manner of consecutive two-centimeter sections of the limb. Assuming the volume center of each section as one centimeter from each face, sum the products of section volume and section moment arm about the desired axis of rotation. The net volume center for the body segment is then this sum divided by the total volume of the segment. In a similar fashion, using the appropriate combination of tanks, we find the volumes of other segments, hand, foot, and leg. The use of an immersion tank to find hand volume is shown in <b>Fig. 11</b>. The data on volume and volume centers can also be used along with density as a check against methods of obtaining mass and center of mass.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Determination of the hand volume. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Photogrammetry Method</i></p> <p>In order to find the volume of an irregularly shaped body part such as the head or face a photographic method may be employed. Such a procedure, called photogrammetry, allows not only the volume to be found, but a visual picture of the surface irregularity to be recorded as well. The two types of this technique are mono- and stereophotogrammetry. The principles are the same for each, except that in the latter procedure two cameras are used side by side to give the illusion of depth when the two photographs are juxtaposed. The segment of interest is photographed and the resulting picture is treated as an aerial photograph of terrain upon which contour levels are applied. The portions of the body part between successive contour levels form segments whose volumes can be found by use of a polar planim-eter on the photograph as described by Wild (1954). By summing the segmental volumes, the total body segment volume can be found. A controlled experiment by Pierson (1959) using a basketball verified the accuracy of such a procedure. Hertzberg, Dupertuis, and Emanuel (1957) applied the technique to the measurement of the living with great success. The reliability of the photographic technique was proven by Tanner and Weiner (1949). For a more detailed discussion of the photogram-metric method, refer to the paper by Contini, Drillis, and Bluestein (1963).</p> <p><i>Method of Reaction Change</i></p> <p>In searching for a method which will determine the segment mass of a living subject with sufficient accuracy, the principle of moments or of the lever has been utilized. The use of this method was suggested by Hebestreit in a letter to Steinhausen (1926). This procedure was later used by Drillis (1959) of New York University. Essentially it consists of the determination of reaction forces of a board while the subject lies at rest on it. The board is supported by a fixed base at one end <i>(A</i>) and a very sensitive weighing scale at the other end <i>(B). </i>The location of the segment center of mass can be found by the methods described elsewhere in this paper. The segment mass is <i>m, </i>the mass of the rest of the body is <i>M. </i>The reaction force (measured on the scale) due to the board only should be subtracted from the reaction force due to the subject and board. First the reaction force <i>(S0) </i>is determined when the segment (say the arm) is in the horizontal position and rests alongside the body; second, the reaction force <i>(S) </i>is determined when the segment is flexed vertically to 90 deg. with the horizontal. The distance between the board support points <i>A </i>and <i>B </i>is constant and equal to <i>D. </i>The distance <i>(d) </i>of the segment mass center from the proximal joint is known and the distance <i>b </i>from the proximal joint to support axis <i>A </i>can be measured. From the data it is possible to write the corresponding moment equations about <i>A. </i>The solution of these equations gives the magnitude of the segment's mass as: <b>Eq. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To check the test results, the segment is placed in a middle position, approximately at an angle that is 45 deg. to the horizontal, in which it is held by a special adjustable supporting frame shown at the right in <b>Fig. 13</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Reaction board with supporting frame. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The magnitude of the segment mass in this case will be determined by the formula:<b>Eq. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By replacing the sensitive scale with an electrical pressure cell or using one force plate, it is also possible to record the changing reaction forces. If the subsequent positions of the whole arm or forearm in flexion are optically fixed as in Stick Diagrams, the corresponding changing reaction forces can be recorded by electrical oscillograph.<b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Determination of the arm mass (reaction board method). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is assumed that in flexion the elbow ioint has only one degree of freedom, <i>i.e., </i>it is uniaxial; hence the mass determination of forearm and hand is comparatively simple. The shoulder joint has several degrees of freedom and for each arm position the center of rotation changes its location so that the successive loci describe a path of the instantaneous centers. If the displacement <i>(e) </i>of the instantaneous center in the horizontal direction is known from the Slick Diagram, the magnitude of the segment mass will be: <b>Eq. 9</b>(<b>Fig. 14</b> and <b>Fig. 15</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Stick diagram of forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Stick diagram of arm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Quick Release Method</i></p> <p>This technique for the determination of segment moments of inertia is based on Newton's Law for rotation. This law states that the torque acting on a body is proportional to its angular acceleration, the proportionality constant being the mass moment of inertia. Thus if the body segment, say the arm, can be made to move at a known acceleration by a torque which can be evaluated by applying a known force at a given distance, its moment of inertia could be determined. Such a procedure is the basis for the so-called "quick release" method. To determine the mass moment of inertia of a body segment, the limb is placed so that its proximal joint does not move. At a known distance from the proximal joint at the distal end of the limb, a band with an attached cord or cable is fixed. The subject pulls the cord against a restraint of known force, such as a spring whose force can be found by measuring <i>its deflection. </i>The activating torque about the proximal joint is thus proportional to the force and the distance between the joint and the band (moment arm). The acceleration of the limb is produced by sharply cutting the cord or cable. This instantaneous acceleration may be measured by optical or electrical means and the mass moment of inertia about the proximal joint determined.</p> <p>This technique is illustrated in <b>Fig. 16</b>. The subject rotates his forearm about the elbow, thereby pulling against the spring shown at the right through a cord wrapped around a pulley. The mechanism on the platform to the right contains the cutter mechanism with an engagement switch which activates the circuit of the two accelerometers mounted on the subject's forearm. The potentiometer at the base of the spring records the force by measuring the spring's deflection. The accelerometers in tandem give the angular acceleration of the forearm and hand at the instant of cutting. A scale is used to determine the moment arm of the force. This method is further discussed by Drillis (1959).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Quick release method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Compound Pendulum Method</i></p> <p>This technique for finding both mass moment of inertia of the segment and center of mass may be used in one of two ways: (1) considering the segment as a compound pendulum and oscillating it about the proximal joint, and (2) making a casting of plaster of Paris or dental stone and swinging this casting about a fixed point.</p> <p>Using the first method, it is necessary to find the moment of inertia, the effective point of suspension of the segment, and the mass center; thus, there are three unknown quantities.</p> <p>A study by Nubar (1960) showed that these unknowns may be obtained if it is assumed that the restraining moment generated by the individual is negligible. In order to simplify the calculations, any damping moment (resulting from the skin and the ligaments at the joint) is also neglected. The segment is then allowed to oscillate, and its period, or time for a complete cycle, is measured for three cases: (1) body segment alone, (2) segment with a known weight fixed to it at a known point, (3) segment with another known weight fixed at that point. Knowing these three periods and the masses, one can find the effective point of suspension, the center of mass, and the mass moment of inertia from the three equations of motion. If the damping moment at the joint is not negligible, it may be included in the problem as a viscous moment. The above procedure is then extended by the measurement of the decrement in the succeeding oscillations.</p> <p>In the second procedure, the casting is oscillated about the fixed suspension point. The moment of inertia of the casting is found from the measurement of the period. The mass center can also be determined by oscillating the segment casting consecutively about two suspension points. This method is described in detail by Drillis <i>el al. </i>(1963). Since the weight of both the actual segment and cast replica can be found, the measured period can be corrected on the basis of the relative weights to represent the desired parameter (mass center or mass moment of inertia) of the actual segment. The setup for the determination of the period of oscillation is shown in <b>Fig. 17</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Compound pendulum method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The photograph in <b>Fig. 17</b> has been double-exposed to illustrate the plane of oscillation.</p> <p><i>Torsional Pendulum Method</i></p> <p>The torsional pendulum may be used to obtain moments of inertia of body segments and of the entire body. The pendulum is merely a platform upon which the subject is placed. Together they oscillate about a vertical axis. The platform is restrained by a torsion bar fastened to the platform at one end and to the ground at the other. Knowing the physical constants of the pendulum, <i>i.e., </i>of the supporting platform and of the spring or torsion bar, the measurement of the period gives the mass moment of inertia of the whole body. The principle of the torsional pendulum is illustrated schematically in <b>Fig. 18</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Torsional pendulum method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> and <b>Fig. 20</b> describe the setup in use. There are two platforms available: a larger one for studying the supine subject and a smaller one for obtaining data on the erect or crouching subject. In this way, the moments of inertia for both mutually perpendicular axes of the body can be found.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Body dimensions on torsion table. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Mass moment of inertia determination (squatting position). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> shows a schematic top view of the subject lying supine on the large table. Recording the period of oscillation gives the mass moment of inertia of the body about the sagittal axis for the body position indicated. Figure 20 is a side view of the small table used for the standing and crouching positions. This view shows the torsion bar in the lower center of the picture encased in the supporting structure.</p> <p>This method can also be used to find mass moments of inertia of body segments. Nubar (1962) describes the necessary procedure and equations. Basically it entails holding the rest of the body in the same position while oscillating the system for two different positions of the segment in question. Knowing the location of the segment in each of these positions, together with the periods of oscillation of the pendulum, the segment moment of inertia with respect to the mediolateral centroidal axis may be found. This technique is illustrated by the schematic Figure 19 for the case of the arm. The extended position is shown; the period would then be obtained for the case where the arm is placed down at the subject's side.</p> <p>Both the mass and center of mass of the arm can be determined using the large torsion table. The table and supine subject are rotated for three arm positions-arms at sides, arms outstretched, and arms overhead-and respective total moments of inertia are found from the three periods of oscillation. Assuming that the position of the longitudinal axis of the arm can be defined, <i>i.e., </i>the axis upon which the mass center lies can be clearly positioned, the following equations may be applied:<b>Eq. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>where <i>I1, I2, I3 </i>are the total moments of inertia of table, supports, and subject, found from the periods of oscillation, for the subject with arms at sides, outstretched, and overhead, respectively.</p> <p><i>h </i>is the distance from middle fingertip when arms are at the sides to the tip when arms are overhead.</p> <p><i>l</i> is the total arm length (fingertip to shoulder joint).</p> <p><i>g </i>is the distance from middle fingertip to the lateral center line of the table when the arms are at the sides.</p> <p><i>p </i>is the distance from middle fingertip to the lateral center line when the arms are outstretched.</p> <p><i>s</i> is the distance between the longitudinal center line of the table and the longitudinal axis of the arm when the arms are at the sides.</p> <p><i>d </i>is the distance between the mass center of the arm and the shoulder joint.</p> <p>In this case, the subject is placed so that his total body mass center coincides with the table's fixed point of rotation and there are no initial imbalances. The explanation of the above symbols may be clarified by reference to <b>Fig. 19</b>.</p> <p><i>Difficulties in Obtaining Proper Data</i></p> <p>In the commonplace technical area, where it has been necessary to evaluate the volume, mass, center of mass, etc., of an inanimate object, this object is usually one of fixed dimensions; that is, there is no involuntary movement of parts. The living human organism, on the other hand, is totally different in that none of its properties is constant for any significant period of time. There are differences in standing erect and in lying down, in inhaling and in exhaling, in closing and in opening the hand. It is necessary, therefore, to develop a procedure of measurement which can contend with these changes, and to evaluate data with particular reference to a specified orientation of the body.</p> <p>One ever-present problem in dealing with the body is the location of joints. When a segment changes its attitude with respect to adjacent segments (such as the flexion of the elbow), the joint center or center of rotation shifts its position as well. Thus, in obtaining measurements on body segments, it is necessary to specify exactly what the boundaries are. As yet there is no generally accepted method of dividing the body into segments.</p> <p>When an attempt is made to delineate the boundary between segments for purposes of experimental measurement, one cannot avoid the method of placing a mark on the subject at the joint. This mark will have to serve as the segment boundary throughout the experiment. Unfortunately an error is introduced here when the elasticity of the skin causes the mark to shift as the subject moves. This shift does not correspond to a shift in the actual joint.</p> <p>In an analysis of a particular body segment involving movement of the segment, such as the quick release, reaction, and torsional pendulum methods which have been described, one must take care to ensure that only the segment moves. Usually this involves both physical and mental preparations on the part of the subject.</p> <p>Finally, the greatest error in obtaining results on body parameters is due to variations in body build. As can be seen from the previous data brought forth, different researchers using identical techniques have gotten quite dissimilar data on the same body segment due to the use of subjects with greatly varying body types.</p> <p>In an effort to resolve this conflict, the Biomechanics group at New York University is endeavoring to relate their data on body segment parameters to a standard system of body typology.</p> <p><i>Anthropometric Studies</i></p> <p>In order to develop a means of classifying the subjects according to body build, the method of somatotyping is utilized. Here the body build is designated according to relative amounts of "endomorphy, ectomorphy, and mesomorphy" as described by W. H. Sheldon <i>et al. </i>(1940, 1954) in the classic works in the field. In order to determine the subject's somatotype, photographs are taken of three views: front, side, and back. These are illustrated in <b>Fig. 21</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Photographs for somatotyping. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Biomechanics group of New York University has obtained the services of an authority in the field, Dr. C. W. Dupertuis, to establish the somatotype of the subjects. The photographs also will be used to obtain certain body measurements.</p> <p>The aim of the study is to develop relationships between body parameters and body build or important anthropometric dimensions so that a pattern will be established enabling body parameters to be accurately found for all body types.</p> <p>If sufficient subjects are measured it should be possible to obtain a set of parameter coefficients which take into consideration the effect of the particular body type. When these coefficients are applied to some set of easily measurable body dimensions on any new subject, the appropriate body parameters could easily be determined.</p> <p>It is planned to prepare tables of these body parameter coefficients (when their validity has been established) for some future edition of <i>Artificial Limbs.</i></p> <p><b>References:</b></p> <ol> <li>Amar, J., <i>Le moteur humain, </i>Paris, 1914.</li> <li>Bashkirew, P. N., <i>Human specific gravity in the light of its practical importance to anthropology and medicine </i>(in Russian). Soviet Anthropology, 2 (2): 95-102, Moscow, 1958.</li> <li>Bernstein, N. A., O. A. Salzgeber, P. P. Pavlenko,and N. A. Gurvich, <i>Determination of location of the centers of gravity and mass of the limbs of the living human body </i>(in Russian), All-Union Institute of Experimental Medicine, Moscow, 1936.</li> <li>Boyd, E., <i>The specific gravity of the human body,</i> Human Biology, 5: 646-672, 1933</li> <li>Braune, W., and O. Fischer, <i>The center of gravity of the human body as related to the equipment of the German infantryman </i>(in German), Treat. of the Math.-Phys. Class of the Royal Acad. of Sc. of Saxony, 26: 1889.</li> <li>Contini, R., R. Drillis, and M. Bluestein, <i>Determination of body segment parameters, </i>Human Factors, 5 (5): 1963.</li> <li>Dempster, W. T., <i>Space requirements of the seated operator, </i>USAF, WADC, Tech. Rep. 55-159, Wright-Patterson Air Force Base, Ohio, 1955.</li> <li>Drillis, R., <i>The use of gliding cyclograms in the biomechanical analysis of movement, </i>Human Factors, 1 (2): 1959.</li> <li>Du Bois, J., and W. R. Santschi, <i>The determination of the moment of inertia of the living human organism, </i>paper read at the International Congress on Human Factors in Electronics, Institute of Radio Engineers, Long Beach, Calif., May 1962.</li> <li>Fischer, O., <i>Theoretical fundamentals of the mechanics of living bodies </i>(in German), Berlin, 1906.</li> <li>Harless, E., <i>Textbook of plastic anatomy, Part III </i>(in German), Stuttgart, 1858.</li> <li>Harless, E., <i>The static moments of human limbs </i>(in German), Treatises of the Math.-Phys. Class of the Royal Acad. of Sc. of Bavaria, 8: 69-96 and 257-294, 1860.</li> <li>Hertzberg, H. T., C. W. Dupertuis, and I. Emanuel, <i>Stereophotogrammetry as an anthropometric tool,</i> Photogrammetric Engineering, 24: 942-947, 1957.</li> <li>Ivanitzkiy, M. F., <i>Human anatomy </i>(in Russian); Part I, 3rd ed., Moscow, 1956.</li> <li>Meeh, C, <i>Volummessungen des menschlichen Korpers und seiner einzelner Teile in der verg-chiedenen Altersstufen, </i>Ztschr. fur Biologie, 13: 125-147, 1895.</li> <li>Nubar, Y., <i>Determination of characteristics of the compound pendulum by observing oscillations, </i>unpublished report, Research Division, College of Engineering, New York University, 1960.</li> <li>Nubar, Y., <i>Rotating platform method of determining moments of inertia of body segments, </i>unpublished report, Research Division, College of Engineering, New York University, 1962.</li> <li>Pierson, W. F., <i>The validity of stereophotogram-metry in volume determination, </i>Photogrammetric Engineering, 25: 83-85, 1959.</li> <li>Salzgeber, O. A., <i>Method of determination masses and location of mass centers of stumps </i>(in Russian), Transact. Scient. Researc Inst. of Prosthetics in Moscow, 3: Moscow, 1949.</li> <li>Sheldon, W. H., S. S. Stevens, and W. B. Tucker,<i>The varieties of human physique, </i>New York, 1940.</li> <li>Sheldon, W. H., C. W. Dupertuis, and C. McDermott, <i>Atlas of men, </i>New York, 1954.</li> <li>Steinhausen, W., <i>Mechanik d. menschlichen Korpers,</i>in Handbuch d. Normalen n. pathologischen Physiologie, 14: 1926-1927.</li> <li>Tanner, J. M., and J. S. Weiner, <i>The reliability of the photogrammetric method of anthropometry, with a description of a miniature camera technique, </i>Am. J. Phys. Anthrop., 7: 145-186, 1949.</li> <li>Weinbach, A. P., <i>Contour maps, center of gravity,moment of inertia, and surface area of the human body, </i>Human Biology, 10 (3): 356-371, 1938.</li> <li>Wild, T., <i>Simplified volume measurement with the polar planimeter, </i>Surveying and Mapping, 14: 218-222, 1954.</li> <li>Zook, D. E., <i>The physical growth of boys, </i>Am. J. Dis. Children, 1930.</li> <li>Zook, D. E., <i>A new method of studying physical growth, </i>Junior-Senior High-School Clearing House, 5: 1932.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice Bluestein, M.M.E. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini, B.S. </b></td></tr><tr><td class="clsTextSmall">Senior Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rudolfs Drillis, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Senior Research Scientist, Research Division, School of Engineering and Science, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-9.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_044/tmp267-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Body Segment Parameters: A Survey of Measurement Techniques Creator An entity primarily responsible for making the resource Rudolfs Drillis, Ph. D. * Renato Contini, B.S. * Maurice Bluestein, M.M.E. * https://staging.drfop.org/files/original/527872ee9190fb7a616b0cc70410fbe0.pdf f629c37fa67f701c4b6aea78de76a2a8 https://staging.drfop.org/files/original/a6f09a9bde0aec6c464fbc7043e3fe3b.jpg 8ddc8354987eee1ddb5c98b5d7c77ca5 https://staging.drfop.org/files/original/626f567e943aaa264fa84b5f0333edda.jpg 63014457b9280ffcc858cd9079ba37fd https://staging.drfop.org/files/original/01833bc5541285c909871999020cb9b4.jpg 5fa7af520e891c8f39caf1685065aa51 https://staging.drfop.org/files/original/c3e424fe1ec3be458e58896700d78c4d.jpg 989474fa8119838ea695f94be3cd81cc https://staging.drfop.org/files/original/7a548b290f3da58ff06158588e81e48b.jpg bbbff8ef694a7d53e8ff5f8cf4f70251 https://staging.drfop.org/files/original/4c93630c0224b3c1f43af6f6fbfba87d.jpg 70057c8df762d2494a1232ee7ec2e860 https://staging.drfop.org/files/original/9eabbcd76d348b28f55b9cd7bd0c370a.jpg 03f397225e0cf2ba7432c561fb26e3c9 https://staging.drfop.org/files/original/d3a357f008aed8a49e631b01e0fc41f2.jpg ab424dfa71fd3027cd0b18f150597dc7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_028.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 28 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>The need for a functional and cosmetically acceptable artificial hand for juvenile amputees has existed for many years. A voluntary-opening hook which has been available for a number of years in a variety of sizes was until recently invariably prescribed for children. In response to the demand on the part of both children and parents for a functional device with a more natural appearance, the Army Prosthetics Research Laboratory (now known as the Army Medical Biomechanical Research Laboratory) undertook in 1958 to develop a child's voluntary-opening hand. Earlier studies<a></a> had shown that a spectrum of five sizes should satisfy the needs of the entire arm-amputee population from childhood to maturity. Size No. 1 was the designation given to the smallest. Because it was hoped that a mechanism developed for the Size No. 1 hand might be suitable for use also in Size No. 2 and perhaps in Size No. 3, the smallest size was given the first priority. The Sierra Engineering Company<a style="text-decoration:none;">*</a> contracted to manufacture this hand and two other companies (Kingsley Manufacturing Company<a style="text-decoration:none;">*</a> and Prosthetic Services of San Francisco<a style="text-decoration:none;">*</a>) were enlisted to manufacture suitable cosmetic gloves.</p> <p>Following preliminary testing of a prototype model, modifications to eliminate certain shortcomings were incorporated in 50 production models. A field test was initiated in April 1960 with evaluation of the cosmetic gloves included as an integral part of the study. Preliminary findings based upon experiences in fitting 20 children indicated that the hand was acceptable cosmetically and provided satisfactory function in the activities typically performed by children.<a></a> The general workmanship and cosmesis of the gloves provided by both manufacturers had also achieved a satisfactory level after certain initial fabrication difficulties. However, several problems had been identified, the most serious of which was a lack of glove durability. Ridges and sharp edges on the exterior of the hand apparently contributed to rapid glove damage.</p> <p>Accordingly, the original production-model hands were modified and then refitted to the subjects of the field study. Modifications included eliminating the glove-cutting edges, strengthening the floating-finger attachments and the spring mechanism of the thumb, and raising the cable exit. In November 1960 "old" hands revised in this manner began arriving at New York University Child Prosthetic Studies, and in April 1961 the manufacturer produced a series of new hands which incorporated all the modifications.</p> <p>An Interim Report<a></a>, summarizing the results of the field study to mid-May 1961, was prepared for the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, and the results reinforced earlier findings concerning the acceptability of the hand and gloves. The APRL-Sierra Child-Size No. 1 Right Hand was accepted as satisfactory for general use by child amputees on the basis of this report, and the study was terminated in the latter part of 1961.</p> <p>Following the generally successful outcome of the evaluation of the Size No. 1 Right Hand, manufacture of the Size No. 1 Left Hand was initiated. In May 1961 NYU Child Prosthetic Studies reported the results of a preliminary examination of two units manufactured by the Sierra Engineering Company<a></a>. The hands appeared to be of excellent quality and workmanship with minor exceptions, and in June 1961 the manufacture of 55 additional left hands was authorized for field-test purposes.</p> <p>During September and October 1961, NYU Child Prosthetic Studies received two shipments totaling 40 hands from the manufacturer. These were found to be unacceptable because of engineering deficiencies, and all were returned for modification. In February 1962, 37 hands were finally accepted for use in the field study. Another 14 hands submitted later were also found to be acceptable, making a total of 51.</p> <p>Another Interim Report<a></a> on the status of the field study was submitted at the October 1962 meeting of the Subcommittee on Child Prosthetics Problems. It was reported that the APRL-Sierra Child-Size No. 1 Left Hand was considered to be essentially satisfactory both mechanically and functionally, although more rigid quality control in manufacture and assembly was desirable. The recommendation of this report that the hand and cosmetic glove be approved for commercial distribution was accepted by the Subcommittee and the study was terminated in January 1963.</p> <h3>Purposes of the Studies</h3> <p>The APRL-Sierra Child-Size Mo. 1 Hand (both right and left) was developed to provide the juvenile amputee with a cosmetically acceptable terminal device which would closely resemble the normal hand in size, shape, and coloring. Maximum function-commensurate with cosmesis, simplicity of operation, adequate strength, and reasonable cost-was a concomitant objective.</p> <p>Since the field study of the left hand was essentially an extension of the study of the right hand, the general goals of both evaluations were identical:</p> <ol> <li>To introduce the hand into clinical use.</li><li>To corroborate findings of laboratory studies.</li><li>To determine the acceptability, utility, application, and durability of the production-model hand and glove.</li><li>To investigate indications and contraindications for prescription.</li></ol> <p>In the light of the experience gained in the study of the right hand, three considerations were given closer attention in the study of the left hand:</p> Performance differences between the experimental hand and the hooks previously worn were investigated in greater detail than was the case in the study of the right hand. The short wear-life of the cosmetic gloves used in the study of the right hand presented a definite and challenging problem. In the course of the study, the exterior of the experimental hand was extensively modified to eliminate sharp edges which might contribute to glove damage. The effectiveness of these changes was of particular interest in the study of the left hand. The effect of wearing the hand on the child's school behavior was a planned aspect of the study of the right hand. Data secured on this significant subject were limited, however, since the study overlapped two school years. With the earlier commencement of the study of the left hand (February 1962), these data were obtained for some children fitted during March and April 1962. <h3>Description of the Hand</h3> <p> The APRL-Sierra Child-Size No. 1 Hand (both right and left) consists of a monocoque hand shell of cast aluminum, articulated index and middle fingers, a "two-position" thumb, and nonarticulated but flexible ring and little fingers. A voluntary-opening type of mechanism is housed within the hand shell and the entire unit is covered with a thin plastic glove that can be replaced as warranted ( <b>Fig. 2</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. APRL-Sierra Child Size Model No. 1 Hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The index and middle fingers each consist oi three aluminum castings which, along with a portion of the hand shell, form a four-bar linkage to provide coordinated articulation at points corresponding to the metacarpophalangeal and the proximal interphalangeal joints ( <b>Fig. 3</b> ). This arrangement results in a minimum amount of glove distortion through the range of motion required. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Cutaway views of the APRL-Sierra Model No. 1 Hand (3). When no tension is applied to the control cable B, spring D forces the index and middle fingers toward the thumb to provide prehension of the three-jaw-chuck type. Tension in the control cable B causes the quadrant C to rotate about point A, a point displaced from the true center of quadrant C. The cam action thus provided by the outer edge of the slot in quadrant C against roller G forces lever E to rotate counterclockwise about point F, in turn causing the index and middle fingers to open. A small brass plate is mounted within lever E in such a fashion that, when little or no tension is applied to the control cable, the plate wedges against the periphery of the quadrant C. The wedging action, known as "Bac-Loc," resists opening of the fingers when force is introduced through the finger linkage but has no effect on the system when force is applied through the control cable.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The thumb is an aluminum casting mounted to the hand shell through a locking mechanism that permits it to be held in either of two positions-one for maximum opening between fingers and thumb, the other for a smaller opening for conservation of excursion.</p> <p>The ring and little fingers, the two consisting of a one-piece casting of foam rubber, are simply fastened to the hand shell and left to move with the cosmetic glove.</p> <p>A threaded stud (1/2 x 20) attached to the wrist section of the hand is provided for use with currently available wrist units.</p> <p>Maximum allowable weight is 6 3/4 oz. (without the glove). Less than 9 lb. of tension in the control cable (measured at the point of entry into the hand) is needed to open the fingers and a minimum of 2 lb. of prehension force is provided.</p> <p>Cosmetic gloves for the hand are available in a minimum of seven Caucasian and six Negroid shades from each manufacturer.</p> <p> <b>Sample</b> </p> <p> The sample, which included a variety of upper-extremity types, consisted of 77 subjects, one of whom was fitted with hands bilaterally. All the children in the study, except two, had previously worn Dorrance-type hooks ( <b>Fig. 4</b> ). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Boy wearing Dorrance hook.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A total of 39 children, of whom 36 were unilateral arm amputees, were fitted with the right hand ( <b>Table 1</b> ). Of the three remaining subjects one (with bilateral shoulder-disarticulation amputations) was fitted with a right hand only and continued to wear a hook on the left side; one (with right above-elbow and left short below-elbow amputations) was also fitted with a right hand and retained a hook on the left; and a triple amputee (with bilateral long below-elbow and left knee-disarticulation amputations) was given hands on both sides. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This last subject was included in both the right- and left-hand samples.</p> <p> Thirty-nine children, of whom 36 were also unilateral arm amputees, were fitted with the left hand ( <b>Table 2</b> ). Of the three remaining subjects one amputee (with bilateral shoulder-disarticulation amputations) was given a left hand only; a triple amputee (with bilateral long below-elbow and right below-knee amputations) received a left hand and kept a hook on the right; and the third subject was the aforementioned triple amputee who was included in both samples. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <b>Procedures</b> </p> <p> The fittings in both the Right- and Left-Hand Studies were conducted through the clinics participating in the Child Amputee Research Program. <a style="text-decoration:none;">*</a> In order that wearers of the hand might secure the longest possible wear period before growth of the child caused an objectionable size discrepancy, it was recommended that the clinics select candidates whose nonamputated hand size was such that they should be able to wear the experimental hand for at least a year. </p> <p>The experiences of the clinics were evaluated on the basis of: first, the reactions of the children, their parents, and others to the experimental hand and to other previously worn terminal devices; second, observations of classroom behavior during the treatment period; third, ratings of the children's performance of standard prehensile tasks using the experimental and old terminal devices; and fourth, maintenance.</p> <p>In the course of the studies the children were required to make four visits to the clinic servicing them during a minimum period of five months.</p> <p> <b>First Clinic Visit: Screening</b> </p> <p>A screening session was conducted during the first visit. The children and their parents were oriented to the purpose of the survey, the number of visits required, and the need to follow through with experimental procedures.</p> <p>Parents and children expressing a willingness to participate selected glove shades from shade guides provided by both manufacturers. Neither the experimental hand nor a complete cosmetic glove was shown to the patients or their parents during the first visit. A selection form, recommending the child as a participant in the study and furnishing information concerning him, was completed and sent to the NYU Child Prosthetic Studies.</p> <p>The candidates were evaluated on the basis of information provided on the selection form and sampling requirements. Upon approving a candidate NYU sent the clinic a hand and glove for the child and a questionnaire to be completed by the child's classroom teacher prior to fitting the experimental hand.</p> <p>The questionnaire pertained primarily to the child's psychosocial adjustment to the school environment. The teacher was asked to fill out the questionnaire before the experimental hand was fitted and to fill out a similar form at the conclusion of the study. The purpose of this procedure was to determine whether the child's behavior or performance with a prosthesis in school was affected as a result of wearing the experimental hand. In order to provide comparability of data, it was important that the same teacher provide both pre- and post-fitting observations.</p> <p> <b>Second Clinic Visit: Fitting</b> </p> <p>At the second clinic visit a prosthetic performance test utilizing the old terminal device was administered and the reactions of children and parents to the old device were ascertained. The child was fitted with an experimental hand and initial reactions to the new component were secured from child and parents. The child and parents were then given instructions that the experimental hand was to be worn exclusively until the next clinic visit two months later.</p> <p> <b>Third Clinic Visit: Two-Months Post-Fitting Evaluation</b> </p> <p>Two months after the fitting the reactions of child and parents to the new component were again recorded at the clinic. Comparisons between old and new terminal devices with respect to weight, ease of operation, and usefulness were noted, and a prosthetic performance test, in which first the new hand and then the old terminal device were evaluated, was also conducted. The parents were then told to permit the wearing of either the old or the new terminal device as the child desired and were scheduled for a further clinic visit two months later.</p> <p> <b>Fourth Clinic Visit: Final Evaluation</b> </p> <p>The final evaluation was conducted four months after the initial fitting. The reactions of child and parent to the new hand were again obtained, and the old and new devices were compared in the same manner as earlier. The clinic summarized its data on a form provided for the purpose, and the child's classroom teacher was asked to complete another questionnaire.</p> <h3>Results-Subjective Reactions</h3> <p> <b>Parent and Child Preferences</b> </p> <p>At the conclusion of the test period, the 77 children participating in the study and their parents decided almost unanimously in favor of retaining the experimental hand with only seven rejecting it completely. In contrast to these seven rejections, 21 children expressed a desire to wear the hand exclusively. The remaining 49 children took intermediate positions ranging from a predominantly-hand to a predominantly-hook preference. All in all 42 children and their parents clearly preferred the hand; 15 were ambivalent or offered contradictory opinions; 20 preferred the hook.</p> <p> <b>Hand Used Exclusively</b> </p> <p>Of the 21 children (13 girls and 8 boys) who chose to wear the hand exclusively, 20 were prior hook wearers, one had previously worn a Becker Plylite hand, and one had never worn a prosthesis before because his parents had refused to accept a hook. Cosmesis was extremely important to this group and was often the only factor mentioned by the child.</p> <p>JM, a long below-elbow amputee who was 6 years and 11 months old at the initiation of the study, is typical of the children in this category. When asked what he liked about the hand after four months' wear, he replied, "I like it-the way it looks." He disliked the appearance of the hook and could think of nothing favorable to say about it or anything unfavorable to say about the hand. The hand functioned better, he said, and was important to him for use at school. Schoolmates stared at first, but liked it. JM's mother thought he had better function with the hook, but only because he had not had the new hand very long. She also remarked that he should wear the hand all the time because "it gave him more confidence." The hook's only contribution was that it prepared the child for the hand, she said.</p> <p>Sandra, a short below-elbow amputee, was 5 years and 9 months old at the beginning of the study. She cited better function as the reason for preferring the hand: "...can move things better-holds lots of things better." She disliked nothing about the hand, liked nothing about the hook, and said she wanted to wear the former all the time. Her mother preferred the hand for reasons both of appearance and grasp; schoolmates found it easier to hold on to when playing games, and it didn't slip when the child tied her shoes. Sandra should not wear a hook at her age, her mother declared.</p> <p> <b>Hand Used Predominantly</b> </p> <p>The hand was the terminal device of choice for an additional 21 children (15 girls and 6 boys). The hook was preferred for rough outdoor activities in which hook function was superior.</p> <p>Typical of the group was Curtis, age 5, a very short below-elbow amputee, who liked "everything" about the hand: it resembled his other hand, held paper when he wrote, and grasped a baseball bat better. However, he felt that the hook was lighter, was easier to open, and superior for playing with certain toys. His mother was pleased with the appearance of the hand, Curtis's attitude toward it, and the fact that other children were willing to hold it in games. However, she thought he should wear the hook at home for activities that might damage the glove. During the last two months of experimental wear, when parents and children could choose which device would be worn, Curtis used the hand exclusively, except when repairs were required.</p> <p>Diana, age 5, a short below-elbow amputee, expressed a desire to wear the hand most of the time and the hook only for swimming (sic!). The reason for her preference was that "it looks like my other hand." Earlier she had found the hand somewhat harder to operate and had experienced difficulty releasing it from bicycle handles. Her mother was concerned about tears on the glove fingers, but Diana said, "It doesn't matter what the glove looks like." Her mother agreed that the hand should be worn in most circumstances, but thought the hook could be used for swimming and as a replacement in case the hand broke.</p> <p> <b>Hand and Glove Used About Equally</b> </p> <p>Seven children (5 girls and 2 boys) and their parents desired to retain both hook and hand and to use them on an approximately 50-50 basis. For example, Carol, an 8-year-old short below-elbow amputee who lived on a farm, preferred the appearance of the hand: "It gives me another hand and people don't stare"; and the function of the hook: "I don't drop things with the hook or worry that someone might bump into me and knock them out of my grasp." She also was concerned about tearing the glove. Carol chose to wear the hand both to regular and Sunday school and the hook for farm chores and play. Her father agreed with the child's viewpoint. He thought the glove not rugged enough, but the hook handy and sturdy.</p> <p> <b>Parent and Child Disagreement</b> </p> <p>There were eight children (6 boys and 2 girls) whose primary choice of terminal device differed from that of their parents. In five instances, the child chose the hand and the parent the hook; in the other three cases, the positions were reversed. The basis for disagreement was usually a relative emphasis upon appearance and function.</p> <p>Michael, age 6, whose partial hand amputation was fitted as a wrist disarticulation, was pleased that the hand "looked like my other one," but acknowledged that the hook was lighter and easier to use. If he could retain only one device, he would choose the hook, since he could do much more with it; however, his mother and friends preferred the hand.</p> <p>The latter were sometimes afraid of the hook. Michael's father preferred the hand for cosmetic reasons and cited other advantages: "... more chance to play cowboy and wrestling . . . children not afraid . . . danger of bumping into others when playing with the hook."</p> <p> <b>Hook Used Predominantly</b> </p> <p>Six boys and seven girls preferred the hook for daily use and the hand for dress occasions. Five of the children were under 5 years of age (one, age 3 and four, age 4), and four of these had not yet attended primary school, kindergarten, or play school. Eleven of these children rated the hook function better and ten specifically said the hand was heavy or hard to operate; one older boy complained that the hand did not afford a tight grasp and a younger girl said the hook held things in a better position. Parents of twelve of these children declared hook function was better; the other parent expressed no preference.</p> <p>Danny, with an elbow disarticulation and split-ray hand, was the youngest child in the study-barely 4 years of age when fitted with the hand. To open it, he had to hold his elbow completely extended with maximum tension on the cable. Even in this position, full opening required more effort than he typically cared to exert, although he was pleased that the hand looked like his natural one. Danny stated that the artificial hand was heavier and harder to operate than the hook and did not pick up objects as well. The hook was better for grasping a swing chain and for holding his bread to push food. The child's mother hoped that his skill with the hand would improve, but after four months she reported that he wore it only for "going visiting." She thought the hand would be of greater use when he was older.</p> <p> <b>Hand Rejections</b> </p> <p>In view of the fact that complete rejection of the experimental hand was rare, it is interesting to note the instances when it occurred. Seven children rejected the hand completely; four of these were 4- or 5-year-old boys, one was a 7-year-old girl with bilateral shoulder disarticulations, and the other two were a boy and a girl, both 9 years old, who were excellent users of their hooks and apparently were not concerned with the appearance of this device. Various factors contributed to these rejections. Several of the younger boys and the 9-year-old boy and girl obtained better function with the hook and seemed relatively unmindful of appearance. The bilateral shoulder-disarticulation amputee was a marginal user of any prosthesis and found the increase in operating forces and the difficulty of positioning the hand without a wrist-flexion unit intolerable. Three children experienced excessive hand malfunctions and two others, because of frequency of glove damage or difficulty in getting replacements, wore unsightly gloves for prolonged periods.</p> <p> <b>Age and Sex in Relation to Acceptance Level</b> </p> <p>The data contained in the last two categories of acceptance level (Hook Used Predominantly and Hand Rejections) suggest that age is a strong consideration governing hand or hook preference. Such a relationship would not be surprising, since younger children may be expected to: first, experience difficulty with hand weight and operating forces because of limited physical development, and second, be more careless in their use of a device, less concerned with the niceties of appearance, and would not be subject to the social pressures of the school environment.</p> <p> Age, however, cannot be regarded as an absolute criterion, since several of the children in the study who selected the hand as their primary choice were 4-year-olds. In fact, when the age and sex of the children are tabulated against indicated levels of preference ( <b>Fig. 3</b> ), sex appears to be more significantly related to choice of device than does age. Thus, girls of all ages for whom the hand is of appropriate size appear to be potentially the best candidates for the No. 1 Hand, while younger boys would seem to be less likely to accept the device. </p> <p> <b>Effects on School Adjustment</b> </p> <p>The questionnaire to be completed by the classroom teacher was designed to secure pertinent information concerning the behavior of the child in school while wearing the old terminal device and the experimental hand respectively. It was hypothesized that the child's classmates and teacher might react more positively to a hand than they had to a hook and as a result adjustment of the child to the school situation would show discernible changes. This type of improved behavior had been noted previously when a child who had been a nonprosthesis wearer was fitted for the first time.<a></a></p> <p>Historically, two significant problems frequently encountered by juvenile amputees wearing hooks to school have been the indignity of being called "Captain Hook" and similar names by classmates and refusal by other children to hold their hooks in hand-holding games. Elimination or reduction of these difficulties was anticipated when the child was fitted with a functional terminal device that closely resembled a normal hand.</p> <p>The teacher's opinion was obtained concerning various aspects of the child's school behavior: attendance, homework, conduct, friendships, social participation and leadership, and extent of use of the prosthesis. As provided in the study plan, the teacher's questionnaires were to be completed twice: once while the child was still wearing a hook, and again after four months of hand wear when the child would presumably have acquired sufficient skill in the use of the hand, and changes in school behavior would have had an opportunity to develop.</p> <p>When it became apparent that a majority of the children in the Left-Hand Study would not have worn the hand for four months before the end of the 1961-1962 school year, the original plan was modified to provide for completion of the second questionnaire just prior to the end of the academic year regardless of length of time the hand had been worn.</p> <p>Unfortunately, comparable hook-and-hand questionnaires (that is, both completed by the same teacher) are available for only 16 of the 77 children in the sample. The majority of the remaining 61 children were of pre-school age or were fitted with the hand toward the end of the school year or during the summer, so that they did not have the same teacher at the beginning and the end of the study. The data from the teachers' questionnaires were, therefore, supplemented by information concerning school and personal adjustment from other sources wherever available.</p> <p> <b>Reactions and Representative Comments</b> </p> <p>Of the 29 boys and 21 girls in the sample who were 6 years of age or over, 26 boys and 21 girls were either wearing the hand in school at the termination of the experiment or stated that they intended to do so when the fall term began. Included in this group were four of the children whose preferred device was the hook. Nevertheless, they wore the hand to school. One boy, age 8, summarized the opinion of these four children when he said, "I wear it because the kids like it better."</p> <p>As mentioned previously, a number of children reported that prior to using the hand they had been called "Captain Hook" by other children and that this had disturbed them. There is considerable evidence that the effects of this name-calling can be quite destructive to social relations among children. One girl, in fact, refused to wear the prosthesis to school after such an incident. When the hand was worn these difficulties tended to disappear. The essence of the reaction to and acceptance of the hand may be gathered from the large number of favorable comments made by playmates, schoolmates, teachers, and others.</p> <p> Representative statements <i>reported by the children</i> included the following: </p> <p> "My schoolmates were excited about the hand because I have five fingers on the left hand now." <br /> "It smells nice, looks nice, and works nicer than the hook." <br /> "I like the feel of the hand; it looks real." "One little girl thought my hand had grown back." "They said it was prettv. The girls aren't scared of it." <br /> "I wanted to look at it. I always wanted to know when I was going to get it. It drives me out of my mind." "My school friends stared at first; they liked it." "At school they all liked the looks, especially how real it looked, including the fingernails." <br /> "Kids like to see the way I can bend the fingers (floaters) all the way back. They like to feel it. One boy bit it to see what it would do." </p> <p> Representative reactions <i>reported by the parents</i> included these remarks: </p> <p> "They were surprised when they found out he could move the fingers and thumb." <br /> "Children in school were not aware of his prosthesis until he wore a short-sleeved shirt. They displayed curiosity and then seemed to be very casual." <br /> "In many cases the fact that it is not a natural hand has had to be brought to their attention, even when it was worn without long sleeves." <br /> "Danny will start school this fall and the principal was amazed to see the hand. He said he had to look twice to make sure it was the same child. Danny's playmates were sure he had gotten a 'real' hand." <br /> "His friends are afraid of the hook. But with the hand, they will take hold of it and play games." <br /> "The child said she used to like the hook and wore it all the time, but now some of her friends don't like it and are afraid of it." <br /> "Her schoolmates noticed the change and they completely accepted it. Her sisters were quite proud and anxious for their friends to see she had a new hand." <br /> "When he played games with other children, most of them were afraid to hold his hook. Since he's worn the hand they aren't afraid." <br /> "Cindy is happy about the better attitude of the children around her, especially in school." <br /> "She said that one of her best friends 'almost fainted,' she was so delighted to see her with two hands." <br /> "The appearance has done wonders for her at school." <br /> "The children at school crowded around him and asked to see how it worked." <br /> "Her friends had called her 'Captain Hook' (when she wore the hook). Little ones cried and would run away from her, afraid. We actually had to bribe her to wear the hook to school. Now we have no difficulty getting her to wear her arm with the hand all the time." <br /> "Children don't call him names ('Captain Hook')." <br /> "School children are delighted and fascinated with the hand." <br /> ". . . interested because it is different; want to see how it works. Betsy will show it." <br /> "It is easier to hold on to when playing games." <br /> "The change from the hook to the hand caused a lot of questions to be asked at first. But it was soon accepted." <br /> "Danny wore the hand every day for two weeks and some of his classmates were not aware that it was not his own hand." </p> <p> Only a few <i>children</i> volunteered negative remarks: </p> <p> "His brother got scared of the hand, but later liked it." <br /> "Sister afraid of it at first." <br /> "Pammy (sister) thought it was a 'weirdy.' " </p> <p> <b>Attendance, Preparation, and Conduct in Class</b> </p> <p>The teachers' reports concerning the children's attendance, preparation, and conduct in class yielded very little information of significance. Only one child (a triple amputee) was considered below average in attendance as a result of absences related to his prosthesis. The factors of preparation for class and conduct showed slight changes in ratings from the first to the second questionnaire, but there were no differences specifically attributable to hand wear.</p> <p> <b>Friendships, Participation, and Leadership</b> </p> <p>Ten of the 16 children for whom teachers' questionnaires were available appeared to have achieved excellent to adequate adjustment and participation in class with both the hook and the experimental hand. Despite these satisfactory relationships, these children still found the appearance of the hand advantageous in the school setting as a means of decreasing social prejudice. Several of these 10 children remarked that their classmates were now more willing to hold hands in games and seemed friendlier. This pattern of increased acceptance tended to enhance the self-concept of the children in the study.</p> <p>Five children were reported as improved in class participation or friendships after being fitted with the artificial hand, although the prosthetic performance of two of this group was considered to have deteriorated. However, the improvement in appearance was obviously more important than the decrease in function. For this small group of children regardless of their skill in or amount of hand usage there was a discernible change in the type and extent of their social interactions. This took the form either of an increased number of social contacts with various children or of an improved relationship with one or two selected classmates.</p> <p>An example of the personal importance attached to the hand is apparent in the report of one child's physical therapist which describes his behavior after being fitted:</p> <p>"On the way back on the train, Randy patted his hand against his face and scratched the tip of his nose several times before settling down to sleep. Until then, he couldn't keep his eyes off it, and when he lay down he put the hand on his chest 'for all the world to see.' As we neared Bloomington, he wondered if we shouldn't go by the school because 'perhaps Mrs. Sheveland (the teacher) will still be there.'</p> <p>"After dinner he put his prosthesis on and toured the neighborhood to show everyone his hand. His mother reportedly was greatly pleased; so much so that she could not hold back the tears on more than one occasion during the evening, so that when Randy said his prayers, she had to leave the room. He wanted to wear his hand to bed but when his mother explained that it had to be put into the plastic bag, he accepted the explanation.</p> <p>"This morning he arrived at school in 'clam-digger' pants and a long-sleeved shirt. He had told his father yesterday that if he wore long-sleeved shirts no one would ever know his hand was not real."</p> <p>Other examples of the significance of the hand follow:</p> <p>"The teacher said the boy is actually using the hand more than he had ever used the hook. (This was in spite of the fact that all reports indicated that his functional capabilities with the hook were greatly superior.) His mother said, 'We were very pleased that he had the hand for his first Holy Communion.'</p> <p>"The nun said Randy did not need to hold hands in prayers or going to and from the altar, since she thought this might be a difficult thing to do, but he did as the other children were doing and was very proud."</p> <p>Another child, Sheila, had reconciled herself to the reluctance of other children to hold the hook:</p> <p>"Some children don't like to touch it (the hook), but I know a girl who has long fingernails and I don't like to touch her hands, either. When I first got it, I thought the kids in school will be surprised. They will think I don't belong in a crippled children's school!"</p> <p>Another child, Philip, used his artificial hand to shake hands.</p> <p>The last of the 16 children for whom data were available, a girl of 6, did not have a good relationship with her teacher or with the other children. There was no discernible improvement in the situation after she was fitted with a hand. Still, by the time of the second questionnaire report, she was somewhat more willing to display her prosthesis in public and make use of it.</p> <p> <b>Conclusion</b> </p> <p>Although there was no clear-cut evidence of widespread, dramatic changes in behavior attributable to the use of the APRL-Sierra Hand, the data all point in the direction of improved self-perceptions as well as better social attitudes and relationships. With the exception of the 10 per cent of the sample who rejected the hand for a variety of reasons, the remaining amputee children and their parents, teachers, and classmates reported a variety of positive social consequences related to hand wear. For the most part these reports referred to improved feelings, opinions, and attitudes of the subjects, although a small number of positive behavioral changes could also be documented. In general, the children themselves as well as their classmates and parents were socially more comfortable as a result of the introduction of the hand.</p> <p>The functional limitations of the hand in comparison to a hook will be documented in a subsequent article in Artificial Limbs. In contrast, the evidence concerning the cosmetic benefits of the device, particularly its concomitant psychosocial implications, is most impressive.</p> <h3>Results-Prescription Considerations</h3> <p> <b>Size of Sound Hand and Age</b> </p> <p>For the purposes of the Right-Hand Study, the No. 1 Hand was hypothesized as being appropriate for child amputees between the ages of 4 and 10. Consequently, experimental wearers were selected on the basis of this age range rather than of size. In the course of the study, however, it became apparent that the hand was undersized for many of the children selected.</p> <p>The clinics were then requested to report the following dimensions in all cases of noticeable discrepancy: circumference at the metacarpophalangeal knuckles, excluding the thumb, with hand in closed position (5% in, on the No. 1 Hand); and the length from the styloid process of the radius to the tip of the thumb (3 5/8 in. on the No. 1 Hand). Several clinics also reported hand dimensions of children for whom the No. 1 Hand was considered of appropriate size.</p> <p> <b>Table 4</b> presents the measurements of sound hands of children in the Right-Hand Study for whom the No. 1 Hand was too small; small, but acceptable; and well matched, according to the opinion of clinic personnel. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It would appear difficult to derive a precise range of sound-hand sizes or ages for which the No. 1 Hand provides an acceptable match. In one case, where the sound hand was 6 5/8 in. in circumference and 4 1/2 in. in length, the clinic rated the hand as unacceptably small, but in another instance it was considered suitable for a child whose hand was 7 1/4 in. in circumference and 4 1/2 in. in length. It should also be noted that while the majority of the "oversized" children were 8 years of age or older several younger children fell into this category. Furthermore, even hands regarded as unacceptably small by the clinics were retained by the children and worn, at least for dress, for several months longer.</p> <p>In the selection of candidates for the Left-Hand Study dimensions of the children's sound hands were taken into consideration. In general, an effort was made to accept as wearers only those children with a sound-hand circumference of not over 6 1/4 in. and a length up to 3 7/8 in. It was also anticipated that the majority of such children would fall into the age range of 4 to 8 years. As a consequence, there were few complaints about size in the Left-Hand Study.</p> <p>Christine, age 10, had sound-hand dimensions of 6 3/8 in. circumference and 3 7/8 in. length at the time of selection. These became 6 1/2 in. and 4 1/2 in. by the time of the four months' check and the clinic was then of the opinion that the hand was too small. Christine and her parents agreed, but strongly preferred even a poorly matched hand to the alternative of a hook. There were six other children in the sample with sound hands of excessive circumference or length, i.e., larger than 6 1/4 in. in circumference and 3 7/8 in. in length. There was indication that all the children in this group were not completely satisfied with the size of the No. 1 Hand, but their lack of enthusiasm was generally expressed in the comment, "a little small, but still all right."</p> <p>Thus, as a general guide in considering the prescription of a No. 1 Hand, it is possible to state:</p> <blockquote><p>For children whose remaining hand dimensions do not exceed 6 1/4 in. in circumference and 3 7/8 in. in length, the No. 1 Hand can probably be fitted without objectionable size disparity. Naturally the closer the children are to this level when fitted the faster they will outgrow the No. 1 Hand. 2. Children with these hand dimensions will typically fall into the age range from large 3-year-olds to small 8-year-olds, with a predominance of 4- to 6-year-olds. However, considerations of hand weight and operating forces may exclude some children at the lower end of this age range.</p> </blockquote> <p> <b>Clinic Opinions</b> </p> <p>Clinic opinions concerning various aspects of the No. 1 Hand were obtained in both phases of the study. Clinic personnel were also asked to express themselves on the question: "Are there any contraindications to prescribing this hand (age, sex, performance, etc.)?" Responses, however, were confined primarily to the experiences of the particular child under observation as each questionnaire was completed. Hence the comments made were essentially confirmatory of information gathered from other sources.</p> <p>Expressions of a general attitude toward prescription and use of the No. 1 Hand were relatively rare. Thus, it is possible that the typical reaction of the clinics participating in the study was one of reservation concerning the experimental item-of not wishing to take a strongly positive or negative position until more experience had been acquired and "all the returns were in."</p> <p>This situation reflects the fact that the majority of the clinics participating in the program appeared to be "functionally oriented," some of them strongly so. Hence, a device which historically and in fact provides lesser function was likely to be viewed with skepticism. Some clinics were also concerned about the initial cost of the hand and glove and the expense of repairs and replacements particularly of the glove.</p> <p>If this interpretation of the prevailing frame of reference is correct, such comments as were made concerning "contraindications to prescription" take on added significance by their infrequent occurrence. To cite the Left-Hand Study data again: For only nine of the 36 children discussed was dissatisfaction with some aspect of the hand strong enough to be mentioned as a possible contraindication to use. These instances were:</p> <table> <tbody><tr> <td> <p><b>No. of Children</b></p> </td> <td> <p><b>Contraindications</b></p> </td> </tr> <tr> <td>2</td> <td> <p>Discrepancy in size</p> </td> </tr> <tr> <td>2</td> <td> <p>Frequent breakage or malfunction</p> </td> </tr> <tr> <td>2</td> <td> <p>Force requirements excessive for particular child</p> </td> </tr> <tr> <td>1</td> <td> <p>Functional limitation as compared with hook</p> </td> </tr> <tr> <td>1</td> <td> <p>Rapid wear of glove a possible contraindication for a wry active child</p> </td> </tr> <tr> <td> 1 <a></a> </td> <td> <p>Emotional difficulty</p> </td> </tr> </tbody></table> <p>Excerpts from a letter written by one of the clinic chiefs might be appropriate as a summary statement of prescription considerations. His comments not only reaffirm reactions to the hand which appear to have been fairly typical, but also express an approach to prescription which seems to be conservative yet reasonable:</p> <p>"The mother's comment with regard to cosmesis is that the hand is 'beautiful.' She is perfectly willing to go to all extremes in cosmetic appreciation. The mother feels that the child's reaction to the appearance of the hand was one of 'being proud of it.' This was exemplified by the child's desire to always wear the hand at school. It was interesting to me that, after approximately six months of wear, Debra was anxious to wear the hand all the time and not to wear the hook any more. However, in the recent episode, when the hand became no longer functional, she was perfectly agreeable to return to the use of the hook. This is particularly interesting to me, because the mother feels that Debra actually lost no function in the transition from the hook to the hand.</p> <p>"At age 6, Debra learned to operate the thumb adjustment and, as a consequence, was able to continue with the prosthetic hand as the assisting side at school in such functions as holding a book while reading so that she could turn the pages with her normal hand; holding papers while writing; and holding papers while cutting. At home, she was able to hold fork and knife with the prosthetic hand but, at age 7, is still able to cut only soft meat, such as a hamburger. She uses the hand in all bi-manual activity.</p> <p> "Our own opinion here is that we will prescribe this hand for children who are already using a hook. In the unilateral case where there is reasonable dexterity, I feel that with the prosthetic side being the assisting side we can sacrifice the minimal loss of function which one <a style="text-decoration:none;">*</a> probably gets in the transition from hook to hand. The only criticism is the amount of force necessary to operate the hand." </p> <h3>Acknowledgments</h3> <p>The late Dr. Carleton Dean, former Director of the Michigan Crippled Children Commission, played a prominent role in the early stages of the child's hand program, particularly in the procurement of the experimental units. Colonel Maurice J. Fletcher, Dr. Fred Leonard, Colonel John Butchkosky, and Victor T. Riblett, of the Army Prosthetics Research Laboratory, were responsible for the development of the hand and assisted in the resolution of problems encountered in the study. To all these gentlemen, we express our appreciation.</p> <p>We also acknowledge the valuable cooperation and assistance of the children and personnel associated with the clinics participating in the Child Amputee Research Program.</p> <p>Roberta Bernstein, Alfred Brooks, Herbert Bursky, Bertram Litt, Deborah Osborne, and Dr. Edward Peizer, staff members of New York University Child Prosthetic Studies, have also made significant contributions at various stages during the development and testing of the APRL-Sierra Child Size No. 1 Hand and in the preparation of the report upon which this article and a subsequent article to appear in the Autumn 1964 issue of Artificial Limbs are based.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Child holding swing with artificial hand.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector VV. Kay,<i>Acceptability of a functional-cosmetic artificial hand for young children</i>,Child Prosthetic Studies, Research Division, College of Engineering, New York University, January 1964.</li> <li>Fletcher, M. J., and Fred Leonard,<i>The principles of artificial-hand design</i>, Artificial Limbs, May 1955, p. 78.</li> <li>National Academy of Sciences-National Research Council, Final <i>summary report, APRL-Sierra Child-Size Hand, Size 1, Model A,</i> March 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right)</i>, October 1960.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right)</i>, May 1961.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Interim report, APRL-Sierra No. 1 Hand {left)</i>, October 1962.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering,<i>Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left)</i>, May 1961.</li> <li>S. Peizer, Edward,<i>The clinical treatment of juvenile amputees, 1953-1956</i>, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">One clinic felt strongly that prescription would be a dubious practice where cosmesis was highly important for child and parent if the next larger hand size was unavailable later.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">S. Peizer, Edward,The clinical treatment of juvenile amputees, 1953-1956, Report No. 115.26C, Child Prosthetic Studies, Research Division, College of Engineering, New York University, August 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich. Amputee Clinic, Childrens Division, Institute of Physical Medicine and Rehabilitation, New York, N. Y., Amputee Clinic, Newington Hospital for Crippled Children, Newington, Conn., University of Illinois Amputee Clinic, Chicago, Ill., Birmingham Child Amputee Clinic, Birmingham, Ala., Duke Orthopedic Amputee Clinic, Duke Medical Center, Durham, N. C, Georgia Juvenile Amputee Clinic, Crippled Childrens Service, Emory University Branch, Atlanta, Ga., Amputee Clinic, Childrens Rehabilitation Center, Buffalo, N. Y., Child Amputee Prosthetics Project, University of California Medical Center, Los Angeles, Calif., Amputation Clinic, Kernan Hospital, Baltimore, Md., Child Amputee Prosthetic and Congenital Deficiency Clinic, Childrens Orthopedic Hospital, Seattle, Wash., Juvenile Amputee Clinic, Florida Crippled Childrens Commission, Orlando, Fla., Amputee Clinic, Home for Crippled Children, Pittsburgh, Pa., Child Amputee Clinic, State Hospital for Crippled Children, Elizabeth-town, Pa., Juvenile Amputee Clinic, Crippled Childrens Hospital, New Orleans, La.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, APRL-Sierra No. 1 Hand {left), October 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Memorandum report: preliminary considerations of the APRL-Sierra Child Size Model 1A Hand (left), May 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Chili Size Model 1 hand (right), May 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering,Interim report, field test-APRL-Sierra Child Size No. 1 Hand {right), October 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">San Francisco, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Costa Mesa, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sierra Madre, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fletcher, M. J., and Fred Leonard,The principles of artificial-hand design, Artificial Limbs, May 1955, p. 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 342 East 26th St., New York 10, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-02.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-03.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-04.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-05.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-06.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-01.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_028/1964_01_028-07.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Acceptability of a Functional-Cosmetic Artificial Hand for Young Children, Part I Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/48ab984f63ee9944e8e12c1bf86b8f60.pdf eb995e5594f719eb9d7d1ab8a1c490d7 https://staging.drfop.org/files/original/30569f396b331fcb2e12947a520b6ac1.jpg b543805b7c4b513f32d0060281f28c1e https://staging.drfop.org/files/original/0bc95d63b994e86882e4517d2359f830.jpg 0069caac4493054393b8321505a3418b https://staging.drfop.org/files/original/0ac31bbaa9a0a7f0fec072dd32eb01f6.jpg 19f787d2297a18ef0b242b756a3d565c https://staging.drfop.org/files/original/56454d222bdd3468d5eed2e8285140ef.jpg 04a3c0120545162192a92cc89fdd5ea9 https://staging.drfop.org/files/original/b3e026292277cb859e0e3f4e1784de44.jpg 04e4a36aff5d4f3465d4ab2fe4c2eb7e https://staging.drfop.org/files/original/a446473c17f3288b20207e31bf640f91.jpg 3dd944585433639209e6aba1f6d7e02b https://staging.drfop.org/files/original/b4220edb41cf61a457cbce3d8d3a85e0.jpg dad70000c6445e43ad5115934dfa2024 https://staging.drfop.org/files/original/1a34ee9269e75b1fa11438a645cd9358.jpg 2359c6121a81674e01e8e0aa1813a104 https://staging.drfop.org/files/original/3b83b9695f8d5a45b85fa5f3a3ce8226.jpg b08bd2cf52601d42a9580945fdf0d194 https://staging.drfop.org/files/original/5f2a0eb01af4723d6ad1e673e29af358.jpg d7d0dd21ba3d40e30d463c485cd9df31 https://staging.drfop.org/files/original/a17dff824e882e699ea4241bfdbf1846.jpg 509a6217d3f638c8106e4550bf96d6fc https://staging.drfop.org/files/original/c30118b21e4ccd90a540f956aff44c6b.jpg 5f8d71453173a61fea69ddf09fcf2826 https://staging.drfop.org/files/original/5777bdcd4ca4e1a7990e70d71a0df8e7.jpg 312c5c5027c454f6003665d2d9181936 https://staging.drfop.org/files/original/b80f2cd616a14438719aca13ed27bc35.jpg 6b1cc88760e3fbc9d7438c15ca4ca148 https://staging.drfop.org/files/original/343ea7b1198667406303ad4a8eac51f4.jpg 17767ee459c4d8018faba396f8f5c19e https://staging.drfop.org/files/original/963b2539a143b91e55ee0cf19833183e.jpg 76527cfc69d9e0f23e1f447c0cbf9c91 https://staging.drfop.org/files/original/2a72f1972ae1c761efec324edc5046c8.jpg a02cf0378a7b652331dfffc2f591a00e https://staging.drfop.org/files/original/9f3416f8d473f377d1f6f6ac162f7396.jpg 0cae68f411ca1165884fc7275b632e7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_003.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 3 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_003.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_003.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Hemipelvectomy Prosthesis</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>A Hemipelvectomy amputation involves removal of the entire lower extremity and half of the pelvis, separation generally being effected at the sacroiliac and symphysis pubis joints. Whenever possible the gluteus maximus and oblique abdominal muscles are preserved and usually are sutured together along the lower anterior aspect of the abdominal cavity. Because of disease or trauma, it is often necessary to remove the gluteus maximus, in which case the "stump" consists simply of a skin-covered abdominal cavity. The operative procedure is described and pictured in detail in <i>An Atlas of Amputations </i>by Dr. Donald B. Slocum.<a></a></p> <p>Because there is no longer a skeletal structure on the affected side to assume the forces required during ambulation with a prosthesis, many workers have attempted to design sockets that will transfer weight-bearing loads directly to existing bony structure. Some have tried to use the ischial tuberosity on the unaffected side to support body weight, but with limited success. Others have felt it necessary to extend the socket so that the rib cage can absorb most of the weight-bearing forces, but this arrangement greatly restricts body motion and heat dissipation.</p> <p>However, it has been found that it is entirely feasible for the "stump" to carry the loads if the socket is designed so that the semisolid abdominal mass of the stump is upward and medially toward the somewhat firmer area of the lower rib cage. Sometimes it is possible to utilize the sacrum for some support but relief for the coccyx must be provided because pressure on this sensitive bone almost always results in pain. Some additional support can often be achieved by utilizing the area of the gluteus maximus on the unaffected side.</p> <p>Such support may be achieved by means of a piece of 1-in. Dacron webbing anchored to the inner distal area of the socket so that the anchor point is anterior to the ischial tuberosity on the sound side. The Dacron tape is led from its anchor point in the socket, under the gluteus maximus on the sound side, passing just distal to the trochanter and then diagonally across the anterior of the socket to a buckle (<b>Fig. 1</b>). Because the strap passes across the sound side at the level of the trochanter, it acts as a counterforce to the shearing action of the stump slipping in the socket under weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sketch shows webbing used as additional support to help to stabilize the amputee in the socket during stance phase. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article describes a method for fitting the hemipelvectomy patient in such a manner that the major loads are carried through the stump. The hemipelvectomy prosthesis incorporates many of the features of the Canadian hip-disarticulation socket, which was fully discussed in the Autumn 1957 issue of <i>Artificial Limbs. </i>However, the opening used for donning the prosthesis has been moved from the anterior portion to the lateral side of the socket. Greater stability is achieved by this arrangement since both the anterior and the posterior sections of the socket can contribute more support.</p> <p>The hip-disarticulation socket utilizes the ischial tuberosity on the amputated side to support the patient in the socket, and the crest of the ilium for suspension of the prosthesis. In the hemipelvectomy case, the skeletal structure is absent and support of the patient in the prosthesis depends upon oblique upward pressure on the stump with an equivalent opposing pressure on the sound side, obtained by the shape of the socket <a></a> (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Hemipelvectomy socket. Arrows indicate pressure applied by the socket to the "stump," upward and medially. Shaded areas indicate bulges produced by the use of hip sticks. The bulges aid in suspension of the prosthesis, in preventing rotation, and serve as guides for correct alignment while donning the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During casting, hip sticks (<b>Fig. 3</b>) are used to obtain the desired contours of tissues necessary for good suspension of the prosthesis.<a></a> Casting a patient while suspended in a sling is one method of compressing tissues in an upward oblique direction, resulting in a cast of the desired shape.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Hip sticks. <i>A, </i>two sticks, approximately 14 in. in length, 1 in. in diameter, joined by a piece of 2-in. webbing, adjustable by means of a buckle. <i>B, </i>hip sticks as applied to the "stump" during casting to create relief for the crest of the ilium on the sound side and desired shape of tissues on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The hemipelvectomy prosthesis utilizes the principles of alignment of the Canadian-type hip-disarticulation prosthesis. Moreover, the mechanics of the hemipelvectomy prosthesis are essentially the same as those of the hip-disarticulation prosthesis.<a></a></p> <p>New features incorporated in the hemi-pelvectomy prosthesis are: First, silicone foam is used in the socket construction to fill the cavity at the location of the hip joint; silicone foam is nontoxic, easily used, and provides a surface that is not as slippery as the polyester laminates. Second, the attachment for the hip joint is an integral part of the socket. Third, there is an articulated thigh fairing which is lightweight, easily fabricated, allows reduction in the size of the thigh block, and greatly enhances cosmesis in both the sitting and standing positions. Fourth, there is a support strap under the ilium and around the trochanter.</p> <p>The prosthesis includes the use of a single-axis knee and a SACH foot with a very soft heel wedge. This soft heel wedge increases the stability of the prosthesis at heel strike.</p> <h3>Examination of the Amputee</h3> <p>When an amputee with a hemipelvectomy stump is first seen, a visual examination will reveal scar tissue or other surface conditions that may affect the design of the socket. The location of sensitive areas should be noted so that they may receive special treatment if necessary. All hemipelvectomy amputations are not sectioned at the same level; some surgeons leave behind a small amount of the ilium or a small amount of the pubic bone. Palpation of the stump will usually permit determination of any remaining bony structure, but for definitive evaluation an x-ray of the pelvic area is desirable.</p> <p>When all the conditions relative to the amputation are known and recorded on the Prosthetic Information Form (<b>Fig. 4</b>), the prosthetist is ready to proceed with the first step of prosthesis fabrication; namely, production of a model of the stump and adjacent areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Prosthetic Information Form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting the Stump</h3> <p>It has been found that a minimum of modifications to the positive model is required if the cast is taken under weight-bearing conditions. To achieve these conditions, a simple adjustable overhead sling is used. The arrangement shown in <b>Fig. 5</b> utilizes existing structure in the laboratory and a tent-rope tension bar to achieve height adjustability, but a number of equally satisfactory designs can be devised.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Adjusting the sling to obtain proper height. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The seat area of the sling may be made with a piece of 6-in. or 8-in. stockinette tied to the rope at both ends. The stockinette should be long enough to clear the outline of the superior brim of the socket.</p> <p>In taking the cast, hip sticks are used to assist in locating and providing relief for the anterosuperior spine of the ilium on the sound side, and to produce a similar impression on the amputated side. This impression assists in suspension of the prosthesis and helps to prevent rotation of the socket on the stump. Materials required for taking the cast are:</p> <table> <tbody> <tr> <td> <p>4-in. or 6-in. plaster bandages</p> </td> <td> <p>Indelible pencil</p> </td></tr> <tr> <td> <p>3-ft. length of 8-in. or 10-in. stockinette    </p> </td> <td> <p>Plumb bob</p> </td></tr> <tr> <td> <p>Two 3-ft. lengths of 1-in webbing</p> </td> <td> <p>Yardstick</p> </td></tr> <tr> <td> <p>Four harness clamps</p> </td> <td> <p>Paper</p> </td></tr> <tr> <td> <p>Container with water</p> </td> <td> <p></p> </td></tr></tbody></table> <h3>Preparation of the Patient</h3> <p>A 3-ft. length of stockinette (8-in. or 10-in. width as required) is pulled up on the amputee until it is quite snug on the sound thigh. Proximally, it should cover half the thorax. The stockinette is secured with 1-in. webbing over the shoulders and should be pulled tight enough to give some support to the stump mass (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Tentative outline of socket drawn on stockinette. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal portion of the rib cage and any areas that need relief are outlined with an indelible pencil. The remaining anterosuperior spine of the ilium is located and outlined. The trochanter on the sound side is located and marked.</p> <p>An approximate outline of the socket is drawn (<b>Fig. 6</b>). The anterior distal portion of the outline starts at the pubic ramus and arcs upward along the inguinal crease onthe sound side with clearance for the sartorius muscle, then passes down to a point just superior to the trochanter. The posterior distal portion of the outline passes from the midline of the body to a point just lateral to the ischial tuberosity, then arcs upward to join the anterior line superior to the trochanter. The proximal outline circumscribes the body at the level of the tenth rib.</p> <h4>Sling Orientation</h4> <p>The amputee is seated in the sling after it has been positioned approximately for height. Pressure on the stump should be diagonally upward and toward the opposite shoulder. Therefore, the sling should pass diagonally across the body to the sound side. A piece of 1-in. webbing under the axilla on the sound side will hold the rope away from the neck and face of the amputee.</p> <p>A slot is cut in the sling posteriorly and just superior to the seat area. Another slot is cut opposite this in the anterior section. A piece of 1-in. webbing is pulled through these slots, around the thigh, and clamped together to prevent the seat from sliding on the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Orientation of amputee in sling. Retention strap adjusted just distal to trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is instructed to place more weight on the sling than on the sound leg, and the sling is adjusted for height. It is ascertained that the seat area is contacting the remaining ramus.</p> <p>The setting of the hip sticks is checked. The length of the webbing should be adjusted to fit the patient so that the groove for relief of the remaining ilium and a corresponding groove on the amputated side will be in the proper position. The fulcrum of the hip sticks should be slightly posterior to the crest of the ilium to obtain leverage necessary to bring adequate pressure against the proximal posterior portion of the plaster wrap.</p> <h4>Wrapping The Stump</h4> <p>The procedure of wrapping the stump usually requires two people. Except for obese cases, the patient is removed from the sling for application of the plaster wrap. This is done to contain the tissues and so prevent lateral distortion of the stump when weight is reapplied in the sling. An obese amputee, however, should not be removed from the sling. The wrap cast should be made to incorporate the stockinette initially, because it is too difficult to wrap the stump and properly orient the patient back into the sling before the plaster starts to set.</p> <p>The wrap is started at the lateral proximal brim on the sound side and is brought diagonally upwards across the anterior (<b>Fig. 8</b>). Moderate pressure is placed on the wrap, but ridges should be avoided. The stump should be completely wrapped just past the outline previously drawn on the stockinette. Care must be taken to include the trochanter on the sound side. While the wrap is still wet, the amputee is positioned back in the sling, and the ropes are adjusted until he is standing erect, with at least equal weight being borne on the amputated side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Beginning diagonal wrap of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The webbing of the hip sticks is placed across the back of the patient and under the stockinette sling, if it is bridging. The sticks should slant diagonally down just medial to the anterosuperior spine of the ilium on the sound side and a corresponding position on the amputated side. The crest of the ilium on the sound side is palpated by hand to ensure that the hip sticks are not impinging on the anterosuperior spine of the ilium. When the hip sticks are in the correct position, they are held with sufficient pressure to ensure adequate relief. At the same time, an oblique upward pressure is exerted to the lateral distal area of the stump and a counterforce is applied on the opposite ilium. This condition is maintained until the plaster is set. The hip sticks are removed, and the cast is reinforced with additional bandages over the sling. The wrap should touch the remaining ramus, and a portion of the gluteus on the sound side should be included.</p> <p>The trochanter is marked (<b>Fig. 9</b>), and the amputee is removed from the sling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Locating trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is then placed on a table with the stump toward the near side of the table. The gap between the plaster cast and the patient's abdomen is checked to determine if alteration to the wrap is required to contain the viscera and ensure an intimate fit to the socket (<b>Fig. 10</b>). The plaster wrap is cut from the proximal to the distal rim just medial to the socket section. The gap, if there is one, is eliminated by pushing the cast down to meet the abdomen, care being taken not to squeeze the cast mediolaterally and so disturb the placement of the bulge caused by the hip sticks on the sound side (<b>Fig. 11</b>). One side of the cut is covered with vaseline to a depth of approximately 4 in. to facilitate removal of the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Checking the gap between the cast and the patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Closing the gap by downward pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A panel of plaster-of-Paris bandages approximately 8 in. wide is formed and laid across the front of the cast, the cast being held in the desired position. Lines to relocate the position of the panel and the cast are drawn, and the cast is secured on the patient by means of a web belt. This will prevent the cast from spreading when the amputee stands and will result in more accurate datum lines.</p> <p>With the amputee standing, the cast is checked for lit and comfort.</p> <h4>Reference Lines</h4> <p>To provide datum lines for alignment of the prosthesis, vertical reference lines are marked on the cast at this time.</p> <p>The amputee should stand erect using an adjustable support under the cast. The spine should be straight and the shoulders level and at right angles to the line of progression.</p> <p>A plumb bob is suspended from the sternum (<b>Fig. 12</b>), and a vertical line is drawn on the cast. A plumb bob is suspended from the spine, and a vertical line is marked on the cast. A plumb bob is suspended from tinder the axilla to bisect the trochanter on the sound side, and the line is drawn on the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Use of plumb bob to obtain reference lines on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is removed from the amputee and, after being cut down to the outline previously drawn on the stockinette, is used as a check socket. It should be checked for support and comfort under weight-bearing while the amputee is standing, for pressure on the rib cage, and for clearance of the sound leg while the amputee is sitting. The area of the coccyx should be checked, also the area providing relief for the anterosuperior spine of the ilium on the sound side.</p> <p><b>Pouring the Plaster Positive Model</b></p> <p>The common method of forming the plaster positive model is to pour the negative cast full of a plaster slurry. A mixture of plaster and vermiculite in equal proportions results in a lighter model and one that is quite easy to work. A slush, or hollow model, may be used, but care should be taken to make the model thick enough for it to withstand the pressures involved when lamination is carried out.</p> <p>The leg opening is closed, and the cast is reinforced with plaster bandages. A separator such as vaseline or silicone spray is applied to the inside of the cast.</p> <p>The reference lines are reestablished if they were covered by the reinforcement.</p> <p>A sheet of paper large enough to extend beyond the cast is laid out and divided into four equal parts by means of two perpendicular lines. The cast is placed on the paper so that the vertical reference lines on the cast coincide with and are vertical to the lines on the paper. The cast is secured in this position by blocking it up with plaster.</p> <p>After the plaster has been poured into the cast to form the positive model, a pipe is inserted not only to provide for ease of handling but also to act as a pathway for the air to be drawn out of the laminate by a vacuum pump. A paper cup is installed on the pipe, as shown in <b>Fig. 13</b>, to keep plaster from clogging holes that have been drilled in the pipe to allow the passage of air. The pipe is inserted so that it is aligned with the vertical reference lines; thus it can be used as a reference line when the negative mold has been removed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Setting pipe vertically using vertical lines on cast as reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of the Hip Joint</h3> <p>Before any modifications to the positive model are undertaken, a buildup is made so that the finished socket will contain a flat area suitable for installation of the hip joint. Instructions given here are for the so-called Northwestern hip joint,<a style="text-decoration:none;">*</a> a unit which provides for alignment adjustment.</p> <p>The hip joint should be placed laterally to provide adequate clearance in the crotch area, placed well forward to ensure adequate stability during the stance phase of walking, and high enough so that the extension stop does not interfere with sitting.</p> <p>If the hip joint is placed too far to the rear, the amputee will be insecure, the joint will interfere with sitting, and more energy will be expended in walking. If it is placed too far forward, the prosthetic knee will extend past the normal knee when the patient is seated. This condition can be partially alleviated by shortening the thigh and lengthening the shank. However, a compromise in the location of the joint is essential.</p> <p>Location of the hip joint in approximately the optimum position may be achieved by the following method:</p> <blockquote><p>Before the positive model is removed from the cast, a reference trochanter, the point on the cast directly opposite the trochanter on the sound side, is established. By means of a height gauge, the trochanter mark on the cast is transposed to a point vertical to the layout line on the opposite side. A point on the surface of the cast 1 1/2 in. vertically below this point is marked. Through this last mark, a line is drawn on the cast at an angle of 45 deg. A useful aid for this is a piece of wood approximately 1 in. thick, cut on an angle of 45 deg. (<b>Fig. 14</b>). In scribing the line, the pencil must be held flat on the 45-deg. surface. All reference lines from the cast are cut through to the positive model by use of an awl. When the cast is removed, the lines are marked on the model with an indelible pencil.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Scribing 45-deg. line on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>An outline of the socket is drawn on the model. Heretofore, it has been the common practice to cut the anterior portion of the socket to allow entry and exit of the torso. Experiments at the Northwestern University Prosthetics Research Center have shown that more stability between patient and socket can be achieved if the opening is made on the lateral wall.</p> <h3>Modification of the Positive Model</h3> <p>To provide additional relief for the antero-superior spine of the ilium on the sound side, a skived piece of leather or a plaster buildup 1/4 in. thick on the positive model should be adequate.</p> <p>The anterior section of the model usually has a ridge caused by overlapping during the casting procedure. This ridge should be eliminated by removal of plaster. If there is a large bulge posteriorly in the gluteal area, the bulge should be reduced by removal of plaster. Sometimes the angle of the lateral wall will continue to the ramus. If this is apparent, the distal seat area may be modified and flattened slightly by removal of plaster in order to minimize slipping. Any other ridges should be removed, and the entire model should be smoothed with files, wire screen, or sandpaper. A good finish may be obtained by wet sanding with a piece of Wetordry Fabricut.</p> <p>Moisture must be contained in a new model to prevent the PVA bag used as a separator from becoming wrinkled. Application of a sealer, such as Ambroid or parting lacquer, will serve to retain moisture.</p> <p>Leather tongues used at the closure of the socket will deteriorate from sweat. A molded flexible polyester tongue is more durable and sanitary. It should be formed to the model before the flare is added to ensure a smooth transition from the tongue to the socket surface. The tongue is made by laminating four staggered pieces of nylon stockinette across the proposed opening with a flexible mixture of polyester resin (60 per cent Laminac 4134 to 40 per cent Laminac 4110 is an adequate mix). After the tongue has set, it should be trimmed to the desired shape and taped to the model.</p> <p>The outline of the socket on the model is built up to provide a flare with a radius of approximately 3/4 in. The buildup is accomplished by folding a piece of 4-in. plaster bandage lengthwise approximately seven times, wetting it, and laying it on the outline as a beading. The plaster bandage is formed over the tongue to provide a lateral opening at least 1 in. wide. The beading is formed to the desired flare and smoothed with plaster (<b>Fig. 15</b>). The flare should be coated with Ambroid or parting lacquer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Construction of flaring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model is now inverted and mounted in a vise with the sagittal plane vertical. The mounting pipe should be set at an angle of 45 deg. to the horizontal, with the anterior surface of the model upward (<b>Fig. 16</b>). The 45-deg. line on the model should now be vertical, and it should be extended past the flare, both proximally and distally.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Positioning joint on positive model using 45-deg. line as reference. (Model is held in vise at 45-deg. angle, so 45-deg. line, previously scribed, is now vertical.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The configuration of many hemipelvectomy sockets will not allow sufficient clearance for the joint in the crotch area. To allow the joint to be placed more laterally and to provide a flat area for mounting the joint, it is necessary to build up the positive model with rigid poly-urethane foam.</p> <p>The principal considerations in planning the joint location are: First, the flat area must be large enough to receive the mounting plate (about 2 3/4 in. in diameter). Second, the flat area will be horizontal when the model is mounted at the 45-deg. angle. Third, usually the axial center of the joint is somewhat anterior to the 45-deg. line. (It should be kept as close as possible to the line, but the joint must not be permitted to interfere with the sitting position.) Fourth, in most hemipelvectomy sockets, the joint will project beyond the lateral edge of the socket, but it should not project further from the midline of the body than the corresponding joint of the sound leg.</p> <p>Cardboard is formed on the positive model to form the buildup for the joint location and to allow for contours that will blend well with the socket. Polyurethane foam (Pelron 4-lb. density No. 9664<a style="text-decoration:none;">*</a>) is mixed and poured into the cardboard form (<b>Fig. 17</b>). As the foam is being shaped, care should be taken to shape the area immediately medial to the joint to permit full adjustment of the joint. <b>Fig. 18</b> shows the completed buildup on the positive model for the location of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Pouring polyurethane foam into cardboard form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anterior view of positive model showing flat area necessary to receive hip joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Fabrication</h3> <p>Although it is not necessary to use any specific laminating procedure, the vacuum technique described in this article is presented as one that has produced consistently good results in the Northwestern University Prosthetics Research Center.<a></a> </p> <p>Radial suction grooves are cut with a sharp knife from the crest of the flare on the positive model to the cup, or approximately eight 1/8-in. holes are drilled through the model into the cup, the holes being so situated as to ensure the evacuation of air from undercuts.</p> <p>A thin smear of vaseline or motor oil is applied over the sealed surfaces of the model and the polyurethane foam buildup. (Caution: Ambroid should not be applied to the polyurethane foam; the thinner in the Ambroid will soften the foam.) A light plaster slurry is used to blend the edges of the foam into the contours of the socket. A light plaster wash is then applied to the foam and allowed to dry. Ambroid, then vaseline or oil, may be applied to facilitate pulling the PVA separator over the model.</p> <p>A tailored PVA bag is pulled down over the positive model. One end is gathered and tied over the area of the sound leg. The other end is taped tightly around the pipe. Three or four holes are punched in the bag near the cup.</p> <p>Fabric is applied as follows:</p> <ul> <li>1 layer 1/2-oz. Dacron felt.</li> <li>1 layer nylon stockinette.</li> <li>7 layers of glass cloth over the joint and seat areas. The pieces of cloth should be of varying size to produce a gradual transition in rigidity.</li> <li>1 layer Dacron felt over all.</li> <li>5 layers of nylon stockinette pulled on tight and tied to the pipe. A PVA bag is pulled down over the layup and taped tightly to the pipe.</li> </ul> <p>Resin, in an appropriate amount, should be prepared in the proportion of 80 per cent rigid Laminac 4110 to 20 per cent flexible Laminac 4134. ATC catalyst-2 per cent of the weight of the resin mixture is added and spatulated thoroughly. Appropriate pigment, amounting to about 2 per cent of the weight of the resin mixture, should be added: 12 drops of Nauga-tuck # 3 promoter results in approximately 20 min. working time. This will vary according to temperature and humidity.</p> <p>One method of impregnating the fabric with the resin is to pour the resin into the top of the outer PVA bag and "string" the resin downward, working it into the layup, especially into the reinforced seat area, to obtain complete saturation. After the resin has been "strung" into the layup, the vacuum is applied and a head of resin is maintained at the top to prevent air from being sucked into the laminate. Insofar as possible, air is excluded from the top of the PVA bag, and the bag is tied off tightly at the top.</p> <p>Another method is to apply vacuum prior to "stringing" the resin into the layup. In this procedure, the resin is poured into the top of the PVA bag, which is then tied off and vacuum is applied. The resin is then "strung" down into the layup.</p> <p>In both procedures, the hands must be used to force the resin from undercuts, considerable "stringing" downward must be done to remove bubbles, and "stringing" upward to remove excess resin.</p> <p>Low negative pressure should be maintained until the plastic has set (<b>Fig. 19</b>). Excessive vacuum will pull the resin from the laminate, causing "starving."<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. View of laminate of socket using vacuum technique. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Removal of Socket from Positive Model and Replacement of Polyurethane Foam Buildup with Silicone Foam</h3> <p>With the flare as a guide, a Stryker cast cutter is used to cut through the laminate along the outline of the socket. If a molded tongue has been attached to the positive model, care should be taken when making the cut on the lateral side. It is prudent to leave a little extra laminate for subsequent trimming.</p> <p>The polyurethane buildup for the location of the hip joint is removed from the positive model. The positive model is smoothed in this area, and a thin smear of vaseline is applied. A piece of lightweight stockinette is stretched over this part of the model and stapled in place.</p> <p>Using the back plate as a template, three 1/4-in. holes are drilled. The center hole is drilled with a 1/2-in. drill. The back plate is mounted in the socket with two bolts and nuts. The bolts should not be cut.</p> <p>The socket is replaced on the stump model and secured tightly with a web belt or friction tape (<b>Fig. 20</b>). It is in position for the injection of silicone rubber through the 1/2-in. center hole in order to provide support for the amputee over the area of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Socket replaced on stockinette-covered cast preparatory to injection of foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In choosing the silicone rubber to be used, it should be remembered that Silastic 386 Foam Elastomer is relatively soft and may not be capable of supporting the weight of the amputee, while Silastic 385 Elastomer forms a solid rubber which will, if used by itself, add considerable weight to the prosthesis. Accordingly, a mixture of 70 per cent by weight of 386 with 30 per cent by weight of 385 is recommended. This is poured into a caulking gun. The 386 catalyst-6 per cent by weight of the mixture-is added, and the mixture is spatu-lated for 25 seconds. Because of the small amount of catalyst, the viscosity of the Silastic, and the shape of the chamber of the caulking gun, it is very difficult to get a homogeneous mix if spatulated by hand. A mixing rod should be formed that can be used in conjunction with a 1/4-in. electric drill. A rotary up and down movement should be used, mixing for 25 seconds. It is then injected through the center hole of the spherical plate to fill the socket cavity (<b>Fig. 21</b>). The mixture will expand approximately four times its volume during foaming. If necessary, more of the same mixture is added until the cavity is filled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Injection of silicone foam through center hole of spherical plate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is removed from the cast. The silicone pad is removed and the nuts are removed from the two bolts. The spherical plate is attached to the socket with three 1/4-in. flat head bolts. The bolts should be locked tight with a locking compound. The bolts are threaded into the spherical plate with a screwdriver, but they should be tightened with vise grip pliers applied to the protruding threaded portion of the bolt. If this spherical plate is not tightened sufficiently, movement and noise will result. The bolts should then be cut and ground to maintain the spherical contour (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket with spherical plate attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The edges of the socket are sanded and buffed to provide a smooth radius.</p> <p>For fitting purposes, the foam pad is secured in the socket by means of friction tape. It can be glued to the socket when the prosthesis is being completed. The edges of cloth reinforcement on the foam should be trimmed, and the surface coated with a skin of Medical Silastic S-5391 Elastomer (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. View of silicone foam pad with stockinette reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Layout of Thigh Block</h3> <p>One method of determining the configuration of the thigh block is as follows:</p> <ol> <li>On a large piece of paper, line A is drawn to represent the length of the foot (<b>Fig. 24</b>). The distance from the end of the heel to the center of the ankle bolt is measured and marked on line A.</li><li>Line B is drawn perpendicular lo line A from the point representing the foot attachment bolt. The length of this line is the distance from the ischial tuberosity to the floor.</li><li>On line B a point is located equal to the height of the medial tibial plateau (MTP) plus 1 1/4 in. for adults. The location of the hip joint often causes the prosthetic knee lo protrude beyond the sound knee when the patient is in the sitting position unless the thigh is shortened and the shin is lengthened. Therefore, 1 1/4 in. is added to the dimension between the floor and the MTP.</li><li>Two inches above this point a 6-in. line is drawn to represent the attachment plate of an adjustable leg. This line is drawn 3 1/2 in. anterior of and 2 1/2<i> </i>in. posterior of line B.</li><li>A line is drawn at right angles to line B at its topmost point. This line, D, represents the height of the level of the seat of the ischium from the floor.</li><li>From a point 1 in. behind the heel, line E is drawn to intersect the prosthetic knee center (PKC) and the horizontal line D.</li><li>The socket is superimposed on the layout, with the joint attached and in a neutral position. The inner edge of the socket must fall on line D and the hip joint center must pass through line E.</li><li>The hip joint is adjusted so that the angle of the straps with line D is 73 deg. in order to maintain the 45 deg. originally planned for the placement of the hip joint.</li><li>The position of the side straps is marked and outlined, line F, and also the offset for the shoulder of the straps, line G.</li><li>There should be 1/4 in. of wood anterior to the hip joint. Therefore, from a point 1/4 in. anterior to the shoulder of the side strap outline, a line should be drawn connecting with the anterior end of the socket attachment plate line. (Angle <i>a </i>in <b>Fig. 24</b> is the flexion angle.)</li><li>From a point 1/4 in. posterior to the shoulder of the side strap outline, a line is drawn to form the posterior outline of the thigh block. Often, this is not a direct connection with the posterior end of the socket attachment plate line, as this would not provide sufficient thickness of wood for screws at the attachment plate of the adjustable leg.</li><li>An anterior view is drawn of the thigh section in which the proximal center point is offset the equivalent of the distance from the center of the artificial hip joint to the vertical support line on the prosthesis, less 1 in. (distance H in lower part of <b>Fig. 24</b>). This establishes the approximate angle of adduction needed in the thigh block. The objective is to place the artificial foot in the approximate amount of adduction.</li><li>The thigh block, of correct length, is positioned with the lateral side up and angle <i>a, </i>obtained from step 10 above, is inscribed upon it.</li><li>The thigh block is positioned with the posterior side up. A goniometer is placed with one arm parallel to the lateral side of the posterior wall; the other arm, set in the angle required, should lie across the posterior wall and connect with the flexion angle previously established. If the adduction required is excessive, it is sometimes necessary to bend the side straps. A bend of approximately 8 deg. is usually sufficient. Care must be taken not to produce nicks and notches in the side straps which may cause premature fracture.</li><li>The table of the saw is set at the adduction angle and a cut is made along the flexion line.</li><li>The hip joint is centered on the thigh block, and the width of the straps is marked. The outline of the straps should be left showing after the excess wood has been cut away. Enough wood must be left for the socket attachment plate. Care must be taken that the distance between joints is accurately reproduced on the thigh block, otherwise binding will result when the joint is assembled and shimming will become necessary.</li><li>The joint is clamped to the thigh block. After the two indicated 1/4-in. holes have been drilled, the joint is bolted to the thigh block.</li></ol> <h3>Bench Alignment of Prosthesis</h3> <p>Two general rules to be followed in the bench alignment of the prosthesis are: First, the socket should be the correct height above the floor, with the transposed point of the ischium directly over the center of the foot. Second, the knee should be set in slight hyper-extension so that a straight line drawn through the hip joint intersects the floor about 1 to 1 1/2 in. behind the heel.</p> <p>It is recommended that a SACH foot with a soft heel wedge be used. A knee extension aid is important; it is provided by a piece of 1-in. elastic which also functions as a stride length control. This is adapted for temporary use on the adjustable leg by mounting a piece of leather on the socket approximately 2 in. behind the hip joint in such a way that the elastic strap can pass through the attachment. For a woman, the extension aid is built into the knee mechanism and the socket bias strap is secured to the distal thigh block. One end of the elastic is screwed to the shin 2 in. down from the PKC, and the other end of the elastic is secured by a buckle mounted in the corresponding position on the other side of the shin. A keeper of 1/2-in. Dacron webbing, with a buckle, is positioned about 1 1/2 in. proximal to the knee bolt. This keeper should be adjusted so that it holds the bias strap anterior to the knee bolt center when the patient is standing and walking but allows it to pass posterior to the knee bolt center when the patient is sitting.</p> <p>Velcro offers a convenient method of closure for the lateral opening of the socket (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Arrangement of closure straps using Velcro. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the prosthesis is assembled, the axes of the hip joint and of the knee joint should be essentially parallel to the floor and at right angles to the line of progression.</p> <h3>Static and Dynamic Alignment</h3> <p>Satisfactory suspension of the prosthesis often depends upon the proper application of the socket (<b>Fig. 26</b>). The stump should be forced as far laterally as possible and the closure straps should be tightened alternately until the amputee is well supported. The ischial support strap should be secured last. The relief provided by the socket for the an-terosuperior spine of the ilium on the sound side is a useful guide in orienting the socket to the patient. The socket should then be checked for fit and comfort under weight bearing in the areas of the ramus, the coccyx, and the rib cage. Lateral stability of the socket should be evaluated by supporting the prosthesis against a chair and asking the patient to raise his good leg without leaning over the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Socket mounted on adjustable leg preparatory to dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment line from hip center through PKC to a point behind the heel should be verified for stability. It should be ascertained that the height of the prosthesis is correct; that the extension bias strap is forward of the PKC; that there is no friction in the knee joint; and that the bumper and stop are in contact. The patient should not be in a forced position of lordosis, and the socket should not exert pressure proximally in the back. If either of these conditions exists, the bumper is contacting the stop too soon and the socket should be tilted backward by means of the adjustable hip joint. If the bumper is not in contact with the stop, correction should be made by adjustment of the hip joint.</p> <p>The amputee should then sit upright in a hard chair, and the anterior distal portion of the socket should be inspected for clearance of the thigh. If the amputee tends to lean to the amputated side, the exterior gluteal area of the socket should be built up with foam for support and to improve cosmesis. It should be ascertained that there is no pressure between the proximal edge of the socket and the rib cage; that the thigh block clears the chair; that the shank is vertical; that the prosthetic knee axis does not protrude excessively beyond the normal knee center; that toe-out is approximately correct; and that the extension bias strap is holding the shank in flexion.</p> <p>In training the amputee to walk, he should be impressed with the importance of standing upright by holding his hands parallel to or slightly posterior to the long axis of his body. If he leans forward to watch his feet, the hip bumper will not contact the stop, making it impossible to propel the leg forward. He should alternately bear his weight on the prosthesis and then lift it clear of the floor. To initiate flexion of the knee, the amputee should be instructed to "scoop" his stump and pelvis forward and flex his spine. This should be jepeated a few times and the bias strap ad-rusted to obtain the proper stride length.</p> <p>The amputee should be instructed to take a few steps. If the knee appears unstable just after heel contact, the durometer of the heel wedge should be checked, and it should be determined whether the shank is reaching full extension; whether the knee is in some hyper-extension; whether the hip joint is contacting the stop before the foot is flat on the floor; and whether the alignment line runs correctly from the center of the hip joint through the center of the knee joint to 1 1/2 in. behind the heel of the shoe. To eliminate medial or lateral whip, rotational adjustments are necessary at the knee or hip axis.</p> <p>Many amputees wear a stump sock, which decreases the friction between the patient and the socket during the stance phase and loses some of the socket's support. To increase the friction, it is sometimes advantageous to line the lateral aspect of the socket with a rubber material or with horsehide.</p> <p>If toe clearance is still a problem, the length of the prosthesis should be reduced. The hemipelvectomy amputee will tend to vault on the sound foot to increase the clearance of the prosthesis. This tendency should be minimized as much as possible, but it must be remembered that the patient cannot "hike" his pelvis on the amputated side since there is no remaining skeletal structure. Where obesity is a problem, it is sometimes necessary to use a shoulder strap to aid suspension.</p> <p>If the patient experiences rotational instability in the socket, a "teardrop" cutout on the lateral aspect of the socket will help to alleviate the problem and to aid suspension. The cutout should be approximately 2 in. wide at the lateral proximal edge of the socket and extend three-quarters of the length of the socket (<b>Fig. 27</b>). The foam insert in the socket should be removed before the panel is cut out. The edges of the panel should be sanded smooth to prevent cracking. A strap and buckle or Velcro should be attached proxi-mally for closure of the cutout. When the prosthesis is donned, this strap should be loose and should be tightened last.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Teardrop opening in socket on amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Duplicating and Finishing</h3> <p>For duplicating and finishing, the socket is removed and the duplicating jig is used; excess wood is removed from the thigh block and the block is faired into the knee; the knee, thigh, and shin sections are laminated; the keeper for the extension bias strap and all straps and buckles are riveted; and the prosthesis is reassembled (<b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Finished thigh block in reassembled prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Thigh Fairing</h3> <p>The chief purpose of the thigh fairing is to compensate for the differences in circumference between the thigh block and the sound leg, both in standing and in sitting. This must be done without impairing the function of the prosthesis.</p> <p>A light, articulated fairing has been developed at the Northwestern University Prosthetics Research Center. It utilizes a piece of 1/32-in. light aluminum alloy, 1/8-in. Kemblo rubber, and lightweight horsehide, with Velcro for closing. It is pivoted distally by two screws just superior to the knee bolt and fastened proximally by a snap fastener to the anterior wall of the socket.</p> <p>A piece of cardboard is used to make a pattern for the aluminum (<b>Fig. 29</b>). Distally, it should be wide enough to receive the pivot screws approximately l 1/2 in. superior to and vertical to the knee bolt center. Anteriorly, it forms an upward arc. To allow the pivot action, the posterior section is open and the anterior proximal section is cut away so that the socket can be fully flexed without touching the cardboard. The posterior medial and lateral edges govern the amount of anterior displacement of the fairing in the sitting position and the fullness of the thigh in the standing position. In the sitting position, both edges should be in full contact with the seat of the chair (<b>Fig. 30</b>). The cardboard pattern should fit close to the anterior thigh block in the standing position and should be cut and formed to allow the medial and lateral contours of the Kemblo rubber fairing to blend in with the contours of the socket (<b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cardboard used as template for metal portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Template shown on prosthesis in sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Contouring rubber portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the aluminum has been cut out, it is formed to the desired shape and attached with a screw to the knee. A sheet of 1/8-in. Kemblo rubber is wrapped around the metal to obtain the desired fullness (<b>Fig. 32</b>). The Kemblo should be long enough to start at the distal end of the aluminum and fair in proximally to the contours of the socket. The distal edge is skived to blend in with the metal form. The anterior proximal edge of the Kemblo should come up to meet the socket in the sitting position. The posterior proximal edge should meet the socket during the stance phase. The Kemblo is glued to the aluminum form.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Open view of completed thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Kemblo rubber is covered with lightweight horsehide, and the leather is rolled over the edges of the rubber.</p> <p>The fairing is attached to the socket anteriorly by means of a snap fastener. The leather continues from the medial and lateral sides to produce a triangle anteriorly with enough slack to allow displacement of the fairing in the sitting position. In the standing position, the attachment should return the fairing and eliminate any slack in the attachment area.</p> <h4>Acknowledgments</h4> <p>For valuable assistance in the development of this prosthesis (<b>Fig. 33</b>) and for help in the preparation of this article, I am most grateful to Colin A. McLaurin, B.A.Sc, Robert G. Thompson, M.D., H. Blair Hanger, C.P., Edwin A. Bonk, Mary Farnan, Walter Horiuchi, and Paula Hamilton.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. View of finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Schematic drawing (not to scale) for layout of thigh block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Lyquist, Eric, <i>Canadian-type plastic socket for a hemipelvectomy, </i>Artificial Limbs, Autumn 1958, pp. 130-132.</li> <li>McLaurin, Colin A., and Fred Hampton, .4 <i>method of taking hip disarticulation casts using hip sticks, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 71-77.</li> <li>McLaurin, Colin A., and Fred Hampton, <i>Fabricating hip disarticulation sockets using the vacuum method, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 66-70.</li> <li>Radcliffe, Charles W., <i>The biomechanics of the Canadian-type hip-disarticulation prosthesis, </i>Artificial Limbs, Autumn 1957, pp. 29-38.</li> <li>Slocum, Donald B., <i>An atlas of amputations, </i>C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">At sea level, the atmosphere will support a column of mercury 30 in. high. Most vacuum gauges, therefore, are calibrated in inches of mercury (in. Hg.), reading from 0 to 30. 10 in. Hg. negative pressure means 10 in. of mercury below atmospheric pressure.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Hampton, Fabricating hip disarticulation sockets using the vacuum method, Orthop. &amp;Pros. Appl. J., June 1960, pp. 66-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Pelron Corp., Lyons, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">NHJ-100, Hosmer Corp., Santa Clara, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 29-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Hampton, .4 method of taking hip disarticulation casts using hip sticks, Orthop. &amp;Pros. Appl. J., June 1960, pp. 71-77.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Lyquist, Eric, Canadian-type plastic socket for a hemipelvectomy, Artificial Limbs, Autumn 1958, pp. 130-132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations, C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-10.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-11.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-12.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-13.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Hemipelvectomy Prosthesis Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/3a52a8d4775fa3efd09318a22cf6e7b3.pdf 820ff6a0c1135f0effa1bae156a7f712 https://staging.drfop.org/files/original/a1127c14978be6ddba76a103d184fb20.jpg be7afb490777286577070fbfccb774fc https://staging.drfop.org/files/original/78848ce98a4983ca8bf83352f38fd5eb.jpg 254b27df04281f573e9df2cee9c33abc https://staging.drfop.org/files/original/6825c3c6eea1009afaf91c7abf8227ca.jpg 166a7fea19db92181e6cbf2a89d08b40 https://staging.drfop.org/files/original/aaf817a225ef897343a8c2a894b1cb69.jpg 537a989bf8ed7128316bdca570ab2915 https://staging.drfop.org/files/original/14f06bf8a55bb3dfed87489cacd1e28a.jpg fac89206bdc9aba86a21e615d9c70faf https://staging.drfop.org/files/original/f985278fc90ed029c1cc392206138e17.jpg 228d46ddc1545dc9fe5b34cf26bc0a72 https://staging.drfop.org/files/original/dab6c070737e365ed5aabce3fcf2bde1.jpg 6305700f03605ff97f24df6a08155562 https://staging.drfop.org/files/original/2d289146083105144b69c9c79a98b25a.jpg 5fd23e93a85b7ff731445a12a77fad61 https://staging.drfop.org/files/original/b63a1c7506812aa1f371254f1f53b919.jpg e3d7a7321d595d0fdfa23dd3c162429d https://staging.drfop.org/files/original/6cc643811deadfa2ead2f26357104ceb.jpg 5b94dac9a6d3f5727b81c3abfb6f7875 https://staging.drfop.org/files/original/2e7a46fb0b770171b5189860ba9f368d.jpg e82ff8d146f3473fbc167b759af9a148 https://staging.drfop.org/files/original/23562bc9cb410180cad1610a008e5cc1.jpg ff7b7f3b0ce7d6269d5364de3956538e https://staging.drfop.org/files/original/d92a31d65ae1a659d76f5e29b10d470d.jpg 25398ed94e7c48ac3b146aa62c192d24 https://staging.drfop.org/files/original/57a0d24e094a84654d83bd92944f70dc.jpg 3262f1eacd42160e24ca088febd063c8 https://staging.drfop.org/files/original/f40eee279da314366168879def856866.jpg 842e6fcd496ecdbae607d0554dea8d78 https://staging.drfop.org/files/original/3a999ee1d480ce73e8f934dd4e2117a2.jpg 2e3f15ea4f5f19befc8183e0723376d8 https://staging.drfop.org/files/original/e0315e1fb3761348b30e9c2a1a2d86d8.jpg 3cc0d759597ea5812be8ae99b3c204fb https://staging.drfop.org/files/original/8c2dc6b9dac90d6aa61cae8c1791afd5.jpg 56951aad21e6f648183614a200b26b17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_031.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 31 - 42 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Dynamic Alignment of Artificial Legs with the Adjustable Coupling</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p> Since World War II one of the most significant advances in limb prosthetics has been the introduction of rational principles for fitting and aligning artificial legs.<a></a> The University of California (Berkeley-San Francisco), sponsored by the Veterans Administration, has been primarily responsible for the steady improvement in methods and devices used by prosthetists in artificial-leg construction. </p> <p> To assist the prosthetist in carrying out these principles, a number of mechanical aids or tools were devised. The two adjustable legs-one for above-knee cases (<b>Fig. 1</b>), the other for cases below the knee (<b>Fig. 2</b>) and an alignment duplication jig (<b>Fig. 3</b>) were developed by the University of California, and are now recognized as important tools of the prosthetist.<a></a> And dynamic alignment of artificial legs is a standard part of the curriculum of prosthetics schools<a></a> and standard operating procedure in most limbshops. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An above-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 2. A below-knee adjustable leg used in current practice. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alignment duplication jig. A, Adjustable leg mounted in jig. B, Adjustable leg has been removed and wooden set-up substituted. Prosthetist is sawing shank to proper length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But there have been problems. For one, the limbshop must have a minimum of two adjustable legs for adult cases, and two smaller ones for child cases. A shop of any size requires multiple quantities because frequently a given unit must remain attached to a socket for a particular amputee for an extended period of time. And to make best use of the adjustable legs an alignment transfer jig is needed. </p> <p> Other limitations in the above-knee adjustable leg appeared when knee units or knee-shank-foot units with fairly complex functions were introduced. Use of the UC adjustable AK leg, with its single-axis, constant friction joint for achieving alignment which is to be transferred to a permanent leg having a somewhat different type of function, is a questionable procedure; i.e., alignment suitable for a constant friction unit may not make proper use of the functions provided by more sophisticated devices. Some prosthetists have learned to accommodate for the required deviations by rules of thumb, but essential are some method and some tool for dynamic alignment to be made directly on the knee or knee-shank-foot mechanism to be used in the final prosthesis. </p> <p> Ideally, the device should be of simple design and useful for both above-knee and below-knee cases. For the above-knee case, such a device should be inserted between the socket and permanent prosthetic knee for "functional" alignment. </p> <p> If the unit were simple enough, it would be expected that more generalized use of alignment tools might result, and that facilities in other countries, where it is difficult to procure adjustable legs, could enjoy the advantages of dynamic alignment. Moreover, the alignment-transfer process needed scrutiny to see if simplifications in the equipment necessary might result. </p> <p> For these reasons, the VA Prosthetics Center developed the Adjustable Coupling, sometimes termed the "Staros-Gardner Coupling." </p> <h4> Description of the Adjustable Coupling </h4> <p> The adjustable coupling (<b>Fig. 4</b>) consists essentially of two plate assemblies held together by a central toggle pin. Mounted to a middle or intermediate plate but part of one plate assembly are four screw subassemblies, spaced 90 deg. apart, which contain independently adjustable, knurled screws used to "lock" the entire coupling as well as to provide adjustment for adduction-abduction and flexion-extension. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The adjustable coupling assembled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 5</b> are illustrated the major assemblies of the coupling. The single-flange part of the toggle and the top plate constitute the top assembly. The bottom assembly contains the "box" part of the toggle, the bottom plate, the intermediate plate, the four tilt-screw subassemblies, and the toggle pin. The bottom and intermediate plates both contain "A" and "P" marks to indicate the anterior and posterior sides, respectively. The two assemblies contain countersunk holes for screws used for attachment to the prosthesis. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Major assemblies and parts of the adjustable coupling. The toggle pin is permanently located in the semi circular channel just above the AA marks on the intermediate plate.<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The top assembly, primarily offering medio-lateral and tilt adjustability, contains a 1-1/4 in., 1/8 in. increment scale for gauging medio-lateral adjustments (with an index on the single-flange toggle which is free to slide with respect to the top plate). A tilt scale<a style="text-decoration:none;">*</a> is provided by markings on the threaded bushings of the four tilt-screw subassemblies. The indexes for tilt scaling are the lower surfaces of the knurled screws. Scale sensitivity for tilt adjustment is 2 deg. </p> <p> The bottom assembly provides rotation about the vertical axis and anteroposterior adjustability because the intermediate plate (and toggle "box") is free to move with respect to the bottom plate. On the anterior surface of the bottom plate is the 20-deg. (2-deg. increment) rotation scale. The index is located on the intermediate plate. The anteroposterior adjustment scale consists of a series of arcs, 1/8 in. apart for 1-3/4 in., etched on the top surface of the bottom plate. The index for this scale is simply the outer contour of the intermediate plate. </p> <p> The coupling, made primarily from an aluminum alloy (except for the toggle assembly which is steel), weighs 12 oz., is 3-3/4 in. in diameter, and is 1-1/8 in. thick when the plates are parallel. Ranges of adjustment are as follows: </p> <ol> <li><i>Mediolateral: </i>Total Range-1-1/4 in. <ul> <li>Increment of Scale Markings-1/8<i> </i>in. </li> </ul></li><li><i>Anteroposterior: </i>Total Range-1-3/4 in. <ul> <li>Increment of Scale Markings-1/8 in.</li> </ul></li><li><i>Tilt: </i>Total Range-10 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li><li><i>Rotation: </i>Total Range-20 deg. <ul> <li>Increment of Scale Markings-2 deg.</li> </ul></li></ol> <p> The coupling is disassembled by first lowering each of the four tilt screws two increments on the tilt scale. This operation loosens the entire assembly because it is held together as a result of the forces produced by tightening the force screws, and the toggle pin can thus be disengaged from the toggle box and flange. The top assembly and bottom assembly can then be separated. </p> <p> Installation of the coupling into a prosthesis is made with the coupling so separated. </p> <h4> Installation of the Coupling for Dynamic Alignment<a></a> </h4> <p> (<b>Fig. 6</b> and <b>Fig. 7</b>) show the coupling in position for dynamic-alignment trials. When installed, the coupling should be located as close as possible to the distal end of the stump. A piece of material may have to be added to accommodate the wood screws without affecting the socket sealing plate itself. By so locating the coupling, small tilt adjustments on the coupling will produce major changes in the geometrical relationship of stump to prosthetic components distal to the coupling. When the "bench" or static alignment is reasonably close, the 10 deg. range of tilt adjustment is more than adequate. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The coupling installed in an above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The coupling installed in a below-knee prosthesis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the socket is constructed and the components approximately dimensioned<a style="text-decoration:none;">*</a> lengthwise, the top assembly of the coupling is attached to the bottom of the socket using as many wood screws as possible (<b>Fig. 8</b>). The bottom assembly then is attached to the top assembly by placing the single-flange part of the toggle within the "box" part and pushing the toggle pin through the holes in both toggle parts. One must make certain that the "A" marks (or "P" marks) are located properly with respect to the socket. The coupling is then set with all adjustments on "neutral" so that top plate and bottom plate are parallel and coaxial, care being taken to ensure that the intermediate plate is not rotated with respect to the bottom plate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Attaching the top assembly of the coupling to the bottom surface of the above-knee socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket with the coupling attached is then temporarily placed on the above-knee setup (knee-shank-foot) or on the below-knee setup (shank-foot). A height check<a style="text-decoration:none;">*</a> is made with the amputee standing on the prosthesis. </p> <p> Since the coupling has not been fully assembled into the prosthesis, the prosthetist must, of course, assist the amputee in maintaining stability. After the height check has been made, the section of the prosthesis below the coupling (on the knee block or shank) can be sanded to obtain the correct height. </p> <p> One must consider the desired static or bench alignment before fully attaching the bottom plate assembly to the prosthesis. A recently published chart<a></a> shows recommended guides for "bench" alignment when the SACH foot is used. In any case, care should be exercised in locating the bottom assembly to assure that the ranges of adjustment available in the neutrally set coupling will not be exhausted during dynamic alignment. </p> <p> When the bottom plate is being installed, the countersunk clearance holes are made accessible by shifting the intermediate plate with respect to the bottom plate (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Attaching the bottom assembly of the coup ling to the top surface of the knee block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Dynamic alignment can begin when the coupling is reassembled and "locked" in the neutral position. This procedure should ordinarily be carried out in the following fixed sequence, making the linear adjustments first and the lilt adjustments second: </p> <ol> <li>With the amputee seated, loosen only the two front tilt screws and make the anteroposterior adjustment. Tighten the two front screws.</li><li>With the amputee seated, loosen only the two front till screws and make the mediolateral adjustment. Tighten the two front screws.</li><li>With the amputee standing, provide tilt adjustment by turning down one of the two tilt screws on the side to be depressed (The screw should be turned down only as far as needed for the angular adjustment desired.) Then tighten the till screw diagonally opposite to establish the angular adjustment desired. Next loosen (the same amount) the second screw on the side to be depressed and tighten the screw diagonalh" opposite to complete the angular adjustment and "lock" the coupling.</li><li>rotation may be established or reestablished before the screws are completely tightened in any of the above three adjustments. The rotation scale reading may be recorded before making any adjustment so that the position of rotation may be readily restored.</li></ol> <h4> Alignment Transfer </h4> <p> No special jig is required for alignment transfer with the coupling. Actually, alignment is not "transferred" but rather "maintained" while the coupling is replaced with a permanent material. </p> <p> Around the periphery of the bottom plate of the coupling, there are ten radial holes located 36 deg. apart that serve as centers for a special compass which is used for scribing reference marks on the socket after dynamic alignment has been completed. The alignment compass is inserted in each of the holes in the periphery of the bottom plate, and small arcs are drawn or scribed on the socket base (<b>Fig. 10</b>). The <i>tops </i>of these arcs are then connected bv a circumferential line which will be exactly 2 in. above the bottom surface of the bottom plate and parallel to it. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 10. Use of the special compass for an alignment-transfer reference. The vertical reference lines will be used to reestablish anteroposterior, mediolateral. and rotation positions. The horizontal line tangent to the tops of the compass arcs will reestablish tilt. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At least four vertical reference lines (90 deg. apart) are made on the socket and continued onto the distal component (knee block or shank). </p> <p> The toggle pin of the coupling is removed and the top and bottom plate assemblies are detached from the socket and from the knee block (or shank). </p> <p> A saw cut is then made in the socket base<a style="text-decoration:none;">*</a> <i> just below </i>the horizontal circumferential line (<b>Fig. 11</b>) and the socket base is sanded to the line (<b>Fig. 12</b>). A 2-inch-thick wood or foam block (with parallel top and bottom surfaces) is then placed between the socket and the knee block (or shank). The wood or foam block is then firmly attached (with cement, resin, and/or other fastening media) to both socket and knee block (or shank), care being taken to restore the coincidence of the vertical reference lines on the assembled components (<b>Fig. 13</b>). Although not necessary, an apparatus for holding the parts together during cement or resin cure can be used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Using the band-saw to cut the socket immediately below the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Sanding of the socket to the horizontal-circumferential reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Replacement of the coupling with a 2-in. wood block. Coincidence of the vertical reference lines must be restored in the alignment-transfer process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> If one wishes, the standard alignment transfer jig may be used instead. Following standard procedures, the prosthesis with the coupling may be fixed in the jig and then the coupling removed. Saw cuts through the socket base and knee block (or shank) and substitution of an appropriately sized block of wood will be needed. In the above-knee limb transfer, one saw cut in the socket base will be sufficient if the prosthesis is mounted in the jig with the bottom plate of the coupling perfectly perpendicular to the long axis of the jig. </p> <h4> Experience with the Coupling </h4> <p> The coupling, although primarily designed as a simple device for alignment of "permanent" lower-extremity prostheses, can also be used for temporary, or interim, prostheses. </p> <p> The coupling has been in routine use in the Limb and Brace Section of the VA Prosthetics Center since March 1961. The numbers of permanent prostheses aligned with the coupling in the 22-month period ending December 31, 1962, were as follows: </p> <table> <tbody><tr> <td>Hip_disarticulation............</td> <td>13</td> </tr> <tr> <td>Above-knee....................</td> <td>130</td> </tr> <tr> <td>Knee-bearing...................</td> <td>16</td> </tr> <tr> <td>"Bent" Knee.....................</td> <td>3</td> </tr> <tr> <td>Below-knee....................</td> <td>192</td> </tr> </tbody></table> <p> In addition, 34 above-knee and 22 below-knee sockets were replaced on existing prostheses by use of the coupling. </p> <p> Experience indicates some economic benefits in use of the adjustable coupling. Starting at the same point in an above-knee prosthesis fabrication (with the socket roughly fitted), the adjustable leg-transfer jig procedure takes, on the average, slightly over 1/2 hr. more than the coupling-compass procedure. The end point for this time measure, in both procedures, is completion of alignment transfer with the prescribed prosthetic components assembled. </p> <p> A more significant advantage of the coupling accrues from its use in aligning above-knee prostheses when special knee or knee-ankle mechanisms have been prescribed. A prosthesis system with functional features providing more than just a mechanical-friction control at the knee may require some deviation from that alignment which might be used with only mechanical friction. Even an extension bias strap will affect the alignment to be used. Thus, for such devices as the Bock Safety Knee, the Hydra-Cadence (with a relatively free plantar-flexion control), the Mauch hydraulic devices, polycentric linkages, and others, it is well to align the prosthesis with the prescribed special-function system installed. The coupling is designed primarily for dynamic alignment of such systems. </p> <p> Added to the economic advantage of one device for both below-knee and above-knee use is the simple and inexpensive process for alignment transfer. For a new shop, this means that investment in an expensive jig is not mandatory. Also, because of the comparatively low cost of the coupling itself, many more alignment devices can be available in the shop. Thus, shifting alignment apparatus already installed in a setup awaiting an amputee trial may not need to be as frequent as formerly. </p> <p> The coupling also facilitates the alignment of replacement sockets. Fitting problems often require the fabrication of a completely new socket before the remaining parts of the prosthesis need replacement. The new socket and coupling can be installed on the "old" prosthesis for dynamic alignment and replacement-socket fitting. This process is more expeditious than one in which the adjustable leg is used and then transfer is made to the "old" components. Also, proper fairing of new socket to "old" components can be assured by the coupling method of realignment because fairing problems can be readily observed and immediately corrected. When the adjustable leg is used, fairing problems can be noted only at the time of transfer. Major corrective procedures may then be necessary. </p> <p> Many foreign practitioners have read and appreciated the various United States' documents which have emphasized the importance of dynamic alignment. But also, many have felt frustrated for, even though they have realized the value of dynamic-alignment apparatus, economic or technical handicaps prevented them from enjoying the use of the devices the practitioners in the United States had readily available. The coupling, therefore, because of its simplicity, can make a significant contribution to the benefit of the disabled all over the world, particularly in developing areas. </p> <p> The coupling was introduced into Yugoslavia in 1961.<a></a> At about the same time, Denmark became interested in its use. E. Lyquist of the Orthopaedic Hospital, Copenhagen, has published a report on the coupling<a style="text-decoration:none;">*</a> and on the apparatus he designed for clamping the prosthesis on a band-saw bed for alignment transfer<a></a>. See (<b>Fig. 14</b>). Dr. B. Zotovic of Belgrade has kindly offered the photograph (<b>Fig. 15</b>) of a prosthesis with the coupling now in use in Yugoslavia. In 1962, the coupling was introduced into Argentina. Still more applications to foreign use are anticipated. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Special band-saw jig used by Danes during alignment transfer. This jig holds components of the prosthesis in a fixed position to allow parallel band-saw cuts on both sides of the coupling. Subsequent clamping after cementing of wood block to replace coupling is also facilitated by this device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A Yugoslav above-knee prosthesis incorporating the adjustable coupling tor dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Many clinicians have realized the importance of temporary or interim prostheses<a></a> for preliminary trials by an amputee. When temporary limbs which have alignment adjustability are used, dynamic stump conditioning and, especially for geriatric cases, evaluation of an amputee's ability to cope with a prosthesis are possible before a final prosthesis is ordered. Of utmost importance in temporary limb use is that prosthesis <i>"function</i>not be seriously compromised".<a></a> A well-fitted, soundly designed socket must be used, and all parts should be continually maintained in proper alignment. Straps provide additional reinforcement of socket to coupling assembly- mostly for horizontally directed loads. For plaster sockets, they are especially helpful since they can be contained within an outer, reinforcing plaster wrap.</p> <p> There are now available several devices which might be used for temporary prostheses.<a></a> Among these is the coupling. (<b>Fig. 16</b>) illustrates a temporary or interim above-knee. prosthesis incorporating the coupling and making possible the use of the type of knee (and function) anticipated for a permanent prosthesis. Now, not only fit and alignment can be '"tuned" to each other, but both can be "tuned" to function. And, if necessary, function can possibly be altered by a rather rapid change from one knee-shank mechanism to another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. The adjustable couplingused with a plaster -of-Paris above-knee temporary sockel and an unfinished knee shank. The three straps are eaeh 1/8 in by 3/4 in. low-carbon steel. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 17</b>) shows the coupling used in a below-knee temporary, or interim, prosthesis. For this level of amputation, the practitioner has the choice of the coupling or the Northwestern Adjustable Below-Knee Pylon shown in (<b>Fig. 18</b>). This apparatus also has sufficient alignment adjustability available for most below-knee applications in both temporary and permanent prostheses. When attached to a "permanent" (plastic or wood) socket, its advantage is that it can remain in the prosthesis after the dynamic-alignment process is complete. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig, 17. The adjustable coupling used with a plaster-of-Pa.ris below-knee temporary socket and unfinished shank. The three straps have the same cross-section as those used with the above-knee socket. The position of the carbon steel straps in both the above-knee and below-knee sockets should be reinforced with an extra plaster-of-Paris bandage wrap, as illustrated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. A temporary or interim prosthesis with the Northwestern adjustable below-knee pylon, plaster-of-Paris patellar-tendon-bearing socket and SACH foot, The three straps are similar to those of the previous two illustrations. An adaptor plate must be provided to iittach the straps to the pylon. In addition to the alignment adjustability available in the pylon, the position of the socket can still be altered if necessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Further Development </h4> <p> The Northwestern Adjustable Below-Knee Pylon demonstrates a design principle long sought in alignment apparatus. With it, adjustments needed for dynamic alignment can be made as usual during the early stages of prosthesis fabrication, but the adjustable apparatus is now made a part of the limb obviating a transfer process but sometimes causing a slight increase in limb weight. At a later date, if the cosmetic-shank design allows it, readjustment of alignment can be made without a complete alteration of the prosthesis. Use of a relatively flexible cosmetic cover will probably be best for this purpose; if a plastic-covered foam shank is used, only destruction of the shank before realignment and a foam replacement and plastic finishing after realignment will be required. </p> <p> Most desirable would be one apparatus, perhaps coupling-like, which could be used in above-knee and below-knee prostheses alike. The present adjustable coupling is both too heavy and too expensive for this purpose. A. B. Wilson, Jr.<a style="text-decoration:none;">*</a> and Victor T. Riblett<a style="text-decoration:none;">*</a> have designed a simple and inexpensive plastic, tapered-disc device which might remain in the prosthesis after the primary alignment trials (<b>Fig. 19</b>). At present the device usually must be partly trimmed during the shaping of the limb for cosmetic finishing. Therefore, it could probably not be used at a later date for realignment purposes. But still this device will obviate transfer after initial alignment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Schematic drawing of the "Wilson-Riblett wedge," as applied to the VAPC coupling. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In eliminating only the primary-transfer process, a so-called "leave-in" alignment device must be priced at a level which would offer some gain to the prosthetist-user. If, at least with the regular coupling, alignment transfer involves an investment of approximately $5.00 in labor and materials by the limbshop, then the <i>one-time, </i>"leave-in" alignment device should cost somewhat less. But even so, possible saving per prosthesis or additional profit is of a very low order of magnitude. </p> <p> Needed is a device (and prosthesis design) which would allow realignment at a later date without major reconstruction of the prosthesis. Economic benefits would accrue to prosthetist and amputee alike; at least some of the major cost-saving in the realignment process can be passed along to the customer. Perhaps many prostheses now condemned for alignment reasons would not need to be. </p> <p> But most of all, such a device would offer convenience, allowing almost immediate accommodation to an amputee's needs. Instead of major delays in receiving a new alignment in a new or grossly altered older prosthesis, rather prompt prosthetist attention can be focused on an alignment problem in the existing limb. The prosthetist, if uncertain of an amputee's over-all fitting problem, can start with realignment of the existing prosthesis in his progressive analysis of the situation. He might be able to overcome what may seem to be socket-fit difficulties without major changes there. But, in any case, he would have readily available the mechanism for study of the problem and the problem's dependency on alignment. </p> <p> Prosthesis design must of course be changed to accommodate the permanent installation of such a unit. A below-knee shank should preferably be a pylon-cosmetic-cover type, somewhat similar to the Northwestern device. Preferably, the lower part of the above-knee limb thigh (where this device would be placed) should have an easily removable cosmetic cover. Perhaps a simple plastic finish over foam forced into the spaces around a lightweight, inexpensive coupling would be adequate. The foam would need to be cut away (or possibly dissolved by appropriate chemical means) when realignment was necessary. But even with present plastic-laminate finishing methods, realignment would involve only destruction of the laminate and then refinishing. </p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy,<i> Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars)</i>, Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </li> <li>Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, <i>The locomotor mechanism of the amputee</i>, Chapter 16 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954. </li> <li>Lyquist, Erik, <i>Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01</i>, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artificial Limbs, January 1955, p. 35. </li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputees</i>, Artificial Limbs, Spring 1957, p. 41. </li> <li>Staros, Anthony, and Henry Gardner, <i>Report on orthotics-prosthetics research developments in Yugoslavia</i>, Department of Health, Education, and Welfare, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Suggestions for fitting and aligning the SACH foot</i>, a chart, May 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Temporary prostheses for lower-extremity amputees</i>, Technical Report 1, September 1, 1962. </li> <li>Veterans Administration Prosthetics Center, <i>Use of the alignment coupling</i>, a chart, July 1962. </li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program</i>, Artificial Limbs, May 1954, p. 8. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Supervisor, Mechanical Development Branch, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Forest Glen Section, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, CPRD, NAS-NRC, 2101 Constitution Ave., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Temporary prostheses for lower-extremity amputees, Technical Report 1, September 1, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Lyquist, Erik, Jusieiingsapparat type VAPC oj overforingsapparat type OHK.14.01, Publikation NR 1/62, Ortopaedisk Hospital, Kobenhavn. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Lyquist (in November 1962) reported that the coupling was being used in all patellar-tendon-bearing fittings at the Orthopaedic Hospital. Some above-knee use was also reported.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry Gardner, Report on orthotics-prosthetics research developments in Yugoslavia, Department of Health, Education, and Welfare, 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Normally, if there is enough material here for the wood screws to attach the coupling, there will be enough material for this saw cut and the subsequent sanding without disturbing the socket itself.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Suggestions for fitting and aligning the SACH foot, a chart, May 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> With especially long above-knee stumps, the knee center must be dropped during alignment trials because of the thickness of the coupling. Later, during transfer, true or near-true knee-center height can be restored.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The over-all length of socket, knee unit, shank piece, and foot, plus 1-1/8 in. for the coupling, should be slightly larger than the amputees dimensional requirements. Later sanding after a height check will produce accurate longitudinal dimensioning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">All scales have neutral positions highlighted. The neutral positions on the tilt scales are most important in establishing the middle position of tilt, when top and bottom plates are parallel, or for disassembly, when it is important to unlock the coupling by having all four tilt screws down at least two increments below neutral.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, Use of the alignment coupling, a chart, July 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, Prosthetic principles, above-knee amputations (edited by Raymond E. Sollars), Charles C Thomas, Springfield, Illinois, 1960. See especially pp. 179-241. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954, p. 20. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomotor mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954, p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Anthony Staros, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Chief, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-034.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-035.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-036.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-037.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-038.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-039b.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-041.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-042.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-043.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-044.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-045.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-046.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-047.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-048b.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-050.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_01_031/1963-Spring_OCRBatch-051.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Dynamic Alignment of Artificial Legs with the Adjustable Coupling Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * https://staging.drfop.org/files/original/e9f6b0ca0af8a979b6d3b20f2d9bf767.pdf 1bf7ecb945d70a0277568f72c0dd60e4 https://staging.drfop.org/files/original/e15daffdfb1ccd3c85ae31f758316228.jpg c7dc78f031800bd557e5e56886799610 https://staging.drfop.org/files/original/d7ecccb8dead833240dffb959177354c.jpg c31f94bc12db418af7fb09b67b391776 https://staging.drfop.org/files/original/443471c199b97e3910f5097fdeb8663e.jpg 4d1970fb7af2dcebb6d5aab2f7a0cf6c https://staging.drfop.org/files/original/8dbf7c64f23ae2955b3479bbb5fb302b.jpg 6b10e90231ab54505b1f29f0b21d1b18 https://staging.drfop.org/files/original/3a7c493869b8831afd00e9855e6c13ed.jpg f1fadc470bf7c0e5e704d5a587bda07f https://staging.drfop.org/files/original/eafcf91b4f973afa24add247a75817cf.jpg ea25252f54c00432d4ae8cdacd36ceb0 https://staging.drfop.org/files/original/eaea3592bc911874251c428e1ed0160b.jpg c21941b7ba4a91a5aa35d3e543daa7b1 https://staging.drfop.org/files/original/c585a3d3e836903584dba11878c0eac4.jpg 27ffd0226c847cdedb8ccf353f198219 https://staging.drfop.org/files/original/d7bd659b04aae888f075c506f9f1384c.jpg 53058ebbcd650e261bf37943275d6def https://staging.drfop.org/files/original/c54a555fdecec535e9a9d65b05a7edad.jpg bb55f6b1b0e326f1b85948db260a2740 https://staging.drfop.org/files/original/8cd98250a947dc0e83ffe62feb4ce885.jpg 88a53d4cfc08a94c502625bde4132277 https://staging.drfop.org/files/original/df58327f0134c1887a1fbe9da76db215.jpg a1bcc591f0218b53b85af82918d4d5a3 https://staging.drfop.org/files/original/abfc8d66ef593ba1303fdceca612b1f7.jpg 3ab086cb4672a061b9c84c4f105a6734 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_017.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 17 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_017.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Porous Plastic Laminates for Upper-Extremity Prostheses</h2> <h5>James T. Hill, C.E., B.S. <a style="text-decoration:none;">*</a><br />Fred Leonard, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The problem of perspiration and its removal from the amputee's arm and leg stumps encased in sockets has engaged the attention of the doctor and limb fitter for as long as limbs have been fitted. </p> <p> In the early days of leather prostheses, a few months of wear during the summer were sufficient to cause the leather to rot and degrade because of perspiration. Since it was not possible to wash leather prostheses easily, severe hygienic problems were created. Efforts to coat leather with plastic films to overcome this difficulty were only partially successful for, in many instances, the adhesion of the coating was poor and frequent re-coatings were necessary. With the development of the all-plastic arm, it became possible to wash the socket thoroughly and virtually eliminate the hygienic problem. However, because the plastic did not permit diffusion of water vapor, sweat gathered profusely in the socket and became a source of discomfort and irritation. Efforts to permit diffusion of sweat by drilling gross holes in the plastic socket were not very successful. Although this practice permitted greater removal of sweat than in undrilled prostheses, the strength characteristics were seriously affected when a sufficient number of holes were cut to permit adequate removal. In addition, there still remained between the holes impervious plastic which could block large numbers of sweat pores-approximately 155 per square centimeter on the forearm<a></a>-and permit puddling between the plastic and the stump. </p> <p> It appeared that for optimum socket ventilation a porous-plastic socket should be developed which contained a large number of interconnnected pores. Such a socket should permit rapid diffusion of sweat with minimal blocking of sweat pores. The porous laminate envisioned would consist of a layered fabric resin composite with unbridged voids between the filler strands. Such material should be easily cleaned by soaking in detergent, followed by flushing with water. The following design criteria were outlined for the desired socket material: </p> <ol> <li>The socket material should have a uniform distribution of minute pores which would result in high porosity without blockage of sweat pores. </li><li>It should be easily cleaned.</li><li>Porous socket fabrication should conform as closely as possible with well-known fabrication techniques current in the practice of upper-extremity prosthetics.</li></ol> <p> Procedures for preparing porous upper-extremity prostheses were developed, utilizing the design criteria as a guide. In general, the method comprised the use of a solvent or diluent with an epoxy resin. After initial cure had occurred, the solvent was permitted to evaporate by removal of the outer polyvinyl-alcohol (PVA) bag. </p> <p> A series of experiments determined the combination of diluent, curing rate, and other factors necessary to produce a laminate with the optimum ratio between porosity and strength.<a></a> Evaluation at New York University indicated that the procedure initiallv developed by the Army Prosthetics Research Laboratory produced a satisfactory material insofar as porosity and strength were concerned but that use of the conventional stockinet as filler produced rough surfaces that made cleaning difficult. Subsequent experiments at the Army Prosthetics Research Laboratory showed that this problem could be overcome by using a nylon stockinet of 200-denier Banlon knit (<b>Fig. 1</b>) for the outer and inner layers of the laminate and by the reapplication of a PVA bag at a critical time in the curing process. Further testing and development resulted in a practical technique which is described in detail in a manual prepared by the Army Prosthetics Research Laboratory.<a></a> Sockets fabricated in accordance with this manual have smooth surfaces and high porosities. Patients fitted with porous sockets have reported a definite increase in comfort as a result of improved ventilation.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Porous epoxy laminate made in accordance with the procedure developed at the Army Prosthetics Re search Laboratory. Magnification approximately 21X. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Laboratory tests have shown that porous epoxy laminates are not as strong in compression and tension as nonporous laminates, but that resistance to impact loads appears to increase with the porosity and reach a maximum at approximately 17 per cent of effective porosity.<a style="text-decoration:none;">*</a> In practice, the combination of physical properties possessed by the porous laminate which has been developed is satisfactory for use in arm prostheses. Experiments in the use of porous laminates for lower-extremity prostheses are under way. </p> <p> If actual prosthetist working time is considered, the man-hours required for fabrication of porous laminates are somewhat longer than those required for the conventional plastic laminates. Depending on the technique employed, the porous laminating process may take up to one-and-one-half times as long as the conventional technique. </p> <p> The components of the liquid resin system may elicit allergic reactions in certain sensitive individuals. Therefore, fabrication should take place in a well-ventilated area and protective gloves should be used in preparing the layup. </p> <p> No stump dermatitis or other adverse reactions have been reported from the use of the porous laminates to date. </p> <p> Because the socket is porous, it is necessary that it be cleaned thoroughly and often in order to preclude an accumulation of foreign matter in the pores of the wall. It is recommended that ordinary soap and water be used for this cleaning. </p> <p> Porous laminates may be considered for application to all upper-extremity amputation levels from below-elbow to shoulder-disarticu-lation. The technique is of particular value whenever perspiration presents a significant problem. </p> <h4> Epoxy-Resin Mixture </h4> <p>The following epoxy-resin system has been found to produce a satisfactory porous laminate:</p> <table> <tbody><tr> <td> </td> <td> </td> <td>parts by weight</td> </tr> <tr> <td>Epoxy resin    </td> <td>ERL 2795<a style="text-decoration:none;">*</a>or Epon 815<a style="text-decoration:none;">*</a>    </td> <td>65</td> </tr> <tr> <td>Curing agent</td> <td>Versamid 140<a style="text-decoration:none;">*</a></td> <td>35</td> </tr> <tr> <td>Solvent</td> <td>Trichloroethylene</td> <td>43</td> </tr> </tbody></table> <p> The "pot life" of the liquid resin mixture resulting from this formulation is never less than 30 minutes and usually considerably longer. </p> <p> The individual limb fitter can best determine the actual amount of resin mixture required for a particular lamination. Appendix A (page 29) contains a table which may serve as a guide in determining the correct amounts of materials for various applications. </p> <h4> Fabrication </h4> <p> Briefly described here is the fabrication of a double-wall, below-elbow, porous prosthesis, utilizing a plaster-of-Paris (or wax) buildup; this account is followed by a brief description of the fabrication of a single-wall, below-elbow, porous prosthesis, based on the Mylar<a style="text-decoration:none;">*</a> cone method.<a style="text-decoration:none;">*</a> </p> <h4> Double-Wall, Below-Elbow, Porous Prosthesis </h4> <p> For the fabrication of a double-wall, below-elbow, porous prosthesis, the stump model is prepared in accordance with common practice<a></a>. As shown in (<b>Fig. 2A</b>), the model is then placed in a vise, distal end up, and coated with a lacquer such as Hi-Glo.<a style="text-decoration:none;">*</a> When this coating has dried, a moistened sheet of PVA is stretched over the model and tied at the base (<b>Fig. 2B</b>). The next step in preparing the layup is to cut one length of tubular Banlon stockinet with a 200-denier weave<a style="text-decoration:none;">*</a> and three lengths of tubular orthopedic stockinet so that each is at least 6 inches longer than the stump model (<b>Fig. 2C</b>). The end of each piece of stockinet is sewed in a curve to match the distal end of the model, and the excess stockinet is trimmed at the sewed end. The Banlon stockinet is turned inside out and pulled down over the model (<b>Fig. 2D</b>). Two of the orthopedic stockinets are pulled down over this. Then the remaining piece of stockinet is turned inside out and pulled down over the layup. The stockinet is smoothed, pulled down tightly, and tied at the base. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Preparing the layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A PVA pressure sleeve is now prepared in the usual manner, pulled down snugly over the layup, and tied at the base rod (<b>Fig. 3A</b>). The layup is ready for impregnation, and it is time to mix the resin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Applying the resin mixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To measure the ingredients for the resin mixture, it is well to balance a disposable container, such as a paper cup, on a scale. The resin, curing agent, and solvent are then put in the cup in the proper amounts by weight. By referring to the table contained in Appendix A (page 29), it can be seen that the following quantities should be sufficient for a short below-elbow socket: </p> <table> <tbody><tr> <td>ERL 2795 (resin).................</td><td>45.5 grams</td> </tr> <tr> <td>Versamid 140 (curing agent)......</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene (solvent)......</td> <td>30.0 grams</td> </tr> </tbody></table> <p>To this resin mixture should be added an appropriate pigment; for example, 2.5 grams of Caucasian epoxy pigment or 3.5 grams of Negroid epoxy pigment (Appendix A, page 29). The pigment is stirred into the mixture until it is uniformly blended. </p> <p> The resin mixture is poured into the open end of the PVA sleeve and worked down into the stockinet. Twisting the end of the sleeve (<b>Fig. 3B</b>) develops considerable force and aids in the impregnation. </p> <p> When the stockinet is fully impregnated, the PVA sleeve is pulled down, and the excess resin is "strung" down to the proximal end of the layup (<b>Fig. 3C</b>). Next, the PVA sleeve is cut and removed from the layup. Care should be exercised not to spill the excess resin contained in the bottom of the sleeve. The sleeve and the excess resin are discarded. Spilled resin may be cleaned off with isopropyl alcohol or trichloroethylene. The layup is "strung" with a heavy string until no further excess resin appears (<b>Fig. 3D</b>). </p> <p> The layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), for what is known as the pre-cure. During this stage, the solvent evaporates from the layup, leaving it porous. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven, and the oven is set at 212 deg. F (100 deg. C) for the cure. At this step in the procedure, the solvent has evaporated and the resin has gelled slightly. If any areas of the laminate contain excess resin, the excess is "strung" to the proximal end. When the oven has reached a temperature of 212 deg. F (100 deg. C), the laminate is placed back in the oven for one hour. During this hour, the laminate will be cured sufficiently to permit the buildup for the outer socket. </p> <p> At the end of the hour, the laminate is removed from the oven, and the oven is set at 115 deg. F (47 deg. C). </p> <p> As soon as the laminate is cool enough to handle, a sheet of Saran-Wrap or rubber sheeting is placed over the laminate as a separating medium. This sheet will facilitate the release of the outer socket which is to be laminated over the inner shell. </p> <p> For the forearm buildup, plaster of Paris is considered preferable rather than wax, for the reason that wax may enter the pores of the prosthesis. The buildup is done in the usual manner (<b>Fig. 4A</b>). After the plaster has hardened, the paper cone is removed and the plaster of Paris is shaped to the desired contour. Any plaster on the knurled surface of the wrist unit is removed. The plaster is coated with Hi-Glo or some similar lacquer. A PVA sleeve is prepared, moistened, pulled down over the buildup, and trimmed at the wrist unit (<b>Fig. 4B</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The forearm buildup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, a piece of Banlon stockinet and a piece of orthopedic stockinet are cut, each about 3 to 5 inches longer than the layup. Another piece of orthopedic stockinet is cut, a little more than double the length of the layup. (Additional lengths of stockinet may be used if additional strength is desired.) </p> <p> The Banlon stockinet is turned inside out, pulled 1 to 2 inches over the distal end, and tied at the wrist unit (<b>Fig. 4C</b>). Excess stockinet that is proximal to the wrist unit is trimmed off. </p> <p> The short piece of orthopedic stockinet is pulled over the longer piece so that both pieces meet at one end. The other end of the short piece should extend just past the middle of the longer piece. </p> <p> These pieces of stockinet are extended and slipped, double end first, down over the wrist unit until the double thickness covers the entire layup (<b>Fig. 4D</b>). The double thickness of stockinet is tied at the wrist unit and pulled down and tied at the proximal end. The Banlon stockinet should be on the inside. Two PVA pressure sleeves are now prepared in the usual manner, with the shiny surface of the material on the inside. One sleeve is set aside to be used later. The other is pulled down snugly over the layup and tied to the base rod at the proximal end. </p> <p> Resin and pigment are mixed in the manner described previously. For a short or medium below-elbow forearm, the following quantities should be sufficient: </p> <table> <tbody><tr> <td>ERL 2795............</td> <td>68 grams</td> </tr> <tr> <td>Versamid 140........</td> <td>37 grams</td> </tr> <tr> <td>Trichloroethylene...</td> <td>45 grams</td> </tr> <tr> <td>Pigment..................</td> <td>As required to match previous mix</td> </tr> </tbody></table> <p> The resin is poured into the pressure sleeve (<b>Fig. 5</b>) and worked into the stockinet. When the stockinet is fully impregnated, the pressure sleeve is pulled down as far as possible, and the excess resin is "strung" down from the layup. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Impregnating the forearm layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the layup has been thoroughly "strung" down, the PYA sleeve is stripped off and discarded. The layup is "strung" once more to remove all excess resin. </p> <p> There may be considerable resin in the stockinet around the base rod. This excess resin should be absorbed in the scrap stockinet wrapped around the base, so that it will not be drawn back into the laminate during the cure. </p> <p> For the pre-cure, the layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), allowing the solvent to evaporate. </p> <p> While the pre-cure is taking place, the second PVA pressure sleeve previously prepared should be moistened by wrapping it in a damp towel for 10 to 15 minutes. The next step in the procedure gives the prosthesis a smooth surface, and it is essential that the PYA sleeve be thoroughly moistened. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven. The moistened PVA sleeve is pulled down until the entire layup is in contact with the sleeve. Light contact pressure is most desirable, for this will result in a smooth surface without reducing the porosity. It is important that the sleeve slide easily over the layup; otherwise, the force and pressure may cause pooling of the resin. At this point in the procedure, there should be no pools of resin on the stockinet. If there are, they should be "strung" out. </p> <p> The PVA sleeve is taped around the wrist unit (<b>Fig. 6</b>); any severely undercut areas should also be taped. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Molding the surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The layup is now placed for one hour in an oven pre-set at 212 deg. F (100 deg. C). During this period the PVA sleeve shrinks around the layup, giving the surface a smooth gloss and aiding in molding the undercuts. At the end of the hour, the laminate is removed from the oven and the PVA sleeve is stripped off. At this point the laminate should be firm and free from tackiness. </p> <p> The laminate is now ready for the final cure. It is replaced in the oven, set at 212 deg. F (100 deg. C), for 75 minutes to complete the final cure. </p> <p> While the plastic is still warm, the layup is cut to the desired length. The outer socket will separate easily from the inner socket. The plaster may be removed by striking the socket with a rubber mallet. If necessary, a chisel may be used to dig the plaster out of the distal end of the socket. Remaining PVA film can be stripped off by hand or dissolved with hot water. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked, after which the socket is removed and trimmed in the usual manner. After the socket and the forearm have been properly aligned, the edges are sanded and bonded together with liquid epoxy resin (ERL 2795, 65 parts; Versamid 140, 35 parts) (<b>Fig. 7</b>). The bond may be cured with a heat gun, or the prosthesis may be placed for one hour in an oven set at 212 deg. F (100 deg. C). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Bonding the socket and forearm </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The porosity of the finished prosthesis can be tested by holding it under a water tap and allowing the water to run through the prosthesis (<b>Fig. 8</b>). If the prosthesis has been prepared properly, the laminate should show a uniform porosity. The prosthesis is now ready to be harnessed in the usual manner. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Testing the porosity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Single-wall, Below-Elbow, Porous Prosthesis (Mylar Cone Method) </h4> <p> For the fabrication of a single-wall, below-elbow, porous prosthesis, the stump model is prepared in the usual manner,<a></a> placed in a vise, distal end up, and coated with lacquer. When the lacquer has dried, a moistened PVA sheet is pulled down over the stump model and tied at the base. </p> <p> The stockinet layup, consisting of one length of tubular Banlon stockinet and three lengths of tubular orthopedic stockinet, is prepared in the same manner as the stockinet layup for the socket of the double-wall prosthesis previously described. </p> <p> When the stockinet layup is completed (<b>Fig. 9</b>), a sheet of PVA is pulled down over the layup and tied at the base rod. This PVA cover will protect the layup during subsequent steps. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The stockinet layup on the model. A PVA sheet is pulled down and tied at the base rod. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, on an 8 in. X 12 in. sheet of Mylar (5-10 mils), a crayon mark is made halfway along one of the sides, about one-quarter in. from the edge. A second mark is made one-half in. inside the first mark. Then two final marks are made; one 3 in. above the first mark, the other 3 in. below the first mark. A curve is drawn from the edge of the Mylar sheet through the upper mark, through the inside mark, through the lower mark, and thence to the edge of the sheet. A cut is made along the curve. This cut side will permit the standard adult wrist unit to fit squarely to the Mylar sheet when it is fitted into a cone (<b>Fig. 10A</b>). The wrist unit should be fitted a minimum distance into the cone. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Mylar cone buildup and impregnation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The cone is placed over the stump model and adjusted so that the desired contour of the finished prosthesis will be obtained. Next, the prosthetist holds the cone and wrist unit in one hand, placing the unit flat on a table. With the other hand, he positions the stump model in the cone so that the distance between the elbow axis and the table surface corresponds to the required forearm length. The cone is adjusted at the proximal end, and the excess is trimmed off. The shortest cone that will give a desirable final shape to the forearm should be used, since it will provide the greatest bond area between the forearm and the socket. When the correct conical shape is obtained, the cone is closed with transparent tape, the proximal end of the cone is taped to the socket with transparent tape, the wrist unit is taped in place, all holes in the unit are closed with a sealer, and all seams are taped. </p> <p> Next, a piece of orthopedic stockinet is cut so that it is at least 10 in. longer than twice the length of the layup. The stockinet is pulled down over the entire layup in such a manner that half of the stockinet extends above the wrist unit. The stockinet is tied at the wrist unit, and the extended half of the stockinet is pulled back down over the layup. The stockinet is pulled smooth and tied at the base rod. </p> <p> The proximal edge of the Mylar is found by palpation, and a light line is drawn around the layup just distal to the edge of the cone. All the areas below this line are covered with masking tape (<b>Fig. 10B</b>). </p> <p> A batch of resin is mixed as follows: </p> <table> <tbody><tr> <td>ERL2795...................</td> <td>45.5 grams</td> </tr> <tr> <td>Versamid 140..............</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene.........</td> <td>30.0 grams</td> </tr> </tbody></table> <p> Sufficient pigment is added to give a slight color to the batch. </p> <p> The entire layup is inverted and brush-coated with this resin mixture. The excess resin is "strung" down toward the wrist unit (<b>Fig. 10C</b>). </p> <p> The layup is now placed for 30 min. in a pre-heated oven set at 115 deg. F (47 deg. C) for the pre-cure. After the cone has been pre-cured for 30 min., the oven temperature is increased to 212 deg. F (100 deg. C) and the cone is cured for 30 min. at this temperature. </p> <p> The layup is then removed from the oven, the masking tape is removed from the lavup, and the cone is separated from the inner socket. The Mylar sheeting is removed from inside the porous cone. The porous cone is sanded around the wrist unit until a smooth taper is obtained (<b>Fig. 11</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Sanding the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With the table contained in Appendix A (page 29) as a guide, a 250-gram batch of resin mixture is prepared, including in it a suitable amount of pigment. </p> <p> At this point the PVA sheet placed over the socket layup early in the procedure is removed, and a PVA sleeve is placed over the socket layup. </p> <p> The inner socket layup is impregnated with resin in the usual manner. Excess resin is removed from the layup by "stringing," the PVA sleeve is removed from the layup, and any excess resin is "strung" out. </p> <p> Now the porous cone is pulled down over the inner socket and aligned so that the wrist unit is in the proper position. The stockinet is tied at the base rod (<b>Fig. 12A</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Preparing the layup combining the socket and the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A piece of Banlon stockinet is cut so as to be 3 to 5 in. longer than the layup, and a piece of orthopedic stockinet is cut so as to be twice the length of the Banlon stockinet. One end of the Banlon stockinet is tied around the wrist unit. The orthopedic stockinet is pulled over the Banlon stockinet and tied at the middle around the wrist unit. (Additional layers of stockinet may be used if greater strength is required.) All layers of stockinet are pulled down over the layup and tied at the base rod (<b>Fig. 12B</b>). </p> <p> The layup is now thoroughly impregnated with the remaining resin mixture, with the use of a PVA sleeve and "stringing." It is very important that all the excess resin be "strung" down toward the proximal end, so that there will be no pooling of resin when a PVA bag is pulled down in a subsequent step. A few pieces of scrap stockinet should be wrapped around the base pipe to absorb excess resin. </p> <p> The layup is now placed for 30 min. in an oven pre-set at 115 deg. F (47 deg. C) for a pre-cure. While the layup is pre-curing, a PVA sleeve is prepared to fit the forearm. The PVA sleeve is wrapped in a moistened towel for 10 to 15 min. during the pre-cure. At the end of the pre-cure, the layup is removed from the oven and any excess resin is "strung" out. The oven temperature is increased to 212 deg. F (100 deg. C). Meanwhile, the moistened PVA sleeve is pulled down over the layup so that the entire laminate is in firm contact with the sleeve. If the sleeve is sufficiently moist, it will slide easily over the layup without causing any resin pools. However, if any resin pools do form, they should be "strung" out of the laminate. The PVA sleeve is taped around the wrist unit and any undercut areas to insure proper lamination. </p> <p> The laminate is now placed for 60 min. in the oven, previously set at 212 deg. F (100 deg. C). At the end of 60 min., the laminate is removed from the oven and the PVA sleeve is stripped off. At this point, the laminate should be free from tackiness. </p> <p> For the final cure, the laminate is replaced in the oven, still set at 212 deg. F (100 deg. C). </p> <p> After the final cure, the laminate is removed from the oven and cut to the desired length. The laminate should separate easily from the mold. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked. Then the socket is removed and trimmed in the usual manner. </p> <h4> Polyester-Resin Mixture </h4> <p> Shortly after the initial success of the porous epoxy laminates, attempts were made to produce similarly porous polyester laminates. At first these attempts were unsuccessful. Although highly porous laminates were produced, their physical strengths were inadequate for prosthetic application. </p> <p> However, because of significant improvements in the method of preparing porous epoxy laminates, particularly through the reapplication of a PVA bag at a critical time in the curing process, it was decided to reinvestigate the porous polyester system. The Army Prosthetics Research Laboratory has produced a series of cylindrical, porous polyester laminates which have shown when tested a strength sufficient for prosthesis<a></a>. Preliminary results of the evaluation are promising. The fabrication procedures presently recommended are the same as have been described for porous epoxy laminates in this article and set forth in full in <i>A Manual for the Preparation of Above and Below Elbow Prostheses, </i><a></a> published by the Army Prosthetics Research Laboratory. <b>Appendix A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Appendix A: Color appropriate for the individual should be added to the resin mixture and stirred in until it is uniformly blended. For a 100-gram mixture, 1 to 4 grams of color is sufficient. Epoxy pigment, Caucasian, tan, No. 22826 (60% pigment) and epoxy pigment, Negroid, brown, No. 22831 (53% pigment) (Plastics Color Company, 22 Commerce Street, Chatham, N. J.) have been used successfully at New York University (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The following polyester-resin formulation is tentatively suggested for a medium below-elbow porous prosthesis: </p> <table> <tbody><tr> <td>Laminae 4110<a style="text-decoration:none;">*</a></td> <td>80 grams</td> </tr> <tr> <td>Paraplex P-13<a style="text-decoration:none;">*</a></td> <td>20 grams</td> </tr> <tr> <td>Luperco ATC<a style="text-decoration:none;">*</a></td> <td>3 grams</td> </tr> <tr> <td>Trichloroethylene</td> <td>43 grams</td> </tr> <tr> <td>Naugatuck Promoter No.3<a style="text-decoration:none;">*</a>   </td> <td>6 drops</td> </tr> <tr> <td>Polyester pigment</td> <td> +/- 1 gram</td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li><p>Gray, Henry, <i>Anatomy of the human body</i>, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </p> </li> <li><p>Hill, James T., <i>A manual for the preparation of above and below elbow porous prostheses</i>, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </p> </li> <li><p>Hill, James T., and Egbert de Vries, <i>Evaluation of porous epoxy laminates for use in prosthetic arms</i>, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </p> </li> <li><p>Hill, James T., Egbert de Vries, and Fred Leonard, <i>Porous plastic laminates</i>, SPE Journal, Vol. 16, No. 9, September 1960. </p> </li> <li><p>Hill, James T., <i> Porous polyester laminates</i>, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </p> </li> <li><p>New York University, <i>Adult Prosthetic Studies</i>, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</p> </li> <li><p>New York University, Prosthetics and Orthotics, Post Graduate Medical School, <i>Guide for fabrication of double wall porous epoxy prosthesis for short B/E</i>, September 1961. </p> </li> <li><p>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B Lippincott Co., Philadelphia, Pa., 194S. </p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper-extremity prosthetics</i>, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">U. S. Rubber Co., Naugatuck Chemical Division, Naugatuck, Conn.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Wallace and Tiernan, Incorporated, Lucidol Division, 174 Military Road, Buffalo, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Rohm and Haas Company, Philadelphia 8, Pa.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">American Cyanamid Company, Plastics Division, 30 Rockefeller Plaza, New York 20, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hill, James T., Porous polyester laminates, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Wm. H. Horn and Bros., Philadelphia, Pa.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> Western States Lacquer, Dallas, Tex. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Both accounts compiled for CPRD, NAS-NRC, from A Manual for the Preparation of Above and Below Elbow Porous Prostheses(2), published by the U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">DuPont Corporation Trademark.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">General Mills Chemical Division, Kankakee, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Shell Chemical Company, New York, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Bakelite Chemical Division, Union Carbide Chemical Company, New York, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Effective porosity is the ratio of the quantity of water that flows through the laminate to the amount that flows through the stockinet alone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Egbert de Vries, Evaluation of porous epoxy laminates for use in prosthetic arms, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </td></tr><tr><td class="clsTextSmall"><b> 4.</b> </td><td class="clsTextSmall">Hill, James T., Egbert de Vries, and Fred Leonard, Porous plastic laminates, SPE Journal, Vol. 16, No. 9, September 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Gray, Henry, Anatomy of the human body, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Leonard, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Scientific Director, APRL, WRAMC, Washington 12, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James T. Hill, C.E., B.S. </b></td></tr><tr><td class="clsTextSmall">Chief, Process Engineering Section, U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-21.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-24.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-25.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-26.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-27.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-28.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29b.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-31.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-32.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-33.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Porous Plastic Laminates for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource James T. Hill, C.E., B.S. * Fred Leonard, Ph.D. *