7 20 371 https://staging.drfop.org/files/original/e678471a88e3fafdcc78502486bb9378.pdf 0c896873793ae2afd1dd418dddff6f7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_001.pdf Year 1956 Volume 3 Issue 1 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/1956_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_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>Lesson In Lesions</h2> <h5>C. Leslie Mitchell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human integument, with its complex structural and functional organization, is one of the most remarkable packaging materials in the world. Unlike inanimate wrappers however elaborate, it has under ordinary circumstances the extraordinary facility of regenerating itself, of adapting to the local environment, and of resisting attack by all kinds of agents-chemical, physical, and biological. The reason for this situation lies in the fact that living skin, as is the case with other living tissues, undergoes continuous metabolism, with consequent growth and decay.</p> <p>But in addition to its mechanical function-that of providing a tough, protective outer covering for the body-the skin has many important but little-recognized physiological properties, among these being its ability to function as a respirator in the exchange of oxygen and carbon dioxide; as a regulator of body temperature by means of sweat glands under control of the sympathetic nervous system; as an agent in the conservation of water and electrolytes; as a sensory organ to record heat, cold, pain, and touch; as a corridor for the reception of vitamins and hormones; and as a barrier against infection. Despite all these indispensable services, the integrity of the skin is so much taken for granted by almost everybody that usually no attention is directed to it until some deviation from the normal develops. Its numerous functions are poorly understood by most laymen, if not indeed by many physicians. Yet neglect of its proper care can result in serious consequences.</p> <p>Proper functioning of the skin is dependent on many factors, such for example as freedom from constriction and irritation, adequate exposure to air, prompt removal of waste products from its surface, and avoidance of extremes of heat and cold. Whenever the skin is subjected to abnormal insults, the problem of skin care is multiplied many times. Since the wearing of a prosthesis, particularly on the weight-bearing lower extremity, unavoidably creates most of the conditions-constriction, excessive moisture, increased heat, mechanical irritation, and undue pressure-conducive to poor skin health, it quite naturally places upon the skin of the stump a set of demands far in excess of the normal. And not only that. Having lost one of his principal heat-radiating "fins," and being at the same time required to exert in locomotion more energy than does the normal person, the leg amputee commonly perspires more freely than normal, and hence his needs for skin hygiene are more acute than are those for one who walks on two natural legs.</p> <p>The basic requirements of a lower-extremity prosthesis are to provide comfort, function, and appearance. Of these, comfort is unquestionably of chief importance, for without comfort the amputee will fail to obtain satisfactory function, or appearance, or both, and will ultimately either limit use of the prosthesis or else find it impossible to wear it at all. In a large percentage of cases of difficulty or failure, skin lesions of one type or another involving the stump are found to be the cause of discomfort, thus preventing the amputee from wearing the limb. Prophylaxis is, therefore, a <i>sine qua non </i>in this regard, and only through adequate knowledge of skin physiology can these disorders be anticipated and thus prevented.</p> <p>Although disabling skin lesions on the stump of the leg amputee have constituted a serious complication ever since prostheses were first used for the lower extremity, full appreciation of the problem and suggestions for solution have not been forthcoming until recently. As has been typical with most problems in medicine, little was accomplished until a concerted effort was made to understand normal function and to investigate reaction to the abnormal. It is encouraging to note that there is now well under way, with the sponsorship of the Prosthetics Research Board of the National Academy of Sciences-National Research Council, a systematic attack aimed at solution of the cutaneous problems of the leg amputee.</p> <p>Because even the most satisfactory lower-extremity prosthesis is of no avail if the amputee is deprived of wearing it, and because painful skin lesions in a leg stump have so frequently been the cause of inability to use an artificial leg properly, the then Prosthetic Devices Research Project at the University of California, Berkeley (now the Lower-Extremity Amputee Research Project), in conjunction with the Department of Dermatology at the University of California Medical School in San Francisco, organized in the autumn of 1954 a skin-study group to investigate the cutaneous difficulties of the lower-extremity amputee. In the course of the succeeding two years there has been accumulated a considerable body of new knowledge, not only on the nature and physiology of healthy skin but also on some of the specific clinical manifestations of skin disorders in amputees. Since the proper management of cutaneous disturbances is so essential to lower-extremity function, this issue of Artificial Limbs is devoted to a presentation of some of the information gathered thus far. In the first of two articles, a dermatologist discusses the anatomy and physiology of normal skin and what is to be expected when healthy skin is subjected to unfavorable conditions. In the second, another dermatologist characterizes the common skin maladies of leg amputees and offers suggestions for prevention and treatment.</p> <p>An interesting observation is that proper care of the stump skin is found to be the responsibility not only of the attending physician and the prosthetist but, and even more important, of the amputee himself. Nevertheless, simple attention to good practices of daily hygiene is not enough. A considerable number of skin disorders peculiar to the lower-extremity stump present themselves despite all precautions. Some are common to all leg amputees. Many are the result of individual skin idiosyncrasies or of climatic conditions. Some are so intractable as to be amenable to cure only by total excision.</p> <p>While the newer understanding has in recent years appreciably decreased the incidence of serious skin lesions in leg amputees and has made it more readily possible to deal successfully with some of those that do occur, it is obvious that much work remains to be done. For the complete etiology of many of the characteristic disease states yet remains to be elucidated. It is to be hoped that the initiative taken by the pilot study group at the University of California may prove to be a stimulus for similar investigative work at other centers of medical research throughout the world. The lesson is here for us to learn. Unless skin problems can be eliminated once and for all, there can be no true rehabilitation of the lower-extremity amputee.</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>C. Leslie Mitchell, M.D. </b></td></tr><tr><td class="clsTextSmall">Surgeon-in-Charge, Division of Orthopaedic Surgery, Henry Ford Hospital, Detroit; member, Prosthetics Research Board, NAS-NRC.</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 Lesson In Lesions Creator An entity primarily responsible for making the resource C. Leslie Mitchell, M.D. * https://staging.drfop.org/files/original/4466dc9f88049d40488d6be216fd66d6.pdf df7dcc4340714709da0ed7b7c1699d85 https://staging.drfop.org/files/original/53b5a7a21d9da4b70e22698b5a760aaa.jpg 580a52b9ef39dda90026098898a6a1ce https://staging.drfop.org/files/original/a0eb985726680bed7cd45922e2034e1d.jpg c4a800fceb94238c2677ac1353245ed1 https://staging.drfop.org/files/original/67e644fd9e00ecd25e6e49a71794f407.jpg 60eaf7d0437847d9e266dcd9fbc1c939 https://staging.drfop.org/files/original/589ba45ffbb62595ca1df05cfeb159c0.jpg 8566b117423ddacb7a5d4153e234f8a8 https://staging.drfop.org/files/original/36ba8f4a7fa3b03421d6f86028269823.jpg 1abb24b7a318ac3b59305fe354af6d54 https://staging.drfop.org/files/original/073598b3381e4a6ac1c6962280a87675.jpg 5b5ae92ad35825fadc4a43eca508978b https://staging.drfop.org/files/original/720a349f49e9cd4af439cb42bebb620b.jpg 10091d4c9cdda7e591209ada36971ae1 https://staging.drfop.org/files/original/f376141812a404af3010dfdf6dbedf29.jpg da6eec89495628a12e65102fc753e2b6 https://staging.drfop.org/files/original/206ae750fa9a0a06275a4a9cc9a4dce8.jpg 724c967272fa84216d1830d4dd4d9548 https://staging.drfop.org/files/original/73d9f7175d3a09f5fd09ba00e95cca0e.jpg 394abd72058740013c9e1f4ea0d5011f https://staging.drfop.org/files/original/a44144b9c6d5a256cd7da054cf8621d2.jpg 418b6d99ee67aedca58cceff52f4205e https://staging.drfop.org/files/original/a716afbeccd1b0841e1ff0e4c66fc23d.jpg e9abb6131a86c67ffdd79c69428ff2a8 https://staging.drfop.org/files/original/eb429fccd53602c04c0a0d04864cad6f.jpg 99826548df6f19c657326b20ba9434f3 https://staging.drfop.org/files/original/16212ba76062ab46774d405e1c0d6dbb.jpg 10231e0bc58bc0d853c27072bd4f19fd https://staging.drfop.org/files/original/8eb0c9a2760981415e2d2ac1a225b498.jpg 1078787fef23aa145c6f4ba544fa286b https://staging.drfop.org/files/original/c7712445845a41b936dc9aeb5cf902d3.jpg 18d9adab9f4fb258d754543b62f65721 https://staging.drfop.org/files/original/067afcb3523416f2f0455fb4e8973fd5.jpg 6b11e8017d8bf6ffd5e528d796afc842 https://staging.drfop.org/files/original/05def91a2bbdd073ada3f01fe3651289.jpg e36c49e73001acd8cb53a05c873baf00 https://staging.drfop.org/files/original/30f0645250433050bcfeab5015060e2d.jpg e054259f8d752d7f0859d67bd239c669 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_026.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 26 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_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>Harness Patterns for Upper-Extremity Prostheses</h2> <h5>Robert J. Pursley, Lt., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The comparatively recent development of more functional components for artificial arms has made it necessary to analyze in greater detail the requirements of harnessing the power needed for effective operation. Just as an automobile is helpless without a well-designed and well-built engine and transmission system, so an arm prosthesis is helpless without a well-designed and well-constructed harness. To build a successful harness system requires not a knowledge of some long-lost art but, instead, a careful appraisal of the wearer, of the device to be worn, and of the available tools to be put to work. Since the modern body harness constitutes a dynamic coupling between a human being and a mechanism designed to replace a living extremity, the problem of devising it is also one of dynamics and of what some call "human engineering."</p> <p>Many illustrations of typical harness patterns are presented later in this article. But it is not enough for the harnessmaker simply to reproduce what is shown in these drawings of typical patterns or to superimpose on an individual amputee a generalized harness pattern of any particular type. He must first understand the purpose of the harness, the requirements of the particular prosthesis involved, and the body motions available, and he must then apply his own skill and judgment in making appropriate modifications to suit the individual case. It is, of course, far more important to produce a harness that will give the desired functional results than it is to produce one that looks exactly like any one of the drawings. The illustrations are therefore intended as general guides only, not as a detailed description applicable to every case of amputation at the indicated level. When planning and making any harness, the prosthe-tist should examine the location of each element to ensure proper function with the expenditure of minimum effort on the part of the particular wearer concerned.</p> <p>The first and most simple requirement of any harness is that it must hold the prosthesis securely on the stump. The second is that it must be comfortable to the amputee. Generally, suspension, as such, is easily obtained, but to suspend the prosthesis properly and at the same time to assure maximum comfort for its wearer is more difficult. If either of these requirements becomes a matter of choice, then comfort must be the more important consideration. If the harness is not comfortable, or at least tolerable, the person for whom it was intended will soon hang it politely on a suitable nail. Since almost no harness can be constructed satisfactorily without a few compromises at first, it is unwise to promise complete success on the first try.</p> <p>The third and all-important requirement of functional body harness is that it must supply a source of power for the operating components of the prosthesis. This means simply that residual body motions must be harnessed to replace lost functions of the natural member, but to provide controls that are operable in an effective and yet inconspicuous manner poses a complex problem. It requires an examination of the body motions that can be utilized by the harness without detracting from the usefulness of the remaining normal hand and without introducing unduly awkward gyrations of parts of the anatomy not ordinarily involved in arm activity. The higher the level of amputation, the greater the control requirements but the fewer the sources of control. The problem is further complicated by the need to maintain the proper balance between adequate suspension, acceptable comfort, and worthwhile function, for each of these needs is often satisfied only at the expense of the other two. A look at the background of harnessing for upper-extremity prostheses <a></a> reveals that, when devices were generally passive in nature, so was the harness. As devices have increased in function, so has the harness also. Today the development of devices has in general surpassed the art of harnessing them. With the proper approach, however, and using a common-sense analysis both of the amputee's capabilities and of the requirements of the prosthesis, an accomplished limbfitter can in almost every case turn out a very acceptable harness that will meet functional needs to a surprising degree.</p> <h4>Harnessing for the Below-Elbow Cases</h4> <p>The prosthesis for the unilateral below-elbow case is unquestionably the simplest to harness. For the reason that the below-elbow amputee retains his own elbow, and therefore usually requires replacement of prehension only, he can almost without exception be harnessed successfully. At least three feasible control motions are to be had. In order of decreasing usefulness, they are arm flexion on the amputated side, shoulder depression on the amputated side, and scapular abduction. The choice and extent of use of these three motions, singly or in combination, is largely a matter of personal preference depending on the area in which the terminal device is required to operate. With the elbow flexed to 90 deg. and with the terminal device located slightly above the level of the head, for example, arm flexion is almost completely spent. Using scapular abduction under the same circumstances, however, the below-elbow amputee can still operate the terminal device satisfactorily. Successful wearers of below-elbow prostheses develop their own individual patterns of operation and subconsciously learn to operate the device in all areas in which it is called upon.</p> <p>The problem of transmitting the force and excursion of body motions from the source to the point of use has in the past involved a wide variety of materials. Rawhide thongs and leather laces are only two of many that have been used, even as late as only a decade ago.<a></a> The flexible metal cable and wrapped-wire housing adopted from the aircraft industry is currently the most widely used and is the most satisfactory available today. It is based on the Bowden principle (<b>Fig. 1</b>), which makes it possible to transmit force and excursion from the body to the terminal device regardless of elbow angle.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The principle of the Bowden cable for transmitting tension forces applied at one end. Although point <i>C </i>is brought closer to point <i>A </i>when rotation occurs about <i>B, </i>the housing <i>D </i>prevents slack in cable <i>E </i>by preserving the <i>effective </i>path length <i>A </i>to C. A counter-force is required at the opposite end to return the flexible cable to its original position. Other types of Bowden cables are based on the torque principle, as used in speedometer cables, or the push-pull principle, as used in the temperature controls of the automobile heater. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Utilizing any or all of the three useful body motions, together with the Bowden-cable transmission system in every case, two alternate harness patterns are available for the below-elbow amputee with a stump of medium length. The first is known as the "figure-eight" harness, the second as the "chest-strap" harness. In addition, there are two special modifications, one for the very long and another for the very short below-elbow stump. These are, respectively, the "double-axilla-loop" harness and the "dual-control" harness. Finally, there is the special harnessing arrangement using the biceps cineplastic muscle tunnel to provide force and excursion.</p> <h4>The Below-Elbow Figure-Eight Harness</h4> <p><i>The Harness Pattern</i></p> <p>The figure-eight pattern, of which <b>Fig. 2</b> presents a typical example, is the harness most commonly used in the unilateral below-elbow case, the axilla on the sound side being the site of anchor for capturing the relative motion. The front view of <b>Fig. 2</b> shows the suspension portion of the harness. The front harness strap, passing over the shoulder at the pectoral interval on the amputated side, buckles to the inverted Y-strap supporting the leather triceps pad, which in turn supports the socket through the flexible elbow hinges. The back view shows the transmission system from harness to terminal device. The general path of the control cable is such that sharp bends and curves of small radius are avoided as much as possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The below-elbow figure-eight harness. A simple webbing loop passes around the sound shoulder, the front portion being used for suspension, the back for attachment of the control cable. The inverted Y-suspensor. triceps pad, and flexible elbow hinges are constructed of 4 to 6-oz. strap leather and lined with 4-oz. pearl horse-hide or equivalent. The proximal retainer on the triceps pad is of the flexible leather type to improve cable life. The three circled inserts show possible variations in individual cases. Circle <i>A </i>illustrates the leather half-cuff as used in combination with rigid elbow hinges and a single billet. Circle <i>B </i>shows a hall-cuff with two billets, again in combination with rigid elbow hinges. Circle <i>C </i>shows the inverted Y-strap as made from fabric instead of leather. Any of the combinations shown may be used as required to furnish the necessary stability depending upon occupational needs, level of amputation, and other factors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chief purpose of the control system is to transmit force and excursion to the terminal device. When, however, the amputee must pick up loads with forearm extended, the cable is expected to assist in support whenever the load is of any appreciable magnitude. This, then, is an example of what is meant by the proper balance of forces that is needed to meet amputee requirements. Both suspension and control system should be so constructed and adjusted as to be comfortable and yet be able to meet a reasonable load-support requirement without unnecessary displacement of the prosthesis. Tests for determining allowable displacements and other important factors have been set forth by Carlyle.<a></a></p> <p>As shown in <b>Fig. 2</b>, the harness is padded and protected under the axilla, and the control cable is so adjusted that it cannot come into contact with the amputee's back. For maximum excursion, the cross of the harness should be below the cervical vertebrae and not more than 1 in. toward the sound side of the vertebral spine. The control attachment strap <i>(i.e., </i>the strap attached to the flexible control cable) should lie at the midscapular level. In the course of constructing the harness, visual observations of all these details should be made while the wearer goes through the movements to be expected in normal use.</p> <p>Because of the simplicity of the figure-eight harness, minor deviations usually are not serious. Occasionally, indeed, exceptions to the normal placement of the harness cross are necessary and desirable to improve comfort. The figure-eight harness can be worn successfully by the majority of below-elbow amputees with ordinary duties, it is easy to construct and there is little chance for error, and it is functional and comfortable in most cases. Together these advantages generally represent the reason why it is so widely used. It readily adapts itself to vocations that are clerical in nature and to individuals requiring medium duty, such, for example, as the lifting that might be required of a stockroom worker.</p> <p><i>Below-Elbow Cliffs, Pads, and Hinges</i></p> <p>To furnish suspension and socket stability, three types of cuffs and pads, with and without fillers, are available, and any of several types of hinges, some flexible and some rigid, may be used. The circled inserts <i>A </i>and <i>B </i>of <b>Fig. 2</b> show some of the variations giving greater and greater stability as needed in the individual case. The choice of cuff and hinge combination is strictly a consideration for the prescription team, the rule being to provide maximum stability with the absolute minimum of harness. Prescription criteria and suitable templates for cuffs are described in considerable detail in Section 5.6 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> It should be remembered that many combinations of hinges and cuffs are available and that no one cuff must necessarily be accompanied by any particular type of hinge. Moreover, the prescription for any given amputee should take into account his own individual requirements and personal preferences.</p> <p>There are at least two ways of making cuff suspension systems, material selection being the principal distinguishing factor. The preference of the limbmaker may enter into the choice of technique largely because of the fabrication facilities that happen to be available. Leather has long been used in the limb industry, and it is readily adaptable because of its molding characteristics. Although the ability of leather to conform readily to the shape of the arm represents something of an advantage over webbing straps (circled insert <i>C </i>of <b>Fig. 2</b>), its tendency to absorb perspiration and thus to deteriorate, as well as to acquire unpleasant odors, is considered by many to be a distinct argument against its use in arm cuffs. The webbing strap, while perhaps less stable, offers the advantage of being easily washed and quickly replaced. Modern synthetic fabrics now available commercially can be laundered without undue shrinkage and may be reapplied without stretching under load.</p> <p>The below-elbow cuffs and pads usually are made of 4- to 6-oz. strap leather and are lined with horsehide or similar material. The fabrication of this component calls for the cutting, sewing, and fitting skills of the limbmaker. To make the Y-shaped leather suspension strap, a paper pattern is first cut to conform to the amputee's arm. When the template lies smoothly against the arm above the bulge of the biceps and will reach properly from the triceps pad or cuff to the webbing suspension strap passing over the shoulder at the pectoral interval, its shape is reproduced in 4- to 6-oz. strap leather or equivalent. The lower legs of the leather suspension strap are then riveted to the cuff or pad in such a position that the "V" lies smoothly against the arm and will support axial loads.</p> <p>The webbing inverted Y-suspensor is prepared by folding a piece of 1/2-in. webbing back on itself in such a way as to form a "V." The apex of the "V" is then sewed directly to the front suspensor strap of the harness at such a level as to give a smooth transition from the harness to the cuff or pad. The lower attachments to the cuff or pad are made by means of 1/2-in. buckles.</p> <p>Again, material selection is the chief factor determining technique. When leather is used, it is hard to determine the proper length of the legs of the "V" and to assure proper alignment without later adjustments. Moreover, unless leather components are coated with nylon <a></a> or similar material, the effects of perspiration will soon become apparent. Conversely, the webbing Y-suspensor offers easy adjustment of alignment and also resistance to perspiration by virtue of its washability. When fitted properly, both systems are acceptable, and hence personal preference is an influencing factor.</p> <h4>The Below-Elbow Chest-Strap Harness</h4> <p>Although the figure-eight harness is suitable for most below-elbow cases, it does not meet all vocational requirements. Heavy-duty activities, such as those of a farmer, requiring frequent lifting of loads greater than 50 lb., can best be accommodated by a below-elbow chest-strap harness. <b>Fig. 3</b> shows a typical example. By the addition of the shoulder saddle to reduce unit stresses on the shoulder and opposite axilla, the load-supporting capabilities and amputee comfort can be greatly improved, but to obtain a satisfactory result with the chest-type harness presents a greater challenge to the harnessmaker.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The below-elbow chest-strap harness The two suspensor straps running through D-rings are attached to a leather shoulder saddle Improved stability and reduced unit stresses over the shoulder offer greater ability to lift axial loads. Normally, the below-elbow chest-strap harness, used on amputees requiring heavy-duty service. is constructed in combination with half-cuff and rigid elbow hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><a></a> It has been said that some limbmakers construct the chest-strap harness simply because they do not know how to make the figure-eight design. There ap pears to be no real evidence to prove which type really is the older, but it is generally accepted that the chest strap was the forerunner of the figure-eight. Regardless of priority, both patterns are acceptable, and each offers advantages and disadvantages.</p> <p>As shown in <b>Fig. 3</b>, there are basically three elements in the below-elbow chest-strap harnessâ€"the chest strap to hold the harness on, the shoulder saddle to serve as an anchor for suspending the prosthesis, and the control attachment strap for operating the terminal device. To connect the shoulder saddle and to suspend the prosthesis, two lengths of 1/2-in. leather or webbing are used. They originate on the back of the shoulder saddle, thread through D-rings on the cuff, and then buckle to the front of the saddle. This arrangement distributes the load on four points of the saddle and two points of the cuff and offers the inherent self-equalizing effect by virtue of the D-rings.</p> <p>The control attachment strap is connected to the chest strap and utilizes arm flexion and scapular abduction on the amputated side. Since no definite anchor is involved, neither scapular abduction nor shoulder flexion on the sound side can be harnessed, so that, unlike the case with the figure-eight harness, in the chest-strap design these body motions cannot be used as a source of reserve excursion. Although this basic difference is responsible for the improved comfort of the chest-strap harness, lack of a positive anchor not only robs the amputee of a third control motion but actually permits the harness to rotate upon the chest when excessive forces are applied to the control cable.</p> <p>The indications for and advantages of the chest-strap harness lie in its improved comfort and greater lifting capacity. The chief reasons for its selection over the figure-eight arrangement are concerned with vocational considerations, relief of unavoidable discomfort in the opposite axilla, and amputee preference based on his past experience. Both the figure-eight and the chest-strap harness may be used with almost any combination of hinges and cuffs. It may not be desirable to use a triceps pad and a shoulder saddle in combination, but there is no law against this possibility. The rule, as always, is to try for maximum stability with a minimum amount of harness. This being the case, the figure-eight harness should be tried first.<a style="text-decoration:none;">*</a> If it is not satisfactory, then the more complicated chest-strap harness may be resorted to. For detailed discussions of fabrication techniques for both harnesses, reference may be had to Section 5.0 of the <i>Manual of Upper Extremity Prosthetics .</i><a></a> </p> <h4>The Double-Axilla-Loop Harness</h4> <p>The increased frequency of successfully fitted wrist-disarticulation cases has led in such instances to a departure from the typical below-elbow harness pattern. A very simple and useful harness has been reported by the Naval Prosthetics Research Laboratory<a></a> for use with transcarpometacarpal cases, and the technique is also adaptable to wrist-disarticulation cases. As shown in <b>Fig. 4</b>, a double axilla loop originates the initial body motion on the sound side and provides its own reaction point on the amputated side. A solid piece of Bowden cable extends from the proximal reaction point located on the axilla loop on the amputated side to the distal reaction point located on the arm socket. The cable housing is covered with a piece of plastic tubing to prevent pinching of flesh and pulling of hair on the subject's arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The double-axilla-loop harness for wrist disarticulations and transcarpometacarpal amputations. The loop on the amputated side serves as the reaction point, relative motion being produced when the sound shoulder is flexed. The control cable continues to the distal reaction point on the arm socket ([link5]) The auxiliary elastic strap indicated by dotted lines may or may not be needed. <i>Courtesy U S Naval Hospital, Oakland, Calif. .</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the double-axilla-loop harness is only a means of supplying terminal-device operation. Suspension must be inherent in a well-fitted socket, which usually must be split to facilitate donning, the condyles of the wrist being the principal means of retaining the socket on the stump (<b>Fig. 5</b>). Wrist disarticulations can be fitted by this technique at first. If it proves to be unsuccessful for any reason, the harness may easily be replaced with a conventional below-elbow figure-eight harness.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Wrist-disarticulation socket for use with the double-axilla-loop harness. Control cable extends to the proximal reaction point located on the axilla loop on the amputated side ([link4]). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Below-Elbow Dual-Control System</h4> <p>As opposed to the problem of fitting the wrist disarticulation and other long below-elbow stumps, there is the one involving the fitting and harnessing of the very short below-elbow slump. Use of the split-socket type of prosthesis furnishes a means of increasing the range of elbow flexion through a mechanical step-up. Thia expedient greatly improves the versatility of the below-elbow prosthesis and in the majority of cases proves to be very satisfactory when using the below-elbow figure-eight harness based on the single-control principle.</p> <p>For marginal cases with insufficient torque about the elbow to lift the prosthetic forearm, another departure has been made from the usual pattern of control. The below-elbow dual-control system, shown in <b>Fig. 6</b>, uses a forearm lever loop and a split-housing cable system. Since in this case the cable housing is in two separate pieces, the effective distance between the reaction point on the arm cuff and that constituted by the lever loop on the forearm shell is no longer independent of elbow angle, so that arm flexion produces forearm flexion. When used with the very short below-elbow stump, the dual-control system thus provides an assistive lift for forearm flexion, sometimes especially needed when forearm flexion is begun from full forearm extension. Ordinarily the short below-elbow case has enough torque about the elbow to stabilize the forearm, so that no elbow lock is required. When the forearm socket is stabilized by the stump, the force from the harness is transmitted to the terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The below-elbow dual control using the split-socket type of prosthesis for the short below-elbow case. Since the cable housing is in two pieces, arm flexion assists in lifting the prosthetic forearm. The stump is then used to stabilize the elbow for terminal-device operation, no elbow lock being needed. The design of the step-up elbow hinges has been discussed in detail by Alldredge and Murphy (<i>1</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The familiar rule of first trying the less complicated harness should be applied at this level also. If the forearm cannot be flexed by the stump without unnecessary fatigue, or if forearm flexion is painful, then the dual system is indicated. Amputees fitted with the dual control should be checked periodically to see whether the residual muscles have hy-pertrophied enough to be adequate for unassisted forearm flexion, in which event the single control may be substituted. No harm is done by using the below-elbow dual-control harness when its necessity is questionable, but again the usual desirability of simplicity of harness would suggest discard of the assist lift when adequate function can be obtained without it.</p> <h4>The Below-Elbow Biceps-Cineplasty System</h4> <p><i>The Case for Cineplasty in General</i></p> <p>Since World War II, there has been, especially in the United States, a considerable revival of cineplastic surgery <a></a> to produce muscle tunnels capable of harnessing for the operation of artificial arms. Practically all available muscles of the arm and two major muscles of the chest (the pectoralis major and minor) have been harnessed by various means to operate arm prostheses. Two basic philosophies have developed in the use of the cineplastic muscle tunnel. First established was the idea of using the muscle motor to power the terminal device. The advantages of this means of independent terminal-device operation, without relying upon body motions, were readily apparent, to say nothing of the possibility of eliminating body harness completely in some cases.</p> <p>Some authors, for example Mount and Bernberg,<a></a> discuss the advantages of an increased sense of pressure and generally improved sense of perception when a muscle motor is harnessed to a terminal device. Mount and Bernberg say "The results generally indicate that the two Ss [subjects] using cine-plastic prosthesis distinguished, compared and recognized given objects with greater skill and precision than the Ss [subjects] using prosthesis of the harness type." Although further scientific tests to support this observation have not been conducted, subjects successfully fitted with both a conventional and a cineplastic prosthesis indicate that they have a better sense of pressure or feel with the latter.</p> <p>In the second philosophy developed, the pectoral tunnel is used to operate the elbow lock in the shoulder-disarticulation case. Obviously, the advantage in this case lies in the provision of the additional source of control.</p> <p>It may be stated, without reservation, that of all the possible arrangements involving cineplasty, the greatest degree of success has been obtained using the biceps muscle tunnel to power terminal-device operation in the below-elbow case. This does not mean that the combination of other muscle tunnels and other levels of amputation may not be successful in individual cases. Spittler and Fletcher,<a></a> Kessler , <a></a> Alldredge <i>et al., </i><a></a> and Taylor<a></a> report other muscles and other levels of amputation successfully fitted with cineplastic prostheses. Because, however, the other cases have not yet been proven clinically in the general sense, the discussion of the fitting of cineplasty is here restricted to the below-elbow biceps system.</p> <p>In the below-elbow biceps case, fitting is greatly simplified because the muscle tunnel is above the first sound joint in the amputated stump. The socket may thus be made to harness residual pronation and supination, and it does not require window-type construction <a></a> since the tunnel is once removed in the upper arm.</p> <p>Because the biceps tunnel in the below-elbow case is able to avail itself of the physiological characteristics of muscle, <a></a> adequate force and excursion are to be had. Since normally muscles are contracted to produce prehension, contraction of the biceps muscle tunnel should effect closing of the terminal device. For this reason it is generally accepted that a voluntary-closing device is most desirable for use with cineplastic amputees. Of course if the improved sense of pressure is to be had, then it may be best to use the voluntary-closing terminal device. Regardless of all data presented here and elsewhere, however, many biceps tunnels have been successfully harnessed in the below-elbow case with the voluntary-opening terminal device.<a style="text-decoration:none;">*</a> This circumstance can only suggest that the prescription of the terminal device in cineplasty is largely in the same area as is the prescription of the terminal device in the conventional case using body harness.</p> <p>The back-and-forth discussion of these factors is endless. It is therefore useful to have a look at the indications for cineplasty as seen from the point of view of the amputee. Needless to say that, in the growth of prosthetics clinic teams, new amputees are seeing more and more the types of prostheses worn by other amputees. Usually when the wearer of a conventional arm prosthesis sees a cineplastic type he feels that a "Cadillac" version of an artificial arm is available for him. No doubt personal choice, or the individual desire for a cineplastic type of prosthesis, is the major consideration. Amputees who were not too favorable at the time of discussing the cineplasty procedure have not obtained the same degree of success and training as have those who indicated their preference for cineplasty from the beginning.</p> <p>Another important factor relates to vocation. If a below-elbow amputee desires to do, for example, mechanical work on an automobile, he often finds himself lying on his back on a dolly. In this position, he is quite restricted in body motions for using a shoulder-harness prosthesis. For the wearer of a conventional prosthesis to operate his terminal device in this position involves the use of many body motions other than those ordinarily involved.</p> <p>Although no real criterion has yet been developed for the selection of individuals for the cineplasty type of prosthesis, it can be stated categorically that the personal preference of the individual and the vocational considerations are of prime importance and should therefore be discussed thoroughly with the patient before reaching a decision.</p> <p><i>The Two Established Systems</i></p> <p>Prosthetic fitting and socket construction for a biceps-cineplasty below-elbow prosthesis are very similar to the conventional techniques. The socket must provide stability and a means of attaching a terminal device. Suspension of the prosthesis may be handled in various ways. Two power-transmission systems have been developed, one at the University of California at Los Angeles and the other at the Army Prosthetics Research Laboratory. A comparison of the efficiencies of the two systems has revealed that they have quite similar characteristics.<a></a></p> <p><i>The UCLA Below-Elbow Biceps-Cineplasly System. </i></p> <p>The power-transmission system of UCLA consists of a muscle-tunnel pin, a dual-cable power-transmission system, and a twin cable mounting harnessed to the terminal device. All parts of this system, shown in <b>Fig. 7</b>, have been available commercially for some time, and the arrangement has received wide use in the field. Three types of cuffs are available for suspension in the UCLA system. The epicondyle cuff (<b>Fig. 8</b> and <b>Fig. 9</b>), the epicondyle clip (<b>Fig. 10</b>), and the epicondyle strap (<b>Fig. 11</b>) may be used with any selection of either flexible or metal double- or single-axis elbow hinges. The method of installing the UCLA system is described in detail in Section 10.0 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The UCLA below-elbow biceps-cineplasty system with epicondyle cuff and rigid elbow hinges. The twin cable mounting is connected to the yoke to allow positioning for adequate operating excursion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Pattern for the UCLA epicondyle cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Alternative design of the UCLA epicondyle cuff, constructed of stainless steel and covered with horsehide, the rigid hinges being attached to the cuff before covering. The cross strap at the top helps to stabilize the cuff on the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The UCLA epicondyle clip, constructed of stainless steel and covered with horsehide. Conventional baseplates are attached to be used as the proximal retainers for the dual cable system. The clip can be used with or without the auxiliary elastic strap as needed to maintain the clip in position when the arm is flexed. The epicondyle clip has also been constructed of a semirigid plastic such as Royalite. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical pattern for the APRL epicondyle strap, reduced to exactly half the size needed to produce a strap for an arm with a circumference of 10 1/2 in. Placed as drawn on the grain side of the selected leather, this template makes a left or a right strap depending on whether the amputee prefers to have the strap buckle toward the medial or toward the lateral side of the arm. To produce a strap buckling in the reverse directions, the template is turned over and placed on the grain side of the leather. The dotted lines indicate a modification to accommodate a biceps tunnel located low on the upper arm when it is desirable to save space in the anterior fold of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The UCLA system is quite adequate and very simple to harness and provides easy pre-positioning and ready adjustment of effective cable length. It has met with a very large degree of success throughout. Compared to the APRL system,<a></a> it offers the advantage of being applicable to a wider selection of terminal devices inasmuch as the control system may be mounted either on the top or on the bottom of the arm socket (<b>Fig. 12</b>). It offers also the advantage of allowing pre-positioning of terminal devices with less friction throughout the cable system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Alternate locations of the twin cable mounting for various terminal devices in the UCLA below-elbow biceps-cineplasty system. If it is desirable to interchange between the voluntary-opening hook and the voluntary-closing hand, two snap portions of the twin cable mounting may be used, one toward the lower side and another on the top side of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The APRL Below-Elbow Biceps-Cineplasty System. </i>The APRL system, as it appears in the <i>Manual of Upper Extremity Prosthetics</i><a></a>has been revised to improve function. The principal modifications (<b>Fig. 13</b>) have been to adopt flexible leather hinges and to discard the so-called "transit elbow hinges." Since these changes,<a></a> indications have pointed to a greater degree of success when the biceps tunnel is used with a voluntary-closing terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Completed installation of the APRL below-elbow biceps-cineplasty system. The epicondyle strap is used in conjunction with flexible leather hinges, the hinges being adjustable by means of strap-type buckles placed at the points of attachment on the arm socket. The ox-bow tunnel pin, fitted with "Dot Fasteners" for joining to the sheave-type cable equalizer, is recommended for use with the APRL system. A flat cable-extensor mechanism is used to allow cable adjustment within the system and to permit interchangeability of terminal devices. Insert shows a variation in pin design that is available commercially. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although both the voluntary-closing and voluntary-opening hands and hooks are recommended routinely for use with biceps tunnels in below-elbow amputees, experience has shown that voluntary-closing devices have offered a number of special advantages. The available excursion can be increased by utilizing spring forces in the terminal device to recover excursion, thereby stretching the biceps tunnel into pre-tension beyond the rest length of the muscle.<a></a> Moreover, the improved ability to select prehensile forces at the finger tips makes it possible for amputees to handle, say, an ice-cream cone without crushing it or to wield a hammer or other heavy object without dropping it. Expressed amputee reaction seems to indicate, furthermore, that a considerable amount of pressure appreciation is realized through the use of the voluntary-closing terminal device, where the biceps is contracted for gripping an object. Of course, some pressure appreciation is lost when the voluntary-opening device is used, for then the biceps is contracted to open the device against the tension of the spring or rubber band, and the grasping force is exerted by the spring or rubber band upon relaxation of the muscle. Although no published data are available to support the claim of improved pressure appreciation with the voluntary-closing device, there are sound indications from active users that such a cue to the pressure exerted is of definite advantage.</p> <p>Since no published instructions for installing the APRL below-elbow biceps-cineplasty system are available, a simplified set is included here. The first step is to cut and check a paper template for the epicondyle strap in order to assure proper size and shape before proceeding to make the finished strap. The typical size and shape are indicated in <b>Fig. 11</b>. The pattern should be placed around the arm and examined for comfort, both with the patient's elbow extended and in maximum flexion (<b>Fig. 14</b>). If the biceps tunnel is located low on the arm, the template should be shaped as indicated by the dotted lines in <b>Fig. 11</b> to allow for maximum passive stretch. By thus lowering the front portion of the epicondyle strap, comfort, as well as excursion, is improved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Procedure for checking the paper template when making the epicondyle strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the epicondyle strap fastened in place, the normal elbow center is marked on the projecting hinge tabs. Standard baseplates are located as close to these points as possible and are held in place with a clamp on the upper edge (<b>Fig. 15</b>). They are then so aligned that the cable housings will follow smooth curves from the tunnel pin through the elbow center to the two distal retainers on the arm socket. Notation should be made of the approximate angles shown in <b>Fig. 11</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Placement of the baseplates on the epicondyle strap. They should be so positioned that the cable housings pass through gentle curves from the muscle tunnel to the distal baseplates on the arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The extending ears adjacent to the rivet holes on the two proximal baseplates should now be bent, as shown in <b>Fig. 16</b>, to follow the contour of the epicondyles, thus giving greatly improved comfort as well as added stability in supporting axial loads. The baseplates are then riveted to the epicondyle strap by means of the top rivets only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bending the ears of the proximal baseplates to conform to the contour of the epicondyles. This detail gives added stability in supporting axial loads and improves amputee comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Two pieces of 4-oz. strap leather 5/8 in. wide are now cut long enough to connect the epicondyle strap to the arm socket. A piece of nylon or vinyon strap is attached by rubber cement to the inside of the leather straps, and the whole is stitched along each side. One end of each of these two flexible hinges is then laid under one of the lower ears of the proximal baseplates and the lower rivets are driven in.</p> <p>With the epicondyle strap fastened in position, the arm socket is placed on the patient, and the proper length of the flexible hinges is determined. Finally, the positions of the distal hinge attachments are marked, and the hinges are riveted to the socket, adjustment being provided for by the two buckles.</p> <p>The arm socket and epicondyle strap are now put in place, the cable-housing retainers are attached to the baseplates on the epicondyle strap, and the cable housings are continued through the elbow center in such a way as to maintain a gentle wave to a point approximately 2 in. below the top of the arm socket (<b>Fig. 13</b>). The arm is then removed from the patient, and the baseplates are riveted in position on the socket. The male end of the cable lengthener is now attached to the terminal device, the lengthener is extended to the full-open position, and the other end of the lengthener is attached to the sheave equalizer.</p> <p>Next the cable housings are installed and adjusted to obtain maximum elbow flexion and extension without compression or stretch of the housings. The ends of the housings are trimmed so that, when the ferrules are installed, the housings will terminate flush with the rivets on the baseplates. The ferrules are then pinched slightly with a diagonal cutter.</p> <p>A female snap-on attachment is now fastened to one end of a length of cable, and the attachment is snapped to the pin. The free end of the cable is fed through one cable housing, down through and around the sheave, and back up through the other cable housing. The terminal device is opened, the muscle tunnel is pulled into passive stretch, and the cable length is measured. The cap fitting is installed according to manufacturer's instructions. Normally, the cable will be a little too long. Adjustment may be made by taking up on the cable-length adjuster.</p> <p>After a period of use of the prosthesis, the amputee may find that the adjuster can no longer remove slack from the system. This development can be expected in some cases. It is only an indication that the tunnel has stretched with use. In this event, the control cable should be detached, shortened, and reattached as in initial cable installation.</p> <p>The APRL system as described here has been used experimentally with a great deal of success, but the lack of commercial availability of components in the past has limited its use in the field. It is designed primarily to be used with the voluntary-closing type of terminal device. Furthermore, the frictional losses in pre-positioning are greater than in the UCLA system, and unless the sheave equalizer is placed on the top of the socket use is limited to voluntary-closing terminal devices. This circumstance makes interchange-ability of a voluntary-closing hand and a voluntary-opening hook quite impractical. The APRL system is primarily recommended for use with the epicondyle strap, which normally gives ample support for axial loads without appreciable displacement of the socket.</p> <p>A distinct advantage of the APRL system over that of UCLA is that the effective cable links between the equalizer and the muscle tunnel may be adjusted while at the same time maintaining equalized forces. To adjust the effective cable links between the twin cable mounting and the muscle tunnel in the UCLA system requires a turnbuckle, which in effect changes the links of the cable housing, thus increasing frictionai losses within the system.</p> <h4>Harnessing for the Above-Elbow Cases</h4> <p>Basically, two functional requirements must be met in above-elbow cases. Not only must prehension be provided for but it must be usable at various degrees of forearm flexion. Experience has shown that satisfactory prehension can best be obtained through a normal range of forearm flexion when provision is made for stabilizing the forearm at the selected level of operation. Thus, to the two basic functions there must be added the requirement of elbow lock. The body motions easily accessible and available for controlling these three functions in the above-elbow prosthesis are arm flexion, arm extension, and scapular abduction.<a style="text-decoration:none;">*</a></p> <p>At present there are three satisfactory harness patterns for the above-elbow case, two based on the so-called "dual control" and the third based on "triple control." The two dual-control systemsâ€"the above-elbow figure-eight harness and the above-elbow chest-strap harnessâ€"utilize arm flexion for forearm flexion and terminal-device operation, elbow lock being effected by arm extension. In the triple-control harness, arm flexion is used to produce forearm flexion, arm extension gives elbow lock, and terminal-device operation is obtained by shrug of the sound shoulder. Each of the three systems has its own advantages and disadvantages, and each therefore has indications and contraindications in individual cases.</p> <h4>The Above-Elbow Figure-Eight Harness</h4> <p>From the wearer's point of view, the above-elbow figure-eight harness (<b>Fig. 17</b>) constitutes the easiest way of meeting the requirements of the above-elbow case. It is simply a modified below-elbow figure-eight design with provisions for the added functional requirements. Although in the below-elbow case it is essential mechanically to maintain a constant effective distance between the proximal and distal reaction points of the terminal-device control cable (Bowden principle), in the above-elbow case two functions may be obtained from a single cable by splitting the cable housing and substituting for the distal reaction point a lift lever on the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. The above-elbow figure-eight harness. The basic structure consists of a loop about the opposite axilla, the front portion supporting the arm and the rear portion attaching to the control cable so that arm flexion gives forearm flexion and terminal-device operation. The piece of elastic inserted in the front portion provides for relative motion for elbow locking by arm extension, the elbow-lock control being attached to the nonelastic portion. Suspension is improved by the lateral support strap and indicated auxiliary straps when necessary. As in the below-elbow dual control ([link6]), the cable housing is split so that arm flexion gives forearm lift when the elbow is unlocked, the leather lift loop on the forearm shell serving as the distal reaction point. If it is difficult to start the forearm into initial flexion, two baseplates may be used on the arm socket. The length of the leather lift loop on the forearm shell should be such that, when the forearm is extended, the distance from the center of the cable to the center of the elbow is equal to the distance from the center ot the forearm to the center of the cable housing. This arrangement reduces the amount of force needed to start the forearm into initial flexion without increasing the excursion required for full forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This arrangement couples forearm flexion and terminal-device operation to produce the dual control as used in the case of the very short below-elbow stump. Motion in the control source elicits terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p>In the dual-control system, arm flexion is used as the source of control for forearm flexion and terminal-device operation, sometimes augmented by scapular abduction at large elbow angles, such as when the terminal device is near the mouth. A piece of elastic-webbing is substituted for the nonelastic front attachment strap of the below-elbow figure-eight harness. It is attached at the level of the clavicle and extends to the adjustable buckle on the arm socket, a minimum of 6 in. being desirable for easy operation of the elbow lock. The elbow-lock control cable is attached to</p> <p>the nonelastic portion of (he front attachment strap by means of a piece of 1/2-in. webbing bearing a 1/2-in. adjustment buckle. Arm extension thus produces relative motion between the elastic webbing and the nonelastic control strap in such a way as to induce elbow locking. Thereafter arm flexion controls terminal-device operation. With proper training and practice the amputee can become very adept in effecting smooth operation of all three prosthetic controls.</p> <p>Suspension is improved by adding a connecting strap, known as the "lateral support strap," above the cross on the amputee's back. It extends laterally across the shoulder to a buckle on the lateral side of the arm socket. Proper adjustment of the lateral support strap controls alignment in the abduction-adduction plane. With these modifications, the below-elbow figure-eight harness is adapted to become the figure-eight for the above-elbow case. In summary, the alterations include insertion of the elastic webbing in the front to help suspend the socket and to provide for relative motion for elbow-lock control, addition of the lateral support strap over the shoulder to contribute to socket stability, and the use of the two-piece cable housing to give forearm flexion when the elbow is unlocked.</p> <p>The two optional straps indicated in <b>Fig. 17</b> together improve suspension, increase the available excursion, and assist in maintaining the control attachment strap on the shoulder when the arm is raised. The over-the-shoulder strap forms a webbing network to support axial loads and to stabilize the lateral support strap and front attachment strap on the shoulder. The cross-back elastic strap not only gives greater excursion both in scapular abduction and in arm flexion but it helps to prevent the control attachment strap from riding over the shoulder during extreme arm flexion, such as when the amputee is working in areas over his head. But again, following the rule of simplicity whenever possible, the above-elbow figure-eight harness should be tried first without the two optional straps. If that proves unsatisfactory, then the extra straps may be added.</p> <p>For a detailed description of the technique of fabricating the above-elbow figure-eight harness, reference may be had to Section 6.7 of the <i>Manual of Upper Extremity Prosthetics </i><a></a> or to the report of the NYU Committee on Above-Elbow Harness.<a></a> It will suffice here to describe some of the common errors often leading to difficulties. Careful observation should always be made to be certain that the elastic straps are not too short and that the proximal end and distal buckle of the front suspensor strap are properly positioned. A minimum of 6 in. of elastic is required to give sufficient excursion for operation of the elbow lock and to provide adequate length for adjustment of tension in the strap.</p> <p>Placement of the proximal end of the elastic suspensor not lower than the clavicle enables the amputee to feel the elastic stretching over the deltopectoral interval during the elbow-lock operation, thus furnishing an additional cue to ensure reliable elbow function, and it permits the minimum of 6 in. of elastic to be used without bringing the attachment too far down on the socket. Normally the harness cross should lie approximately 1 in. toward the sound side of the vertebral spine. Crossing the harness at this point usually brings the control attachment strap over the lower third of the scapula, where maximum excursion may be utilized. The cross should be below the seventh cervical vertebra, thus avoiding the discomfort caused when the harness rides up. If the cross is more than 1 in. toward the sound side, the axilla loop is unduly decreased in size, with consequent increase in discomfort at the axilla.</p> <p>The control attachment strap should not fall so low as to prevent arm abduction, and the lateral support strap should not ride too high on the neck. If the cross is farther to the amputated side, the control attachment strap may ride too high. Placement of the lateral support strap 1/2 in. forward of the acromion is found to result in optimal stabilization of the prosthesis on the stump without causing rotation. Attachment of the lateral support strap should be 2 in. below the acromion. When it is attached at a lower point, the strap rolls back and forth over the shoulder, and higher attachment results in poor cosmesis because of the interference of the buckle with the shoulder pad of clothing. Placement of an adjustable buckle at the junction of the front support strap and elastic suspensor provides optimal position for adjustment of the elbow-lock control cable.</p> <p>The placement of the elastic suspensor strap markedly influences the effectiveness of the elbow-lock control motion. If excess slack is left in the elbow control cable, it must be taken up by the control motion before the lock will operate, and consequently the total excursion will then be greater than necessary. At the same time, there must be sufficient slack in the cable to permit relaxation of tension for resetting the elbow-lock mechanism.</p> <h4>The Above-Elbow Chest-Strap Harness</h4> <p>The chief advantages of the above-elbow figure-eight harness are that it is functional and simple and will satisfy the needs of most vocational activities. As in the below-elbow case, however, if there is a requirement for the harness to lift heavy loads, then another type is indicated. Again as in the below-elbow case, the chest-strap harness (<b>Fig. 18</b>) is recommended for the above-elbow amputee whose activities commonly involve heavy-duty work. By supplying a shoulder saddle and thus reducing the unit stresses over the shoulder, the above-elbow chest-strap harness provides greater comfort, and hence greater loads can be accommodated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The above-elbow chest-strap harness using for suspension a leather strap threaded through a D-ring on the lateral wall of the socket and attached to a leather shoulder saddle at two points, The strap for the control cable may be attached either to the shoulder saddle, as shown, or to the chest strap at the midspine position. As in the below-elbow case, this type of harness improves lifting ability and reduces unit stresses over the shoulder on the amputated side. The elbow-lock control cable is attached to the front of the shoulder saddle, and again a piece of elastic is used as the front suspensor between shoulder saddle and arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shoulder saddle has taken two forms, the leather type and the webbing type. The leather type is precisely like that used in the below-elbow chest-strap harness. <b>Fig. 19</b> and <b>Fig. 20</b> illustrate webbing-type shoulder saddles that furnish adequate suspension on the lateral side of the arm socket and provide for the relative motion needed for elbow lock and for dual control. The operational pattern of body motions is identical to that used with the above-elbow figure-eight pattern. Arm flexion manages dual control <i>(i.e., </i>forearm flexion and terminal-device operation), and arm extension controls the elbow lock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. The above-elbow chest-strap harness with webbing shoulder saddle. The functional arrangement is identical to that in the above-elbow chest-strap harness with leather shoulder saddle ([link18]). The leather has simply been replaced with a webbing saddle designed to give the same function. The technique is best used on individuals who perspire freely but who nevertheless need the chest-strap type of harness for heavy lifting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. An alternative construction of the webbing shoulder saddle for use with the above-elbow chest-strap harness. Beginning at the point of attachment on the front of the arm socket, the principal strap passes over the shoulder on the amputated side, continues across the amputees back, goes under the opposite arm, crosses the chest, again passes over the shoulder on the amputated side, and buckles to the rear portion of the socket. This arrangement equalizes the forces when axial loads are encountered. A Y-type construction is used to connect the control cable to the chest strap at the midspine position and at the point where the chest strap crosses the shoulder. A similar construction is used in front, the lower leg of the Y" being made of elastic to permit the relative motion needed for elbow-lock control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The above-elbow chest-strap harness has as its chief advantage the ability to lift axial loads with lower unit stresses over the shoulder. Its primary disadvantage lies in its characteristic tendency to rotate about the chest owing to lack of a positive anchor. Again as in the below-elbow case, the simpler figure-eight design should be applied to the above-elbow case whenever it can be made to serve the amputee satisfactorily. The above-elbow chest-strap harness should be adopted only when the simpler figure-eight harness proves to be inadequate in any given case.</p> <h4>The Above-Elbow Triple Ccontrol</h4> <p>In the above-elbow triple-control harness (<b>Fig. 21</b>), arm flexion produces flexion of the forearm, arm extension provides elbow-lock control, and extreme flexion of the sound shoulder (shrug) gives terminal-device operation. Although the control system is quite simple, it requires the amputee to distinguish between arm flexion on the amputated side and extreme flexion of the shoulder on the opposite side to yield two separate controls. Above-elbow amputees with long stumps can usually make this distinction readily enough; those with medium to short stumps find it very difficult.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The above-elbow triple-control harness. It differs from the dual-control pattern in that three body motions are required. The axilla loop uses shrug of the opposite shoulder to operate the terminal device, so that in this case the chest strap is separated at approximately the midspine position. Relative motion takes place between the axilla loop on the sound side and the reaction point located on the portion of the harness on the amputated side. A supporting shoulder saddle is constructed of a webbing network, and the control attachment strap for forearm flexion is attached at a point over the superior spine of the scapula on the amputated side. Arm flexion then lifts the forearm. Arm extension is harnessed as usual, a piece of elastic being used as the front suspensor strap to provide for the necessary relative motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The advantage of triple control lies in the possibility of operating the terminal device without first locking the elbow. But the complexity of fabricating the triple-control system has been a major disadvantage and has discouraged its use. It is recommended for amputees requiring versatility in the use of the prosthesis, but it should be approached cautiously by the harnessmaker.</p> <h4>Harnessing for the Shoulder-Disarticulation Cases</h4> <p>To provide adequate functional harness for the shoulder-disarticulation amputee has always been especially difficult because of the lack of the control source otherwise available from humeral motion. In the absence of an arm stump, it has been to date, for all practical purposes, impossible to provide any satisfactory voluntary motion of the prosthetic arm about the shoulder, and consequently a substitute must be sought for arm extension, the control source commonly used by the above-elbow amputee for operation of the elbow lock. The alternatives are to use manual operation of the lock by the sound hand or else to harness some residual control source ordinarily remote from arm function.</p> <p>Since in any case manual control is undesirable because it interrupts two-handed activities, the trend has been to utilize other body motions such as those of the head or shoulders. The nudge control,<a></a> with the operating button located on the shoulder cap of the prosthesis, was designed to be operated by pressure from the chin. But this system leads to such awkward appearance in use that it has since been more or less superseded by harness designs utilizing shoulder motions. The perineal strap, with function based on relative displacement between shoulders and pelvis, is disliked by most amputees and therefore has been used less and less except where special complications prohibit other arrangements. The most practical system worked out to date involves use of a waist band or equivalent. At the present time, there are four satisfactory harness patterns for the male shoulder-disarticulation case and two suitable for the female. For the male, there are three dual-control systems, all operated by scapular abduction, elbow lock being accomplished in the first case by shoulder elevation on the amputated side, in the second by flexion of the opposite shoulder, and in the third by shoulder extension on the amputated side. The fourth system for the male utilizes the triple-control principleâ€"scapular abduction to provide forearm flexion, elevation of the shoulder on the amputated side to give elbow lock, and shrug of the opposite shoulder to operate the terminal device. Since all four of these systems involve a chest strap unsuited to the female, two special arrangements have been worked out for women. Both are built around a brassiere, and both utilize dual control, in the one case operated by scapular abduction, in the other by motion of the opposite shoulder. In both cases, elbow lock is effected by elevation of the shoulder on the amputated side.</p> <h4>Harness Patterns for Men</h4> <p><i>Dual Control with Shoulder-Elevation Elbow Lock</i></p> <p>Of the four shoulder-disarticulation harness systems for males, the one most often used with the least trouble involves scapular abduction for dual control of forearm flexion and terminal-device operation, elbow lock being managed by elevation of the shoulder on the amputated side. As in all dual-control systems, excursion of the control source, in this case bilateral abduction of the scapulae, produces either terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p><b>Fig. 22</b> presents the basic details of this harness pattern. A webbing chest strap attaches to the front of the shoulder cap, passes under the axilla on the sound side, crosses the back at the midscapular level so as to utilize the maximum available excursion, and attaches to the control cable positioned on the back of the shoulder cap. An elastic suspensor strap extends from the top of the shoulder cap, diagonally across the back, and attaches to the chest strap at a point just toward the sound side of the vertebral spine. The length of the chest strap is so adjusted as to permit full terminal-device operation without bringing the cable into contact with the skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by shoulder elevation on the amputated side. After Pursley <i>, </i><a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Elbow-lock operation by shoulder elevation is provided for by linking the elbow control cable to a waist strap encircling the trunk below the thoracic cage, thus establishing an anchor to oppose shoulder elevation. Although adequate force for elbow locking is usually available, care is taken to position the cable reaction points in such a way as to eliminate as much frictional resistance as possible.</p> <p>This system offers several distinct advantages over other methods of harnessing the shoulder-disarticulation case. It involves the minimum amount of harness needed to operate the three basic controls, and it has the inherent advantage of avoiding any possibility of interference between elbow locking and the other two functions. Thus training is simplified considerably, and the success of the individual harness may be determined at the time of fitting.</p> <p><i>Dual Control with Opposite-Shoulder Elbow Lock</i></p> <p>A second shoulder-disarticulation harness system seen frequently also uses scapular abduction for dual control of forearm flexion and terminal-device operation, but elbow lock is effected by a forward rotation of the sound shoulder. The arrangement for dual control is precisely like that just described, the difference in the harness as a whole being concerned with the method of elbow locking (<b>Fig. 23</b>). In addition to the chest strap and the elastic suspensor strap, there is provided for the sound shoulder a webbing saddle, the cross-back extension being attached to the elbow control cable near the point of stabilization on the back of the shoulder cap. Again the lengths of the straps are so adjusted as to permit adequate excursion without the cables touching the flesh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by flexion of the shoulder on the sound side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appli~ ance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this system eliminates the need for the waist strap, it obviously introduces more complicated harness about the shoulders, and it offers the inherent disadvantage of the possibility of inadvertent locking or unlocking of the elbow in the course of forearm flexion or terminal-device operation. If, however, care is taken to keep the chest strap at the mid-scapular level while making the opposite-shoulder loop as high as possible, and if the amputee is thoroughly trained, the two operating body motions can usually be separated satisfactorily.</p> <p>Because in this system the elbow-lock control cable traverses a comparatively long path, and also because the associated harness moves across the entire surface of the back, the frictional forces involved are sometimes such that the alternator spring in the elbow is not strong enough to return the control cable to the relaxed position. When this is the case, an additional spring may be added on the inside of the arm section (<b>Fig. 24</b>). Since this extra spring force makes the elbow lock more difficult to operate, it has the incidental advantage of making it easier for the amputee to separate opposite-shoulder shrug from scapular abduction, thus helping to avoid inadvertent elbow action. If difficulty is still encountered, separation of controls is sometimes made easier if the opposite-shoulder loop is adjusted to require an extreme flexion of the sound shoulder before elbow locking is induced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Installation of the elbow-lock cable, showing arrangement when auxiliary spring is needed to return cable to relaxed position. The additional spring force makes it easier to separate the elbow-lock control motion from scapular abduction. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In any event, a considerable period of practice is usually required before the average amputee can manage separation of controls systematically and with the necessary confidence. Training is thus more prolonged than is the case with the shoulder-elevation elbow lock, and consequently the dual-control harness using opposite-shoulder lock offers the further disadvantage that the ultimate success in any given case is difficult to determine at the time of initial fitting.</p> <p><i>Dual Control with Shoulder-Extension Elbow Lock</i></p> <p><b>Fig. 25</b> presents the dual-control shoulder-disarticulation harness utilizing shoulder extension to lock and unlock the elbow. The lower leg of the front attachment strap contains a piece of 1-in. elastic, the front elbow-lock control being connected to the nonelastic part of the chest strap. Thus shoulder extension produces a relative motion for elbow locking.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shoulder-disarticulalion harness using scapular-abduction dual control, elbow lock being operated by extension of the shoulder on the amputated side The chest strap terminates in front in a forked arrangement for attachment to the socket. A piece of 1-in. elastic is inserted in the lower leg of the fork, and the elbow-lock control cable is attached to the base portion of the chest strap just beyond the elastic, thus providing for relative motion upon extension of the shoulder on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To operate the prosthesis starting with forearm extended, scapular abduction is used to produce forearm flexion. While maintaining enough force on the lift cable to hold the forearm in the desired position, the amputee extends his shoulder on the amputated side to lock the elbow. Thereafter scapular abduction operates the terminal device.</p> <p>Although this system may be used on any shoulder-disarticulation case, amputees retaining the humeral neck are the most successful. Patients without the humeral neck experience difficulty in coordinating the two body motions. In any event, the length of the elastic and the position of the wide attachment are both critical. Normally a piece of 1-in. elastic 1 1/2 in. long is used as a start. If the elbow is difficult to operate, the elastic portion is made longer. If the elbow operates inadvertently, the elastic is shortened so as to require more definite shoulder extension to lock and unlock. Although this type of shoulder harness is quite new, experience to date would suggest consideration of new elbow mechanisms especially designed for use with it. An obvious advantage is elimination of the waist band and opposite-shoulder loop used respectively in the other two dual-control systems.</p> <p><i>Triple Control</i></p> <p>In the triple-control system for shoulder disarticulation, as in the triple control for above-elbow cases, the three necessary functions are provided by three control sources, one for each. The usual and generally most successful pattern utilizes scapular abduction for forearm flexion, shrug of the sound shoulder for terminal-device operation, and elevation of the shoulder on the amputated side for control of the elbow lock. The basic pattern (<b>Fig. 26</b>) involves a minor modification of the chest strap seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an elastic suspensor strap also similar to that seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an opposite-shoulder loop with an extension passing over the seventh cervical vertebra or slightly below it, and a linkage between elbow control cable and waist band.<a style="text-decoration:none;">*</a>Although the triple control requires more harness than do the other three patterns for shoulder disarticulation, it offers certain advantages not to be had from dual control. Separation of terminal-device operation from forearm flexion offers improved control over prehension, since during forearm flexion no force or excursion is introduced affecting the terminal device. Likewise, as in the case of the dual control with shoulder-elevation elbow lock, the triple-control system overcomes the difficulty of separating elbow lock from the other two functions, so that inadvertent elbow locking or unlocking is avoided. The result is, again, simplified training and the possibility of determining the success of the harness at the time of initial fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Shoulder-disarticulation harness utilizing triple control. Scapular abduction provides forearm flexion; shoulder on sound side operates terminal device; elbow lock is operated by shoulder elevation on the amputated side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harness Patterns For Women</h4> <p>Since the chest strap, common to all four harness patterns for male shoulder-disarticulation cases, is unsuited for most women, harness designs for female shoulder-disarticu-lation amputees are best based on some other principle. The most satisfactory method found to date for eliminating the chest strap is to utilize as part of the harness a brassiere made of sturdy material.<a style="text-decoration:none;">*</a> As shown in <b>Fig. 27</b>, a strip of 1-in. webbing is sewed around the lower edge of the brassiere known to bra designers as the "diaphragm band." The shoulder cap is so designed as to project in front below the breast on the amputated side to provide an anchor point <i>(B) </i>to which the diaphragm band is attached. An elastic sus-pensor strap attaches to the top of the shoulder cap at <i>A</i>, passes diagonally down the back, and is sewed to the diaphragm band at <i>C </i>somewhat toward the sound side of the vertebral spine. For ease in adjustment and to provide for ready laundering, a buckle is used at <i>D, </i>a clip-type disconnect is installed at <i>E, </i>and attachments at <i>B </i>and <i>A </i>are made with snap fasteners. The arrangement for control of the elbow lock utilizes the waist band<a style="text-decoration:none;">*</a> in the same way as in the corresponding pattern for the male (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Harness for female shoulder-disarticulation cases, made integral with bra but detachable from arm socket for laundering. Scapular abduction provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side. After Pursley, <a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this harness design the diaphragm band crosses the back somewhat lower than the midscapular level desired with the chest strap, adequate excursion is usually available from biscapular abduction, which, as in the male patterns of <b>Fig. 22</b>, <b>Fig. 23</b> and <b>Fig. 25</b>, provides dual control of forearm flexion and terminal-device operation. Shoulder elevation provides control of elbow locking.</p> <p>A problem encountered with the design shown in <b>Fig. 27</b> is that in flat-chested persons or in those with comparatively small breasts it is sometimes difficult to get adequate stability, so that operation of the dual control causes the brassiere to rotate upon the chest. When such a situation prevails, use may be made of the modification shown in <b>Fig. 28</b>, where the brassiere is called upon to provide suspension only, the loop about the sound shoulder furnishing the dual control. Here, as in Figure 27, attachments <i>A, B, </i>and <i>D </i>are made with snap fasteners so that the entire harness can be removed from the arm socket for laundering, the elastic suspensor being sewed to the diaphragm band at <i>C.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Alternative harness for female shoulder-disarticulation cases in which the simpler arrangement of Figure 27 proves too unstable. Here the bra is used for suspension only. The loop over the sound shoulder provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic A ppliance Journal</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Special Cconsiderations</h4> <p>A distinguishing characteristic of the shoulder-disarticulation amputee is that the available control sources are for the most part of comparatively high force but of low excursion. Most commercially available terminal devices require an average of 1 3/4 in. of excursion for full operation, and normally 2 to 3 in. of excursion are needed to produce full forearm flexion of 135 deg. Generally, the total exceeds the excursion available from scapular abduction. This means that if, in a dual-control system with a voluntary-opening hook, where the excursions for forearm flexion and for terminal-device operation are additive, the amputee is to be able to open the hook at the mouth, some means must be found for obtaining the extra excursion. The only other alternatives are to use a voluntary-closing hook, in which case the excursion used in forearm flexion is regained for hook operation, or to use triple control, in which case forearm flexion and terminal-device operation are obtained from two separate sources. But many shoulder-disarticulation amputees do not care for voluntary-closing terminal devices, and others, for this reason or that, are not always able to manage the triple control. Since in general the force available from scapular abduction far exceeds that needed for forearm lift and prehension, some of the force may be sacrificed in the interest of obtaining an increase in excursion. The "block-and-tackle" cable system shown in <b>Fig. 29</b> and <b>Fig. 30</b> provides a two-to-one step-up in excursion at the expense of surplus force. It may be used with any of the six harness systems whenever added excursion is needed either for forearm flexion or for terminal-device operation. In <b>Fig. 23</b>, for example, it is applied to the dual control. In [link26], it is used to step up forearm flexion in the triple control. It could equally well be installed in the system of <b>Fig. 22</b>, should that prove to be necessary in any given case. Conversely, when excursion step-up is not required for the patterns of <b>Fig. 23</b> and [link26], an external cable routing may be used, as in <b>Fig. 22</b>. In any case, careful analysis of the excursion available and of that required for the terminal device prescribed forms the basis of judgment as to whether the step-up system is indicated or not.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cable system for reducing the amount of excursion needed in the shoulder-disarticula-tion dual control. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of the excursion-reducing cable system shown in Figure 29. After Pursley <a></a>, by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the six harness patterns described here represent the most generally successful designs now in common use for the shoulder-disarticulation case, no one of them provides a voluntary control source for motion of the upper arm about the shoulder. This deficiency, of course, imposes upon the shoulder-dis-articulation amputee a rather serious limitation not characteristic of the normal arm. Some provision for arm flexion-extension is possible by making the arm socket in two pieces, a humeral section and a shoulder cap, and using the so-called "sectional plates" .<a></a> But this arrangement is intended for manual pre-position only. Recently<a></a> a shoulder-disarticulation arm has been designed with a shoulder joint giving a combination of flexion and abduction to permit comfortable sitting at a table or desk, but again arm lift is manual, there being no satisfactory control source for voluntary flexion-abduction about the shoulder cap. Development of an additional voluntary control source to simulate the motion of the normal glenohumeral joint is now perhaps the most pressing need of the shoulder-disartic-ulation amputee.</p> <h4>Harnessing for Bilateral Arm Amputees</h4> <p>As compared to the unilateral case, the prosthetic requirements of bilateral arm amputees are magnified many fold. Experience shows that the unilateral subject uses his prosthesis chiefly to hold, carry, or assist in activities requiring two hands. Bilat-erals, on the contrary, are required to rely wholly on their arm substitutes for both one-handed and two-handed activities. The prescription criteria and techniques of fitting are therefore modified for the bilateral in an attempt to provide general operation in areas where the unilateral uses his normal hand. Bilateral arm amputees must, for example, have access to the pockets, both shirt pockets and side and hip trouser pockets if possible. They must be able to brush the teeth, comb the hair, use a buttonhook to manage button closures, and perform a great variety of other essential activities in the course of daily living. In general, all of these functions require action close to the body, behind the back at waist level, or at face, neck, or above the head. The prescription criteria for bilaterals therefore require special attention to personal as well as vocational needs, and consideration must be given to such special items as easily operable wrist disconnects and wrist-flexion units. Fabrication techniques are altered to provide for greater strength, and socket margins must be carefully determined in order to assure maximum socket stability for improved control.</p> <p>In below-elbow cases, residual pronation and supination is, of course, priceless. In every step of amputee care, every effort should be made to maintain forearm rotation. Attention should be paid this matter from the time of the original amputation and should continue through prescription, socket fitting, and fabrication of the harness.</p> <p>A matter of the greatest importance to the bilateral arm amputee is that of being able to get the harness and prostheses on and off without help from others. Bilateral above-elbow and shoulder-disarticulation amputees can almost always manage to get their prostheses off without help, but they sometimes require assistance in putting the arms on. Special brackets mounted on a wall in a bedroom are often needed to help amputees otherwise unable to perform independent donning. If, for example, a bilateral with short above-elbow stumps cannot control his prostheses while reaching for the harness cross on his back to remove the harness by pulling it over his head ("skinning-the-cat"), he hangs the cross over the wall hook by simply backing up to it. He then bends his knees to lift the straps over his head. Leaving the harness cross on the hook, he then removes the prostheses by holding the terminal devices, one at a time, each with the opposite foot. Thus the arms are left hanging in such position that the stumps can again be inserted into the sockets and the harness slipped back over the head.</p> <p>Control in the bilateral amputee is at best difficult. Because the number of controls required is doubled, less effective control motions must be brought into use, and independence of control becomes a problem. At present, six control functions, three for each arm, are about all that can be manipulated conveniently and efficiently. Even so, interaction between controls is noticeable.</p> <h4>The Bilateral Below-Elbow Harness</h4> <p>The easiest way to describe a bilateral below-elbow harness (<b>Fig. 31</b>) is to start by supposing that a unilateral below-elbow amputee has lost his remaining good arm below the elbow and has asked that his old figure-eight harness be used to make the new bilateral harness. The first step would be to cut the axilla loop on what was formerly the sound side. The front portion of the cut strap would then be attached to the inverted Y-suspensor of the new prosthesis. The back portion of the cut strap would be turned back upon itself and attached to a buckle. It thus would become the control attachment strap for the new prosthesis.<a style="text-decoration:none;">*</a> Arm flexion on either side then gives terminal-device operation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The bilateral below-elbow figure-eight harness. A webbing inverted Y-suspcnsor with triceps pad and flexible leather hinges is shown on the right side, while a leather inverted Y-suspensor with full cuff and rigid hinges is shown on the left. Similarly, one type of hook is shown on one side and another type on the other. In the bilateral case, prescriptions should be written independently for the two sides with a view toward providing as much utility as possible. As in the corresponding unilateral cases, the choice of cuffs, pads, hinges, terminal devices, and other details is made on the basis of the individual characteristics of the stump for which the prosthesis is intended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cross on the back may be lowered by loosening the inverted Y-straps in front and taking up the slack in the control attachment straps. The reverse procedure moves the cross up. Should the cross be too far to one side, it may be moved horizontally by loosening the inverted Y-strap and control attachment strap on that side and taking up the slack on the opposite side.</p> <p>An important consideration is the choice of materials best suited to the individual case. In <b>Fig. 31</b>, the right Y-suspensor is made of vinyon, while the left is made of leather. If the amputee finds that getting the harness on and off is a major problem, then the tendency of leather to maintain its shape makes it easier to slip the stumps through the suspensors. If excessive perspiration is a problem, then vinyon tape may be more suitable.</p> <p>Although the combination of one leather and one vinyon Y-suspensor is shown in <b>Fig. 31</b> primarily to suggest the two possibilities, it is not inconceivable to consider the arrangement for actual use. In the bilateral below-elbow cases, the choice of cuffs and hinges is made independently for each side on the basis of such factors as stump length, muscular tone, and elbow mobility. In some cases, it might be well to consider using flexible hinges on one side to encourage the use of residual pronation-supination while applying full cuff and rigid hinges on the other to provide stability. A bilateral so fitted would thus have the added versatility provided by an enhanced function of one kind in one arm and an enhanced function of a different kind in the other.</p> <p>In <b>Fig. 31</b>, a wrist-flexion unit is installed on the left prosthesis. Although in exceptional cases the bilateral fitting of wrist-flexion units might be desirable, ordinarily only one flexion device is necessary. When only one wrist-flexion unit is used, amputee preference, or simply prosthetic dominance of one extremity over the other, is probably the best criterion for determining the side to which wrist flexion should be applied.</p> <h4>The Bilateral Above-Elbow Harness</h4> <p>The unilateral below-elbow figure-eight harness has been adapted for bilateral above-elbow cases as well as for the bilateral belowelbow amputee. It is essentially the same as for the below-elbow cases but with added suspensory harness and means of operating the elbow locks. A typical pattern is illustrated in <b>Fig. 32</b>. If allowance is made for the increased need for function in the bilateral case, then fabrication of the bilateral above-elbow harness is similar to that of the unilateral above-elbow figure-eight pattern. Use is made of the same methods of harness adjustment as in adjusting the harness for the below-elbow bilateral.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. The bilateral above-elbow figure-eight harness. As in the bilateral below-elbow case, here too the choice of components for the two sides is made independently with regard for individual stump characteristics and with the intention of providing as much useful function as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before attempting the fabrication of the bilateral above-elbow harness, the harness-maker must understand the above-elbow figure-eight harness for unilaterals. He should then discuss with his patient any special vocational or personal activities requiring modification of harness design. When the harness is completed, the prosthetist should make it a point to follow up progress in training to make sure that the bilateral amputee can soon become self-sufficient in all necessary activities. If attention is paid to these few details, and if each bilateral amputee is treated as an individual problem, surprisingly good results may be obtained in practically all bilateral cases.</p> <h4>The Bilateral Shoulder-Disarticulation Harness</h4> <p>Because the bilateral shoulder disarticulation and the bilateral above-elbow/shoulder combination represent comparatively rare and highly specialized instances of upper-extremity amputation, it has thus far not been possible to establish any set harness pattern for these cases. Although in general the bilateral shoulder-disarticulation harness is a sort of combination of two shoulder-disarticulation harnesses for the unilateral, every amputee requiring such harness must have meticulous attention to details in the individual case. In any event, it is obvious that, in the bilateral shoulder-disarticulation amputee, the goal of the prosthetist is to obtain as much function as possible regardless of necessary deviations from ordinary practice. Although experience with extreme cases of this kind has to date been limited, the Case Study at the University of California at Los Angeles (page 61) has accumulated some useful information. At present, the knowledge gained at UCLA probably offers the most important guide for management of the individual bilateral shoulder-disarticulation case.</p> <h3>Conclusion</h3> <p>To the student of the art of harnessing upper-extremity prostheses, it will now have become perfectly plain that here, as in almost every other published source, the harness designs presented are principally those applicable to the comparatively young, healthy, adult male amputee. Included, furthermore, are only those systems for which there has been accumulated enough clinical evidence to prove their validity for use with presently available arm components. Noticeably missing are special patterns and fabrication techniques for the very young, for the very old, for the debilitated, for the special cases involving other complicating handicaps, and, with two exceptions, for the female.</p> <p>The reason for this situation lies in the fact that, inspired as it was by the desire to aid the veteran returning from the wars, the Artificial Limb Program, sponsored by the Veterans Administration and the Department of Defense, has quite naturally placed emphasis upon the type of amputee to be expected from the battlefield. But it is not fully appreciated by the general public that there are produced annually from disease or accidentsâ€"in the home, on the highway, in the factoryâ€"many, many more amputees than are ever produced in military campaigns. Such causes of amputation play no favorites with age or sex.</p> <p>Fortunately, the basic principles involved in the harnessing of the adult male are more or less fully applicable to the juvenile amputee. Recently, for example, an armamentarium chart defining child amputee types and offering suggestions for prescription for children of age three and a half to ten years has been prepared under the auspices of the Michigan Crippled Children Commission.<a></a> Two columns of this reference document are devoted to "harness type" and "control type" respectively. Except for the omission of the below-elbow dual control and of the above-elbow and shoul-der-disarticulation triple controls, at every level of arm amputation in the child the recommended harness and control systems are identical with those used for the corresponding level in the adult male. The only significant modifications are concerned with the use of 1/2-in. instead of 1-in. webbing, according to the size of the child, and with the twofold recommendation that the harness be worn over a T-shirt and that the younger children be provided with two harnesses, one to be worn while the other is laundered. Since in general young children do not possess harnessable forces as large as are usually to be had in the adult, the unit stresses produced by the narrower webbing are acceptable to the small child, and hence, following the rule of minimum permissible harness in all cases, it is obviously advisable to use the 1/2-in. material whenever it can serve the small fry satisfactorily. The need of children generally for a frequent change of clothing deserves no further comment here.</p> <p>In any event, it will be recalled that some twelve-year-olds are actually larger and stronger than some adults, and consequently the determining factor in any given child is his own particular size, which in turn determines whether 1/2-in. or 1-in. material will provide the more comfort. Other features of harness fabrication for children are essentially the same as for adult harnessing.</p> <p>As for the adult female, generally the harness for the adult male is applicable, with the exceptions that the chest-strap designs usually are not desirable and that commonly more emphasis is placed on cosmesis. Most women, for example, prefer to have a choice of wearing "V" necklines instead of being restricted to Peter Pan collars or other high necklines. The figure-eight harness pattern is adequate for both above- and below-elbow female amputees. In high-above-elbow cases and shoulder disarticulations, the patterns of <b>Fig. 27</b> and <b>Fig. 28</b> usually serve satisfactorily.</p> <p>Elderly amputees, amputees with multiple limb losses, and those with additional complications such as blindness or deafness all present such highly specialized problems that no single harness pattern can be more than partially satisfactory in all cases. Some evidence seems to indicate that there may even be an age limit beyond which most individuals begin to feel that bothering with an artificial arm at all is no longer worth the effort. But no really scientific evaluation has yet been made of the needs of the aged amputee. Circumstances in the individual case must therefore dictate the course to be taken. As in the case of children, some geriatric patients are healthy, strong. and dynamic; others are ailing, feeble, or lethargic. In the elderly amputee, therefore, as in all special cases, personal factors prevent the recommendation of any generalized harnessing system.</p> <p>In the two illustrations of typical harnessing for bilateral arm amputees (<b>Fig. 31</b> and <b>Fig. 32</b>), the subjects are shown as having amputations at approximately the same level on the two sides. In actual clinical practice, of course, bilateral arm cases present all possible combinations of above- and below-elbow amputations. In all such cases, the problem of devising suitable harnessing combinations presents a special challenge to the prosthetics clinic team. Similarly, in the case of amputations complicated by other mental or physical handicaps, special assessment of the individual patient must be made to determine, first of all, whether use of a prosthesis is actually feasible and, if so, what if any departures from conventional harness patterns are indicated. In all such unusual instances, the considered judgment of the clinic team is indispensable in the development of a specialized harness pattern suited to the needs and abilities of the individual concerned,</p> <p>It may now be reiterated that, even in the so-called "standard" cases, it does not suffice to supply a "standard" harness. The reference chart of <b>Table 1</b> is appended here only for the convenience of the clinic team in selecting the basic kind of harness applicable to any given case. It is, in the end, the responsibility of the prosthetist to see that the details are properly custom-matched to the wearer and that, after adequate amputee training, the harness chosen actually fulfills satisfactorily the needs of the wearer for whom it was intended. Less meticulous avenues of approach lead ultimately to failure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. (For a larger image of this table, please refer to the PDF link at the top of the page.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, cognizance should be taken of the understandable circumstance that the harness patterns presented here have all been developed specifically for use with existing mechanical devices. The above-elbow and shoulder-disarticulation systemsâ€"the dual-control figure-eight, the dual-control chest-strap, and the triple-control patternsâ€"have, for example, all been designed around existing elbows. Because heretofore the art of harnessing has lagged behind the development of arm components, it has been necessary in recent years to design the harness systems to fit the mechanical parts rather than vice versa. A more logical arrangement would have been first to analyze the available body control motions, to design the harness for maximum utilization of these motions in the least awkward way, and then to design the other parts of the prosthesis in such a manner as to be operable by control patterns best suited to amputee characteristics. Future research in harnessing can be expected to influence redesign of desirable operational characteristics of the mechanical devices now available and to encourage the development of wholly new and improved arm components.</p> <h4>Acknowledgment</h4> <p>With the exception of the photographs and of <b>Fig. 12</b>, the illustrations appearing in this article are the work of George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon, </i>Artificial Limbs, 1(3):4 (September 1954).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty,</i>, Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes. </i>McGraw-Hill, New York, 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, <i>Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, </i>21 June 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, <i>Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), </i>8 August 1955.</li> <li>Carlyle, Lester, <i>Artificial arm checkout procedures,</i>Artificial Limbs, January 1954. p. 25.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Applied Microbiology, 3(4):238 (1955).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Hitchcock, William E., <i>Abduction for shoulder disarticulation prosthesis, </i>Orthop, Pros. Appl. J., September 1955. p. 23.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary miscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Kessler, Henry H., <i>Cineplasty, </i>Charles C Thomas,Springfield, Ill., 1947.</li> <li>Langdale-Kelham, R D., and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944.</li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind Eng. Chem., 45:773 (1953).</li> <li>Marks, George E., <i>A treatise on Marks' patent artificial limbs with rubber hands and feet, </i>A. A. Marks, New York, 1889.</li> <li>Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., <i>Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years </i>(a chart), 1955.</li> <li>Mount, George E., and Raymond E. Bernberg,<i>A preliminary comparison of perception undet cineplastic and harness prostheses, </i>Am. J. Psychol., LXII(1):106(1949).</li> <li>New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, <i>The above-elbow figure-eight harness a guide to procedures and principles, </i>September 23, 1954.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial arm and leg research and development, </i>February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Pursley, Robert J., <i>Harness for shoulder disarticulation amputees, </i>Orthop. &amp; Pros. Appl. J., March 1955. p. 15.</li> <li>Spittler, August W., and Maurice J. Fletcher,<i>Technique of cineplastic surgery and prosthetic appliances for cineplasty, </i>Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, <i>Carpometacarpal {harness controlled) prosthesis, </i>September 22, 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17.</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>18.</b> </td><td class="clsTextSmall">Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years (a chart), 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">While this hypothetical case suffices to describe the harness, it carries the faulty implication that the bilateral harness is simply two unilateral harnesses. No such implication is justified, for, as already pointed out, the functional requirement is magnified many fold, there is the complication of effecting separation of controls, and in addition there is the problem of getting into and out of the harness.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hitchcock, William E., Abduction for shoulder disarticulation prosthesis, Orthop, Pros. Appl. J., September 1955. p. 23.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Footnote</b></td></tr><tr><td class="clsTextSmall">When the waist band is disliked by the female amputee, the elbow control strap may be anchored to a girdle or pantie girdle, just as it may be anchored to the trousers in the male.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Not chiffon or lace!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Use of the waist band, as in Figure 22, is largely a matter of personal preference. Some amputees like it, some do not. When the amputee wishes to dispense with the extra waist strap, the elbow control may be anchored to an item of clothing such as a button at the top of the trousers near the fly, as in Figure 26. The control strap then passes out of the shirt between buttons, so that no special opening is needed. But of course when this arrangement is used, the prosthesis is inoperable when the wearer is unclothed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, The above-elbow figure-eight harness a guide to procedures and principles, September 23, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It may be noted that the techniques for harnessing the above-elbow amputee can be applied equally well to articulated braces for flail arms.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), 8 August 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Although common-sense logic might lead one to suppose that improvement in pressure appreciation would be obtainable only were the terminal device voluntary-closing, it turns out that considerable improvement is to be had also from muscle tunnels harnessed to voluntary-opening devices. The tests conducted by Mount and Bernberg were, for example, all made with amputees wearing voluntary-opening hooks. How does the amputee so fitted estimate the amount of force being exerted at the hook fingers? He measures holdback and subtracts it mentally from the known total force exerted by the hook when no restraint is applied. (Ed)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 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>19.</b> </td><td class="clsTextSmall">Mount, George E., and Raymond E. Bernberg,A preliminary comparison of perception undet cineplastic and harness prostheses, Am. J. Psychol., LXII(1):106(1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Except, of course, in those cases where extremely heavy duty is a requirement from the beginning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Applied Microbiology, 3(4):238 (1955).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind Eng. Chem., 45:773 (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>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures,Artificial Limbs, January 1954. p. 25.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial arm and leg research and development, February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3):4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Langdale-Kelham, R D., and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Marks, George E., A treatise on Marks' patent artificial limbs with rubber hands and feet, A. A. Marks, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Pursley, Lt., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Chief, Research Limb Section, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-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 Harness Patterns for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Robert J. Pursley, Lt., USA (MSC) * https://staging.drfop.org/files/original/d3e07ca0af0348fd4c2e920c106b4c65.pdf 809d9e3993c31bb21b2a8dc9b7031253 https://staging.drfop.org/files/original/222baa00904d46e2a3f74ce88ede3447.jpg c7b121f400393dc467ed647aeacdac4e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_061.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 61 - 63 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_061.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_061.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>Some Experience in Harnessing Extreme Arm Cases</h2> <h5>Craig L. Taylor, Ph. D. <a style="text-decoration:none;">*</a><br /></h5> <p>With recent developments in shoulder prostheses, including that for complete removal of the shoulder girdle, it is possible to fit all upper-extremity amputees with useful arm substitutes. But of course it does not follow that all patients with high amputations can obtain from the available harnessing resources a uniformly good level of prosthetic function. It is appropriate to review present experience with such cases in order to establish realistic guides for the fitter. Although there is only a limited number of upper-extremity amputees with multiple amputations or with amputations at very high levels, the UCLA Case Study<a></a> has accumulated a sufficient number to make tentative conclusions possible.</p> <p>Limitation in the potentialities of shoulder harness begins with the unilateral shoulder case of the disarticulation type. Unilateral humeral-neck amputees with an intact shoulder girdle have, in every case known, been able to manage the shoulder dual control, and with any of several elbow-lock arrangements they have been able to carry out all of the operations of the prosthesis. Further unilateral shoulder losses, or losses of both shoulders at various levels, entail such impairment of harnessable shoulder mobility that it is impossible to attain the operating effectiveness ordinarily to be expected from the major prosthetic controls. A review of several types of fittings and the results obtained indicates the nature of these limitations.</p> <h4>Unilateral Shoulder Amputees</h4> <p> In the unilateral shoulder amputee, limitation begins with the disarticulation because the leverage on the amputated side is then so reduced that biscapular shrug no longer gives the necessary excursion. With most men of average to large build, however, the results usually are satisfactory (<b>Table 1</b>). In the case of M.W., pelvic control was required. T.M., a large and broad-shouldered man, obtained good function despite large, but not complete, clavicle and scapula losses. With the fore-quarter case, P.H., the sound shoulder could not manage the full control, and the functional regain was decidedly marginal.</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 /> <h4>Bilateral Above-Elbow/Shoulder Combinations</h4> <p> No case of bilateral humeral-neck amputation has thus far come to notice, but the bilateral above-elbow/shoulder combination is comparatively frequent. Five cases of this type can be cited. All save one are at least moderately successful. The unsuccessful case, C.B., has a number of stump complications that have prevented a satisfactory result. Otherwise, good operation, one prosthesis at a time, is provided by harnessing modifications in which the elements of the shoulder-disarticulation harness from one side and of the figure-eight from the other are combined. It should be noted that in all these cases both shoulder girdles are intact, and there is in addition one humeral stump. Hence, shrug and arm-flexion controls can be managed normally.</p> <p>The first case of this type, L.S., is a young man, age 29, with a right above-elbow stump of 10 in. and a humeral-neck amputation on the left side. The musculature and mobility of both shoulders and of the right stump are good. Amputee L.S. is tall and slender but of moderately broad-shouldered build. He is fitted on the right with an above-elbow dual control, on the left with a modified shoulder-disarticulation harness with nudge control for elbow lock. He is rated as a good wearer and is independent in nearly all activities.</p> <p>The second case, C.B., is an elderly man, age 60. He has a right shoulder disarticulation and a left short humeral stump supplemented with a tibial graft. Neuromata in the shoulder area and tenderness about the tibial graft have made fitting difficult; trial fittings with numerous types of harness have not been successful. The age of the subject, recurrent shoulder pain, and habits of dependence have together prevented satisfactory results.</p> <p>Another case, M.C., is a young woman, age 36, with a right short above-elbow and a left humeral-neck stump, the latter supplemented with a tibial graft not yet ready for fitting. Meanwhile, amputee M.C. is operating well with the right prosthesis only. She has acquired skill in eating, drives a car, does housework, and is rated a good wearer generally. Future addition of the left prosthesis is uncertain.</p> <p>Amputee R.G. is a young man, age 31, with a right short above-elbow and a left humeralneck amputation. He is tall and rangy with broad shoulders. Bilateral pectoral muscle tunnels had been constructed, but they were eventually closed at the amputee's request. When last seen he was fitted with short above-elbow dual control on the right side and shoul-der-disarticulation dual control on the left. For a while the left elbow lock was operated by the pectoral tunnel, but the method of elbow-lock operation after removal of the tunnel is unknown. Over several years of observation this amputee was rated as a moderately good wearer and was independent in most personal activities.</p> <p>Finally, J.L. is a man, age 40, with a right above-elbow stump 9 in. long and a left amputation at the humeral neck. Of fairly tall and rangy body build with good shoulder and stump mobility, he was fitted with a right above-elbow dual control and a left basic shoulder-disarticulation harness, the left elbow lock being operated by a nudge control After fitting and training he attained a good level of performance and as far as is known continues to be a good wearer.</p> <h4>Bilateral Shoulder Disarticulation</h4> <p> The reduced shoulder width associated with the bilateral shoulder-disarticulation case so impairs scapular abduction and shoulder flexion that complete control of the prostheses is not possible. Full operation of the terminal device at elbow angles above 90 deg. cannot be managed with the dual control, and a lower level of operation must be accepted. The pelvic control remains a possibility, but this expedient has so many disadvantages of inconvenience, awkwardness, and discomfort that few if any amputees accept it for continuous use. Shoulder control can at best be unilateral only.</p> <p>Nevertheless, an acceptable level of function may result. For example, J.G. is an elderly man, age 63, with bilateral shoulder disarticulations. Of medium build and with rounded chest, he has to date been completely dependent on help from others. Fitting and care have been sporadic because of infrequent visits to the laboratory. He last was fitted unilaterally with a right prosthesis and a reaction cap on the left shoulder. Thus far the fit has been promising. At the last visit he had managed eating and other activities.</p> <p>With the congenital anomalies, amelia and phocomelia, control functions usually are considered as being the same as those for the shoulder-disarticulation case. Shoulder girdles are narrow because of the absence of humeral heads or owing to loose and nonarticulated rudimentary elements, so that basic shoulder control may not be adequate for bilateral function. In phocomelia, with both forearm and hand or only hand elements, additional help may often be obtained for secondary controls such as elbow-lock operation. In any event, these congenitals early develop "manipulation" with the feet, and these capabilities have not been matched, so far as is known, by any upper-extremity prosthesis.</p> <p><b>References:</b></p> <ol> <li>Gottlieb, M. S., <i>Final report of the UCLA upper extremity amputee case study, </i>Department of Engineering, University of California (Los Angeles), in preparation 1955.</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">Gottlieb, M. S., Final report of the UCLA upper extremity amputee case study, Department of Engineering, University of California (Los Angeles), in preparation 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_061/tmp48F-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience in Harnessing Extreme Arm Cases Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph. D. * https://staging.drfop.org/files/original/2dea17a3a5a3c752d1ee37559bbaa825.pdf 7a4435086ff3850c01c2ef893fa48eac https://staging.drfop.org/files/original/43d8a129940cb8511733726caf27bf79.jpg 5b81f8134177bd4ec394e1f9f2c7aa76 https://staging.drfop.org/files/original/39e08fec5517e38ce66dbeac92235181.jpg 69fe78cabce5d19c388bd5c6790f61fa https://staging.drfop.org/files/original/3a2aea30bf763bcff465c69a91b543c6.jpg 50d23a5eff289ab00376b2787b04b7a4 https://staging.drfop.org/files/original/a8157ca13387fd20c5b413875668ef69.jpg 0ae08cbaf0551506dc3f01cef5e2c987 https://staging.drfop.org/files/original/0b36336724f1ed95ee0fdecea4e24704.jpg 72776be8ad19dce1b202d29195559889 https://staging.drfop.org/files/original/9f72cc18e382ab675a87069c72e62cd2.jpg b62295fcb70277ba0a60bef4591a702f https://staging.drfop.org/files/original/58911f3f64dd71a25a20575b8272b859.jpg b996ee7ff9c38a927feb2bb4ca0678f1 https://staging.drfop.org/files/original/900709fd561acd10c0f47effcf1360ef.jpg b85e77771aac862aba66ec7c33585be5 https://staging.drfop.org/files/original/073bad9839c0df598f8e71002a2f42be.gif 4535091be1c2df849d6a024ab57da422 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_047.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 47 - 56 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Noticeability of the Cosmetic Glove</h2> <h5>Tamara Dembo, Ph.D. <a style="text-decoration:none;">*</a><br />Esther Tane Baskin, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Ahand prosthesis can be useful in more than one way. It can be helpful in dealing with objects, and it can be helpful in interpersonal relations. The latter aspect is the one with which we are here concerned. The usefulness of a prosthesis in human relations is termed "social usefulness." To a wearer who considers his hand amputation a private matter, for example, and to one who does not wish to be recognized as an amputee, a prosthesis is socially useful if it cannot be recognized as an artificial device. Moreover, the amputee may be concerned that another person looking at the prosthesis should feel comfortable. In such a case, that prosthesis is most useful which does not repulse or embarrass another person but is "good to look at."<a style="text-decoration:none;">*</a></p> <p>In 1949 a cosmetic glove, produced at the Army Prosthetics Research Laboratory, was sent for testing to the Research Division of the College of Engineering, New York University. Investigation of the cosmetic glove led to formulation of the problem of the social usefulness of prosthetic devices in general. The methods developed during the study of the glove are, furthermore, generally applicable to the investigation of the social usefulness of other prostheses. This article deals only with the problem of the noticeability of the cosmetic glove. The question of its appearance, <i>i.e., </i>the desirable and undesirable characteristics of the sight of the cosmetic hand, is not discussed.</p> <h3>Experiments and Results</h3> <p>On cursory examination, the experimental prosthesis looked like a normal hand, but on closer scrutiny it could easily be recognized as a cosmetic device. Further, it did not match the normal hand of the particular wearer, although it was, at that time, the best match among several available cosmetic gloves (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). Moreover, the glove simply was filled with vinyl foam, and the hand was thus nonfunctional except insofar as the amputee might wedge light objects between the springy fingers.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Winthrop Sullivan wearing the cosmetic glove on his left (to the reader's right). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Mr. Sullivan's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Brennan C. Wood wearing the cosmetic glove on his right (to the reader's left). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Mr. Wood's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The problem was to determine whether such a glove is realistic enough not to be noticed as a prosthesis, or, rather, how frequently the wearer of such a glove goes unrecognized as an amputee. Four different experiments were conducted.</p> <h4>Experiment I</h4> <p>In the first experiment, 30 separate tests were performed. Each required a wearer,<a style="text-decoration:none;">*</a> an experimenter, an observer, and a stranger. The stranger was the "subject" because his reaction, <i>i.e., </i>whether he did or did not recognize the cosmetic hand as a prosthesis, was of prime importance. The wearer went, as a cus tomer, to various stores and shops in New York City and engaged salemen (subjects) in conversation. In each instance, he put his arms on the counter and, to make sure that the cosmetic glove was in sight of the salesman, gestured, pointed, scratched his hand or face, indicated size or shape of objects, held a newspaper, smoked, soiled the cosmetic hand and wiped it off, or supported objects <i>(e.g., </i>held a wallet against his body with the artificial hand), all the while acting in a leisurely manner in order to prolong the contact, usually for from five to twenty minutes. Experimenter and observer entered the store with the wearer but as a separate party. While the wearer talked to the subject, experimenter and observer stood aside as if engaged in conversation, the observer pretending to listen to the experimenter but actually taking notes on the behavior of the wearer and the salesman. The latter, of course, did not know that he was the "subject" of a psychological experiment.</p> <p>When the wearer left the store, the experimenter approached the salesman and asked some questions about the man who had just left. The observer continued to stand aside and recorded the discussion (interview) between the experimenter and the subject. An example of an interview follows:</p> <blockquote><p><i>Experimenter: </i>Did you notice anythingabout the man who was just in here? <br /> <i>Salesman: </i>In what respect? <i>Experimenter: </i>Well, did you notice anything unusualabout him? <br /> <i>Salesman: </i>About his hand. <br /> <i>Experimenter: </i>What was there about it you noticed?<br /> <i>Salesman: </i>There was no action in it. <br /> <i>Experimenter: </i>When did you notice it? <br /> <i>Salesman: </i>When he had his hand at his side. When helighted a cigarette. He held his hand like this[shows stiff position].<br /> <i>Experimenter: </i>Do you think it could have been an artificial hand? <br /> <i>Salesman: </i>No, it was not an artificial hand. It was his hand. He held it close to his side. Maybe he had no action in the shoulder. He did not use that hand. Used one hand at mirror. Held it. Just turned it.</p> </blockquote> <p>After being informed that the hand was a prosthesis, the salesman said he had not recognized it as such.</p> <h4>Experiment II</h4> <p>In the second experiment, three or four people (college students and their friends) were asked to take part as subjects of a psychological group experiment on "impressions of personality." On their arrival, the subjects found the wearer, who was introduced as one of the group members. Everyone was asked to sit around a table and to wait for another group member supposedly delayed and, in the meantime, to get acquainted with each other. The wearer, holding his hands in plain view on the table, conversed with the group members. After about 10 minutes he left the room, ostensibly to make a phone call. Then each member of the group was asked to accompany an experimenter to another room, where the participant was asked to give his impression about the person who went to make the phone call. If, during the interview, it became clear to the experimenter that the subject had not noticed the hand, the subject was given another opportunity to observe the wearer, and then a second interview took place. Sometimes the procedure was repeated a third time. In all, 29 subjects were used.</p> <p>An example of an interview performed in Experiment II follows:</p> <blockquote><p><i>Experimenter: </i>As you know, we are studying quick impressions of personality. Mr. X is part of the experiment. Could you give your first impressions of him? What struck you about him, mainly?<br /> <i>Subject: </i>He seemed intelligent, friendly, sociable. It seemed as though he could talk on other than his major field of interest.<br /> <i>Experimenter: </i>How would you describe him physically?<br /> <i>Subject: </i>Physical impressions are a pretty personal matter, I think. Would say he was more positive than negative, from the point of view of attractiveness. Genial.<br /> <i>Experimenter: </i>Could you give the outstanding characteristics of his face?<br /> <i>Subject: </i>He had a fairly easy smile, seemingly accompanying a sense of humor and a desire to please.<br /> <i>Experimenter: </i>Could you describe his hands?<br /> <i>Subject: </i>Yes, I noticed his hands. I usually do notice hands.<br /> <i>Experimenter: </i>Could I interrupt to ask why you always notice hands?<br /> <i>Subject: </i>I just always have. It dates from the fact that when I was young I thought I couldn't be beautiful, but I could have nice hands and fingernails, so I always notice other people's. I guess I can visualize the hands of every friend I have ever had. I think his were in between, no particular character.<br /> <i>Experimenter: </i>Anything else?<br /> <i>Subject: </i>He had nice hair, a little wavy. A kind of flushed face, more healthy than not.<br /> <i>Experimenter: </i>Were there any gestures on Mr. X's part that you remember?<br /> <i>Subject: </i>No. He had his hands out on the table most of the time, but I don't remember his gestures particularly.</p> </blockquote> <p>The subject who stated that she usually notices hands did not notice the cosmetic hand or any signs of difference about the hand. The experimenter and the subject returned to the group. After about ten minutes more the wearer left, and the second interview took place:</p> <blockquote><p> <i>Experimenter: </i>Now can you give some further impressions of Mr. X?<br /> <i>Subject: </i>I noticed his eyes more this time, a little different than most people's but difficult to describe, noticeable. I noticed his nose tips up a little, like Sonja Henie's. I noticed his hands more because you called them to my attention, but I don't think these physical impressions mean too much.<br /> <i>Experimenter: </i>Was there anything outstanding about his hands?<br /> <i>Subject: </i>His nails were not particularly graceful, they were a little short, but clean looking. I confirmed the fact that his hair was curly and his face ruddy. He seemed very well balanced, not neurotic, in that he seemed willing to go along on other people's fun. He certainly didn't show any compulsion to take the spotlight or to resent it when somebody else took it.<br /> <i>Experimenter: </i>We'll all go back together again, and then<br /> there will be a third interview. I want you to notice his hands again particularly, and in detail. Notice the movement or lack of it. The subject was interviewed again after she saw the wearer for the third time:<br /> <i>Subject: </i>I did notice his hands, the shape, and the rather short fingernails. They looked clean and healthy, but I like tapering fingernails.</p> </blockquote> <p>Even during the third period of contact with the wearer, the subject did not notice any difference between the wearer's two hands, although she was able to describe them. The results of Experiments I and II are given 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>Of 30 subjects in Experiment I, 24 (80%) did not recognize the cosmetic hand as a prosthesis. In fact, they did not even notice any difference between the two hands of the wearer.<a style="text-decoration:none;">*</a> The remaining 6 subjects (20%) commented that the arm or hand was in some way injured, but they too did not notice that the hand was artificial.<a style="text-decoration:none;">*</a> Thus, in an everyday situation of a salesman dealing with a customer, <i>not one </i>salesman in Experiment I noticed the cosmetic glove <i>as a prosthesis.</i></p> <p>The question arises as to why the prosthesis was not noticed by the salesmen. One could ask whether the unnoticeability may not be accounted for by the "fact" that the busy New York salesman does not have enough time to pay attention to the appearance of his customers. This, however, was not borne out by the data. When asked to describe the customer (the wearer), the salesman was well able to describe how the wearer looked, what he did, and what he said. Yet the saleman had not noticed the cosmetic glove.</p> <p>In Experiment II, 29 subjects took part.<a style="text-decoration:none;">*</a>Within the framework of "description of personality," 23 (80%) did not notice any difference between the two hands, 3 (10%) noticed that one hand looked different from the other but did not recognize it to be an artificial hand, and 3 (10%) noticed that it was a prosthesis.</p> <p>That the cosmetic hand was not recognized by any of the salesmen as a prosthesis and rarely as such by the students and their friends, one may argue, is due to the "fact" that people do not pay attention to the properties of another person's hands. To test this "hypothesis," Experiment III was carried out.</p> <h4>Experiment III</h4> <p>In Experiment III, with a setup essentially the same as in Experiment II, the wearer used a hook instead of the cosmetic hand. Here, 11 out of 12 people (92%) noticed that the amputee was wearing a prosthesis. It appears, then, that the cosmetic hand goes unnoticed not because people are negligent in their observations but rather because it does not deviate sufficiently from the appearance of the natural hand. The hook, however, which deviates radically in appearance the normal is noticed readily (<b>Table 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Experiment IV</h4> <p>In the first three experiments, untrained observers were used. The question arose as to whether different results would be obtained in experiments with people especially trained to notice bodily characteristics. One could expect that art students, for example, would be especially apt to notice the cosmetic hand. Accordingly, in Experiment IV, six art students participated as subjects, all members of a drawing class for which the wearer served as a model. Six to eight feet separated the wearer from the students. They were told that, after having made the drawing, they would be asked how the model impressed them as a person.</p> <p>During the first part of the experiment, the wearer posed with his cosmetic left hand supporting his chin (<b>Fig. 5</b>). Ten minutes were allotted for the drawing. Then the wearer left, and the art students were questioned individually, the interviews being conducted in terms of what impression the art student had of the model's personality. Results showed that not one of the six art students was aware that he had been drawing an artificial hand, although some reference was made to the difference between the two hands, or it was felt that the hand somehow did not fit the person.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mr. Sullivan as sketched by an art student. The hand held to the face is the cosmetic one. While drawing this picture, the art student did not notice a difference between the two hands (Experiment IV, Part 1). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second part of the experiment offered even greater opportunity for direct comparison of the two hands. Here, the subjects were told that the model (wearer) would return for a second pose and that later the subjects would be asked "how his <i>hands </i>expressed personality." During the second drawing period, the wearer sat with his two hands covering his face (<b>Fig. 6</b>). But even under these conditions, only two of the six subjects noticed that one of the hands was artificial. The remaining four did not realize that they were drawing a cosmetic hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Second drawing of Mr. Sullivan by the same art student who drew the picture shown in Figure 5. The notation listing the differences between the two hands is that made by the student at the time of the drawing (Experiment IV, Part 2). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To illustrate how, in spite of differences noticed between the two hands in Experiment IV, it did not occur to the subjects that one hand was artificial, excerpts from two interviews conducted after the second drawing (<b>Fig. 7</b>) follow:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Drawing made by an art student during Experiment IV, Part 2. The left hand (on the reader's right) is the cosmetic one. The student saw the hands as different owing to the occupation he ascribed to the wearer. He thought the wearer was a violinist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>Experimenter: </i>What gives now?<br /> <i>Subject: </i>Interesting things, real interesting. Makes a difference when you know you're supposed to look at hands. About his hands, there is a basic difference in his two hands. The right hand is more used, I would say [left hand is the cosmetic one]. There are several interesting things about them. First of all, the fingernails were fairly short. Gives me an idea that he may play a stringed instrument. The button of his cuff was open, couldn't tell if broken off. I thought of a violinist who would open his cuff so he could handle it. I think he is right handed because that would be the bow hand, and all the movement would have opened the cuff. I don't think this particularly jibes with the feeling that the hand that would do the fingering would be the most wrinkled, worn hand. For this was not the case. Yet had the feeling that he does do something special that involves t h specialized use of one of his hands.<br /> <i>Experimenter: </i>Why do you think this?<br /> <i>Subject: </i>Well, there is a basic difference in structure. 1 couldn't see the right hand before when he was posing [subject refers to <b>Fig. 5</b>], I drew the right hand first. It was thinner. I felt there was more structure visible, it was more wrinkled, I could think of some special occupation. Another interesting thing, the watch was worn inside the wrist on the right hand, which made me think it indicates a little about the personality.</p> </blockquote> <p>Another interview in Experiment IV went as follows:</p> <blockquote><p><i>Experimenter: </i>And what did the hands express?<br /> <i>Subject: </i>Well, it looked to me as if [the hands express] the character of a person in very serious thought.Some trouble, wrestling with some problem, rather unhappy.<br /> <i>Experimenter: </i>Was this because of the hands, or the pose, or both? <i>Subject: </i>Both together. The hands were very tense and tight, not relaxed. Indicated that there was a conflict. <br /> <i>Experimenter: </i>This was the physical appearance?<br /> <i>Subject: </i>Yes, the tense position of the hand and fingers, the fingers close together and tight, not relaxed and easy. They show what's inside the person. He unconsciously clenched his fist and you noticed something.</p> </blockquote> <h3>Discussion</h3> <p>In the first experiment in which the cosmetic glove was worn, not once was the cosmetic hand recognized as a prosthesis. In Experiment II, the glove was seen as a prosthesis by only three (10%) of the subjects. In both experiments, a difference between the two hands was noticed only rarely. In Experiment III, the hook was recognized as a prosthesis in all cases save one. If one wishes to "explain" the unnoticeability of the cosmetic hand during relatively short contacts, one may say that the appearance of the cosmetic hand is similar enough to that of the normal to remain unnoticed. We know, however, that the differences between the glove and the normal hand are pronounced enough to be seen by almost anyone. What, then, are the conditions under which the <i>similarity, </i>rather than the <i>dissimilarity, </i>is decisive? To understand what is involved requires a brief discussion of a few general problems of visual perception.</p> <p>It is a well known fact that objects on which we focus are seen much more clearly than are those seen within the area of our peripheral vision. Distinguished from these two areas in the visual field should be two others, namely, "area of concern" and "area of mere presence." An object is in the "area of concern" if we inspect it, that is, if we concern ourselves with it. If, however, we perceive an object "as just being there," if it is not being examined by us and we do not concern ourselves with it, it is in the "area of mere presence."</p> <p>The area of presence and the area of concern of a visual field do not necessarily coincide with the central (focal) and peripheral parts of the field of vision. Each of the areas, that of concern or that of mere presence, can be either central or peripheral. We can, for example, stare at an object, focus on it, and yet not be concerned with it but with something going on elsewhere in our field of vision. Such is the case, for example, when one is looking at an object but wishes to watch another person unobtrusively. Here, the object focused upon is central and at the same time is in the area of mere presence. The person being watched is in the peripheral field of vision but at the same time is in the area of concern. Centrality and peripherality thus are distinguished by whether we do or do not look at an object directly, areas of presence or concern by whether or not we attend to (examine) the object.<a style="text-decoration:none;">*</a></p> <p>Often there is a tendency on the part of an observer to make the area of concern coincide with the center of his field of vision, while objects that do not concern him are shifted to the periphery. The separation of the field of vision into central and peripheral areas is, however, essentially different from the separation into areas of concern and of mere presence. With regard to the noticeability of the cosmetic hand, the most important fact is that objects in the area of concern differ in appearance from those in the area of presence. Some differences in details perceived when two objects are in the area of concern are not perceived when two objects are in the area of mere presence. Thus, two objects in the area of concern may look different, whereas the same two objects may look alike when in the area of mere presence.</p> <p>In meeting people, we usually do not concern ourselves with their hands, <i>i.e., </i>hands are in the area of mere presence. Because the observer perceives fewer details in this area, hands which on examination look different can appear alike to the stranger and thus may not provoke attention during casual contacts. This would account for the infrequency with which the cosmetic hand was recognized in Experiments I and II. Since looking directly at or focusing on an object does not necessarily mean that the object is examined, glancing and looking at the hands directly, as did some of our subjects, failed to result in observation of significant differences.</p> <p>When something unusual happens, the hands shift from the area of mere presence to that of concern or, to put it in another way, the observer changes the position of the hand from the area of mere presence to that of concern. If, for instance, the subject expects the wearer to use a given hand, and if this hand is not used as expected, or if the action is interrupted (Experiment I), the observer becomes concerned with the hand, examines it, and becomes aware of its deviation from an ordinary hand. Again, if examination of the hands is suggested to a subject, the area in which they are seen becomes one of concern. Moreover, if the subject is told that the hand is artificial, an incentive is provided to examine it. In this case, too, the hand is perceived in the area of concern.</p> <p>The physical properties of the cosmetic hand are such that, on examination, they are seen not to match those of an ordinary hand. Yet the handlike prosthesis is sufficiently similar to a normal hand that, in the area of mere presence, it may be seen as an ordinary hand. A hook, however, differs to such an extent in physical properties that, even in the area of mere presence, it can hardly be mistaken for a hand. This accounts for the results of Experiment III, in which the hook was noticed by all but one subject.</p> <p>In comparatively few instances (Experiments I and II), the cosmetic hand was seen as "different" from the other hand but was not recognized as artificial. The existence of cases in which differences are recognized, but in which the hand is not recognized as a prosthesis, may be due to the fact that, as a rule, people are not aware that a realistic hand prosthesis exists. Were that fact commonly known, the 20 percent who noticed the hand as "injured" in the first experiment, and the 10 percent who noticed it as "different" in the second experiment, might have seen it as a prosthesis. But knowledge of the existence of such a prosthesis would not affect the proportion of those who saw <i>no </i>difference (80 percent in both the first and second experiments). Since they did not notice any difference, these subjects would not even begin to concern themselves with the hand. As long as the hands match in the area of presence, knowledge that artificial hands exist would not in itself lead to an examination of hands.</p> <h3>Future Work</h3> <p>Briefly stated, the results show that strangers in everyday contacts with the wearer rarely notice a difference between the two hands. Yet noticeability is only one aspect of the larger problem of social usefulness of the cosmetic hand. Recognition of the cosmetic hand as a prosthesis is bound to occur in repeated contacts with the wearer. Furthermore, friends and relatives know that a wearer is an amputee. When the hand is recognized as artificial, a new problem arises. The appearance of the hand in the area of concern becomes important. Preliminary investigations indicate that, when the cosmetic glove is recognized as such, its appearance evokes in some people very unpleasant feelings. The study of the appearance of the cosmetic glove thus is necessary in order to determine the emotional impact relative to that of other prostheses and to ascertain which properties of the hand provoke negative feelings.</p> <p>Some people perceive a cosmetic hand as having a yellowish greenish shade. This circumstance might evoke toward the prosthesis feelings as toward a dead hand. Such feelings might be alleviated if the color of the cosmetic hand approached more closely that of an ordinary hand (page 57). It might even be shown that, to appear as real as possible, the cosmetic hand should have a definitely less yellowish tinge than does an ordinary hand. For such determinations, the subjects chosen should have strong negative feelings toward the hand available now, and observations should be made when the hand is worn.</p> <p>In conclusion, it should be stressed again that the problem of noticeability is only one aspect of the larger problem of the social usefulness of prostheses. Further studies are required to uncover those psychological properties of the observer which have to be taken into account in order to develop not only "functionally" but also "socially" (or rather "socio psychologically") useful prostheses.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-34.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-35.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-36.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-37.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_047/table01.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_047/table02.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-40.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-41.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-42.gif 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 Noticeability of the Cosmetic Glove Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D. * Esther Tane Baskin, M.A. * https://staging.drfop.org/files/original/58b9ac3acbd103e06a1b89d3952822dc.pdf 0a1ffc6373173388efb41ba207d3695b https://staging.drfop.org/files/original/484b8daccf6ce6c0aece26201505c00e.jpg 0b54c5978606817a280da5a93803beba https://staging.drfop.org/files/original/c48afbc6a0c4b0e08fe65bc1293586dc.jpg 5610616274d318d4c61c5f823dccceb4 https://staging.drfop.org/files/original/7ad84a93475df636cf432dd2ed54559a.jpg 98eb6b4ed650868e68250eae91be6158 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_036.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 36 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_036.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Problems in the Management of Upper Extremity Amputees</h2> <h5>Frederick E. Vultee, Capt., USA (MC) <a style="text-decoration:none;">*</a><br /></h5> <p>Experience in the rehabilitation of upper extremity amputees in recent years has highlighted the advantages of many concepts not previously considered or else heretofore noted only superficially. Not only has the development of prosthetic devices assured a greater degree of rehabilitation of many more amputees, but consideration of the amputee as a whole also has played a major role. It is now well recognized that, in times past, attention was too often directed only to the amputation stump. After the wound had healed, the patient was referred to a prosthetist without benefit of a physician's final evaluation. The development of the clinic team approach<a></a> foreshadowed the end of such practices, and with the growth of the clinic team has come the all important factor of considering the patient as a whole.</p> <p>Implicit in such an approach is the concept that complete upper extremity rehabilitation can rightly be expected only when the amputee has been afforded adequate training in efficient utilization of the prosthesis with which he has been fitted. Incomplete or unsystematic training is, at best, responsible for improper habits in prosthetic usage and hence for awkwardness and inefficiency. In the extreme case, it may lead to discard of the prosthesis entirely even though the components involved may themselves be of the greatest utility to an accomplished amputee wearer. The therapist has thus come to be looked upon as an important member of every prosthetics clinic team.</p> <p>The importance of good health also has come to be realized. The patient who suffers from complicating injuries or diseases may not be able to cooperate fully, and when cooperation is limited, interest and motivation die rapidly. For example, the obese patient will profit by guided weight reduction and proper weight stabilization, and the anemic and allergic will benefit by proper corrective measures. Dermatological problems frequently are a serious complication for the amputee, especially when involvement of the stump is threatened or when harnessing excoriates areas of existing dermatitis. Here proper therapeutic measures may permit continued use of the prosthesis or ensure only a temporary suspension of its use. If, however, such conditions are allowed to continue unchecked, they may result in a prolonged period of inactivity.</p> <p>Equal in importance to good physical condition is a healthy mental attitude. Unless rehabilitation therapy includes consideration of the patient's mental outlook, the entire process of recovery may result in complete failure. Accordingly, some cases may require the assistance of specialists in psychiatry and related fields.</p> <p>With respect to the patient's mental condition, an important factor relates to vocational and avocational pursuits. Whether an amputee can engage successfully in work and recreation to his own liking, and whether he has a taste for such activities as are possible to him, may together spell the difference between success and failure in any given case. Proper attention by a qualified occupational therapist is therefore essential.</p> <p>Functional loss aside, a number of other problems arise from hand loss. In addition to the functions of grasp and tactile sense, the hand is used in many symbolic patterns in benediction, in supplication, in the salute, in the handshake. These are ancient and time honored functions denied the person who has suffered loss of the hand. In the rehabilitation of the upper extremity amputee, too much stress often is laid upon the restoration of functional losses relating to prehension, often forgetting the extraprehensile activities essential to the amputee's existence.</p> <p>In addition to these matters are the problems associated with the importance of early fitting and those involved in the special cases of multiple amputation. And finally, mention deserves to be made of the largely faulty but widespread notion that people are inherently right handed or left handed. In the rehabilitation of the upper extremity amputee, the popular concept of hand dominance leads to one of the most difficult problems to be overcome.</p> <p>Since each of these individual problems is closely interrelated with all the others, the order in which they are considered by the clinic team is of no particular significance. Of greatest importance is that they all <i>be </i>considered and that over all evaluation of the amputee's status take into account all the individual factors that, together, constitute total rehabilitation.</p> <h3>The Problem of Hand Dominance</h3> <p>Most people define handedness solely on the basis of whether the right or the left hand is used in writing, or in throwing a baseball, or the like. The less specific definition of a medical dictionary, which describes handedness as the preferential use of one hand over the other, is perhaps more acceptable, for handedness does not appear to be a flat case of one "necessary" and one "nice to have" hand but rather a case of two cooperating members either one of which could be trained as the leader. Nevertheless, the concept of dominance is so widely established that loss of the writing hand is considered by most compensation authorities to constitute severe disability, whereas loss of the other often is viewed lightly. Similarly, loss of one hand in the ambidexterous generally is considered to present no great rehabilitation problem.</p> <p>How do we determine whether an individual is right or left handed? When the average person is asked which is his dominant hand, he usually selects the writing hand. In the upper extremity amputee, we seemingly are presented with a case of "dominance" or "sub dominance." Simply to ask the patient whether he is, or was, right or left handed is, in most cases, a wholly inadequate method of determining the degree of dominant handedness. It produces premature evaluations of disability and of future rehabilitation problems, both of which may need complete revision before the patient is discharged from the care of the clinic team. The problem of handedness is of primary interest to those directly responsible for all phases of training the upper extremity amputee. It is during the preprosthetic stage that the real aspects of dominance present themselves, for during this period the patient is a one handed individual.</p> <h4>The Dictates of Convention</h4> <p>Judging from the design of many of the articles we use daily, it appears that society already has dictated that ours shall be a colony of right handed individuals. From the position of the knife and fork at the table to the placement of the gearshift lever on the modern automobile, we are reminded constantly that we are expected to use our right hand much more than our left. This decision of engineers and of authorities in etiquette causes no small concern to the parents of children who seem to use the left hand more than the right. Parents recall other left handed individualsindividuals who always find themselves crowded when seated at the dinner table (<b>Fig. 1</b>), or whose bodies assume the position of an animated corkscrew when attempting to write at a desk. For these and other reasons, parents try subtly to encourage the use of the right hand in the young child, despite some of the beliefs of medical science. Even the garmentmakers have conspired against the man who uses his left hand for some tasks. Commonly, a button is placed over the left hip pocket, where it seems understood the wallet will be placed, while the right hip pocket is free for easy withdrawal of the handkerchief. The man who uses the left hip pocket for the handkerchief has no protection for the wallet when it is kept on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The southpaw at dinner. Convention dictates the norm; habits in conflict with the established pattern usually lead to trouble. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Popular Fallacy</h4> <p>These elementary observations indicate that hand usage is dictated by habit patterns, possibly as a means of conforming to the norms of the society in which we live (page 9). It is important, however, to consider whether or not truly right or left handed individuals exist and, if so, to consider what is meant by the terms. As has been noted, when the arm amputee first is questioned about handedness, writing is apt to be the first thing considered, and the answer is likely to be made on that basis. Additional questioning usually reveals that, although the patient may have used the right hand for writing, many other tasks requiring delicate, coordinated movements might have been done with the left hand, or vice versa.</p> <p>Too many persons believe that the writing hand also is the only hand capable of performing all other smoothly coordinated tasks. As more probing questions are asked of the patient, it may be evident that the opposite hand also performs many functions. If the keys or small change are carried in the pocket opposite from the hand used in writing, bilaterality rather than simple dominance may well be indicated. Information in this connection can be elicited more readily with male patients by asking which pocket carries the handkerchief, which pocket holds the wallet, which hand holds the pipe or cigarette, and which hand is used to strike a match.</p> <p>It often is surprising to find that, with the exception of writing, almost all daily activities involve equal participation of both hands, one serving as a helper to the other with interchangeable ease. When loss of the use of a hand occurs, either temporarily or permanently, the most frequent problem stems not from the inability to write but rather from the inability to perform the tasks requiring use of both handstying shoes, buttoning clothes, cutting food, and so on. Hence, it is important that a prosthesis be designed to restore bilateral activity rather than dominance or the ability to write. When a patient loses a so called "subdominant" hand, he soon expresses some degree of surprise at the number of jobs formerly done by the missing member. He also notes, with as much surprise, that many tasks are quite difficult for the remaining hand alone, even though it be the dominant or leading hand. But the amount of time required to relearn all these tasks, including writing, with some degree of agility is quite short. Except in bilateral cases, the patient soon becomes reasonably independent. If allowed to continue as a one handed individual, the unilateral arm amputee soon learns short cuts that permit him to be more independent and ultimately to feel that he has no need for a functional replacement of the missing hand.</p> <p>Such a patient gives the greatest cause for concern. Perhaps the inability of some to recognize the absence of a true dominance or to understand the rapidity with which a one handed individual can adjust and become reasonably independent may, in some measure, account for a number of failures in upper extremity rehabilitation. Certainly there are other causesinadequate surgery, poor prosthetic replacement, inadequate training contributing to these failures. But only when all of these factors are considered and eliminated can full utilization of the prosthesis be expected.</p> <p>The patient who has learned to do reasonably well with one hand is the very patient most likely to be a failure when fitted with a prosthesis. His training will be most difficult and frustrating for all concerned simply because he cannot recognize the need for a prosthesis. Training for such a patient comprises largely a program of unlearning all of the grotesque contortions to which he has become accustomed. Because here the individual, having been pleased with his one handed accomplishments, must learn to be a two handed person again somewhat against his "better judgment," frustration becomes an important consideration. The more complicated the prosthesis, the lower is the frustration tolerance of the patient because he cannot accept the need for a device which seems to complicate rather than to simplify his life.</p> <h4>A Two-Handed World</h4> <p>One might now properly ask why so much concern should be shown for such a patient. Would it not be easier to permit his unilateral activities to continue and thereby eliminate all problems of fitting, training, and further care? Unfortunately, the solution is not so simple. We live in a two handed world. To maintain our place in society, two hands are needed, or at least substitutes for them. One need only consider the obvious difficulties encountered by the one handed individual when carrying a loaded cafeteria tray, serving himself at the table, or attempting to tie up a parcel (<b>Fig. 2</b>). In the effort to prevent similarly embarrassing situations, the one handed person may gradually seek less and less public contact, social and vocational, and with this self inflicted isolationism ultimate loss of his own security may develop. Despite all short cuts and self helps, the amputee who remains without a prosthesis must still require a degree of additional assistance for many tasks. A functional prosthesis offers independence. An unfitted stump usually leads only to a gradual but ultimate deterioration of self pride in all tasks, public or private.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The empty sleeve versus the upper extremity prosthesissome examples. Although the unilateral arm amputee may learn to perform well with the remaining sound hand many activities formerly conducted with the amputated member, and although the stump and other parts of the anatomy may be called upon to substitute in "two handed" activities, a great many essential functions are carried out awkwardly, if at all, by the arm amputee who remains unfitted. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Psychological Problems</h3> <p>When it appears that a patient has emotional complications that are not responding to treatment, he should be referred to other medical specialists. Such emotional problems may occur at any phase of the patient's course, and the use of proper specialists will, in many instances, permit the rehabilitation team to continue its work while the patient receives the indicated treatment. Prompt recognition and treatment of such unfortunate situations often will salvage the patient, where otherwise he might drift aimlessly through prosthetic fitting and training until the symptoms are so pronounced as to be recognized by everyone on the street.</p> <p>Initial interviews rarely, if ever, disclose an amputee's underlying feelings about his loss. As he advances through the rehabilitation processes, the amputee may feel that it is too late to open questions of fear and misgiving, in which case his feelings of insecurity are only perpetuated. Hence, it is wise for the physician to suggest possible questions and answers when the amputee is first interviewed. To focus attention upon likely questions may offer an opportunity for the patient to talk about his family's acceptance of his amputation, to discuss social problems resulting from his physical and mental condition, and to air any other problems peculiar to the individual. Unfortunately, no hard and fast rule can be applied; for no two amputees are alike, either in physical or mental make up or in social and economic status. In any given case, each question should be answered as frankly as possible, and, if the answer is not known, every effort should be made to provide one as quickly as possible. Although left to themselves most amputees ultimately find the answers to their own questions, the answers thus obtained usually come only after many frustrations and sometimes after severe emotional stress.<a></a></p> <h3>Medical Problems</h3> <p>The problems of pain, real and phantom, and of phantom sensation, sometimes are so difficult as to postpone actual fitting and training or even to suspend use of the prosthesis after it has been fitted. Recently, phantom pain and phantom sensation have been explored at length<a></a> and more complete concepts of etiology and treatment now are evident. When it is caused by thin or densely adherent scar tissue, neuromata, or bony spurs, stump pain is one of the most common causes for delayed initial fitting or for abandonment of the fitted prosthesis.</p> <p>In such cases it is futile to delay treatment in the hope that actual fitting, continued use of the prosthesis, exercise, or physical therapy may render a neuroma painless or reduce a spur so that it no longer is troublesome. As time passes and the pain or tenderness persists, the patient is entirely justified in questioning whether or not he ever will be able to wear a prosthesis. Specific difficulties that do not respond to conservative measures should be corrected surgically and with the least possible delay. When it seems wise to attempt a conservative approach to minor stump difficulties, an explanation will ensure the patient's continued confidence in the physician. During such a period, the patient's progress must be evaluated regularly. When and if the conservative treatment fails, more radical measures are in order.</p> <h3>Vocational Problems</h3> <p>All amputeesthose, like the housewife, engaged in the home as well as those employed in business and industryhave vocational problems at one time or another. Again, the patient requires much honest and factual reassurance. Although the trend in employment of the physically handicapped is much more gratifying now than it has been in previous years, rose colored pictures of industries seeking amputees for all types of employment lead only to false comfort and to eventual disillusionment of the patient. Although true vocational counseling has become a specialty in itself, the physician must never lose sight of the fact that the job of restoring the patient to useful function is his, the physician's, personal responsibility. Even though the patient may at some time be evaluated by a vocational counselor, the physician must regard the evaluation as a type of referral with continued follow up to ascertain the progress being made.</p> <p>Proper use of the social worker may prove invaluable in maintaining close liaison with the employer and the rehabilitation team.<a></a> The employer should be encouraged not to discharge the amputee patient until the possibilities of further employment have been fully explored. To the new amputee still in the hospital, nothing can be more devastating than a notice to the effect that he has lost his employment as a result of his newly acquired handicap (<b>Fig. 3</b>). Assurance that there is a reasonable chance of continued employment, or that efforts are being made to place the patient in some similar position, will do much to speed his total recovery and to provide motivation, the one factor without which there can be no genuine rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The pink slip versus the helpful proprietor. In total amputee rehabilitation, morale is important. Full cooperation of the employer is essential to the success of the prosthetics clinic team. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is fortunate that current trends in aiding the physically handicapped are toward providing vocational training and placement rather than monetary compensation and the subsequent opportunity to sit in the park and collect the pitying, sideward glances of the passers by. The amputee who formerly held a job requiring bilateral hand use very early recognizes the need for a prosthesis, accepts it readily, and receives training as quickly as possible. With the younger, inexperienced person, who perhaps has drifted aimlessly through several more or less unproductive jobs, the problem of prosthetic acceptance and use is more complicated. Such a person has yet to learn the true value of two hands.</p> <p>Unfortunately, some of the veterans of World War II and of the Korean conflict have been victims of such an experience. These men, many coming directly from high school or from odd jobs, had no opportunity to learn vocations or skills requiring use of two hands. Consequently, many of them accept a prosthesis, cooperate halfheartedly in training and follow up, and then discard the prosthesis to look the country over for a job they can do with one hand and sympathy. When an effort is made to offer these people vocational guidance, many indicate they are "going to school," apparently in the belief that one can get through school with one hand. But as a matter of fact the process of education more often than not demands bilaterality, and the inability to recognize the value of a prosthesis constitutes the principal reason why many amputees eventually withdraw from schools.</p> <h3>Training Problems</h3> <p>Although there can now be no doubt of the value of prosthetics training, it is interesting to note that many amputees, usually those who have worn a prosthetic device for many years, indicate that they see no need for training. The patient and prosthesis become one, and little tricks of operation and short cuts, all of which lead to increased efficiency, become second nature. From such a peak of efficiency it is difficult to remember the basic training required to perfect every motion, In the past, moreover, training rarely was conducted as intensively as it is today. Simple instruction in the use of the terminal device, usually by the prosthetist, was about all the patient could expect, and he depended on trial and error and the passage of time for the remainder of his training.</p> <p>A patient who has gone through such a procedure may scoff at the prolonged period of time now thought necessary to assure adequate training in prosthetic control. But the time thus spent really is immeasurably short because it saves the patient much false motion and wasted effort and prepares him to resume his place in society more quickly than the patient with no training. Of course, training must not be confined to the period of prosthetic wear; rather, it must start as soon as the condition of the stump permits.<a></a> Prepros thetic training includes maintenance of joint mobility and muscle strength as well as maintenance of cerebral patterns of motion.</p> <h3>The Problems of Multiple Amputation</h3> <p>The bilateral hand amputee presents both to the patient and to the medical staff a problem of the greatest difficulty. The patient who has lost both hands still possesses two stumps which afford some means of gross prehension. A pencil can be grasped for crude writing, an eating utensil can be held between the stumps for clumsy eating, and the stumps fill out the sleeves. But all delicate prehension, all discrete tactile senses, are lost. Initially, the bilateral amputee is apt to be deeply depressed, and he therefore usually responds poorly to the first rehabilitation contacts. He requires as rapid a fitting as possible, because otherwise he remains almost completely dependent for all necessities, not only economically but, more important, socially and in the home. The latter situation is the one usually most devastating and the one which unfortunately most often is brushed over when the patient first is met. He must have assistance not only in eating but in all toilet activities as well and finds himself relegated to a crude and almost infantile existence.</p> <p>Prosthetic training is much more detailed and prolonged for the bilateral amputee than for the unilateral because the patient has no remaining natural hand for a prosthesis to assist. All acts of dexterity must be accomplished by one or the other terminal device. The therapist cannot consider training complete when the patient meets the requirements of the unilateral amputee but must, in addition, cover use of the prostheses in all acts of everyday lifefeeding, toilet care, and dressing. It is fortunate that such activities are well within the realm of accomplishment for the bilateral hand amputee, especially when the stumps are comparatively long and the natural elbows are intact.</p> <p>An additional complication, usually resulting from trauma, involves amputation of part of a leg in addition to loss of an arm. In the light of present experience, neither amputation truly can be said to take priority over the other, and each case must be considered on an individual basis. In every case, body mechanics and sense of balance are impaired seriously. Gait training becomes more difficult when a part of an arm has been lost. Similarly, upper extremity training is made more difficult without the use of both normal lower extremities. The patient is necessarily confined to bed or uses a wheel chair or crutches for support. If one of the arms is artificial, crutches are used only with difficulty and often in a manner potentially dangerous. The patient may find his arm prosthesis so attached to the crutch that, in the event of a fall, he is unable to free himself rapidly and to discard the crutch. There is thus always the possibility of damage to the stumps or other parts of the body. Considering these potentials, it would seem best to undertake gait training first. When it can be instituted safely, this practice seems to present fewer problems to all concerned.</p> <h3>The Problems of Early Fitting</h3> <p>Early fitting of the prosthesis has come to occupy a major place in present day concepts of amputee management. To postpone fitting until maximum stump shrinkage has occurred often gives the patient those few extra weeks of one handed experience that lead him to believe he does not need a prosthesis. Although there is no known criteria for determining exactly when a stump has stopped shrinking, it now appears that the greatest incentive to maximum shrinkage is actual wear and use of a prosthesis. Once the patient is shown that early fitting and constant practice are the shortest roads to recovery, he usually cooperates willingly.</p> <p>With early fitting naturally comes the problem of continued stump shrinkage, which usually results in a loose socket. It is entirely possible that fabrication of a second socket may be necessary before complete adjustment has taken place. The patient should be made aware of this possible complication, and, when it appears that a second socket may be required, the added cost might be included in the price of the prosthesis. In a patient's decision to abandon a device, repeated expenditures for prosthetic adjustments often play as important a role as does a loose socket. But if initially the patient is told the reasons for possible additional expenditures, more than likely he will accept the conditions without protest and without discouragement.</p> <h3>Some Solutions</h3> <p>What can be done to solve some of the problems that are potential sources of failure in the proper utilization of an arm prosthesis? First, it must be realized by all concerned with the management of upper extremity amputees that the present concept of dominance is a relative one. The person who loses the so called subdominant hand is just as seriously disabled as is the one who loses the dominant hand, and he stands just as much chance of becoming a nonwearer. The remaining member often can be taught to perform many of the functions of the missing hand. If this situation is allowed to persist for long, the amputee begins to feel that prosthetic replacement is unnecessary.</p> <h4>The Education of The Physician</h4> <p>To the end that all upper extremity amputees shall be properly fitted and trained, it is imperative that the education of all physicians and ancillary medical personnel be continued and expanded. Current knowledge and new techniques must be passed on not only to those physicians and technicians who, because they are specialists, see amputees regularly but also to all general practitioners, especially to the family doctors who usually are first to see the amputee. The general practitioner must be brought to realize that new skills and devices are available to help his patients, and he also must be made aware of the fact that the longer assistance is delayed the more unlikely is the amputee to wear and use a prosthesis. Education must be carried to every level, ideally down to the county medical society, which in many instances is the only group in which the general practitioner can participate regularly. Information relating to amputee management should appear in <i>all </i>medical literature, for technical assistants also are responsible for extending any educational program devoted to the amputee. If complete success in total rehabilitation is to be expected, an amputee must be presented to the various specialized centers or clinics with the least possible delay after amputation.</p> <h4>The Education of the Amputee</h4> <p>Equal stress must be placed upon educating the amputee. If, for example, he has a short stump or some other problem requiring that he be fitted with a more complicated and hence less efficient device, the limitations of the prosthesis must be explained in detail. Too many patients are given the benefit of excellent surgery and fit but are not prepared for the shock that comes when they discover that the prosthesis is, at best, only a device to assist the remaining hand. Such a disappointment often produces discouraging results and sometimes complete failure. Many specialists and technicians are prone to be overenthusi astic about a particular prosthesis. What to them appears to be an excellent prosthesis well may be to the patient a hideous collection of bolts and ropes. As a result of some specialists' enthusiasm, many amputees envision a prosthetic device far more functional than actually is possible.</p> <p>When a patient is counseled for the first time, therefore, every effort should be made to point out all the factors involved in total rehabilitation. The limitations of the prosthesis should be explained at once, so that no false concepts or hopes are allowed to exist or to be perpetuated. Even if nothing more than a photograph is available, the patient should be shown a prosthesis similar to the one he eventually will use, and the necessity for training must be outlined so that the patient realizes that wearing the prosthesis and using it efficiently are two distinct functions. Many patients are astonished to find that training is necessary, and many look upon it as just one more stumbling block in an already confused amputee existence. Each step in the program must be explained fully, and the possible complications also must be outlined. Only in this way can the amputee be spared the bitter disappointments that often attend rehabilitation.</p> <h4>Training and Checkout</h4> <p>Adequate checkout procedures should assure efficient mechanical function as well as correct fit.<a></a> An inefficient cable system may, for example, render an otherwise satisfactory prosthesis so difficult or clumsy to operate that even the patient with a great desire to learn may find it impossible to use the device. The disinterested patient who does not appreciate the true value of prosthetic replacement may seize upon such a situation as the final excuse to give up training completely.</p> <p>Prosthetic training and final checkout complete the patient's initial steps toward rehabilitation, but unfortunately training can be responsible for failure. Therapists must be sympathetic with the patient's initial efforts, but they also must be firm in developing adequate control before actual use of the prosthesis is attempted. The patient's first desire after receiving the prosthesis is "to do something with it," and time spent in learning control techniques may seem worthless to him. Here again explanation of the reasons for the training steps is essential.</p> <p>If the patient is unable to demonstrate adequate control skill in a reasonable time, it often is wise to postpone or slow the training process rather than to provoke marked frustration in both patient and therapist. In such instances it is important that the therapist keep the prosthesis until sufficient basic skills are developed by the patient. If the amputee is permitted to wear the device immediately, he is likely to develop inefficient and sometimes weird methods of operation, thus negating all of the valuable time expended in fabrication and fitting. It is essential, however, that the patient understand the reasons for his sometimes difficult and slow progress in training and why it is necessary for the therapist to retain the prosthesis until basic skills are achieved.</p> <p>In some clinics there are to be found a standard below elbow and a standard above elbow prosthesis with split and laced sockets to permit adaptation to many different kinds of stumps. These so called "standard" prostheses are used in early training to prepare the patient for efficient operation of his prescribed prosthesis. When used with proper care and reasonable patient selection, they serve a valuable purpose, but such a procedure may be unwise if the training arm cannot be adjusted readily to the individual patient or if it contains undesirable components. Attempts to use an ill fitting training arm may be so difficult that the patient becomes discouraged and anticipates the permanent prosthesis with misgivings. Accordingly, training arms should be used only on the advice of the clinic team. Too much training can be as harmful as too little. The higher the level of amputation the less functional usefulness can be derived even from the best prosthesis. Realization of this circumstance can prevent the hypertensive episodes that occur in patient and therapist alike when too much is demanded of the amputee prosthesis combination. There is no personal defeat when, as is often the case, it must be admitted that the prosthesis can serve only as a "helper" hand. Under such circumstances, training, to be effective, must be guided appropriately. Overtraining only discourages the patient whose level of amputation is a basic factor in determining the degree of prosthetic function. Achievement tests should be used to measure and record the patient's progress and final skills, but such tests vary from level to level and from patient to patient and can serve only as a crude measuring stick, not as the final criterion as to whether or not a patient has achieved the maximum benefit of training. The answer to that broad question can come only with careful observation of the patient during activities of daily living and of vocational pursuits.</p> <h3>Conclusion</h3> <p>From these considerations, it is possible to formulate certain basic rules for the management of the upper extremity amputee. It is important first to know as much as possible about the patient besides the fact that he is missing a hand. It is necessary to understand him and to understand his disability. Too much faith must not be placed in the absence of either a so called "dominant" or "subdomi nant" hand as the sole measure of disability. In addition, the patient must be made to understand what is in store for him. Above all, no questions about any phase of his problem should be left unanswered. In some instances the amputee is reluctant to discuss problems not relating directly to his amputation, and the physician should be certain that, aside from the amputation, there are no other physical or mental problems that may affect total rehabilitation.</p> <p>For psychological as well as physical reasons, the patient should be fitted as rapidly as possible. Early fitting allows the amputee to realize the advantages and limitations of his prosthesis. Moreover, early fitting often eliminates the danger of the patient's coming to think that he can get along with one hand a situation which can complicate and prolong total rehabilitation. Finally, because overtraining can be just as harmful as are all the other "don'ts" of amputee management, no attempt should be made to train the patient to do more things than the level of his amputation and the nature of his prosthesis permit.</p> <p>When all of these individual problems are considered systematically by the respective members of the clinic team, over all management of the upper extremity amputee becomes a synthesis of cooperative effort. In no other way can so much success and satisfaction be afforded both the patient and those charged with his care.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee</i>, Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The principles of prosthetic prescription</i>, Chapter 6 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team</i>, Artificial Limbs, January 1954. p. 9.</li> <li>Carlyle, Lester,<i> Artificial arm checkout procedures</i>, Artificial Limbs, January 1954. p. 25.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues</i>, J. Bone and Joint Surg., 36A:981 (1954).</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>,Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Jampol, Hyman, and Jerry Leavy, <i>Training the upper extremity amputee</i>, Chapter 23 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Kuitert, J. H., and F. E. Vultee, <i>Prosthetic training for the upper extremity amputee with cineplasty</i>, Arch. Phys. Med. and Rehab., 34:367 (1953). </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee</i>, June 1952.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures, Artificial Limbs, January 1954. p. 25.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Jampol, Hyman, and Jerry Leavy, Training the upper extremity amputee, Chapter 23 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kuitert, J. H., and F. E. Vultee, Prosthetic training for the upper extremity amputee with cineplasty, Arch. Phys. Med. and Rehab., 34:367 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and Joint Surg., 36A:981 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs,Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frederick E. Vultee, Capt., USA (MC) </b></td></tr><tr><td class="clsTextSmall">Physical Medicine Service, Walter Reed Army Hospital, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-31.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-32.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-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 Some Problems in the Management of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Frederick E. Vultee, Capt., USA (MC) * https://staging.drfop.org/files/original/2af24d33498f903f19fea2c5675a74ef.pdf d4e6f2d65239910f25cf126d68e7c8dc https://staging.drfop.org/files/original/4d3ddcf7651fff9ec5dd9c3427c58e15.jpg 2749c27e2446e4f746ea4e1d8d08afea https://staging.drfop.org/files/original/eb71c2538c5e88109be6c357c40e60cd.jpg a33087cc766f88e31bed11c95885bb6e https://staging.drfop.org/files/original/92f0b57c8b3defb346a3497604e47f3f.jpg 603429119911e70056b4450ef18b92d0 https://staging.drfop.org/files/original/5f498a6651b7e9b8f1eec1ea73532e91.jpg 9fdf9004b81b54e8652950012ccb0165 https://staging.drfop.org/files/original/b041422d191f77298643b52ef852617e.jpg 17c5cb478f84c50ccb8cd4e0527884cd https://staging.drfop.org/files/original/7fe13473de8d4000ed8c8f18cd3c0b4d.jpg 2a4e79271e4ba7bbbe536c18ab728781 https://staging.drfop.org/files/original/2297ac77954f4047d113992c6d45458d.jpg 2cf1cf57dd83112d6fbeee8a32f2027e https://staging.drfop.org/files/original/e8e3e367a8c90615a071af926d0dcc43.jpg a5aa4351b6ee2371ba40f0cf38df6840 https://staging.drfop.org/files/original/aa16b41fd406f041938dd06c277015c2.jpg 649eaeff89a5184e2def9092077444fe https://staging.drfop.org/files/original/121e62ebcf3c71973c3482ab42e53c83.jpg 15b4270a6585a213d7aedf6a76d60520 https://staging.drfop.org/files/original/9a57f9be025587ccf0193133556036ad.jpg 168fdb2039020ed045f4a822c8e13c6b https://staging.drfop.org/files/original/d83a4fc2a02d05be889604c2340a00a2.jpg f4fc363ce2a8acfc59cc24e5042d33da https://staging.drfop.org/files/original/c60c52b30ad7a3259df529b2acf883a3.jpg 8ccb20f11781e2ba1dbbce79edefa8b0 https://staging.drfop.org/files/original/8a8b1b1c51d20c3232be371241d1e215.jpg 12ee4710b77effd0f0bd2c647a1b1aca https://staging.drfop.org/files/original/a876719fff8467e1a527e2a73d31a30b.jpg 2b985f3fea23eaa471be8fac044cb345 https://staging.drfop.org/files/original/6449892d298e50c73e338beea299bbc0.jpg ac35194aca22c469e31de504b9bed2b5 https://staging.drfop.org/files/original/5ed18cbfc520ac464095a32b721c6849.jpg 759e2b53115fae6bf241f4d450875a36 https://staging.drfop.org/files/original/076402ce0eaaee6760087a9c8a6b61a6.jpg 8100a1578a04f465b946f59287bb3d36 https://staging.drfop.org/files/original/ff64515284519fe251c8dd39ea00d384.jpg 74b1d12ca12689370d20ffc2f18789bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_004.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 4 - 25 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of Control in Upper-Extremity Prostheses</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the rehabilitation of the upper-extremity amputee, structural replacement by prosthetic arm and hand is an obvious requirement, and it poses a comparatively easy task; functional replacement by remote control and by substitute mechanical apparatus is more elusive and hence infinitely harder. For the purposes of functional utility, remaining movements of upper arm, shoulder, and torso must be harnessed, and use must be made of a variety of mechanical devices which amplify remaining resources by alternators, springs, locks, and switching arrangements. The facility of control attained through this apparatus is the key to its ultimate value.</p> <p>The future of upper-extremity prosthetics depends upon an ever-increasing understanding of the mechanics of the human body by all who minister to the amputee-prosthetist, surgeon, and therapist alike. It must always be stressed that the final goal is an amputee who can function. Too often there is a tendency to put undue faith in the marvels of mechanism alone, when in fact it is the man-machine combination that determines performance. It is in this broad frame of reference that the biomechanical basis of upper-extremity control must be approached.</p> <h3>Prosthetics Anthropometry</h3> <h4>Surface Landmarks</h4> <p>If successful control is to be obtained, the various components of the prosthesis must be positioned with a good degree of accuracy.</p> <p>To do so requires reference points on the body, of which the most satisfactory are certain bony landmarks. Most of these skeletal prominences protrude to such an extent that location is easily possible by eye. Others require palpation, and this method should be used to verify observation in every case. The bones most concerned in upper-extremity anthropometry are the clavicle, the scapula, the humerus, the ulna, and the seventh cervical vertebra. Surface indications of protuberances, angles, or other features of these bones constitute the landmarks, the locations and definitions being given in <b>Fig. 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and external landmarks in the upper extremity. Definitions: <i>seventh cervical vertebra, </i>most prominent vertebra in the neck region; <i>acromion, </i>extreme lateral edge of the bony shelf of the shoulder; <i>inferior angle of scapula, </i>lowest point on shoulder blade; <i>epicondyles, </i>lateral and medial bony points at the pivot of the elbow; <i>ulnar styloid, </i>projecting point on little-finger side of the wrist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Arm and Trunk Measurements</h4> <p>The typical male torso and upper extremity are shown in <b>Fig. 2</b>, which, together with <b>Table 1.</b>, was derived from average measurements on Army personnel.<a></a> Such an average form serves to establish harness patterns and control paths. The arm, forearm, and epicondyle-thumb lengths constitute the basis of sizing prostheses.<a></a> (In everyday language the word "arm" is of course taken to mean the entire upper extremity, or at least that portion between shoulder and wrist. In anatomical terms, "arm" is reserved specifically for the segment between shoulder and elbow, that between elbow and wrist being the "forearm." Although in the lower extremity the word "leg" commonly means the entire lower limb, whereas anatomically the "leg" is that segment between knee and ankle, confusion is easily avoided because we have the special word "shank." No such spare word is available to describe the humeral segment of the upper limb.-Ed). Arm length places the artificial elbow; forearm length locates the terminal device. The epicondyle-thumb length is an important over-all sizing reference because in the unilateral arm amputee it is customary to match hook length (and, in the case of the artificial hand, thumb length) to the length of the natural thumb <b>(Fig. 3)</b>.The bilateral arm amputee can be sized from body height by means of the Carlyle formulas<a></a>, which employ factors derived from average body proportions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic anthropometry of the male torso and <b>upper extremity. </b>See Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Correct lengths for upper-extremity prostheses. In the unilateral case, hook length is made to coincide with normal thumb length, as is also the thumb length of the artificial hand. For bilateral arm amputees, <i>A = </i>0.19 X (body height); <i>B + C </i>= 0.21 X (body height). After Carlyle (J). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Anatomy</h4> <p>The human torso, shoulder, and upper extremity are exceedingly complex structures. In any dealing with these elements of anatomy, therefore, it is desirable to sort out from the mass of detail those features important to the particular area of study and application. Where prosthetic controls are concerned, the mechanism of movement is the central subject of consideration. This functional anatomy treats of the aspects of bone, joint, and muscle structure that together determine the modes and ranges of motion of the parts. It is a descriptive science, and while to escape dependence upon nomenclature is therefore impossible, the purpose here is to convey a basic understanding of the operation of the upper-extremity mechanisms without undue use of specialized terminology. In any case, the reader should have available basic anatomical references such as <i>Gray's Anatomy</i><a></a> or kinesiology texts such as those of Steindler<a></a> and of Hollinshead. <a></a></p> <h4>Elementary Motions of the Upper Extremity</h4> <p>The geometry of each joint is complex, and most movements involve an interaction of two or more joints. Consequently, a motion nomenclature based on joint movements would be unnecessarily complicated. More simply, the motion of each part upon its proximal joint may be described with respect to the principal planes which intersect at that joint. In this system, moreover, one may define a standard position in which the trunk is erect, the arms hang with their axes vertical, the elbows are flexed to 90 deg., and the wrist planes are vertical to assume the "shake-hands" position. <b>Fig. 4</b> presents the angular movements possible in the three planes of space. The shoulder-on-chest, arm-on-shoulder, and hand-on-wrist actions take place through two angles, as if moving about a universal joint. Geometrically, the arm motions are more precisely defined by a spherical coordinate system where the segment position is given by longitude and colatitude angles. For descriptive purposes, however, the anatomical nomenclature is commonly used. It should be recognized that, for multiaxial joints, flexion-extension and elevation-depression angles describe motions in the major orthogonal planes only, and intermediate angular excursions must be thought of as combinations of these motions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Simplified movement system in the upper extremity. Wrist flexion is omitted since ordinarily it is not involved in upper-extremity controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified movement system depicted in <b>Fig. 4</b> is incomplete in many ways. Not included are such movements as twisting of the shoulder due to various scapular movements, anterior-posterior swings of the arm in positions of partial elevation, and the slightly conical surface of revolution of forearm flexion.(It deserves to be noted here that, taken literally, expressions such as "forearm flexion-extension," "arm flexion-extension," and "humeral flexion-extension" represent questionable nomenclature. To "flex" means to "bend." Limb segments do not bend very readily without breaking. Joints are <i>designed </i>for flexion. In the lower extremity, for example, one speaks not of "shank flexion" but of "knee flexion," not of "thigh flexion" but of "hip flexion." That is, one uses "flexion" or "extension" not with reference to motion of the distal segment but with reference to the more proximal joint. Although Webster accepts the expression "to flex the arm," he obviously uses the word "arm" in the everyday sense of meaning the entire upper extremity, or at least that portion between shoulder and wrist. Because this loose terminology in the upper extremity is so widely established, not only among workers in prosthetics, it is used throughout this issue of Artificial Limbs, with the understanding that "forearm flexion" means "elbow flexion," "arm flexion" and "humeral flexion" mean "flexion of the glenohumeral joint (and associated structures) " See page 9 <i>et seq.</i>-Ed.). These details may, however, be ignored in the interest of the simplicity of description that is adequate for the purposes of upper-extremity prosthetics.</p> <h4>The Shoulder Girdle</h4> <p><i>Skeletal Members and Joints</i></p> <p>The scapula and clavicle are the chief bones making up the shoulder girdle. Secondarily, the proximal portion of the humerus may be included, since the close interarticulation of all three bones at the shoulder joint gives a considerable degree of coordinated activity among them and also extends to the complex as a whole the actions of many of the muscles inserting on the individual members.</p> <p>Details of the skeletal anatomy involved are shown in <b>Fig. 5</b>. There are in the system two joints and one pseudo joint. In the sternoclavicular joint, the clavicle articulates with the sternum in a somewhat saddle-shaped juncture recessed in a concavity within the sternum. The biaxial surfaces permit movements in two planes. Ligaments crossing the joint prevent displacement of the clavicle anteriorly and laterally. The elevation-depression range is 50 to 60 deg., the flexion-extension range from 25 to 35 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Skeletal anatomy of the shoulder region, <i>a, </i>Anterior view. <i>b, </i>Posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the acromioclavicular joint, the distal end of the clavicle articulates with the scapula in an elliptical juncture which permits a ball-and-socket type of action. The acromioclavicular ligaments bind the joint directly. Strong ligaments from the clavicle to the coracoid process give important additional stabilization. The range of movement is small, being only about 10 deg. in the frontal and sagittal planes.</p> <p>The pseudo joint, the scapulothoracic, is a muscular suspension which holds the scapula against the thoracic wall but which at the same time permits translatory and rotatory movements. A large factor in maintaining this joint in position is barometric pressure, which is estimated to act upon it with a force of 170 lb.</p> <p><i>Muscles and Movements</i></p> <p>The complex arrangement of bony elements is rivaled by the involved nature of the muscles of the shoulder girdle and by the intricate ways in which they act upon it. The schematic view of <b>Fig. 6</b> presents the fundamentals. Elevation of the shoulder is seen to be brought about principally by elevators and downward rotators of the scapula, such as the upper trapezius, the levator scapulae, and the rhomboids. Although the rhomboids assist in elevation, they do not contribute to upward rotation. Depression of the shoulder is mediated by muscles inserted on the scapula, the clavicle, and the proximal end of the humerus. Anteriorly the lower fibers of the pectoralis major, the pectoralis minor, and the sub-clavius, and posteriorly the lower trapezius and latissimus, act as depressors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic kinesiology of the shoulder girdle. <i>L, </i>latissimus; <i>LS, </i>levator scapulae; <i>LT, </i>lower trapezius; <i>MT, </i>medial trapezius; <i>PM, </i>pectoralis major; <i>Pm, </i>pectoralis minor; <i>RM, </i>rhomboid major; <i>Rm, </i>rhomboid minor; <i>SA, </i>serratus anterior; <i>SC, </i>subclavius; <i>UT, </i>upper trapezius. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the scapula upward <i>(i.e., </i>right scapula, viewed from the rear, rotates counterclockwise) or downward <i>(i.e., </i>right scapula, viewed from the rear, rotates clockwise) is brought about by a special combination of the elevators and depressors. As shown in <b>Fig. 6</b>, two portions of the trapezius, together with the serratus, cause upward rotation. Conversely, the pectorals, the latissimus, and the rhomboids cooperate to cause downward rotation. As will be seen later (page 13), the mechanical principle of the couple applies in these rotatory actions upon the scapula.</p> <p>Flexion and extension of the shoulder involve as principal elements the abduction and adduction, respectively, of the scapula. The flexor muscles acting on the shoulder complex are the pectoralis major and minor, which swing the clavicle and acromion forward. The serratus anterior aids strongly by abducting the scapula. The extensors, placed posteriorly, include the latissimus, which pulls posteriorly and medially on the humerus, and the trapezius and rhomboids, which pull medially on the scapula.</p> <p>The forward and backward shrugging of the shoulders with abduction and adduction, together with some upward and downward rotation of the scapulae, constitutes a major control source. Even in above-elbow amputees who use humeral flexion for forearm lift and for terminal-device operation at low elbow angles (page 22), scapular abduction is utilized for terminal-device operation at large angles of elbow flexion <i>(e.g., </i>when the terminal device is near the mouth). In shoulder amputees, both these operations depend wholly upon scapular abduction augmented by upward rotation.</p> <h4>The Arm</h4> <p><i>The Humerus and the Glenohumeral Joint</i></p> <p>The humerus, together with its joint at the shoulder, comprises the skeletal machinery of the arm. As noted in <b>Fig. 4</b>, it is capable of flexion-extension, elevation-depression, and rotation upon its proximal joint. The glenoid cavity, a lateral process on the scapula, receives the spherical surface of the humeral head. The glenohumeral articulation is therefore of true ball-and-socket character. The fibrous joint capsule is remarkable in that it envelops the humeral head and the glenoid margins in complete but rather loose fashion, so that a wide range of movement is possible. To some extent barometric pressure, but to larger extent the musculature spanning the joint, is responsible for keeping the articular surfaces together in all angular positions. A group of muscles including the subscapularis, the supraspinatus, and the infraspinatus function principally in this holding action.</p> <p><i>Muscles and Movements</i></p> <p>The kinesiology of the arm is closely associated with that of the shoulder girdle, nearly all natural movements involving a coordinated movement between arm and shoulder. It is helpful, however, first to describe the pure movements of the arm. Schematics of the muscles acting upon the arm are presented in <b>Fig. 7</b>. Elevation is effected by the lateral deltoid and the supraspinatus, depression by the latissimus, the pectoralis major, the long head of the triceps, and the teres major. In both actions, the contributions of individual muscles differ according to the angle of the arm. And it should be noted that, with insertions near the pivot point of the humeral head, the rotatory moments are proportionately small, thus accounting for the large number of muscles necessary to give adequate joint torques. Arm flexion and extension are brought about by two groups of muscles. The biceps, the coraco-brachialis, the anterior deltoid, and the clavicular fibers of the pectoralis major mediate flexion, while the posterior deltoid, the long head of the triceps, the latissimus, and the teres major effect extension. Rotation of the arm depends upon muscles that insert on the surface of the humerus and then pass anteriorly or posteriorly around it to impart medial or lateral torsion. As would be expected, rotational forces are greatest when the arm hangs at the side; torque is reduced drastically when the arm is elevated over the head and the twisting angles of the muscles tend to disappear.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Schematic kinesiology of the arm. <i>AD, </i>anterior deltoid; <i>B, </i>biceps; <i>CB, </i>coracobrachialis; <i>IS, </i>infraspinatus; <i>L, </i>latissimus; <i>LD, </i>lateral deltoid; <i>PD, </i>posterior deltoid; <i>PM, </i>pectoralis major; <i>S, </i>subscapularis; <i>SS</i>, supra-spinatus; <i>T, </i>triceps; <i>TM, </i>teres major; <i>Tm, </i>teres minor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Combined Arm and Shoulder Movements</i></p> <p>In most natural arm movements, such as arm elevation, arm flexion, forward reaching, and to-and-fro swings of the partially elevated arm, both arm and shoulder girdle participate. In full arm elevation of 180 deg., for example, 120 deg. are contributed by rotation of the arm on the glenohumeral joint, 60 deg. are contributed by upward rotation of the scapula.<a></a>In forward reaching, involving partial arm flexion, the shoulder flexes and the scapula abducts and rotates slightly. Properly managed, this motion, the common flexion control motion of both the above- and the below-elbow amputee (pages 19-22) can give marked gracefulness to prosthetic operation.</p> <h4>The Forearm</h4> <p><i>Skeletal Members</i></p> <p>The radius and ulna together constitute a forearm lever which can rotate about the elbow axis. By virtue of the arrangement at the proximal head of the radius and at the distal end of the ulna, the forearm can also carry out torsion about its longitudinal axis to produce wrist rotation. With the aid of the mobility at the shoulder and at the wrist, it is possible to place the hand in space in an almost unlimited number of positions. The skeletal anatomy of the elbow is shown in <b>Fig. 8</b>, the articulations being the ulno-humeral and the radiohumeral. Participating in forearm rotation is the radioulnar joint at the wrist.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The right elbow joint, viewed from in front. The thin capsular ligament is not shown. Note that the ulna, with its posteriorly projecting olecranon, forms a hinge joint with the humerus, while the head of the radius is free to rotate within the annular ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The ulnohumeral joint has an unusual structure. The complex surfaces of articulation between ulna and humerus are such that the axis of rotation of the forearm is not normal to the long axis of the humerus. As the elbow is flexed or extended, therefore, the forearm does not describe a plane. Instead, the ulna swings laterally as the elbow is extended, until at full extension the cubital angle is about 170 deg. Xevertheless, only small error is involved in considering the motion to be essentially that of a simple hinge with an axis of rotation perpendicular to ulna and humerus and allowing the ulna to swing through about 140 deg. of flexion.</p> <p>In the radiohumeral joint, the slightly concave proximal end of the radius articulates with the hemispherical capitulum placed somewhat laterally on the anterior surface of the distal end of the humerus. The radius is free to move with the ulna through the complete range of flexion and, in addition, to rotate with forearm pronation and supination. In the radioulnar joint, the distal end of the ulna forms a curved surface against which the radius opposes an articulating concavity. As the forearm goes through a pronation-supination range of about 170 deg., the radius "swings like a gate" about the distal end of the ulna.</p> <p><i>Muscles and Movements</i></p> <p>As shown in <b>Fig. 9</b>, the musculature for providing forearm flexion and extension is comparatively simple, while that for pronation-supination is somewhat more involved. Flexion of the forearm is effected principally by the biceps, originating on the scapula and inserting on the radius, and by the brachialis, spanning the elbow from humerus to ulna. Secondarily, the brachioradialis and other muscles, originating distally on the humerus and coursing down the forearm, contribute to flexion. Extension is largely the function of the triceps, originating on both the scapula and humerus and inserting on the leverlike olecranon process of the ulna. A small extensor action is added by the anconeus.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Schematic kinesiology of the forearm. <i>A, </i>anconeus; <i>B, </i>biceps; <i>BR, </i>brachialis; <i>BrR, </i>brachioradialis; <i>PT, </i>pronator teres; <i>PQ, </i>pronator quadratus; <i>Su, </i>supinator; <i>T, </i>triceps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rotation of the forearm is a function of many muscles. Some, such as the supinator, evidently are designed for the purpose, while others, as for example the finger flexors, have different principal functions, the contribution to forearm rotation being only incidental. <b>Fig. 9</b> presents the major rotatory muscles only. Supination is mediated by the brachioradialis, the supinator brevis, and the biceps, pronation by the pronators quadratus and teres. Of great importance to upper-extremity prosthetics is the fact that rotation of the forearm is a function of total forearm length. With successively shorter stumps, not only are the rotation limits of the radius and ulna reduced, but also the contributions of muscles are eliminated as their insertions are sectioned.</p> <h4>Musculoskeletal Mechanisms</h4> <p>The upper extremity having been considered from the standpoint of functional and descriptive anatomy, attention may now be turned to a more mechanical view of its operations. Typical elements of mechanism in the upper extremity include joints (bearing surfaces), joint-lining secretions (lubricants), bones (levers and couple members), tendons (transmission cables), and muscles (motors). The arrangement of these elements makes up a complex machinery capable of such diverse activities as precise orientation in space, performance of external work, fine digital manipulations, and so on.</p> <h4>Typical Joint Mechanics</h4> <p>The elbow joint embodies the essential structures of diarthrodial joints. The bearing surfaces are covered with a thin layer of articular cartilage that is continuous with the synovial membrane lining the whole joint capsule. Subsynovial pads of fat serve to fill up the changing spaces that occur during movement of the joint (<b>Fig. 10</b>). It is believed that these fatty deposits serve as "pad oilers" to maintain the continuous film of synovial fluid over the articular surfaces.<a></a> This fluid contains mucin (a glycoprotein which serves as a lubricant for the joint) and other material constituting a nutritional medium for the articular cartilage. Considerable uncertainty exists concerning the method of formation and distribution of the fluid to the joint, but its mechanical function is clear and the normal joint performs as a well-oiled bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Typical change in joint spaces with flexion-extension, as revealed by the elbow. Redrawn from Steindler <i>(17), </i>after Fick. <i>A, </i>Gap of the medial border of the olecranon surface with elbow in extreme extension. <i>B, </i>Gap of the lateral border of the olecranon in extreme flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bones and Their Mechanical Function</h4> <p>The bones of the upper extremity, besides forming a support for soft tissue, provide a system of levers which makes the arm an important mechanism for the performance of gross work, such as lifting, slinging, and thrusting. The arm bones serve further as positioners of the hand, in which other, finer bones constitute the intricate articulated framework of the manipulative mechanism. Two main features of bones merit discussion here-their internal composition and construction and their external shape and adaptations that permit them to serve as members of mechanical systems.</p> <p><i>Internal Structure</i></p> <p>There is much evidence that the gross internal structure of bone is eminently suited to withstand the mechanical stresses placed upon it by the compressive loads of weight-bearing, by the tensions of tendons and ligaments, and by the lateral pressures of adjacent tissues.<a></a>The nature and orientation of the trabeculae in cancellous bone have, for example, long been held, in theory, to provide the maximum strength along the lines of major stresses. This idea, originally suggested by von Meyer, has been championed by many, including Koch, who carried out a stress analysis on the femur.<a></a> Objections to the von Meyer theory have dealt largely with the frequent and incautious extension of the concept. It is now believed that genetic and growth factors determine the essential form and dimensions of bone. Mechanical stresses serve secondarily to mold and modify it to give added strength where stresses are greatest. One must grant from even a superficial examination of the internal structure of bone that Nature has done an admirable job of designing for maximum strength with minimum weight.</p> <p><i>Members of Mechanical Systems</i></p> <p>The second principal feature of bones, that of serving as rigid members in a complex of mechanical systems, is the one that has engaged the most attention. It is surprising that the simple lever concepts of Archimedes have persisted in anatomy and kinesiology texts to the present day. Thus, the forearm-flexor system is said to act as a third-class lever, the extensor system as a first-class lever. Although these assertions are of course true, both of these systems are, in the more complete language of Newtonian mechanics, parts of force-couple systems in which equal and opposite components of force are transmitted through the bones and joints (<b>Fig. 11</b>). Elft-man<a></a> has emphasized this view. The magnitude of the couple is given by the product of the force (either of the equal but opposite forces) and the distance between them, which also is numerically equal to the torque of the muscle force. The concept of the couple calls attention to the existence of the equal and opposite forces in joints and emphasizes the loads placed upon them by muscular work. Another and more complicated application of the couple is seen in scapular rotation. Here, as described by Inman <i>el al.</i><a></a> and as shown in <b>Fig. 12</b>, the pull of the lower fibers of the serratus anterior upon the scapula is such as to give it upward rotation, while the thrust of the clavicle, acting through the acromioclavicular joint, holds a pivot for the rotation. Simultaneously, the pull of the upper trapezius fibers causes the clavicle to undergo angular rotation about the sternoclavicular joint. The result is that, at least through the first 90 deg. of arm elevation, the motion is shared by coordinated angular rotations of scapula, clavicle, and humerus. As a basic part of this rotatory action, the scapula acts as the moment arm of a force couple, the trapezius and serratus providing components of force which are equal and opposite.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Force couples at the elbow. Tensile forces in biceps and brahialis are associated with equal, opposite, and parallel forces through the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Muscle forces acting on the shoulder, anterior view. The trapezius, acting diagonally, gives a supportive component. <i>Fy</i>,<i>, </i>and a horizontal component, <i>Fx, </i>which together with the opposite force from the serratus, 5, comprise an upward rotatory force couple on the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Tendons and Muscles</h4> <p>The specific functions of tendons are to concentrate the pull of a muscle within a small transverse area, to allow muscles to act from a distance, and in some instances to transmit the pull of a muscle through a changed pathway. The mechanical importance of this tissue is nowhere more evident than in the arm, where a large degree of versatility of motion in the segment distal to each joint is preserved by "remoting" the action of muscles through slender, cablelike tendons over joints. By this means lines of pull are brought near the joint axes, thus providing a lever arm consistent with the tensile force of the muscle at all joint angles and also giving at low joint angles an increased angular motion for a given linear contraction. Other advantages of remoting the muscles are seen in the forearm and hand. In order to afford the variety and complexity of interdigital movements, many independent muscle units are necessary, and critical space problems are avoided because muscles such as the common flexors and extensors of the fingers are placed at some distance up the forearm.</p> <p>The predominant function of tendon as a tension member in series with muscle, which is a tension motor, is seen in early growth stages. An undifferentiated cellular reticulum of connective tissue is everywhere found in embryonic tissue. The parent cells are fibroblasts; they elaborate and extrude the collagenous material of which white fibers are made. <a></a> At this point the presence of mechanical tensions in the tissue influences the rate, amount, and direction of the resultant fiber formation. At maturity the tendon is composed almost entirely of white collagen fibers, closely packed in parallel bundles, to form a cablelike strand. It is contained within a sheath which forms a loose covering lubricated continuously by a mucinous fluid to reduce friction with surrounding tissues.</p> <p>Mutual adjustment of the characteristics of muscle and tendon is shown in many respects. The musculotendinous juncture varies with the arrangement of the muscle fiber. It shows a simple series arrangement for fusiform muscles like the biceps, or it comprises a distributed attachment zone by continuation of the tendon into intramuscular septa where pinni-form fibers may insert (<b>Fig. 13</b>). In some unexplained way the relative lengths of muscle and associated tendon are so composed that the shortening range of the muscle is that necessary to move the segment distal to the joint through its maximum range.<a></a> The capacity to adapt the ratio of muscle length to tendon length has been demonstrated in an experiment in which the pathway of the tibialis anterior tendon in the rabbit was shortened. The result was that the tendon shortened while the muscle lengthened to regain the normal joint range.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Muscle fiber patterns. <i>A, </i>Fusiform. <i>B, </i>Bipinniform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The relative strengths of muscle and of tendon also show an approximate compatibility, the tensile strength of tendon, measured at from 8700 to 18,000 lb. per sq. in.<a></a>, being greater than that for muscle. Strength tests of excised muscle-tendon systems show that failure commonly occurs in the belly of the muscle, or at the musculotendinous juncture, or at the bone-tendon juncture, but never exclusively in the tendon itself. Analysis of clinical cases indicates that muscle is still the site of failure even when it is maximally tensed.<a></a> It is clear, then, that of the muscle-tendon combination the tendon is normally always the stronger.</p> <h4>Forearm-Fexor Mechanics</h4> <p>The forearm-flexor system is well suited to serve as an example of biomechanics because the bone-joint system comprises a simple uniaxial hinge while the flexor muscles, though five in number, can be reduced to a single equivalent muscle whose geometry and dynamics can be specified from measurement data. <b>Fig. 14</b> illustrates the lever system on which the equivalent muscle acts. The angle between the axis of the muscle and that of the forearm bones, <i>i.e., </i>the "angle of pull," theoretically ranges from 0 deg. at full extension to 90 deg. at 100 deg. of elbow angle, and since the moment arm is continuously proportional to the sine of the angle of pull the mechanical advantage of the lever also is proportional to it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Forearm-flexor mechanics. Insert gives the geometry of the idealized flexor system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are of course departures from this idealized geometry. For one thing, the angle of pull and the elbow angle are not exactly equal. Moreover, at small elbow angles the torque component does not actually drop to zero because the muscles must always pass over the elbow joint at some finite distance from its center. Finally, the force-length curve<a></a> of the equivalent muscle must also be taken intoaccount in expressing the effective torque. For these and other reasons, actual torque measurements take precedence over theoretical calculations, and the composite curve of <b>Fig. 14</b> has been plotted from the results of a number of investigators. Whereas the moment arm peaks at an elbow angle of 100 deg., the muscle force is declining throughout the elbow-flexion range, and the net effect, as reported by Miller ,<a></a> is a maximum torque of about 625 lb.-in. at from 80 to 90 deg. Clarke and Bailey<a></a> found a peak of about 400 lb.-in. at between 70 and 80 deg., and the author has obtained 550 lb.-in. just under 90 deg. in a group of subjects. Wilkie's data give a value of about 525 lb.-in. at 80 deg., measured on himself.<a></a> These variations can be explained as resulting from the effect of a limited sampling of an inherently variable characteristic. Greater consistency probably could be obtained in a larger series of measurements.</p> <h4>Maximum Torques in Major Aactions</h4> <p>Because they express the fundamental output characteristics, and because they are most easily measured, the muscle torques about the major joints represent the most significant and practical aspects of the statics and dynamics of the musculoskeletal system. Not only is muscular power a concept of uncertain validity but also it is very difficult to measure. The combined effect of muscle and lever, however, can easily be measured in many subjects, so that statistical stability can be achieved in the results. Because muscle agonists change length with joint angle, and because they are thus caused to work on different parts of their length-tension diagrams, joint torques vary as a function of joint angle. As demonstrated by Clarke<a></a>, this phenomenon, shown in <b>Fig. 14</b> for the forearm-flexor system, holds more or less for all major actions about the joints. But these details may be neglected in summarizing the maximum torques throughout the upper-extremity system (<b>Table. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Functional Role of Sockets</h4> <p>The socket is the foundation of the upper-extremity prosthesis. It obtains purchase upon the most distal segment of the remaining member and should be stable, though comfortable, in its fit with this member. The socket must bear weight both axially and in all lateral directions. It is the attachment member for mechanical components and for control guides and retainer points. Hence the socket must be a sound structural member as well as a custom-fit, body-mating part. Finally, the socket extends the control function of the member to which it is fitted, giving movement and direction to the prosthesis. In any discussion of prosthetic controls, therefore, the starting point is the socket.</p> <p>The requirement of formability and strength in sockets has been met satisfactorily by the introduction of polyester laminates.<a></a> These materials permit close matching of the stump impression, and variations in strength can be introduced by increasing the number of laminate layers. The double-wall construction<a></a> provides a stump-fitted inner wall, with an outer wall that can be designed to structural uniformity and cosmetic requirement. Sizing to achieve this aim has now been reduced to standard practice. <a></a> Finally, the texture and coloring of the plastic laminate can be controlled to achieve satisfactory cosmetic results.</p> <h4>The Below-Elbow Socket</h4> <p>The peculiar feature of the forearm, that pronation-supination is a function of the whole forearm length, places a special limitation on the below-elbow socket. Although for stability in flexion the whole remaining forearm stump is best sheathed in the socket, to do so prohibits forearm rotation. In the case of the longer below-elbow stumps, therefore, some sacrifice in stability can be afforded in the interest of retaining forearm rotation. The proximal portion of the socket is fitted loosely to give freedom for forearm rotation while the distal portion is fitted snugly to provide a stable grip. <b>Fig. 15</b> shows the amount of forearm rotation available at various levels of the natural forearm and that remaining in below-elbow amputees of various types. Because of torsion of the flesh, however, and because of slippage between the skin and the socket, effective socket rotation is lost in stumps which are only 50 percent of forearm length. The effective socket rotation remaining in the wrist-disarticulation case is only about 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Below-elbow amputee types, based on average forearm length, epicondyle to styloid. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further adaptations of below-elbow sockets to suit the functional requirements at the various levels are shown in <b>Fig. 16</b>. In the long below-elbow stump, the elliptical cross-section of the forearm near the wrist permits a "screw-driver" fit of the socket to yield the maximum in rotational stability. With the shorter stumps, the possibility of effective rotation is reduced and is lost completely at about 50 percent of forearm length. At this level, the problem of forearm rotation is outweighed by that of providing flexion stability. Dependence upon a rigid or semirigid hinge system is necessary in the short below-elbow stump, and finally, in the very short stump, effective forearm flexion is so reduced that a split socket with step-up hinge becomes a necessity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematics of below-elbow prostheses. For each type, an insert gives the cross-sectional anatomy 1 in. from the end of the stump. Sections are taken from the normal anatomy of the forearm. Sockets, hinges, cuffs, and suspensions are for <i>a, </i>single socket; <i>b, </i>rotation type; <i>c, </i>double-wall socket; and <i>d, </i>split socket. After Taylor <i>(18).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The goal of below-elbow socket design is to regain as completely as possible the control function of the forearm, which includes <i>(a) </i>positioning of the hand by forearm flexion and <i>(b) </i>hand rotation by means of pronation-supination. In the below-elbow prosthesis, adequate forearm flexion is obtained rather easily; rotation is limited to the potential available in the longer stumps. Manual wrist rotation, of course, supplements the remaining natural rotation. In the below-elbow prosthesis, then, control of the terminal device in space depends in fair measure upon the role of the socket in preserving the residual flexion and rotation of the below-elbow stump.</p> <h4>The Above-Elbow Socket</h4> <p>Unlike the below-elbow case, the above-elbow stump presents no problem of diminishing rotation with diminishing stump length because arm rotation is confined wholly to the gleno-humeral joint. Socket design for the above-elbow case is therefore related principally to the requirement of fitting the stump closely so that the humeral lever can be fully effective in controlling the prosthesis. <b>Fig. 17</b> shows the minor variations corresponding to above-elbow type, including the elbow disarticulation. Sockets for the latter must take account of the bulbous end of the stump. They must provide snug fit around the epicondyle projections but maintain sufficient room in the region just above, where the stump cross-section is reduced, to permit insertion of the stump in the socket. In both the elbow-disarticulation and the standard above-elbow cases, the upper margin of the socket is terminated below the acromion for freedom of movement at the shoulder. In the short above-elbow case, the socket is carried up over the acromion to obtain additional stabilization and suspension from the shoulder, as required by the very limited stump area. The control function of the above-elbow socket is twofold. As in the below-elbow case, the socket extends the slump to the next more distal joint and thus gives range and direction to this component upon which the positioning of the still more distal segments depends. But in addition to this feature, the above-elbow socket also has a power function. Through its attachments to shoulders and torso, it provides the forces and displacements needed to produce forearm flexion, terminal-device operation, and elbow lock. To fulfill these functions, the socket must have stable purchase on the stump in both flexion and extension. Hence, for elbow-disarticulation and above-elbow types, the socket should continue to the axillary level; for short-above-elbow amputees, it should come up over the acromion (<b>Fig. 17</b>). Finally, medial and lateral rotation of the socket are necessary for further functional positioning. Close fit and good suspension are required to give stability in these actions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Schematics of above-elbow sockets, including elbow disarticulation. For each type, an insert gives the cross-sectional anatomy at the indicated level. Dashed lines show stump contour and inner wall of the socket. Standard and short above-elbow cases have a double-wall socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Shoulder Socket</h4> <p>In the range of amputation sites from transection of the humeral neck to complete removal of the shoulder girdle, the socket form changes from shoulder cap to thoracic saddle. As displayed in <b>Fig. 18</b>, the bearing area increases as the remaining shoulder elements are reduced; similarly, the amount of "build-out" needed to preserve shoulder outline increases with increasing amputation loss. With disarticulations and all more extreme losses, sectional plates may be introduced at the axillary parasagittal plane. This arrangement makes it possible to fabricate the prosthesis in two sections, a matter of considerable advantage to the limbmaker, and it also affords the functional advantage of a preposition swivel of the humeral section upon the saddle section to simulate flexion-extension of the arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematics of shoulder sockets. Solid lines show residual bony structure, dashed lines the body contour and inner wall of the socket. Disarticulation and forequarter sockets may be two-piece with sectional plates at <i>a.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The functional aspects of the shoulder socket are to some extent secondary to the structural; yet there are certain definite functional ends to be served. Shoulder and scapular mobility in elevation, flexion, and extension should be preserved to the highest possible degree. In humeral-neck and shoulder-disarticulation cases, aid can be given to the shrug control (biscapular abduction), and at least a small range of motion can be given to the elbow, but of course no such function can be expected in forequarter or partial-forequarter amputees.</p> <h4>Major Arm and Shoulder Controls</h4> <p>The common method of operation of upper-extremity prostheses is by means of shoulder harness which provides suspension and which also transmits force and excursion for control motions. In this manner such operations as forearm flexion-extension, terminal-device operation, and elbow lock are managed. <b>Fig. 19</b> presents the essential features of the major harness controls. In principle, each effective control must begin with a point stabilized on shoulder or torso, pass over a voluntarily movable shoulder or arm part, and thus provide relative motions with respect to the origin. At the movable point, the control cable enters the Bowden-type housing, which transmits the relative motion independent of movements of the distal segments. Controls may be used singly or in combination, depending upon the level of amputation, amputee preference, and other practical considerations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Major harness controls. The points stabilized by harness (x) are beginning points for the control cable, which passes into a Bowden-type housing at movable points (¦). The relative motion is transmitted via the Bowden cable to distal points on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides the relative motions between various segments of the human body, still another source of energy for operation of upper-extremity prostheses can be made available by the surgical procedure known as cineplasty, <a></a> in which a skin-lined tunnel is fashioned in the belly of a muscle group. In various experimental programs conducted both here and abroad, muscle tunnels have been made in the forearm flexors, the forearm extensors, the biceps, the triceps, and the pectoralis major.</p> <p>Of all the various combinations tried, the biceps tunnel in below-elbow amputees has proved to be the most successful. Failure of other cineplasty systems has been due in some cases to inability of designers to overcome the mechanical problems involved in harnessing the energy thus provided and in other cases to the inherent properties of the particular muscle group concerned. In the below-elbow case, use of the biceps tunnel eliminates the need for shoulder harness and permits operation of the prosthesis with the stump in any position. It has given excellent results in many instances and has been made available to those beneficiaries of the Veterans Administration who can make effective use of the procedure.<b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Coordinated control motions for elbow lock. Simultaneously the humerus is both extended <i>(a) </i>and abducted <i>(b) </i>while the shoulder is depressed (c) and the trapezius is bulged <i>(d) </i>by downward rotation of the scapula. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cineplasty tunnel in the biceps of the average male will provide sufficient force and excursion to operate modern terminal devices-an average maximum force of 50 lb. and 1 1/2 in. of useful excursion. It is not unusual for some individuals to be able to build up the force available to a value in excess of 100 lb., but such a high force normally is not required.</p> <h4>The Nature and Operation of Ccontrol Systems</h4> <p><i>The Below-Elbow Single-Control System</i></p> <p>The single control for the below-elbow amputee is powered by arm flexion to provide terminal-device operation. This control motion, used by the above-elbow amputee also, depends upon a coordinated flexion of the humerus and abduction of the scapula on the amputated side; little shoulder activity is required on the sound side. It is substantially the same motion as that used in normal unilateral reaching. The displacements of humerus and scapula are additive, so that the resulting motion is quite natural. With full Bowden-cable transmissions of power from arm cuff to forearm socket, there is no influence of elbow angle, and the operation is mastered easily by all amputees with stumps of 35 percent or more of normal forearm length.</p> <p><i>The Below-Elbow Dual-Control System</i></p> <p>(Although the terminology commonly used to describe the several control systems could well afford to be better systematized, it is adopted here because it is now so well established throughout the field of prosthetics. One <i>may </i>think of "dual control" as meaning that two control sources are involved in the provision of all necessary functions, but according to convention it means that two functions, specifically elbow flexion and terminal-device operation, are provided by a single control source, the third function, elbow lock, if needed, being managed by an additional control source. Yet "triple control" (page 22) in the accepted sense means not that three functions are furnished by a single control source but that three control sources are used to provide three functions, one for each.-Ed.)</p> <p>In harnessing below-elbow stumps shorter than 35 percent of normal forearm length, it generally is necessary to use an auxiliary type of lift to help the amputee flex the forearm. This procedure is applicable to a split-socket type of prosthesis. It merely is an adaptation of the above-elbow dual-control system (page 22) using a lever loop positioned on the forearm section so that arm flexion may be utilized to assist in forearm lift. The cable housing is split and assembled so that when the arm is flexed the elbow will flex. The elbow hinge has no locking mechanism, the short below-elbow stump being used to stabilize the forearm. Normally, sufficient torque is available about the elbow axis to give adequate stability in all usable ranges.</p> <p>In prescribing for a new amputee with this level of amputation, it might be advisable first to have the amputee try a split-type prosthesis without the below-elbow dual-control system. If, at time of initial checkout, the amputee cannot lift his forearm, or if he complains of painful contact with his stump, then of course the dual system is indicated. After the assist lift has been worn for some time, the remaining muscles of the stump may have hypertrophied, in which case the amputee might be able to discard the dual system and convert to the below-elbow single control.</p> <p><i>The Below-Elbow Biceps-Cineplasty System</i></p> <p>Force and excursion provided by the biceps muscle tunnel are harnessed by inserting into the tunnel a cylindrical pin of a nontoxic material and attaching a cable to each end of the pin. As in the other types of control systems, the Bowden-cable principle is employed to maintain a constant effective distance between the source of energy and the mechanism to be operated, regardless of relative motions occurring between body segments. In order that conventional terminal devices may be employed, it is necessary to join the two cables before attachment to the mechanism. Several devices for making this coupling are available commercially.</p> <p>Suspension of the socket is provided by an arm cuff, which is attached to the socket by any of the various hinges normally used in fabrication of below-elbow prostheses. The arm cuff is fashioned in such a manner that forces tending to pull the prosthesis from the stump are absorbed by the condyles of the elbow rather than by the muscle tunnel.</p> <p><i>The Above-Elbow Dual-Control System</i></p> <p>In above-elbow amputees, the humeral stump furnishes the motive power for the three operations of the prosthesis-flexion of the forearm, operation of the terminal device, and management of the elbow lock. The first two operations are so linked mechanically that a single control motion, arm flexion, produces either terminal-device operation or forearm flexion, depending on whether the elbow is locked or unlocked (<b>Fig. 20</b>). Although the control motion by arm flexion in the above-elbow case is similar to that described for the below-elbow amputee, there are several differences. Because the cable passes through a lever loop on the forearm to give torque about the elbow, it is affected by elbow position. As the forearm is flexed, arm-flexion excursion is used up, and the excursion needed to operate the terminal device must come from scapular abduction (shrug), as in shoulder cases. Typically, the above-elbow amputee manages a full range of free forearm flexion by a normal arm-flexion movement. But in the elbow-angle range of from 90 to 135 deg., with elbow locked for terminal-device operation, he must call upon supplementary excursions from biscapular abduction. With the terminal device at the mouth, practically all operation depends upon shoulder shrug.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Operation of above-elbow and shoulder dual controls. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the above-elbow dual-control system, operation of the elbow lock depends upon humeral extension and associated coordinations. When the forearm has been flexed to the position desired, the elbow lock is engaged by the arm-extension movement. Skill is needed to maintain tension on the arm-flexion cable so that the arm does not drop during the locking control motion. Well-trained amputees elevate the arm moderately to compensate for the humeral extension and thus maintain the elbow angle. The extension control motion is complex. The humerus is simultaneously extended and elevated so that it moves obliquely to the side. During this phase, the point of the shoulder must be stabilized, or even moved forward, and the trapezius is bulged by downward rotation of the scapula (<b>Fig. 21</b>).<b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Location of the proximal retainer for both above- and below-elbow cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Above-Elbow Triple-Control System</i></p> <p>The triple-control system has been devised to separate terminal-device operation from forearm lift. When the dual-control system is used, the amputee must select, by the use of the elbow lock, either terminal-device operation or forearm lifting. By separating forearm flexion and terminal-device operation, the triple control makes it possible for the terminal device to be controlled by an independent body motion. Although in general an above-elbow amputee fitted with triple control has an elbow lock, a few such cases are able to separate prehension from forearm flexion without use of the lock.</p> <p>A control cable from the terminal device is so attached and positioned that biscapular abduction or merely shoulder shrug will operate the terminal device through its full range of prehension. To lift the forearm the amputee uses arm flexion. Elbow-lock operation is accomplished in the same manner as in the dual-control system, that is, by arm extension.</p> <p>It is apparent that this arrangement will work best with a comparatively stable socket and a relatively long above-elbow stump. The chief advantage of the triple-control system is that at full forearm flexion the terminal device may still be operated through its complete range.</p> <p><i>The Shoulder Dual-Control System</i></p> <p>In the absence of the humeral lever, the shoulder becomes the major power source, biscapular abduction controlling both forearm and terminal device in the dual-control system. The control path courses horizontally across the scapulae, and either opposite-axilla loop or basic chest-strap harness (page 46) captures the action satisfactorily. The combination afforded by the dual principle also is illustrated in <b>Fig. 20</b>.</p> <p>The shoulder amputee has a special difficulty in obtaining the combination of full forearm flexion and terminal-device operation because, unlike the above-elbow amputee, who can add the excursions of humeral flexion and scapular abduction, he must obtain all movement from biscapular abduction. Shoulder amputees with broad shoulders and wide chests usually achieve this action satisfactorily; others must accept the limitation of partial terminal-device operation at full forearm flexion. Partial-shoulder and fore-quarter amputees must depend upon the sound shoulder entirely, and in this case the action range of the terminal device typically is limited to not more than 90 deg. of forearm flexion.</p> <p>In shoulder amputees, operation of the elbow lock must be managed by various special arrangements. The waist control, utilizing shoulder elevation; the perineal strap, based on relative motion between shoulders and pelvis; the nudge control, requiring either manual or chin operation; extreme shoulder flexion on the sound side; and extension of the shoulder on the amputated side complete the array of known feasible possibilities. It is evident that with this class of amputees control motions will be slower and deliberately sequential. They are therefore necessarily more noticeable and awkward.</p> <p><i>The Shoulder Triple-Control System</i></p> <p>The harness required for the triple-control shoulder-disarticulation system consists of a chest strap for forearm flexion, a waist strap to operate the elbow lock, and an opposite-shoulder loop for prehension. The amputee must have excellent scapular abduction and must be able to separate it from extreme opposite-shoulder shrug, and he must have available good shoulder elevation on the amputated side. The chief advantage of the triple control in the shoulder-disarticulation case is identical to that of the triple control in the above-elbow case, namely, that the terminal device may be operated fully in the vicinity of the mouth. To operate the prosthesis from an extended position, the amputee first produces biscapular abduction, thus raising the forearm. Then, with the forearm held in place, he elevates the shoulder on the amputated side to lock the elbow. To operate the terminal device, he then flexes the sound shoulder. Excursion for terminal-device operation is thus unaffected by forearm flexion.</p> <p>Unfortunately this system must be restricted to humeral-neck and shoulder-disarticulation cases. For lack of sufficient excursion on the amputated side, it is unlikely that a forequarter amputee would be able to use triple control.</p> <h4>Mechanical Application of the Major Controls</h4> <p>To elucidate practical amputee biomechanics, it is necessary to refer to several aspects of the connecting mechanism between amputee and prosthesis in the power-transmission system. Of first importance are the proximal retainers, which are located at the point where the cable from the shoulder harness enters the cable housing. These retainers are the beginning points of the transmission systems indicated in <b>Fig. 19</b>. In both below- and above-elbow cases, the proximal retainer is positioned in accordance with the ratios shown in <b>Fig. 22</b>. For all above-elbow stumps of greater than 50 percent of acromion-to-epicondyle length, the proximal retainer point is placed slightly lower than half way down the arm, the reason being that the control passes naturally through this point in its course from opposite shoulder, across the scapula, and thence to the lever loop on the forearm shell. The humeral lever power is quite adequate at this point (<b>Table 3</b>), and no practical advantage is gained by a lower placement. With above-elbow stumps less than 50 percent as long as the normal arm length, acromion to epicondyle, the proximal retainers must be placed at the level of the stump end in order to prevent undue tipping of the socket, as would occur if forces developed beyond the end of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In shoulder cases, the control path is directed horizontally at approximately the midscapular level and brought to the arm section at the axilla. The control motion is purely biscapular abduction, and consequently the proximal retainer is placed on the prosthesis at the midscapular level. The resulting force and excursion are given in <b>Table 3</b>.</p> <p>Arm-extension forces are potentially quite high, as also shown in <b>Table 3</b>. Because only 2 to 6 lb. of force and 1/2 in. of excursion are required to operate an elbow lock, normally there is a generous power excess. The principal concern in harnessing arm-extension control is to obtain operation with minimal movement and thus to avoid awkwardness.</p> <h3>Conclusion</h3> <p>The central purpose of this article has been to outline the biomechanical basis of control in upper-extremity prostheses. Consequently, emphasis has been placed upon the normal and residual functional anatomy and kinesiology underlying this service. The particularized biomechanics of prosthesis control has been defined, and the limitations incurred in amputations at high levels have been stressed. The major message is that a thorough understanding of the motions of control available to each type of patient is necessary to the proper prescription, fitting, and training of the upper-extremity amputee. Thus only can full advantage be taken of the improved functional features to be found in modern arm components.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasly, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carlyle, L. C, <i>Using body measurements to determine proper lengths of artificial arms, </i>Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Clark, W. E. Le Gros, <i>The tissues of the body; an introduction to the study of anatomy, </i>3rd ed., Clarendon Press, Oxford, 1952.</li> <li>Clarke, H. Harrison, and Theodore L. Bailey,<i>Strength curves for fourteen joint movements, </i>J. Assoc. Phys. &amp; Ment. Rehab., 4(2):12 (1950).</li> <li>Cronkite, Alfred Eugene, <i>The tensile strength of human tendons, </i>Anat. Rec, 64:173 (1936).</li> <li>Elftman, H , <i>Skeletal and muscular systems: structure and function, </i>in <i>Medical Physics, </i>O. Glasser <i>el al., </i>eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</li> <li>Haines, R. W., <i>On muscles of full and of short action,</i> J. Anat., 69:20 (1934).</li> <li>Hollinshead, W. H., <i>Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, </i>Saunders, Philadelphia, 1951.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, <i>Observations on the function of the shoulder joint, </i>J. Bone &amp; Joint Surg., 26:1 (1944).</li> <li>Koch, John C, <i>The laws of bone architecture, </i>Am. J. Anat., 21:177 (1917).</li> <li>Lewis, Warren H., ed., <i>Gray's anatomy of the human body, </i>24th ed. revised, Lea and Febiger, Philadelphia, 1942.</li> <li>McMaster, Paul E., <i>Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, </i>J. Bone &amp; Joint Surg., 15:705 (1933).</li> <li>Miller, D. P., <i>A mechanical analysis of certain lever muscles in man, </i>Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</li> <li>Newman, R. W., and R. M White, <i>Reference anthropometry of Army men, </i>Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body tinder normal and pathological conditions, </i>Charles C Thomas, Springfield, Ill., 1955.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasly, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>Unpublished data, UCLA.</li> <li>Wilkie, D. R., <i>The relation between force and velocity in human muscle, </i>J. Physiol., 110:249 (1949).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasly, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 19.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasly, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Wilkie, D. R., The relation between force and velocity in human muscle, J. Physiol., 110:249 (1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clarke, H. Harrison, and Theodore L. Bailey,Strength curves for fourteen joint movements, J. Assoc. Phys. &amp;Ment. Rehab., 4(2):12 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Miller, D. P., A mechanical analysis of certain lever muscles in man, Ph.D. dissertation, Graduate School, Yale University, New Haven, Conn., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">McMaster, Paul E., Tendon and muscle ruptures; clinical and experimental studies on the causes and location of subcutaneous ruptures, J. Bone &amp;Joint Surg., 15:705 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cronkite, Alfred Eugene, The tensile strength of human tendons, Anat. Rec, 64:173 (1936).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Haines, R. W., On muscles of full and of short action, J. Anat., 69:20 (1934).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Inman, V. T , J. B. deC M. Saunders, and L. C. Abbott, Observations on the function of the shoulder joint, J. Bone &amp;Joint Surg., 26:1 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Elftman, H , Skeletal and muscular systems: structure and function, in Medical Physics, O. Glasser el al., eds., Vol. I, p. 1420, Year Book Publishers, Inc., Chicago, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Koch, John C, The laws of bone architecture, Am. J. Anat., 21:177 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, The tissues of the body; an introduction to the study of anatomy, 3rd ed., Clarendon Press, Oxford, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hollinshead, W. H., Functional anatomy of the limbs and back; a text for students of physical therapy and others interested in the locomotor apparatus, Saunders, Philadelphia, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Steindler, Arthur, Kinesiology of the human body tinder normal and pathological conditions, Charles C Thomas, Springfield, Ill., 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Lewis, Warren H., ed., Gray's anatomy of the human body, 24th ed. revised, Lea and Febiger, Philadelphia, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Carlyle, L. C, Using body measurements to determine proper lengths of artificial arms, Memorandum Report No. 15, Department of Engineering, University of California (Los Angeles), 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Newman, R. W., and R. M White, Reference anthropometry of Army men, Report No. 180, Quartermaster Climatic Research Laboratory, Lawrence, Mass., 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-2.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_004/tmp482-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Biomechanics of Control in Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * https://staging.drfop.org/files/original/69dcd7caf7126245f67c576a23eed259.pdf b7b6157c3a00c22ce04eab5fcbcd9bd3 https://staging.drfop.org/files/original/cd52e34d44c4e57526a5fce138f7f698.jpg 7a198c7f047f773bbc6304cfba3cf5ca https://staging.drfop.org/files/original/5d7294a2a8e341f658d1da509204af9b.jpg 7bd95a76b3d734667480ec0dfa10627e https://staging.drfop.org/files/original/41aca07379059375c3292b724c20ad74.jpg 1d4152198663676bd39749aa3927f9a9 https://staging.drfop.org/files/original/67da595e2b69a4eddfa254d7f3e4af1b.jpg 37ef26f3aa707b94fe6ce8c247500085 https://staging.drfop.org/files/original/9b09d3285dd63986158fb6ad3ff17829.jpg 1834799a9a45cb6e9a6a14ebdaeaf347 https://staging.drfop.org/files/original/01becc70231689f01d3e23078ca3d426.jpg a30c1c89e6080e63e83f5a4d21259851 https://staging.drfop.org/files/original/c837aee0438447ad78993b03f0c6c200.jpg a8318e44f6a4c5f16bad1e856293ce4f https://staging.drfop.org/files/original/b42005d371ab6bcdfafd2938aebf111f.jpg e14968ee1a57f38cdb7f3d3f58869784 https://staging.drfop.org/files/original/6d838654a7a10c9c607154be00da4967.jpg 6487b2156f041d65856f1b7fbd7fce04 https://staging.drfop.org/files/original/c721165ea01198ee6aef4e31acd0fdac.jpg f2e09c1ac6e6f04fc5b0a5eb66bcbd18 https://staging.drfop.org/files/original/86e71ac88dc77c0fe807c5821fd82c2a.jpg c276be77977e747e8b61adff1578acb7 https://staging.drfop.org/files/original/594db7f923eba326a0a22d4a72240941.jpg 37b19234f934f0937579f96fc8254bfe https://staging.drfop.org/files/original/7911660ec28bd9831354b1be9725eb7d.jpg 83d75d5dd8bf9a0f175a066cfac8db09 https://staging.drfop.org/files/original/2ce46311925780543b5f166aae06734c.jpg 20250700f961fbca04d3a509217ae6f4 https://staging.drfop.org/files/original/51f64afd51e21f05fcb8be1cf6b566a6.jpg 78db7332d104e619ea0153d0faf72faa https://staging.drfop.org/files/original/67dbcbc2d6e97fce74975c8e5425df4d.jpg 9c9248069a2f1eeb39d500e952d2092d https://staging.drfop.org/files/original/d9cb0275b460dcb93313cf0a93e01dc4.jpg 1b87da727d718119cf9f5981c3028001 https://staging.drfop.org/files/original/bbe231086fad6f1a5604ed09094d496d.jpg 284ec9e3ade0dccb3ab0c62ed1ae442e https://staging.drfop.org/files/original/72335cd71fe5e3195663463b7ff672df.jpg 6e71c69d6cb6b4d01362c92378c81350 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_022.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 22 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anatomy and Mechanics of the Human Hand</h2> <h5>Craig L Taylor, Ph.D. <a style="text-decoration:none;">*</a><br />Robert J. Schwarz, M.D <a style="text-decoration:none;">*</a><br /></h5> <p>It is obvious to all that the human hand represents a mechanism of the most intricate fashioning and one of great complexity and utility. But beyond this it is intimately correlated with the brain, both in the evolution of the species and in the development of the individual. Hence, to a degree we "think" and "feel" with our hands, and, in turn, our hands contribute to the mental processes of thought and feeling.</p> <p>In any mechanism, animate or inanimate, functional capabilities relate both to structural characteristics and to the nature of the control system available for management of functions singly or in multiple combinations. Just so with the human hand. Analysis of normal hand characteristics therefore requires an understanding of both sensory and mechanical features. Of course whole volumes have been written on hand anatomy, and it is not possible in a short article to describe all elements in detail. It is helpful, however, to review the basic construction of bones and joints and of the neuromuscular apparatus for governing motions and forces. Twenty four muscle groups, controlled by the various motor and sensory nerve pathways, with their rich potentialities for central connection, and acting upon a bone and joint system of great mechanical possibilities, give to the hand its capacity for innumerable patterns of action.</p> <h3>The Functional Structure of the Hand</h3> <h4>The Bones</h4> <p>The bones of the hand, shown in (<b>Fig. 1</b>), naturally group themselves into the carpus, comprising eight bones which make up the wrist and root of the hand, and the digits, each composed of its metacarpal and phalangeal segments (<b>Table 1</b>). The carpal bones are arranged in two rows, those in the more proximal row articulating with radius and ulna. Between the two is the intercarpal articulation. The bony conformation and ligamentous attachments are such as to prevent both lateral and dorsal volar translations but to allow participation in the major wrist motions (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Bones and articulations of the hand, including the interosseus muscles. A, volar view; B, dorsal view. For nomencla ture, see Tables 1 and 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. Bones and Joints of the Hand and Wrist </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Angles of rotation about the wrist. A, extension (or dorsiflexion); B, flexion (or volar flexion); C, radial flexion; D, ulnar flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In each of the digits, the anatomical design is essentially the same, with exceptions in the thumb. Metacarpals II through V articulate so closely with the adjacent carpal bones of the distal row that, although they are capable of some flexion and extension, independence of motion is very limited. The metacarpal shafts are arched to form the palm, and the distal ends are almost hemispherical to receive the concave curvature of the proximal ends of the first phalanges.</p> <p>The metacarpophalangeal joint exhibits a pattern seen also in the interphalangeal joints. As shown schematically in (<b>Fig. 3</b>), the virtual center of rotation lies approximately at the center of curvature of the distal end of the proximal member. The lateral aspects of the joint surfaces are narrowed and closely bound with ligaments, so that lateral rotation is small in the metacarpophalangeal joints and lacking entirely in the phalangeal articulations. Hence, the latter are typical hinge joints. The thumb differs from the other digits first in that the second phalanx is missing and, second, in that there is greater mobility in the carpometacarpal articulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Section through radius, lunate, capitate, and the bony structure of digit III, showing virtual centers of rotation of each segment upon the next more proximal one. When the fist is clenched, the prominence of the knuckles is formed by the head of the more proximal member of each articulation. For nomenclature, see Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Muscles and Tendons</h4> <p>Most of the muscles of hand and wrist (<b>Table 2</b>) lie in the forearm and, narrowing into tendons, traverse the wrist to reach insertions in the bony or ligamentous components of the hand. Generally, the flexors (<b>Fig. 4</b>) arise from the medial epicondyle of the humerus, or from adjacent and volar aspects of the radius and ulna, and then course down the inside of the forearm. They are, therefore, in part supinators of the forearm (<b>Fig. 5</b>).The extensors (<b>Fig. 6</b>) of wrist and digits originate from the lateral epicondyle and parts of the ulna, pass down the dorsal side of the forearm, and thus assist in pronation. The thumb shares in the general flexor extensor scheme, but its extensors and abductors originate from mid and distal parts of radius and ulna.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Flexors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Forearm design as related to hand mobility. By virtue of this arrangement, the hand can be rotated through 180 deg., palm up to palm down, with the elbow flexed. With the arm fully extended, participation of shoulder and elbow allows the hand to be rotated through almost 360 deg., palm up to palm up. U, ulna; R, radius; P, pronation; S, supination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Extensors of wrist and digits. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tendons of wrist and hand pass through bony and ligamentous guide systems, as shown schematically in (<b>Fig. 7</b>). Flexor tendons pass through a "tunnel" bounded dorsally by carpal bones, laterally by the greater multangular and the projection of the hamate, and volarly by the tough transverse carpal ligament. Similarly, the dorsal carpal ligament guides the extensor tendons, and a system of sheaths serves as a guide for flexor and extensor tendons through the metacarpal and phalangeal regions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The anatomy of prehension. Schematic sections through digits I and III show essential relations of muscles and bones. The letters LG indicate the presence of ligamentous guides which channel close to the wrist the tendons of muscles originating in the forearm. Guide line X—X indicates relative position of carpal bases of thumb and fingers. For rest of nomenclature, see Tables 1 and 2. From Taylor.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The intrinsic muscles of the hand, <i>i.e., </i>those with both origin and insertion confined to wrist and hand (<b>Fig. 8</b>), are, with the exception of the abductors of thumb and little finger, specialized for the adduction of the digits and for opposition patterns such as making a fist, spherical grasp, and so on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Volar intrinsic muscles of the hand. For nomenclature, see Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Palmar and Digital Pads</h4> <p>The volar aspect of the palm and digits is covered with copious subcutaneous fat and a relatively thick skin so designed in a series of folds that it is capable of bending in prehension. The folds are disposed in such a way as to make for security of grasp, while the underlying fat furnishes padding for greater firmness in holding. Because, however, slipping of the skin over the subcutaneous fat would lead to insecure prehension, the folds are tightly bound down to the skeletal elements, much as mattresses and upholstered furniture are quilted or otherwise fastened to prevent slippage of the filler.</p> <p>In the hand, the volar skin is tied down by white fibrillar tissue connecting the sheaths of the flexor tendons to the deep layer of the dermis along the lateral and lower edges of the palmar fascia. The folds therefore vary with the relative lengths of the metacarpal bones and with the mutual relations of the sheaths of the tendons and the edge of the palmar fascia.</p> <p>The sulci, or furrows, are emphasized because the subcutaneous fat in any given area is restricted to the interval between the lines along which the skin is tied down. Thus pressure upon any individual montic ulus cannot displace the underlying soft tissue beyond the boundaries established by the fibrillar connections. The relative size of any particular eminence is an indication of the size of the muscle involved and of its relative development through usage, with the exception that the size of the hy pothenar eminence depends in part upon the prominence of the pisiform.</p> <h4>The Dorsal Integument</h4> <p>Unlike the volar surface, the dorsal side of the hand is covered with thin, soft, pliable skin and equally mobile subcutaneous tissue, both capable of yielding easily under tension. Because in flexion of the fingers and in making a fist the covering on the back of the hand must be able to stretch from wrist to fingernails, the dorsal skin is arranged in numerous minute redundancies, which, in the fiat of hand, are manifest in the typical transverse wrinkles, particularly over the phalangeal articulations. Special adaptations in the dorsal skin of the thumb accommodate the distinctive rotational planes of that digit about its carpometacarpal articulation. In the normal, healthy hand, the degree of redundancy in any given area is just such that all wrinkles are dispatched when the fist is clenched. Swelling in any area, dorsal or volar, inhibits flexion extension of the part affected.</p> <h4>Nerve and Blood Supply</h4> <p>Three principal nerves serve the muscles of the hand (<b>Fig. 9</b>). Nerve supply is indicated, except for minor variations and exceptions, in (<b>Table 3</b>). Each of these major nerve trunks diverges into countless smaller branches ending in the papillae of the palmar pads and dorsal skin, and the whole neuromuscular system is so coordinated in the brain that motor response to stimuli is ordinarily subconscious and reflex. Thus an object slipping from the grasp is automatically gripped more firmly, but not so firmly as to damage the hand itself. Noxious stimuli are rejected automatically, as when the fingers are withdrawn from an object uncomfortably hot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nerves supplying the hand. Top to bottom, ulnar nerve, median nerve, radial nerve. See Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The wrist and hand receive their blood supply from the radial and ulnar arteries, which run parallel with the bones concerned, enter the hand through the flexor "tunnel," and then join through a double arch system (<b>Fig. 10</b>). Small branches from the arches serve the digits. The major venous system comprises the basilic and cephalic veins superficially placed on the volar surface of the forearm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Blood supply to the upper extremity. A, above, medial view of the elbow. A, bottom, dorsal veins of the hand. B, superficial veins of the arm. C, arteries of the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Resting Hand Pattern</h3> <p>The resting hand assumes a characteristic posture, a feature easily seen when the hand hangs loosely at the side. The resting wrist takes a mid position in which, with respect to the extended forearm axis, it is dorsiflexed 35 deg. (<b>Fig. 11</b>). It is worth noting that this is the position of greatest prehensile force (<b>Fig. 12</b>, bottom). The mid position for radial or ulnar flexion appears to be such that the metacarpophalangeal joint center of digit III lies in the extended sagittal plane of the wrist (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The resting hand pattern. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12 Effect of forearm-hand angle upon wrist flexion and extension forces and upon prehension forces. Above, relationship between forearm-hand angle and maximum forces of wrist flexion and extension measured at the carpometacarpal joint. Heavy lines, flexion (volar flexion); light lines, extension (dorsal flexion). Solid lines, averages; dotted lines, standard deviations. Unpublished data, UCLA, 15 male subjects. Below, relationship between forearm-hand angle and maximum prehension force measured between thumb and opposing index and middle fingers grasping a 1/2-inch block. Right hand, eight normal male subjects. Solid line, average; dotted lines, standard deviations From a UC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Typically, the conformation of fingers and thumb is similar to that shown for palmar prehension (<b>Fig. 13</b>), the fingers being more and more flexed from index to little finger. The relations between thumb, palm, and fingers are such as to permit grasp of a 1.75 in. cylinder crossing the palm at about 45 deg. to the radioulnar axis. Bunnell<a></a> considers this "an ancestral position ready for grasping limbs, weapons, or other creatures."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Six basic types of prehension, as defined by Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fixed Hand Adaptations</h3> <p>In thrusting or striking actions and the like, the hand may assume fixed and rigid postures while functioning with the arm in support. These represent nonspecialized functions in which the hand serves merely as an adapted "end of the arm." The various forms include the flat of hand, the clenched fist, the knuckle and digital support postures, and so on.</p> <h3>Wrist Mechanics</h3> <p>The wrist joint, composed of the radiocarpal and intercarpal articulations (<b>Fig. 1</b>), has an elliptical rotation field with the major axis in the dorsal volar excursion, the minor in the ulnar radial. No significant torsion occurs. Bunnell<a></a> gives the angular excursions about the radiocarpal and intercarpal articulation as shown in (<b>Table 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. Angular Extent of Wrist Flexions" </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rotation within the carpal bones during these movements is too complicated for brief treatment. Not only do the rotations occur at several articulating surfaces, but the virtual axes of rotation lie distal to the contact surfaces owing to gliding motions in the convex concave structure of the joints. Idealization of the motions into those of a simple lever, rotating about a fixed center, as implied in diagrams such as <b>Fig. 2</b>, can be justified only as a convenient approximation.</p> <p>The muscles traversing the wrist include those inserting into the carpus and metacarpus and those mediating flexion and extension of the phalanges. The latter contribute to the wrist action, particularly under loads. In such cases, the finger muscles develop reaction against the object held (or within the hand itself if the fist is clenched) and add their forces to wrist action. The forces, action, and grouping of these muscles are given in <b>Table 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. <br /> ^a From Fick. <a></a> <br /> ^b The palmaris longus, absent in about 15 percent of cases, is omitted from the summed Fick forces of volar flexion.<br /> ^c Averages from measurements of maximum forces normal to the hand, applied at the metacarpophalangeal joint, on 15 young males at the University of California at Los Angeles (unpublished data). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prehension Patterns</h3> <p>It is evident equally from a study of the muscle bone joint anatomy and from observation of the postures and motions of the hand that an infinite variety of prehension patterns is possible. For purposes of analysis, however, it suffices to describe the principal types. Seeking a logical basis for defining the major prehension patterns, Keller et al.<a></a> found that the object contact pattern furnishes a satisfactory basis for classification. From &gt;photographic observation of the prehension patterns naturally assumed by individuals when (a) picking up and <i>(b) </i>holding for use common objects used in everyday life, three types were selected from among those originally classified by Schlesinger.<a></a> These, appearing in (<b>Fig. 13</b>), are palmar, tip, and lateral prehension, respectively. The frequency with which each of these types occurred in the investigation cited is given in (<b>Table 6</b>). While the relative percentages differ in the two types of action, the order of frequency with which the prehension patterns occurred is the same.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. Frequency or Prehension Patterns </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Mechanical Anatomical Basis or Prehension Patterns</h3> <p>It is convenient to analyze digital mechanics in terms of flexion extension variations in the digits, thumb postures, and variations in the radioulnar axis.</p> <h4>Individuation of Digital Flexion Extension</h4> <p>Insertion of flexor and extensor muscle systems into several major segments along the proximal distal axis provides a variety of flexion extension patterns in the digits. In <b>Fig. 7</b>, the essential components are shown schematically for digits I and III. With these attachments, fixation of carpal and metacarpal segments by cocontraction of flexor and extensor carpi muscles provides a firm base for independent movements and fixations of the phalangeal segments. Individual flexions of the second and terminal phalanges stem from separate flexor muscle (<b>Fig. 13</b>). The counterbalancing digital extensor inserts into the two most distal phalanges and, on contraction, rigidly extends the entire finger. Coordinated action between extensor and flexor groups, however, permits fixed intermediate positions of each segment of the system.</p> <p>Two common postures of this system may be pictured. In palmar prehension (<b>Fig. 13</b>), the carpal and metacarpal segments commonly fix the wrist in moderate extension, while the digital configuration, mostly metacarpophalangeal flexion coupled with only slight phalangeal flexion, indicates action of the long flexors, strongly modified by the lumbricals and interossei, which are in position not only to contribute to the metacarpophalangeal flexion but also to maintain the phalangeal xtension. In tip prehension, the action of muscles upon carpal and metacarpal bones is similar, but distributed flexion in all phalangeal segments indicates predominant flexor activity.</p> <h4>Thumb Versatility Patterns</h4> <p>The versatility of the thumb lies, first, in the variety of its flexion extension patterns and, second, in the adjustable, rotatory plane in which flexion extension can take place. The first of these is directly analogous to the digital system for the other four fingers, in that for any given metacarpal position there are numerous possible positions of the phalanges. The second effect is due to the relative mobility of the carpometacarpal joint, which allows the thumb to act in any plane necessary to oppose the digits. The principal oppositions are semidirect, as seen in palmar, tip, and spherical prehensions. Actually, in these cases the plane of the thumb action is inclined 45 to 60 deg. to the palmar plane. In lateral prehension, the plane is approximately parallel to the palmar plane.</p> <h4>Variations in the Radioulnar Axis of the Hand</h4> <p>A third principal mode of variation concerns cross hand alignments. Thus the metacarpophalangeal joints may be drawn into line, and with abducted thumb a flat hand position is assumed. At the other extreme, the hand is cupped for spherical prehension (<b>Fig. 13</b>) as the opponens muscles of thumb and little finger, aided by other adductors and flexors, act to pull these digits toward each other. Similar alignment occurs when a fist is made.</p> <h3>Hand Movements</h3> <p>The large number of muscles and joints of the hand obviously provides the equipment for numerous and varied patterns of movement. Not so evident, but equally important in determining complexity and dexterity of motion, are the large areas of the cerebral cortex given over to the coordination of motion and sensation in the hand. Thus, in the motor cortex the area devoted to the hands approximately equals the total area devoted to arms, trunk, and legs.<a></a> This circumstance ensures great potentiality for coordinated movement and for learning new activities. Similarly, the sensory areas are large, so that they determine such advanced functions as stereognosis, the ability to recognize the shape of an object simply by holding it in the hand. The great tactile sensitivity of the hand is, of course, in large part due to the rich supply of sense organs in the hand surface itself. The threshold for touch in the finger tip, for example, is 2 gm. per sq. mm., as compared to <i>33 </i>and 26 for the forearm and abdomen respectively.<a></a></p> <p>The three major types of movement described by Stetson and McDill<a></a> are in part represented in the hand. They include fixation movements including cocontractions; movements ranging from slow to rapid with control of direction, intensity, and rate; and ballistic movements.</p> <h4>Fixation Movements</h4> <p>In all of the types of prehension described, the hand assumes a fixed position. If the prehended object is unyielding, reactions to the flexion forces are afforded by the object. If the object is fragile, or the hand empty, the hand is maintained in any required prehensile posture by cocontractions of the opposing muscle groups.<a style="text-decoration:none;">*</a></p> <p>The characteristics of balanced muscular action when supporting in the hand loads which produce moments at the wrist have been studied electromyographically by Dempster and Finerty.<a></a> In general, when average potential amplitudes are used to characterize the electrical activity of the muscle, the curves of load action potential are linear. Frequencies range from 35 to 65 per sec. but bear no clear cut relationship to load. Typically, each of the muscles traversing the wrist was found to function as agonist, lateral stabilizer, or antagonist as the moment load was shifted from direct opposition at zero deg. to the 90 deg. and then to the 180 deg. positions. The magnitude of the action potentials associated with each of these roles is approximately in the order 4:2:1.</p> <h4>Slow and Rapid Movements</h4> <p>In movements ranging from slow to rapid, with control of direction, intensity, and rate, there is always some degree of cocontraction to ensure control and to permit changes in force and velocity. A net force in the muscles causes motion. In this category is a long list of activities, such as writing, sewing, tying knots, and pressing the keys of musical instruments. Included are most actions involving differential or integrated motions of the digits.</p> <p>It is of interest to note that the full capacity for these motions is seldom developed by the average individual. With intensive practice, significant increases in the facility of manipulation, even with simple operations, may be achieved, although individuals differ markedly in the amount of training gain. The average individual has latent potential for development of skill, as shown by the feats of manipulation occasionally evidenced. Knot tying, cigarette rolling, and similar complex manipulations may be performed with one hand, as often demonstrated by accomplished unilateral arm amputees. According to Tiffin<a></a>, dexterity differences are correlated neither with mental ability nor with hand shape or dimensions, but Cox<a></a> points out that they have an important effect on the performance of industrial assembly operations.</p> <h4>Ballistic Movements</h4> <p>Ballistic movements are rapid motions, usually repetitive, in which active muscular contractions begin the movement, giving momentum to the member, but cease or diminish their activity throughout the latter part of the motion. It is unlikely that, of themselves, the fingers utilize this type of motion to any marked degree. Barnes<a></a> reviews evidence that in repetitive work finger motions are more fatiguing, less accurate, and slower than are motions of the forearm. Consequently, in repetitive finger activities in which there is a ballistic element, such as piano playing, typing, and operating a telegraph key, wrist and elbow motions predominate while the fingers merely position themselves to strike the proper key.</p> <h3>Hand Dynamics</h3> <p>The hand muscles, their actions, and contractile forces are given in (<b>Table 5</b>) taken from Fick.<a></a> The total Fick force equals the sum mated forces of the individual muscles participating in the action. For each muscle the force is equal to the physiological cross section <i>(i.e., </i>the total cross section of the muscle taken normal to its fibers) multiplied by the force factor of 10 kg. per sq. cm., estimated by Fick to hold for human muscle. These forces are produced along the axis of the muscle and its tendon, but since the effective moment arm upon any of the wrist or hand joints is small, the <i>measured </i>isometric forces are only about 10 percent of the total force.</p> <p>Among the wrist actions, total forces and measured isometric forces assume the same rank order. The variation,. with wrist angle, of both flexor extensor forces in the wrist and of prehensile forces in the hand is of practical importance as well as theoretical interest. The prehensile force reaches a maximum at a wrist angle of about 145 deg. (<b>Fig. 12</b>, bottom). This is approximately the angle at which the maximum forces of wrist flexion and extension occur (<b>Fig. 12</b>, top). It is common experience that the wrist assumes this angle when very strong prehension is required. The lessened forces at wrist angles toward the extreme positions of flexion or extension are attributable to the well known force reductions in the isometric length tension curve as a muscle is markedly stretched or slackened.<a></a> The exception to this rule, seen in the augmented force of flexion at wrist angle 85 deg., apparently means that this degree of wrist extension does not stretch the flexor muscles beyond their force maximum.</p> <h3>Conclusion</h3> <p>This, briefly, constitutes the anatomical basis of hand mechanics, from which it can be seen that normal hand function is the result not only of a highly complex and versatile structural arrangement but also of an equally elaborate and fully automatic system of controls. As will be seen later (page 78), such considerations lay down the principal requirements and limiting factors in the design of reasonably successful hand substitutes. When, in the normal hand, any functional feature, either mechanical or sensory motor, is impaired, manipulative characteristics are reduced correspondingly. In the arm amputee, hand structural elements have been wholly lost, and the most delicate neuromuscular features, those in the hand itself, have been destroyed. Although the lost bone and joint mechanism can be simulated, adequate replacement of the control system defies present ingenuity. Lacking control comparable to that in the natural hand, present day artificial hands are necessarily limited in the mechanical details that can be utilized, which accounts for the fact that the regain in function currently possible in hand prostheses falls far short of duplicating the natural mechanism.</p> <h3>Acknowledgment</h3> <p>The anatomical drawings which accompany this article are the work of John Cassone, medical illustrator at the University of California, Los Angeles.</p> <p><b>References:</b></p> <ol> <li>Barnes, R. M., <i>Motion and time study</i>, Wiley, New York, 1937.</li> <li>Best, C. H., and N. B. Taylor, <i>Physiological basis of medical practice</i>, Williams and Wilkins, Baltimore, 1937. p. 1256.</li> <li>Best and Taylor, op. cit., p. 1418.</li> <li>Bunnell, Sterling, <i>Surgery of the hand</i>, Lippincott, Philadelphia, 1944.</li> <li>Cox, J. W., <i>Manual skill</i>, Cambridge University Press, 1934.</li> <li>Dempster, W. T., and J. C. Finerty, <i>Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study</i>, Am. J. Physiol., 150:596 (1947).</li> <li>Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke<i></i>, Dritter Teil, G. Fischer, Jena, 1911.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle</i>, Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Keller, A. D., C. L. Taylor, and V. Zahm, <i>Studies to determine the functional requirements for hand and arm prosthesis</i>, Department of Engineering, University of California at Los Angeles, 1947.</li> <li>Schlesinger, G., <i>Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen</i>, Springer, Berlin, 1919.</li> <li>Stetson, R. H, and J. A. McDill, <i>Mechanism of different types of movement</i>, Psych. Mono., 32(3): 18 (1923).</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Tiffin, Joseph, <i>Industrial psychology</i>, Prentice-Hall, New York, 1947.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs</i>, 1947. Vol. II.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barnes, R. M., Motion and time study, Wiley, New York, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cox, J. W., Manual skill, Cambridge University Press, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Tiffin, Joseph, Industrial psychology, Prentice-Hall, New York, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Dempster, W. T., and J. C. Finerty, Relative activity of wrist moving muscles in static support of the wrist joint; an electromyographic study, Am. J. Physiol., 150:596 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">There are many other examples of fixation stales, such as the open claw conformation of the fingers and the extended and rigid index finger for dialing a telephone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Stetson, R. H, and J. A. McDill, Mechanism of different types of movement, Psych. Mono., 32(3): 18 (1923).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Best, C. H., and N. B. Taylor, Physiological basis of medical practice, Williams and Wilkins, Baltimore, 1937. p. 1256.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Best and Taylor, op. cit., p. 1418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Predominance of palmar prehension in both activities accounts for adoption of this pattern in the design of modern artificial hands (page 86).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Keller, A. D., C. L. Taylor, and V. Zahm, Studies to determine the functional requirements for hand and arm prosthesis, Department of Engineering, University of California at Los Angeles, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fick, Rudolf, Handbuch der Anatomic und Mechanik der Gelenke, Dritter Teil, G. Fischer, Jena, 1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Schlesinger, G., Der mechanische Aufbau der kunstlichen Glieder in Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, Lippincott, Philadelphia, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Vol. II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Schwarz, M.D </b></td></tr><tr><td class="clsTextSmall">Instructor in Otolaryngology, College of Medical Evangelists, Los Angeles; formerly Assistant in Engineering Research, University of California, l.os Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Craig L Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_022/table01.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_022/table02.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-17.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-20.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-21.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-22.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-24.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_022/table03.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-27.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-29.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_02_022/1955-MayOCRBatch-30.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_02_022/table04.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_02_022/table05.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_02_022/table06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anatomy and Mechanics of the Human Hand Creator An entity primarily responsible for making the resource Craig L Taylor, Ph.D. * Robert J. Schwarz, M.D * https://staging.drfop.org/files/original/e35faf467e1ea9e763ac08ddcf0dbfd3.pdf 1f9fe1e89568efceb15d185fd6f39011 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_001.pdf Year 1955 Volume 2 Issue 3 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/1955_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_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>Harnessing- Here and Hereafter</h2> <h5>John Lyman, PhD <a style="text-decoration:none;">*</a><br /></h5> <p>However well designed the other parts of an artificial arm may be, the functional success of the upper-extremity prosthesis must ultimately depend upon the adequacy of the coupling between the human being and the inanimate mechanism. Since this man-machine linkage is intended to hold the arm on the stump and to secure from residual body sources the mechanical power necessary for operation and control of the prosthesis, the technique of constructing it has come to be known simply as "harnessing." Because body harness is such ah intimate piece of apparel, and because arm amputees exhibit the same kinds of individual differences as characterize the rest of the population, it seems likely that proper harnessing will long remain a tribute to the personal skill of the prosthetist, despite all advances in prefabricated components. Although the clinic team may prescribe the specifications for a prosthesis within the existing framework of medical and engineering knowledge, the final result depends largely upon the prosthetist's talent for constructing and fitting the harness in such a way as to meet anatomical, physiological, and functional requirements.</p> <p>Functionally, the harness may serve one or more of three purposes: it may hold the prosthesis in place; it may transmit power and excursion to produce force and movement in operating components; it may convey to the wearer the intelligence needed for arm control. In conventional construction of upper-extremity prostheses, it has been customary to rely upon the harness for the performance of all three of these services and, further, to obtain them all from a single harness system. Such an arrangement is of course grossly unlike that of the normal limb, where the control function, mediated by the nervous system, is clearly separated from the functions of suspension and of power transmission. Only in externally powered prostheses, as for examples the TBM Electric Arm and the Vaduz hand, has an attempt been made to separate the control function from the power and suspensory functions. Although to date such devices have not proved to be as useful or reliable as simpler ones, they are representative of an approach which may, in the long run, lead to far more refined limb substitutes than can be contemplated by further development of a harnessing philosophy which stresses the combining of suspension, power transmission, and control.</p> <p>The use of body power for operating an artificial arm forms an inherent control link between the neuromuscular system and the prosthesis. To the extent that a "closed loop" is effected via the sensory feedback available to the power-producing muscles, control of force and excursion through the power-transmission system is possible without the aid of external sensory-feedback loops such as vision and hearing. While the latter cues are generally present, they can at best serve only in an auxiliary capacity. The rich sensations of touch, pressure, pain, and temperature, which have been lost with the natural limb, have no substitute beyond their dim reflection in the signals from harness strap or cineplasty muscle pin of present-day prosthetics technology.</p> <p>One can argue, with considerable sustaining evidence, that the modern arm prosthesis is quite functionally adequate in most respects and that the addition of refinements in the form of further sensory cues for improved control would only complicate harnessing unnecessarily. But to take this viewpoint is paying tribute to the adaptability of the human mechanism rather than to the adequacy of today's prosthetics research and development. As facts currently stand, it appears that no clear-cut assessment has been made of the importance of sensory losses to the amputee. The effort has been to achieve prosthetic replacement of motor function, and it still is not generally recognized that this goal has been approached with the present degree of success only because sensory control loops are established incidentally in the course of harnessing for power transmission. The major inadequacies leading to failure in externally powered prostheses can be traced directly to shortcomings in the design of control loops-loops which are intrinsic even in the crudest of body-powered prostheses.</p> <p>Since in the present state of the art the optimum connection between the amputee and the operating mechanism is still so indispensable to the proper functioning of the upper-extremity prosthesis, this issue of Artificial Limbs is devoted to a summary of current harnessing technology as developed under the auspices of the Advisory Committee on Artificial Limbs. Although progress in the improvement of body harness has been substantial since World War II, even the latest techniques fall far short of duplicating the neuromuscular mechanism of the normal arm. And consequently there is still a great deal of forward-looking to be done in the research, development, and production phases of upper-extremity prosthetics.</p> <p>Where will the technology come from that may make possible "sensory prostheses" with attendant refinements in the present "motor prostheses"? Probably not directly from current trends in artificial-limb research. As is common knowledge, a very real and dynamic revolution is under way in the modern engineering sciences. It is accompanied by a plethora of popular terms like"cybernetics," "servomechanisms," "information theory," "digital and analogue computers," and "automation," to name a few. From the developments that are taking place, many new materials and processes are becoming available. Just as the aircraft industry, through the Northrop design studies, has contributed the present lightweight plastic artificial arm and the Bowden-cable transmission system, so it may be anticipated that within a relatively few years the electronics and missile industries may make even greater contributions. Compact, reliable, and lightweight items like the famed transistor may become as commonplace in the control systems for artificial arms as is presently the case in hearing aids. New products from metallurgy and chemistry may eventually make it possible to realize direct attachment of prosthetic devices to remaining skeletal members of the body through the skin and surrounding tissue, with consequent elimination of the socket and of the suspensory elements of harness. Much of the theory and much of the methodology for accomplishing the direct coupling of man to mechanism, including the all-important link to the nervous system for control, are either available already or else are promised within the foreseeable future.</p> <p>Because in the field of amputee rehabilitation there are never apt to be available the amounts of research money now characteristic of other fields of science and invention, it is fortunate that a systematic plan for the advancement of limb prosthetics has become so well established in the decade since World War II. The Artificial Limb Program furnishes an organized means of following progress in other areas and of adapting to limb substitutes new approaches and new techniques that would otherwise lie far beyond the purse of prosthetics research itself. The future in design of limb replacements is thus perhaps now greater than ever before. Even so, no matter how sophisticated upper-extremity prostheses may become, the actual utility of any given artificial arm will continue to reside largely in the degree to which the fitter can attain the optimum sensory-motor association through accomplished harnessmaking. In no other known way can so much satisfaction be afforded the individual arm amputee.</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>John Lyman, PhD </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, University of California, Los Angeles.</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 Harnessing- Here and Hereafter Creator An entity primarily responsible for making the resource John Lyman, PhD * https://staging.drfop.org/files/original/704be8285e9e81b00a548f4079273dd0.pdf 8d139ddf679c176348350d328a543afd https://staging.drfop.org/files/original/49cf18e648ecc82d654ec1eff2291631.jpg c1cfed36a05f0a2fc50153fd5c760913 https://staging.drfop.org/files/original/75674097e4e35c77fdec5a976ff86d62.jpg 9f31ccdf0294986d2aea9d550887f50f https://staging.drfop.org/files/original/6e8abc5344c8c89a34bb7bb7e58e2657.jpg 6093fff8491a17af6fc0bb951f2df011 https://staging.drfop.org/files/original/37d0211a1c3964d660b5475199ef272d.jpg e15ab0ecdc3c30f04f9a0f88d1e7f911 https://staging.drfop.org/files/original/074ff2c61033b2276ba9ba6b32d533dc.jpg 18833eb4185b3218e31d0f5a35889396 https://staging.drfop.org/files/original/25f6feb898b3105da3d22efedaad8b5f.jpg 14cd923437e363674f1305376f929c93 https://staging.drfop.org/files/original/98c6f90be1d6a610b1532fee234863eb.jpg 77448c6435f7e839884d481f8bb7c0bc https://staging.drfop.org/files/original/bf8014ecf9aef0436238851fa1474e8e.jpg a485adc4c47126a56ef395422b794cc0 https://staging.drfop.org/files/original/a3f8fed82c099bfaf63d22effee25dc9.jpg 3aafbd4368cc3968a6ed5d0bf3d576af https://staging.drfop.org/files/original/63989f61bdf02ae37100a3e5d28a3065.jpg 3b2ff7b083f358ef57a6a637a5333dc6 https://staging.drfop.org/files/original/6a514f0e2ba1bfd9ba93437672e576c3.jpg 17049ac032017d5b129e9629dd56a9f4 https://staging.drfop.org/files/original/dd2a27378293b40a365d988be7038823.jpg 487fe803ef2ffdf12201d3e066227729 https://staging.drfop.org/files/original/79421da1d5927a2f575339efaaae587a.jpg 7727b475ea61106ccba34b7e0a8fea80 https://staging.drfop.org/files/original/85780afcefa210b16b3180eb1a8a32c7.jpg 0929c4e5349737a970d707389cc7e591 https://staging.drfop.org/files/original/80b1690efe4254fee0a6b928f0221b73.jpg b35fcbb513359778fadce4c9655b88ac https://staging.drfop.org/files/original/a7b48775e41332452941b1805803de4f.jpg 2d1f4f535f9b9df473d2a83b9a61d6db https://staging.drfop.org/files/original/354cad5e63e3f2ee432a2a43b8af480f.jpg f54280fbcdcd946cade07b9a0e67cf76 https://staging.drfop.org/files/original/8932dd244d2f177f348642bab3474157.jpg a9162486c8f3c0b05d8e402bb14cb9cc https://staging.drfop.org/files/original/172fcac01d1f6b60da95c9da079d9b0c.jpg 29f465e6e6425c776b16326e64e5ec8a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_004.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 4 - 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/1955_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_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 Lower-Extremity Clinical Study-Its Background and Objectives</h2> <h5>VerneT. Inman, M.D., Ph.D., <a style="text-decoration:none;">*</a><br />Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p> If it may be postulated correctly that the most satisfactory artificial leg is the one which most nearly simulates the static and dynamic behavior of the natural limb it replaces, the successful practice of lower-extremity prosthetics poses a twofold requirement. The first is an intimate and detailed knowledge of the characteristics of the normal leg in all common activities, and the second is the ability to reproduce as nearly as possible, by a combination of design and fit of the substitute limb, the kinetic and kinematic features essential to normal locomotion. In the Artificial Limb Program, principal responsibility for fundamental studies in normal and amputee gait and in lower-extremity prosthetics has, since 1945, resided in the Prosthetic Devices Research Project at the University of California, Berkeley Campus. </p> <p> But the problems facing the leg amputee are not wholly prosthetic. Many, indeed, are clearly medical. For the amputee, being no longer the whole normal individual, manifests gross structural and physiological changes to be dealt with successfully only by the physician. </p> <p> The Lower-Extremity Clinical Study being conducted jointly by the Department of Engineering, University of California, Berkeley, and the University of California Medical School, San Francisco, and in cooperation with the U. S. Naval Hospital, Oakland, has as its chief objectives the analysis of medical problems inherent in the amputated state and the application of fundamental knowledge to practical problems in the management of lower-extremity amputees. Current techniques and practices in the fitting of leg amputees still are so varied from place to place and from prosthetist to prosthetist that some orderly means has been wanting for establishing what is, everything considered, the best prosthetics practice in the lower extremity. Designed to close the gap between basic work in the laboratory and work in the field, the Clinical Study is an outgrowth of the fundamental research in locomotion conducted earlier by the Berkeley Project. </p> <h3>The Background </h3> <p> For a number of years during World War II a group at the University had been conducting research in the field of biomechanics and had published data relating to the behavior of the upper extremity. In the autumn of 1945, therefore, the University was approached by a representative of Northrop Aircraft, Inc., a company which at that time was already engaged in prosthetics research<a></a> under contract with the then Committee on Artificial Limbs of the National Academy of Sciences- National Research Council. It was requested that the University group undertake an investigation aimed at providing information that could be utilized in the design and construction of lower-extremity prostheses. </p> <p>The suggestion having been taken under advisement, the entire Committee on Artificial Limbs met at the University shortly thereafter to consider the proposal and to evolve details of contractual arrangement. Out of this meeting came two basic observations. One was that, inasmuch as the financial support for the work was to come from public funds, any information derived from the contract would have to be shared with all other contractors participating in the Artificial Limb Program as well as with the general public. The other was that, in the opinion of the conferees, between five and seven years of study would be required before sufficient detailed and quantitative information could be accumulated to effect substantial improvement in lower-extremity prostheses.<a></a> At the outset, the University group insisted that it be kept free of the task of developing prosthetic devices-that it simply be permitted to investigate normal human locomotion and to furnish the collected data for others to use. The original concept of the scope of the project-as a program of basic research in human locomotion-has been adhered to up to the present time, the only deviations having involved development of experimental devices<a></a> needed to assist in the locomotion studies. </p> <p> The early years, then, were spent in working out techniques suitable for recording objectively the motions and the forces involved in the gait of man.<a></a> Of course, the investigators took advantage of all the previous work in this field, not only that done by other contractors<a></a> participating in the Artificial Limb Program but also that contained in material, particularly that of Elftman<a></a> published in the United States and in foreign countries over a period of many years. By 1947, enough data had been accumulated to publish a comprehensive report<a></a> on the walking pattern of normals and of leg amputees.<a style="text-decoration:none;">*</a> </p> <p> Attempts to translate the results of basic research into criteria for the improvement of prosthetic devices led to the second phase of the project, that is, to developmental research, an area that involves engineering and prosthetics technology. During the last few years, this phase of the project has been conducted on a relatively small scale. As devices were prepared for trials by amputees, the problem of fit and alignment had to be attacked, and hence fundamental studies were undertaken in this area in order to establish a set of basic principles and techniques.<a></a> Because fitting and alignment contribute most to the comfort and therefore to the success of any artificial leg, the validation of these principles and techniques formed the basis for embarking on the third phase of the project, the Lower-Extremity Clinical Study, an activity that provides a laboratory where medical and prosthetic problems can be handled under controlled conditions. It offers an opportunity to see how individual solutions may be obtained by applying a set of general principles based on biomechanical considerations. Until recently, the study group has been concentrating on the problems of the above-knee amputee because that case appeared to offer neither the most difficult nor simplest set of circumstances. </p> <h4> The Locomotion Studies </h4> <h5> <i>Muscle Physiology</i> </h5> <p> When the Prosthetic Devices Research Project first was organized, man was viewed as a machine, the object being to measure the displacements, accelerations, and forces required in human locomotion.<a></a> But man is more than a single machine. He is powered by a complicated system of many internal engines served by muscles. Accordingly, the study was broadened to include the field of muscle physiology.<a></a> Investigation of the behavior of the musculature during normal locomotion (<b>Fig. 1</b>) revealed the basic action of the various muscles involved<a></a> It was shown that in locomotion each muscle acts when it is near its rest length but that it acts for a very short period of time in each walking cycle.<a></a> This action makes the contraction essentially isometric and limits the activity of each muscle fiber to a few twitches. Under these conditions the muscle works with minimal energy and maximum tension, which helps to explain why a person can walk considerable distances without tiring. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical electromyographic summary curves, in this case for the hamstring group. Ten subjects. Cadence: 95 steps per minute, level walking. Data from UC studies 102. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon working out the speed of contraction, it was found that, if muscles are halved, their contractile velocities likewise are halved (<b>Fig. 2</b>). Utilizing a profile electromyographic recording (electromyogram rectified and dampened to give a relatively smooth line), and taking the maximum amplitude in a given cycle as 100 percent, the average durations with an amplitude greater than 75, 50, or 25 percent are approximately 0.04, 0.1, and 0.2 second, respectively.<a></a> Since it seems probable that the profile electromyographic amplitude largely indicates relative numbers of active motor units, it would appear that most of the units participating in this phasic action are active during bursts of 0.1 to 0.2 second only. According to Weddell<a></a>, at a repetition rate of 20 per second or less most motor units would fire in each cycle one to four times only. In such a case, any temporal summation taking place at neuromuscular junctions would not be effective fully, and the action of a motor unit, at least in a normal phasic pattern like locomotion, would not have the character of a sustained tetanus. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Relation between the maximum speed with which a muscle can contract and the weight with which it is loaded. When the length of the muscle is halved, its speed of contraction is also halved. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As a result of these investigations, in 1947 the group at Berkeley, noting the earlier work of Blix<a></a>, was first to call attention to the length-tension relationships existing in human muscles<a></a> and thus laid the basis for the decision to use certain muscles for the cineplastic technique.<a></a> The characteristics of the length-tension diagram have since proved to be of fundamental importance in devising prosthetic aids for upper-extremity amputees.<a></a> The cineplastic muscle tunnel, comprising a skin-lined tube placed through the distal end of a muscle, permits an amputee to utilize effectively his own muscle forces for activating an artificial arm or hand. But in order to operate a cineplastic prosthesis efficiently, it is necessary that the muscle be near its rest length, so that it can generate a force sufficiently large and so that it can shorten enough to carry out necessary movements.<a></a> Appearing in publications as early as 1949, the work conducted at the University of California has been recognized by Buchthal<a></a> of the University of Copenhagen as the best so far done on normal human muscle dynamics. </p> <h5> <i>Energy Requirements</i> </h5> <p> In another study, an investigation was made of the dissipation of energy (<b>Fig. 3</b>) in human locomotion.<a></a> Results showed that approximately 50 percent of the energy consumed in walking is used simply in bouncing up and down, that is, in vaulting over one leg and then the other. The other half is used in the oscillations of the legs. It is therefore apparent that, if the amputee is not to be subjected to unduly large energy demands, he must have a smooth pathway of displacement of the center of gravity of the body.<a></a> Any deviation from the smooth, natural locus of the center of gravity means excessive dissipation of energy and consequent degradation into heat.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 3. Typical moment-angle diagram for the leg of a normal subject during level walking. From Bressler [sic] and Berry (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Contrary to much popular belief, man not only pushes his way through space. He also <i>pulls </i>his way.<a></a> Indeed, deceleration of the swinging leg, not push-off from the other toe, provides the greater part of the energy for locomotion, the proportion attributable to deceleration of the swinging leg being about 4, that attributable to push-off only 3. Energy is absorbed by the knee to decelerate the leg and foot during the swing phase, but not all of the energy so absorbed is lost.<a></a> A considerable portion is stored and returned to the system in the later part of the swing phase to impart continued forward acceleration at the time when most of the body's potential energy is lost.<a></a> Thus locomotion is due not only to the push of the member in support but also to the pull of the deceleration in the swinging knee. </p> <p> Because the above-knee amputee has no calf group, and therefore cannot contribute the equivalent of this force at push-off, it was suggested that some conservation of energy might be effected in a prosthetic device without an ankle joint.<a></a> That this was a correct deduction has since been demonstrated (<b>Fig. 4</b>) in the Stewart-Vickers leg,<a></a> in which the ankle is locked at toe-off until 20 deg. of knee flexion has occurred.<a></a> It has the highest net output and the lowest total input of all legs tried to date (<b>Fig. 5</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Cadence changes observed in above-knee amputees asked to walk at "normal" speed first with a conventional limb and then with the Stewart-Vickers (locked ankle) prosthesis 114. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Energy characteristics of the normal ankle compared with those of the conventional leg and the Stewart-Vickers leg. Top, total input, total output, and net output of both ankles per stride. Bottom, input and output of each ankle per step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Amputee Pain </h4> <p> Intimate contact with amputees led to the early investigation of pain as related to the amputee patient.<a></a> In 1946 a team of interviewers set out to question amputees in various hospitals, particularly in the Veterans Administration Hospitals and in the Naval Hospital then at Mare Island. Over a period of a year and a half, detailed histories were obtained from 80 patients. As a result of this review, further funds were provided by ACAL to establish a Pain Clinic at the University of California, primarily to evaluate pain as found in the amputee. Established in August 1949, the clinic functioned until January 1953. </p> <p> In June 1952, an analysis of 218 amputees was reported.<a></a> In this study, which constitutes one of the largest series on record, the type and frequency of pain in the amputee were explored. Because it was thought that perhaps deficiencies in stump circulation might contribute to the pain experienced by the amputee, circulatory studies were undertaken. Concurrently, innervation of the deeper tissues was studied.<a></a> Sections of tissue were taken from periosteum, muscle, and skin, and the nerve supply to these tissues was demonstrated by a methylene blue technique. </p> <p> One of the most intriguing aspects of this investigation was the work with normal individuals in whom irritative lesions purposely were produced in the deeper tissues.<a></a> With the authors, some 75 medical students, and three laboratory assistants serving as subjects, 0.5 to 1.0 cc. of 6-percent saline solution was injected systematically into the paravertebral muscles at each intervertebral level from the atlanto-occipital area to the lower sacrum. Five subjects were used in the testing of each injection site, a total of 140 individual observations being made. Although the distribution of pain approximated a segmental plan, it also overlapped considerably and differed in location from the conventional dermatomes. It was found that, in any irritation of deep somatic tissues, pain did not restrict itself to the area of injection but tended to radiate distally into the extremities. Injection of 6-percent saline into any given interspinous level produced in the normal a characteristic pain distribution that was remarkably constant from subject to subject. The distribution of pain referral from deep structures in the normal suggested similar investigations in the amputee. To elicit the sensation of the phantom limb, it was necessary to inject the salt solution into the appropriate interspace. In the normal, radiation of pain into the lower limb was most marked when the interspinous tissue between L4 and L5 was affected, and in the above-knee amputee the L4-L5 interspace also gave the best response. The immediate reactions of amputees resembled those reported by normals-a rapid onset of pain close to the site of injection and then, in the case of L4-L5 injection, radiation into the buttocks and the posterolateral aspect of the thigh. In nearly all instances there occurred a rapid "filling" of the absent areas of the phantom limb, the subjects usually evidencing surprise at the sudden totality of a phantom limb even though the new portions were seldom, if ever, immediately painful. </p> <p> Severe pain was a frequent feature in the portion of the phantom present before injection. After injection the pain often spread into the newly "filled in" portion of the phantom limb. Transient pain following injection occurred in phantom limbs regardless of the existence of preinjection pain. But in many cases involving pre-existing phantom pain, a secondary decrease in the amount of pain followed the injection, in some but not in all instances the decrease being preceded by a transitory accentuation of the pre-existing pain. Occasionally, the decrease reached the point where no pain was felt, so that the amputee experienced the first complete relief in many months. </p> <p> The decrease in pain is even more remarkable when one considers that it is brought about by the application of a noxious stimulus to a tissue remote from the phantom itself. For example, in an above-knee amputee who had undergone amputation two months before the investigation, there was a phantom sensation of the "foot" only, the phantom being very painful with the sensation of severe constriction of the great "toe" (<b>Fig. 6</b>). When saline was injected into the L4-L5 interspace, much of the intervening phantom limb was filled in almost immediately, the anterior aspect of the "leg" becoming the most prominent part. Soon after the phantom was "completed," the preexisting pain in the "foot" increased in intensity and area. This state continued for five or six minutes, whereupon the pain began to decrease and continued to do so until, in another five minutes, it had disappeared completely. Numbness, but not pain, remained in the "foot" only. In some instances even phantom awareness disappeared after saline injection. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Effect of interspinous injection of saline on the painful phantom limb of one subject. A, Phantom before injection. B, Radiation of sensation induced by injection of 6-percent sodium chloride solution. C, Residual sensation following injection. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the saline injections had greater effects on phantom limbs than on real ones, a peculiar susceptibility best illustrated by the effects of mid-line injections. An accurately placed mid-line injection in a normal subject produces very little radiation, the severe pain being confined to a rather small area in the immediate vicinity of the injection. In the case of the amputee, however, such minimal radiation in the trunk is accompanied by profound effects on the phantom extremity. Every conceivable change in phantom form and phantom pain can result from interspinous injection of an irritating hypertonic saline solution, the changes probably stemming from the sudden increase in the sensory inflow at the particular segmental level. </p> <p> Out of these observations came, then, one method of treating phantom pain, for when a small amount of hypertonic saline was injected into the appropriate segmental interspinous ligament, the phantom experience was changed and pain occasionally was relieved. This finding led to the use of hypertonic saline for the treatment of various painful conditions. Although permanent cures resulting from such techniques are not numerous, the method may prove to be a valuable addition to the modern medicine chest, which is by no means rich in effective pain palliatives.<a></a> </p> <p> It deserves to be noted that, in seeking the origin of the phantom experience, one must look not only for direct involvement of the nerves of major nerve trunks. The entire segment of the extremity must be investigated for any irritative skeletal lesions arising from the joints, the muscles, or the connective tissues of the stump or from portions proximal to the stump. </p> <h3> Evolution of Basic Data </h3> <p> From the basic studies now has come much information of value in prosthetics. As early as 1947 it was determined<a></a> that in normal walking the leg rotates in space internally and externally about 15 deg. on the average (<b>Fig. 7</b>). That this horizontal rotation of the extremity might be of some importance in human locomotion has since been known as the "Berkeley fetish," and as far as is known no one has yet taken cognizance of the fact in any successful limb design. In 1950 it was suggested<a></a> that it would be of considerable value if deceleration at the end of the swing phase could be incorporated through some sort of variable-cadence knee joint. This has been done in at least one device, the U.S. Navy above-knee leg,<a></a> now available commercially (see <i>Digest, </i>this issue, page 65). Several others currently are under development. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 7. Typical relative rotations of the pelvis, femur, and tibia in normal, level walking. Data from UC studies </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the same time it was suggested that, inasmuch as the above-knee amputee can obtain no forward propulsion by contraction of the calf group, the ankle joint is of little use- that, indeed, if an ankle joint with rubber bumpers is used, energy is lost by hysteresis of the bumpers. As already mentioned, the improved performance of the Stewart-Vickers leg, in which the ankle is locked at toe-off up to 20 deg. of knee flexion, proves the validity of the original observation. Similarly, it was pointed out that, because of the interrelationship between the ankle-foot function and the knee-joint function, greater stability would be required of the knee joint were the articulated ankle to be abandoned. </p> <p> In 1953, Saunders, Inman, and Eberhart<a></a>, summing up the results of all the basic studies, pointed out that there is an interrelationship between all displacement patterns of all segments of the lower extremity, that there are six major determinants in locomotion, that modification of one results in modification of the others, and that any changes in the knee or ankle, either in normal or in amputee, are necessarily accompanied by compensatory changes in the remaining joints. Basically, locomotion is the translation of the center of gravity through space along a pathway requiring the least expenditure of energy (<b>Fig. 8</b>). The six major determinants of the pathway are pelvic rotation, pelvic tilt, knee flexion, knee extension, knee and ankle interaction, and lateral displacement of the pelvis. Serial observations of irregularities in these determinants provide insight into individual variation and a dynamic assessment of pathological gait, which may be viewed as an attempt to preserve the lowest possible energy consumption by exaggerating motions at unaffected levels. Compensation is reasonably effective with the loss of one determinant, that at the knee being the most costly. Loss of two determinants makes effective compensation impossible, the cost of locomotion in terms of energy then being increased threefold, with an inevitable drain upon the body economy. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The sum of the effects of the six determinants of gait. The pathway of the center of gravity is a smooth curve in both horizontal and vertical planes. From Saunders, Inman, and Eberhart<a></a>, by permission of The Journal of Bone and Joint Surgery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With regard to the surgery of amputation, the studies in muscle physiology suggested that considerable improvement might be effected in lower-extremity prosthetics were muscles fixed in the distal end of the stump so that they could not retract.<a></a> As previously pointed out, retraction of these muscles means shortening, and shortening means an inability to develop natural tensions. More recently the studies have suggested that, in order to retain normal weight-bearing through the shaft of the femur, more attention should be paid to the possibility of end-bearing rather than to the more conventional method of weight transmission through the ischial seat. All of these ideas, derived from the results of the early studies on locomotion, were offered to the limb industry by the University group in the hope that designers or manufacturers would incorporate the recommended features into new prostheses. </p> <h3> The Clinical Study </h3> <p> In the spring of 1953, after years of basic study, the question arose as to what might be done toward applying to the amputee problem some of the knowledge gained. After several months of discussion, the UC Prosthetic Devices Research Project accepted a proposal to institute the so-called "Clinical Study," the principal objective being to draw upon the pool of fundamental knowledge, to attempt to apply it toward the solution of practical problems, and to see whether or not there would emerge certain definite devices or methods which could be passed on to the artificial-limb industry and to prosthetists. Last year, then, the clinical program was established, and currently it is the center of attention. </p> <p> To organize such a clinical study obviously required a limbshop and examining rooms. Through the kindness of the Navy, space was afforded at the Navy Prosthetics Research Laboratory at the U.S. Naval Hospital at Oakland, California. There the setup includes a small limbshop where prosthetics work is done, a medical examination room, fitting and training rooms, an evaluation and photography room, and conference rooms, the entire operation being conducted in cooperation with the limb industry. Through the Industry Advisory Committee, amputees are selected on the basis of referral by limbshops, by physicians, by rehabilitation agencies, by the Veterans Administration, and by direct personal contact. After preliminary screening by the Clinical Study Group, an individual is selected only with the approval of the Industry Advisory Committee, and all of the work is done with the knowledge, assistance, and cooperation of the artificial limb industry. </p> <p> Because it is concerned primarily with research, the Clinical Study is not a commercial operation, and consequently production is not high and is not supposed to be. Thus far only 16 subjects have entered the clinic. Of these, 10 are unilateral above-knee amputees ranging in age from the teens to the seventies, two are bilateral above-knee cases, one is a bilateral above-knee/below-knee case, two are hip-disarticulation cases, and one is a unilateral below-knee case. Five are in the follow-up stage, six in the postfitting adjustment stage, three in the fitting stage, and two in the pre-prescription stage. All save one have been complicated cases, presenting difficult problems that nobody else wished to tackle. From particular cases such as these have come practical answers for other difficult cases. </p> <p> A thorough and complete study-from the medical, biomechanical, and prosthetic points of view-is made of each case, and individual problems are diagnosed and corrected. To find the best possible solution in any particular case requires a knowledge of what attempts have been unsuccessful and why they failed, for sometimes a great deal more is learned by determining why one proposed solution failed than by determining why another was successful. </p> <h4> The Clinic Team </h4> <p> The clinic team consists of an orthopedic surgeon, a prosthetist, a physical therapist or amputee instructor, and sometimes an engineer<a></a>. This group makes the initial evaluation and provides a prescription<a></a> based on complete data including a medical history, an analysis of existing condition of the stump and of the rest of the body, and an evaluation of the old prosthesis. The prescription is reviewed by the Clinic Study Panel, including several orthopedic surgeons, a psychiatrist, a prosthetist from industry, and an engineer familiar with prosthetic problems. Once the prescribed device is fitted, the results are viewed by the Panel, and the reasons for success or failure are documented fully so that the case may serve as an example for future reference. No experimental devices are used in the clinic program. Only those devices available commercially are fitted to the subjects. </p> <h4> Industry Participation </h4> <p> Active participation by individual members of the artificial-limb industry has not yet started, but plans are now being made for such activity in the immediate future. That part of the program will involve working with prosthetists, screened by the industry, who will visit the clinic for a period of orientation. They will follow cases through the clinic study and then be assigned a shop case on a cooperative basis. The clinic team will act initially as a review committee in preparing the prescription, but the individual prosthetist will fill the prescription in his own shop. After fitting, the amputee and the prosthetist will return to the clinic for evaluation. This procedure provides a twofold check. It evaluates the prosthetist's degree of efficiency and tests the validity of the clinic's method of prescription. </p> <h4> Prosthetic Problems </h4> <h5> <i>Crotch Pressure</i> </h5> <p> Because enough time has now elapsed to be sure that more than temporary success has been achieved, some general ideas can be discussed with a fair degree of confidence. The most common complaint heard by the group relates to crotch pressure. In every instance, however, the condition has been eliminated. Correcting for excessive crotch pressure involves two things-the right socket shape and correct alignment (page 35). Proper socket shape is ensured by providing for ischial-gluteal bearing (which prevents sinking into the socket), by controlling the anteroposterior dimension, and by raising the height of the socket brim. </p> <h5> <i>Localized Socket Pressure</i> </h5> <p> The next most common complaint relates to edema. Rarely has there been a case of the suction socket where edema could be traced to high negative pressure alone. Excessive crowding or tightness invariably were contributing factors. Edema may result principally from a high rate of pressure change at any point along the length of the stump. Because emphasis has been placed on socket shape near the top brim, not enough attention has been given to good fit throughout the length of the stump. Any constrictions or ridges, including those formed by muscle groups, cause pressure changes that interfere with venous return. The inside finish of the socket also may be a factor. In one instance, for example, a severe case of edema was alleviated by providing the socket with a smooth, high-gloss finish. </p> <h5> <i>Socket Brim</i> </h5> <p> Skin irritation around the socket brim also is a source of annoyance and discomfort. Accordingly, dermatologists are cooperating in the program. They examine amputees having skin problems and outline procedures for therapy, including the taking of biopsies of the skin. Pigmentation is evaluated to determine whether or not it is due to capillary hemorrhage caused by decreased suction or whether it is merely a pigmentation that often occurs in areas of friction. Out of this study should come a routine test and a new modality of skin care for the leg amputee. </p> <p> Again, the condition can be eliminated by controlling the shape and height of the anterior and lateral brim above the ischial seat. Medial width also is a controlling factor because it determines the total amount of pressure exerted by the front of the socket to maintain stability on the posterior weight-bearing surface. And, as in the case of edema, the inside finish is important in preventing skin damage. Sitting discomfort, a complaint often heard, usually is relieved by using a flat back, by not having the inside edge of the seat too sharp, and by ensuring that any channel for gluteal relief is not too large. </p> <h5> <i>Alignment</i> </h5> <p> Alignment is a continuing problem, and the development of guiding principles is most important. Although general principles are comparatively simple to state, to understand them fully and to apply them to individual cases is difficult. One of the objectives of the clinical program is to apply to typical problem cases the alignment principles developed through fundamental research and to develop examples showing how these principles can be applied, why they work, and the end-results that can be obtained. Naturally, the best results are obtained when the stump is so oriented as to take full advantage of the remaining hip musculature. There is a growing body of information relating to a number of common problems-problems associated with changing from a pelvic belt to a suction-socket leg; problems concerning the very muscular stump with prominent hamstrings or with some particularly firm muscle or muscle groups isolated in the stump; problems of the short and the long above-knee stump; problems caused by the flabby stump; and problems of inside finish. </p> <h4> Medical Problems </h4> <p> Often the problems of the amputee, both in the lower extremity and in the upper, stem not from an ill-fitting prosthesis. More often the problems can more properly be termed medical. Accordingly, the Clinical Study includes investigation of those aspects of amputee rehabilitation related to physiological changes associated with loss of limb. </p> <h5> <i>Pain</i>-<i>Phantom and Real</i> </h5> <p> As pointed out long ago<a></a>, loss of the normal limb so often is followed by the appearance of some form of phantom limb that, when a patient does not acknowledge one, it is suspected that he is withholding information or that the phantom has been repressed. Statistics show that the phantom is a normal phenomenon in the sense that most amputees have it. It is pathological, however, in the sense that the amputee perceives something that actually does not exist. </p> <p> In general, awareness is a matter of degree and, to some extent, a matter of verbal conventions. Some amputees say that the phantom has the same unobtrusive quality as does the material counterpart, that it appears only when called upon. Sometimes the amputee has difficulty in remembering that the phantom is unreal and that it does not serve in the capacities of its living predecessor. The normal person is not particularly aware of his limbs unless his attention is drawn to them in some way. Except under the impact of a sudden stimulus, or when a special effort is made, preferably together with a movement, our awareness is potential and shadowy in nature. With the eyes closed, and with the limb at complete rest, awareness is, in fact, not too far removed from mere imagination. To make certain that the limb exists, we move it, look at it, or rub some part of it. The amputee cannot conduct such an empirical test. </p> <p> Sometimes the patient can sense his lost limb as acutely as he can the remaining real one, and he often can imagine that he can "move" the phantom. More often, however, the phantom draws attention to itself by some "abnormal" sensation which makes the amputee more aware of it than he is of his real limb. Fortunately, only a small percentage of all phantoms habitually are painful. Some typical ones are shown in (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The phantom limb, a phenomenon of almost universal occurrence among amputees. A, Phantom toes and ankle, reported more frequently than are other phantom parts of the amputated lower extremity. B, Mild "tingling," characteristic of the painless phantom, is often described in terms of "crawling ants." C, The "telescoping" phantom, in which the foot, over a period of time, gradually approaches the stump and finally disappears within it. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Frequently the "foot" seems to shorten and approach the end of the stump. The patient illustrated in Figure <i>9C </i>experienced "telescoping" of the phantom, a phenomenon which, contrary to the observations of most other writers on the subject, was found infrequently in the Berkeley series. It is true that relatively undifferentiated parts like the calf and the forearm commonly are not felt. Some phantoms of distal parts are, from their onset, situated at the normal distance from the trunk. Others always seem to be located closer to the stump than normal. A few patients experience a gradual shrinkage of intermediate phantom parts, as has occurred over a period of years in the subject illustrated in (<b>Fig. 10</b>). In this case, all that remains of the shrunken ghost are the "toes," and these have come to lie not in empty space, as is the rule, but inside the stump. Not infrequently a phantom which has shortened may, on application of a prosthesis, lengthen and actually become identified with the artificial limb. Thus, in one instance, a young above-knee amputee felt as though the shortened "foot" were appended to the stump. When he wore his prosthesis, however, the phantom foot felt as though it were in the position corresponding to that of the artificial foot. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. A rare and peculiar form of phantom experience. Here the two "toes" seem to reside within the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Awareness of the missing member may or may not be described as basically unpleasant, but it is subject to intermittent unpleasant sensations-itching, tingling, or pain (<b>Fig. 11</b>). As pointed out by Livingston <i>, </i><a></a> the pattern of the painless phantom bears no resemblance to the areas of distribution of the major peripheral nerves. Thus the partial nature of the phantom cannot be ascribed to the affection of certain nerve lesions in the stump. Rather, the pattern of the phantom seems to relate to the most mobile parts and to those serving the highest degree of sensory function. But a substantial number of amputees experience, at one time or another, some sort of painful phantom of varying duration (<b>Table 1</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The painful phantom, of fairly common occurrence among amputees at one time or another. Only some 30 percent experience no phantom pain at any time. Probably about 10 percent face persistent and sometimes incapacitating pain. A, Among the similes used to describe a phantom pain is "as if my toes are being crushed by a hammer." B, Pain experienced at the site of an injury leading to amputation, such as a fracture, often persists as a part of the phantom pattern. C, The "hot wire" sensation and involuntary cramping of phantom toes are among the other frequent manifestations. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> How many amputees have pain? Taking into consideration the inadequacies of follow-up information, the subjective character of the pain experience, and the semantic difficulties beclouding the term "pain," a conservative estimate would be that 80 percent of all amputees are substantially free of pain and are either being trained for useful work or else are already actually so engaged. It is likely that, of the remaining group, possibly half are faced with severe intermittent or persistent pain. Because of persistent, incapacitating pain, approximately 10 percent of all amputees never get into a limbshop, never get out of the doctor's office. They become narcotic addicts and often commit suicide. Where pain enters the phantom syndrome, it may assume large clinical importance. If it is excruciating and persists for long periods, it may take a devastating toll of the whole personality and physical well-being. </p> <p> In describing severe pain, we all use a vocabulary taken from common objects known to produce injury. Lesser pains are described in terms of cutaneous and deep sensations. Thus we speak of "pressure," of "pins and needles," of "sharp" pains and "dull" aches, of "stabbing" and "shooting" pains. It seems unlikely that man at his present stage of evolution ever will devise a specific terminology for pain because he has no special organ for observing his discomforts. No matter how introspective a person may be, his account of pain always is phrased in imagery taken from other fields of experience. Nothing could be more real than these sensations, but we say "as if" to give them intelligible expression. The vocabulary is metaphorical. </p> <p> It is not surprising, therefore, to find amputees using language akin to that of the torture chamber when they try to do justice to their agonies. They hardly go further than anyone else in telling about physical sufferin. Nor do they hallucinate when they talk about "ropes" and "vises," for they remain aware of the imaginary character of these similies. It is possible, however, that, as the tearing and squeezing sensations are felt in a part of the body known to be missing, the suffering is heightened and the imagery made more vivid by the ghostly character of the phantom. </p> <p> It has been argued that phantom sensations are hallucinations because they entail a belief in the reality of an absent object, or that they are illusions because irritations of the stump are being misinterpreted, or that they are normal sensations because the cerebral representation of the once-present member still is intact. Some workers have correlated the type of sensation with the "level" of its origin in the nervous system, painful sensations being ascribed to pathological conditions of the cut nerve end in the stump or to mental aberrations. But classifications of either the amputee's descriptions or of the presumptive causes bringing about the sensations have thus far been unsatisfactory. The various frames of reference used in the statistical survey at Berkeley do, in fact, overlap. Duration and frequency of pain have some influence on the complaint of severity. Tingling and burning seem to be more superficial and, however annoying, more tolerable than do tearing, stabbing, cramping, squeezing, and crushing. It should be understood, however, that there are degrees of each of these and that, as such, intensities may, to a point, be compared with each other. </p> <p> It is obvious that a patient's account of his painful feeling is colored by his personality. The way a person describes such experiences depends not only on the abnormal processes causing them but also on his imagination, his previous experience, his learning, his cultural inheritance, and his vocabulary. But any view which discounts the abnormal physiological processes and credits only their "mental" interpretation is probably in error. The complexity of the nervous system and its integration into one functioning whole does not favor the idea that there is one chief recipient and executive who sorts out the messages from the various parts of the body and, in the case of pain, edits them as writhings and groans or as sentences made up of more or less colorful language. It seems improbable that there is simply one stimulus arising somewhere in the organism and that the ego reacts to this stimulus in a more or less stoic way. A so-called "neurotic" or "imaginative" disposition is likely to pervade the most "bodily" of processes, while a steadfast person is apt to have a stomach and blood vessels no more stable than his emotional display. </p> <p> Regardless of individual personalities, however, there is a certain uniformity in the complaints of pain-stricken amputees. Although the matter has not been explored from the point of view of psychophysiological typing, it appears that pain phenomena cannot be predicted either from the age of the patient or from the age of his phantom. By the same token, racial or cultural background and physical or mental make-up cannot be used to predict pain phenomena. Nor have the local pathological factors before, during, and after amputation-the factors that might be held responsible for the appearance of pain-been elicited. </p> <p> Aside from the problem of the painful phantom is that relating to painful stumps (<b>Fig. 12</b>). Amputees may have spontaneous stump pain. Or they may have so-called "trigger points," certain areas which, on slight pressure, tend to produce a flash of pain persisting for various intervals of time. Patients have complained of circumscribed areas of pain in the stump even though palpation revealed no corresponding point of tenderness. These two conditions usually are found together. Nodularities in the stump often are palpable, as indeed they are, on a minor scale, in other subcutaneous parts of the body. Some of these are tender, some are not; some are and some are not connected with phantom pain. In fact, separate places in the same stump may represent exclusive triggers-one for stump pain, the other for phantom pain. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Types of stump pain. About a third of the clinical reports of pain refer to discomfort in the stump rather than in a phantom part. Stumps may be painful to the touch (A) or spontaneously (B). Frequently present are "trigger points," pressure upon which gives rise to pain over a larger area, either in the stump or in a phantom or both (C). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But the conditions prevailing at the end of the stump, including such nodules as the famous "amputation neuroma," do not provide a basis for intelligent speculation. The mere fact that stimulation of a presumptive neuroma often produces pain in the phantom is no proof for the theory that the "cause" of this pain lies solely in the periphery. In order to be disabused of such a notion, one has only to look at certain cases of known diseases of the central nervous system or at. complete transections of the spinal cord. In the latter, the brain receives no communications from the stump. In cases of painful diseases of the central nervous system, stimulation of the normal peripheral tissues having their nervous connections with the diseased part of the central nervous system often produces an abnormal sensation, including pain. This phenomena always is referred to the periphery. Nobody sounds convincing when he says that he feels pain in the brain or spinal cord. The central nervous system has no conscious sensory representation of itself. The mere description of a painful sensation does not permit detection of its origin. The origin has to be deduced from circumstantial evidence which, in the case of amputees, is lacking. Even where sensations are "triggered off" from the periphery, they can be completed only by participation of the central nervous system, and disturbances may occur anywhere along the line. </p> <p> We are confronted with the anomaly that stimulation of a certain trigger point within the stump arouses not a distant, painful phantom but one incorporated in the flesh of its own trigger. The specificity of this trigger further is illustrated by the fact that, on the opposite side of the same stump, there may be another tender spot, stimulation of which sets up increased local stump pain. </p> <h5> <i>Circulatory Problems</i> </h5> <p> Investigation of circulation in the amputee reveals that the stump acts as though it were poikilothermic, that is, it has no ability to change its temperature. Rather, the temperature of the stump matches that of the surroundings, as occurs in a cold-blooded animal. </p> <p> Studies concerning the relationship of the vascular system to pain in amputees have been conducted along three general lines. First has been evaluation of the status of the circulatory system in amputation stumps, both in patients suffering from phantom or stump pain and in amputees free of pain. The second has involved clinical and laboratory studies of selected nonamputee patients suffering from pain syndromes possibly related in pathophysiology to phantom pain. And finally tests have been conducted with various sympatholytic drugs and blocking procedures, first with respect to their effects on phantom-limb pain and related pain syndromes and second in regard to their effects on the circulation of blood in stumps and in painful limbs. </p> <p> Studied in detail were 43 amputees, 31 without known vascular disease (Group A) and 12 suffering from vascular disease either as the underlying cause of amputation or as a concomitant to the amputation (Group B). Pain in the stump or phantom limb was an important problem for 15 of the patients in Group A and for 8 of those in Group B. The remainder described varying degrees of phantom awareness but denied that pain existed or, if it did exist, that it was disturbing. </p> <p> One method of investigation was simple clinical examination. In that survey, stumps appearing to have an adequate blood supply were found, when exposed to air at room temperature, to be almost uniformly cold to the touch as compared with the opposite extremities. In oscillometric tests, the pulse of arterial blood into the stump was found to be significantly smaller than that into the normal limb (<b>Fig. 13</b>). In skin tests with histamine, the appearance of normal flares and wheals indicated that local denervation could not account for the failure of the skin to warm during generalized body warming. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Pulsations recorded during generalized vasodilatation in a below-knee amputee. Oscillometric records show a smaller amplitude of pulsation in the blood vessels supplying the stump (A) than in those supplying the sound limb (B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 14</b> and <b>Fig. 15</b>) indicate graphically the results of surface-temperature measurements on the normal extremities and on the stumps of two amputees. <a></a> Skin temperature was measured after initial exposure of the body to cool air in a room with controlled atmosphere, the subject being exposed until finger and toe temperatures were stabilized. Recordings were made by means of thermocouples taped to the skin of the stump and to the contralateral extremities at multiple points along the length of the limb, the thermocouples being applied symmetrically so that points equidistant from the trunk could be compared. All such measurements were made with the subject in a basal state and exposed to room air between 17deg and 21deg C, conditions leading uniformly to constriction of the cutaneous vessels of the extremities in normal subjects. Under such circumstances, a temperature gradient exists between the proximal and distal portions of a normal arm or leg, so that the surface temperature of a finger or toe is several degrees lower than the temperature at points near the trunk. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Surface temperatures in the upper extremities of a below-elbow amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 65 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Surface temperatures in the lower extremities of an above-knee amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 74 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Temperatures then were recorded during maximal vasodilatation induced by oral administration of whiskey and wrapping the trunk in an electric blanket. After vasodilatation, the gradient is abolished or reversed in the normal limb, finger and toe temperatures rising to 30deg C or higher. </p> <p> At the end of the initial cooling period, when subjects had been exposed to cool room air for periods of from 30 to 150 minutes, the surface temperature at the distal end of the stump almost invariably was cooler than was the skin at a symmetrical point on the corresponding intact limb. Analysis of the temperature gradients found after cooling showed further that, in at least a third of the Group A amputees and in half of the Group B amputees, the stumps were cooler than were the opposite extremities, not merely at the distal ends but for distances of from 20 to 55 cm. from the ends. </p> <p> In one instance a patient was put in a room at 18deg C with nothing across his body except a towel. Over a period of two hours the body temperature was lowered to a point just above that at which shivering occurred. The temperature of the toe in the normal extremity dropped to a low level. When the patient suddenly was given 2 ounces of whiskey and warm water and had an electric blanket placed across his chest, the temperature of the normal extremity rose rapidly. But the temperature of the stump remained constant during the entire procedure, a phenomenon characteristic of all amputation stumps. </p> <p> A total of 40 amputees (28 Group A, 12 Group B) were subjected to one or more vasodilatation tests, and the responses of 45 stumps were observed. Of these, nearly two thirds failed to warm significantly at a time when the skin temperature of the normal extremities had risen to 30deg C as a result of indirect or "reflex" vasodilatation. Only occasionally did stumps show evidence of significant vasodilatation. It occurred with higher frequency in those patients with underlying or concomitant vascular disease than in amputees of Group A. Thus, of 11 stumps in which the temperature rose to the same level as the corresponding point on the contralateral limb, or even to levels reflecting "ceiling" blood flow for skin, only six were among the 32 stumps of Group A patients, and five were among the 13 stumps of Group B patients. In brief, a smaller proportion of stumps showed vasodilatation in Group A patients (one fifth) than in Group B patients (two fifths). </p> <p> In the majority of trials, experiments with other methods of inducing vascular relaxation were equally ineffective in causing a rise in stump temperature. In a total of eight intravenous injections of vasodilator drugs, the temperature of the stump increasedonlyslightly on two occasions (2.5deg C or less). A rise in temperature was effected once with Priscoline (2-benzylimidazoline hydrochloride) and once with tetraethylammonium chloride. Injections of prccaine in the region of the lumbar sympathetic ganglia produced a significant warming of the stump in one of two cases only. No correlation was found between the degree of phantom or stump pain experienced by these patients and the extent to which slump temperature fell during the initial period of exposure or the extent of stump warming during generalized vasodilatation. Amputees rarely complained of stump or phantom pain during these experiments, even though they were subjected to extremes of temperature requiring rapid vasomotor adjustments. </p> <p> The ease with which stumps become cool on exposure to a cold environment can be attributed to two factors. First, surface-volume relationships in stumps favor cooling. Second, less blood passes through the stump than through comparable portions of the intact limb because, in the stump, distal tissues are absent. Apparently the shunts between the arterial and the venous side, which permit an increased volume of blood to flow through the extremity, are located distal to the wrist joint and to the ankle joint. In amputations at or above the wrist or ankle, therefore, flow of blood to the extremity is impaired. Normally, body heat is lost chiefly through radiation from hands, head, and feet. When the body is deprived of one of these radiating "fins," the remaining stump cannot be warmed. Neither can excess heat be radiated away, and for that reason an amputee often finds intolerable an environmental temperature that is quite acceptable to the normal. The amputee is distressed in a heated room, while the normal subject suffers no discomfort. Since the radiating mechanism is lost with amputation of an extremity, and since the only other means of cooling is through evaporation of sweat, the amputee is more likely to be troubled with problems of perspiration. </p> <h5> <i>Skeletal Changes</i> </h5> <p> In addition to problems of pain and changes in circulation, the amputee sometimes is troubled by decalcification of the stump and adjacent portions of the pelvis, a change that occurs when the body weight no longer is borne along the axis of the major articulations but along the prosthetic weight line (page 36). Because in an osteoporotic extremity the covering of the bone is more sensitive than is that in the normal, a decalcified bone often becomes exceedingly tender and develops spontaneous pain. </p> <p> An interesting fact is that the joint itself, in (<b>Fig. 16</b>) the hip joint, begins to show early degenerative changes because it no longer transmits weight. In future studies it should be possible to evaluate more closely what changes are to be expected in the proximal articulations of an amputation stump, and more particularly in the joint cartilage covering the articulations, as a result of elimination of normal weighi-bearing through thesearticulations. Obviously, the only way la preveni osteoporosis and increased sensitivity is to resort to some type of end-bearing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16 Roentgenogram of an above-knee amputee, showing skeletal changes that occur when the hip and the remainder of the leg on the amputated side are deprived of the normal stimulation of weight-bearing </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In the younger leg amputee, moreover, especially in growing children, other bony deformities develop (<b>Fig. 17</b>). Instead of the normal curvature of the neck of the femur, there develops a valgus deformity as is seen in polio and in dislocated hips. And finally, of course, because of loss of the mass of the limb, one must expect to find scoliosis and other abnormalities in the spine (<b>Fig. 18</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Complicating deformities in juvenile amputees. When amputation is necessitated in childhood, defects often occur in the subsequent growth of related bony structures. Here, for example, the pelvis is smaller, and the pelvic-femoral angle larger, on the amputated side than on the sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Scoliosis, a postural defect often a sequel to amputation of the lower extremity. Loss of the weight of the amputated limb leads to habitual compensatory positioning of other body elements and thus complicates rehabilitation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3> Summary </h3> <p> In summary, it may be said that, first, amputation produces changes in musculature, not only the familiar contractures and atrophy <i>{50,88) </i>but other changes as well. If a muscle is cut in half, its ability to shorten is decreased. A mid-thigh amputation decreases the effective normal range of motion of the hamstring group. If the hamstring group is cut in half, the velocity of contraction is halved, and an amputee thus afflicted cannot therefore perform certain functions with any degree of facility. </p> <p> The mechanism of normal level walking requires the expenditure and distribution of considerable energy, for which the body depends largely upon the leg musculature. Thus, the handicap resulting from loss of any part of the leg is due not only to the loss of support but also to the loss of power available from the muscles. The skeletal structure of a normal limb can more or less easily be simulated in a prosthesis, but such a device has little value without simultaneous provision for the necessary power. Accordingly, an understanding of the energy characteristics of normal level walking is important in considering the design criteria for artificial legs. Judging from the results of the energy studies at Berkeley, at a given pace an above-knee amputee uses two and a half to three times as much energy as does the normal. The adverse effect of this overexertion is only further complicated by the fact that heat production is increased at a time when the radiating mechanism has been impaired. In the manufacture of any lower-extremity prosthesis, then, an important consideration, is to design the substitute limb for maximum energy conservation. </p> <p> Medical problems are common to all amputees. Some of them, for example those related to circulation, cannot be solved, but proper surgical procedures help to preserve the musculature and skeletal structures of adjacent joints. Moreover, many things can be done to relieve pain, both spontaneous phantom pain and the tender trigger points occurring in stumps. All amputees suffer some discomfort at one time or another. They are bothered by skin changes occurring over the bony prominences, by edema at the distal end of the stump, and by attritional lesions occurring in the folds of the groin (<b>Fig. 19</b>). A minor skin lesion can disable a leg amputee completely, especially when it means staying off the leg or going on crutches. Increased perspiration and poor ventilation of the stump in the prosthesis may close the sweat glands and make the skin susceptible to fungal diseases, and contact dermatitis may result if the patient is allergic to certain materials used in the manufacture of the prosthesis. Such problems must be solved by socket fit, by alignment, or by other procedures. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Problems of fit. Among them are irritation and swelling in the crotch area, edema at the stump end, and tenderness at pressure points. Because such problems are more or less readily corrected by proper fit and alignment, they are less medical than prosthetic, although chronic skin irritation may need the attention of a dermatologist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> From the Clinical Study have come valid recommendations concerning fit, alignment, and functional characteristics. As already noted, some horizontal rotation (between 9 and 15 deg.) is desirable in an artificial leg. Further, increased stability in the knee joint increases the leg amputee's sense of security. Some conservation of energy can be effected by eliminating the articulated ankle joint. And finally, the matter of appearance deserves consideration. In this regard, attention must be given to the color, contour, and texture of the artificial leg. </p> <p> In the last analysis, the problem of the leg amputee is more than that of providing him with a prosthetic device. He has many medical problems, including pain, abnormalities in circulation, heat intolerance, and skeletal and muscular changes. The prosthetic device itself raises other problems-conservation of energy, proper alignment, comfort, and cosmetic appearance. The Lower-Extremity Clinical Study is concerned with the solution of all these problems. The manner in which solutions are sought is shown in (<b>Fig. 20</b>), where the central area represents the pool of fundamental knowledge accumulated over a period of nine years. As the amputee moves around the circle, each problem is studied and solved before he is allowed to move into the next phase of processing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Functional organization of theLower-Extremity Clinical Study:. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To date, pain and skin irritation have been the predominant problems, and study groups are being organized to investigate these areas in detail. Study groups also have been organized to investigate skeletal and muscular changes. At each step in the process, the panel itself often is faced with difficult problems. For example, the question of evaluation always is present, and it is not easy to determine whether or not the amputee actually has benefited from the time and effort devoted to his case. But as each difficulty is solved, the information derived is placed at the disposal of all those concerned, not only those within the Clinic Study Group but also all others whose interests lie in the field of amputee management. Seminars are held weekly to ensure that the information is brought to the attention of all interested persons. Eventually, all of the problem-solving data stemming from the investigations will appear in educational publications and will be available to members of the artificial-limb industry. </p> <p> Finally, it may be said that the University group has no intentions of producing prosthetic devices and, indeed, makes excursions into that field only when it is necessary to develop experimental models pertinent to the study. </p> <p> The only function is to produce sound ideas that can be used by the artificial-limb industry in the manufactuie and fitting of improved prostheses. The study must, however, continue to be active until the basic scientific information can be translated into useful guides for the professions involved in the rehabilitation of the amputee. </p> <h3> Acknowledgments </h3> <p> For the illustrations appearing in this article, the authors are indebted to two people in particular. Thomas Raubenheimer, of the Department of Medical Illustration, University of California Medical Center, San Francisco, prepared the charcoal halftones. With the exception of <b>Fig. 8</b>, all line drawings were worked up by George Rybczynski, free-lance illustrator of Washington, D. C. </p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </li> <li>Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</li> <li>'Bartholomew, S. 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Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </li> <li>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </li> <li>Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </li> <li>Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </li> <li>Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </li> <li>Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </li> <li>Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </li> <li>Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </li> <li>Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </li> <li>Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</li> <li>Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </li> <li>Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </li> <li>Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </li> <li>Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </li> <li>Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </li> <li>Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </li> <li>Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </li> <li>Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </li> <li>Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </li> <li>Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </li> <li>Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </li> <li>Gordan, G. S., B. Feinstein, and H. J. Ralston, Effect of testosterone upon atrophy of denervated skeletal muscle, Exper. Med. and; Surg., 7:327 (1949). </li> <li>Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </li> <li>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </li> <li>Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </li> <li>Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </li> <li>Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </li> <li>Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </li> <li>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </li> <li>Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </li> <li>Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </li> <li>Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </li> <li>Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </li> <li>Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </li> <li>Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </li> <li>Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </li> <li>Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </li> <li>National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </li> <li>New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </li> <li>Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </li> <li>Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </li> <li>Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </li> <li>Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </li> <li>Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </li> <li>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </li> <li>Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</li> <li>Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </li> <li>Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </li> <li>Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </li> <li>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </li> <li>Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </li> <li>Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </li> <li>Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </li> <li>Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </li> <li>Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </li> <li>Ralston, H. J., E. W. Wright, Jr., B. Feinstein, and V. T. Inman, Effect of stretch upon action potential of voluntary muscle, Am. J. Physiol., 159:586 (1949). </li> <li>Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </li> <li>Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </li> <li>Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </li> <li>Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </li> <li> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </li> <li>Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 1953. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </li> <li>Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </li> <li>Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </li> <li>Wagner and Catranis, op. cit., p. 511. </li> <li>Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </li> <li>Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (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>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>114.</b> </td><td class="clsTextSmall">Wagner and Catranis, op. cit., p. 511. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>20.</b> </td><td class="clsTextSmall">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] 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>40.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Elftman, Herbert, The functional structure of the lower limb, Chapter 14 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>57.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b> 64.</b> </td><td class="clsTextSmall">Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </td></tr><tr><td class="clsTextSmall"><b> 116.</b> </td><td class="clsTextSmall">Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>8.</b> </td><td class="clsTextSmall">Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </td></tr><tr><td class="clsTextSmall"><b>111.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 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>References</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall"> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>103.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </td></tr><tr><td class="clsTextSmall"><b>104.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, |Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948. </td></tr><tr><td class="clsTextSmall"><b>106.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr><tr><td class="clsTextSmall"><b>108.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </td></tr><tr><td class="clsTextSmall"><b>110.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, 2nd ed., August 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>Footnote</b></td></tr><tr><td class="clsTextSmall">The 1947 report contains an extensive bibliography of earlier work, mostly German, on the mechanism of human locomotion and on related matters. It is available, either in photostat form or on microfilm, from the U. S. Armed Forces Medical Library, 7th Street and Independence Ave., S. W., 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>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951. </td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b> 112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>113.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>VerneT. Inman, M.D., Ph.D., </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, School of Medicine, University of California, San Francisco; Professional Associate, Advisory Committee on Artificial Limbs, National Research Council; member, Technical Committee on Prosthetics, ACAL, NRC. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_004/table01.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-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 Lower-Extremity Clinical Study-Its Background and Objectives Creator An entity primarily responsible for making the resource VerneT. Inman, M.D., Ph.D., * Howard D. Eberhart, M.S. * https://staging.drfop.org/files/original/fcf5e10ffc3bff3cb89b517eb63ea5a2.pdf 0b8215ed539490f64e8cf75633dbb151 https://staging.drfop.org/files/original/5df5af90029daa1b7947c5ee33d08bc8.jpg 949b68f099a2ded1f6d45b1a93835af6 https://staging.drfop.org/files/original/e885e588918c3f3ed5fed4be446f6515.jpg 9c9edb182b521a4f3c55907aac2c12c4 https://staging.drfop.org/files/original/8ae9ef1f9e51a1ffe5839ee578fde9ec.jpg 3e30a207b5d92d01eaba842dbb9ce17e https://staging.drfop.org/files/original/dc315daacc177135b612f6d9d75dac9f.jpg 80cbacdea646e05d40116aa522d6538c https://staging.drfop.org/files/original/d6a0e71d869fdf811919200fc92af175.jpg 8af7b934c360f7d8be36455e7d27b56d https://staging.drfop.org/files/original/dcd15d5b2cb3600bbb9a16ceee230a8a.jpg b4bee6b427deadb2481ef102215ea90d https://staging.drfop.org/files/original/fbab7c843102fc1a6a56f0387d6474e7.jpg eecb06f6a79e8bf93b309fd4571aa73e https://staging.drfop.org/files/original/a36d8df923391175c131cc2503b2ad4f.jpg f12d7502edc79a9815ea0effa5a61252 https://staging.drfop.org/files/original/65c39b075e4ed74821b311f1425e07fe.jpg 33cdcc9406cbfccab6083b95a496cd32 https://staging.drfop.org/files/original/7ad63a3c7138be2c4aeadf85e67c3352.jpg 7f4f5ea9d217ef6cb6424c830141f675 https://staging.drfop.org/files/original/2c83de4880188f302b29099589602a5f.jpg c8b1c39cf8255f9580c8abf663fd469e https://staging.drfop.org/files/original/ae139375a47c70c260990878a1f0ae09.jpg 9e529d7b3beb3edc4fb97f0b018934f9 https://staging.drfop.org/files/original/dddd1109e0786871b6890b901ad89193.jpg f0c7d156e4cf6e475c16a3ffd9013a96 https://staging.drfop.org/files/original/43b8b6068ae6129c2d30f9f07c50ffce.jpg a10cd2406b8ed3c261645d2669705d61 https://staging.drfop.org/files/original/6fc43a0cc84ce447ae02214678f3688f.jpg f11a6615dd5d7161c615453a358094c1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_035.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 35 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_035.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_035.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>Functional Considerations in the Fitting of Above Knee Prostheses</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the fitting of any artificial limb, the goal of the prosthetist is simply to restore to the amputee the ability to perform everyday activities in an easy, natural, and comfortable manner. The basic requirements are therefore three in number-comfort, function, and appearance, the latter embracing both cosmetic appearance and appearance in use. Unless a prosthesis is reasonably comfortable, the amputee will be unable to wear it. Unless it performs the necessary functions with reasonable ease and dexterity, the amputee is not apt to find the device very useful. Unless it is reasonably acceptable cosmetically, and unless it can be operated in a natural manner, the limb is likely to be disagreeable both to the wearer and to his friends and associates. But this seemingly simple set of requirements is vastly complicated by the fact that the three are all mutually interrelated. That is to say, the degree of satisfaction attained in one condition is influenced greatly by the situation prevailing with respect to the other two. Cosmetic appearance, for example, is necessarily limited by details of mechanism, and vice versa. No matter how elaborate a prosthetic device may be, it cannot be made to function properly unless it can be manipulated with ease and without discomfort. And conversely, no device can be comfortable in use unless its functional characteristics are properly integrated with the residual biomechanics of the wearer. Any change aimed at improvement in one condition unavoidably affects the other two-sometimes favorably, sometimes unfavorably.</p> <p>In the lower extremity, cosmesis presents no serious problem. Since it is comparatively easy to fashion an artificial leg to an external shape and appearance more or less like that of its normal counterpart, and since in both sexes the lower extremity may be concealed beneath some sort of clothing, the actual cosmetic properties of a lower-extremity prosthesis amount to refinements to be added after all other requirements have been met. More critical in the lower extremity are comfort, function, and appearance in use. The leg prosthesis is in almost constant service, and it must provide both adequate support and a natural-appearing gait with as modest consumption of energy as possible. In fitting an above-knee limb, therefore, correct practices based on established biomechanical principles are mandatory if success is to be had.</p> <p> Because during all activities the suction-socket above-knee leg<a></a> is controlled by the amputee through the use of remaining hip musculature, every effort must be made to ensure that these muscles are used to the fullest possible extent without causing discomfort. The intent here<a style="text-decoration:none;">*</a> is to present the basic concepts that apply to the fitting of all above-knee prostheses, regardless of type of suspension, but which have particular application to the suction-socket above-knee leg. Although the details of fitting must necessarily be modified as dictated by the individual case, the basic features apply to all cases.</p> <h3>The Principles of Above-Knee Alignment</h3> <h4> Mediolateral Stability</h4> <p>When one watches the walk of a typical above-knee amputee, two characteristics of gait often are particularly apparent. First, sidesway, <i>i.e.,</i> lateral movement of the torso from side to side, is exaggerated. Second, the amputee usually walks with his feet farther apart than does a normal individual of similar build. The average individual walks in such a manner that the lateral distance between successive points of heel contact is from 2 to 4 in. In order for the gait of an amputee to appear as normal as possible, therefore, he must walk with a base equally narrow. The amputee with a walking base of from 6 to 12 in. never can achieve a normal gait appearance. If such an amputee is asked why he walks with a wide base, he usually gives as the reason that it is more comfortable or that he feels more secure with his feet farther apart. </p> <p>This circumstance is accounted for by the fact that, as an amputee attempts to walk with his feet closer together, certain functional requirements are placed upon the fit of the socket and upon orientation of the socket in space. In general, these requirements are not fulfilled in a prosthesis aligned for a wide-base gait. If an attempt is made to use such a prosthesis with a gait of narrow base, difficulties arise because certain forces come into play that cannot be accommodated by the stump in a comfortable manner. Although a poorly fitted prosthesis may be reasonably comfortable for many months provided the amputee walks so as to compensate for errors in fit and alignment, the same prosthesis may be very uncomfortable if the wearer attempts to change to a more normal-appearing gait. It is, however, possible to construct for the average above-knee amputee a prosthesis that allows a reasonably normal gait, that is comfortable in all normal activities, and that eliminates common points of stump irritation such as those in the crotch area and near the end of the femoral stump.</p> <h5> <i>The Weight-Bearing Line</i> </h5> <p>One of the most common terms used by the prosthetist in the fitting and alignment of an above-knee prosthesis is the "weight-bearing line." It serves as the guide for many phases of setting up the prosthesis, but its exact position is subject to considerable difference of opinion. One prosthetist may use a weight line drawn from the ischial tuberosity through the center of the ankle joint; a second may select a line falling along the medial side of the foot; and a third may advocate use of a line drawn from the geometric center of the socket at the ischial level to the center of the heel. It is possible to get many other definitions of the weight-bearing line. As a matter of fact, they probably are all equally helpful in the alignment of prostheses. In considering the manner in which the weight-bearing line is used, it becomes apparent immediately that such a line actually serves as a "reference line" or "construction line."</p> <p> In the discussion that follows, the term "weight line" is used to establish a mental picture of a theoretical line in space along which the force of the body weight acts. This concept differs from "weight-bearing line" in that "weight" is due to the gravitational attraction of the earth, whereas "weight-bearing" refers to the transmission of a force through the structural elements of the anatomy and the prosthesis. Although it would appear difficult to establish any one line which accounts for the net effect of the weight of the various and widely separated parts of the anatomy, that can be done in a theoretical, idealized way by defining a point within the body at which the effect of all body weight can be assumed to be concentrated. This point is usually designated as the "center of gravity" of the body as a whole. With all the weight assumed to be concentrated at the center of gravity, the body weight must then always be considered as acting directly downward from this point, as though it were a plumb bob suspended on a string hanging from the center of gravity. The string would represent the body weight line. A short definition of the weight line as shown in Figure <i>A</i> might read as follows: <i>The weight line of the body is a line through the center of gravity along which the body weight can be assumed to act vertically downward at all times.</i> </p> <h5> <i>Variations in Vertical Force</i> </h5> <p>Thus far we have considered only the effect of the body weight acting downward. For either an amputee or a person with two good legs, the body weight must be supported by the contact between foot and floor. For many reasons, the force of contact between foot and floor is very difficult to measure accurately because, for either foot, the contact force is extremely variable over the short time the foot is supporting weight. Shortly after the heel strikes the floor, the leg receives an initial load which, because of the slight reduction in the rate of progression of the body as a whole, quickly increases to a value greater than body weight. During the mid-portion of the stance phase, as the center of gravity of the body is reaching the lowest point in its path of motion, the load on the leg decreases to a value somewhat less than that of body weight. As the body is being elevated and propelled forward into the next step, the load builds up again to a value greater than that of body weight.</p> <h5> <i>Forces in Shear</i> </h5> <p>While all this is occurring, the person also is swaying from side to side and varying in speed slightly as he walks. This condition requires that the contact force must also provide some horizontal frictional forces along the floor, as everyone has realized after slipping on ice or when making a sharp turn. The forces acting on the foot during walking are, then, of two kinds-those acting perpendicular to the floor, which support the body weight, and those acting parallel to the floor, which are necessary to provide resistance to the impetus of the body moving forward, backward, or sideways.</p> <h5> <i>Floor Reaction and Load Line</i> </h5> <p> The total force exerted on the sole of the foot-the combination of all these effects-is known as the "floor reaction." It acts along the same line as does the total force exerted by the amputee on the socket of the prosthesis. The floor-reaction force is the load which the leg, whether normal or prosthetic, must transmit upward from the floor. In general, the line of these forces, known as the "load line" ( <b>Fig. 1</b> <i>B),</i> is not perpendicular to the floor but is directed upward, inward, and forward or backward with an inclination that varies continually during the time either foot is supporting the body. It is very definitely not a line drawn from the center of the hip joint through the knee and ankle joints. A line so drawn should, instead, be designated as the "mechanical axis of the lower extremity." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Definitions in alignment of the lower-extremity prosthesis. A, The "center of gravity" of the body is a point at which all body weight can be assumed to be concentrated. The effective body weight passes through the center of gravity and acts vertically downward along the "weight line." B, The "load line" is a line along which the force between the foot and the floor acts. In general, it is not perpendicular to the floor surface, since this force has two effects. First, it supports the body weight in a vertical direction, and second, it provides the horizontal forces necessary to cause motion of the body in the forward and medial directions. C, The "support line" is a vertical line along which the effective supporting force exerted between the rim of the socket and the stump of the amputee is assumed to act. In general, the support line does not pass through the center of gravity or through the center of foot pressure.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>The Support Line</i> </h5> <p> An additional necessary concept is that of the "support line" (<b>Fig. 1</b>). In order to define the support line, it is necessary first to identify a "support point," which may be defined as the center of action of all the vertical supporting forces at the top rim of the socket, including the ischial-bearing force, support in the gluteal region, and support in other weight-bearing areas around the socket rim. Where such a point lies is very difficult to establish, its actual location depending largely upon the individual prosthetist's methods of fitting. In a typical ischial-bearing socket, the support point is probably somewhere anterior and lateral to the point of contact of the socket with the ischial tuberosity. The support line is defined as a vertical or plumb line, passing through the support point, along which the effective supporting force between the socket rim and the stump can be assumed to act. In general, the support line coincides neither with the weight line nor with the load line. </p> <h5> <i>Use of the Hip Abductors</i> </h5> <p> <b>Fig. 2</b> presents a rear view of an above-knee amputee, walking with a narrow base, at an instant during the walking cycle when the full weight is carried on the prosthesis. During the stance phase, the amputee, like the normal individual<a></a>, keeps his pelvis horizontal primarily by action of the hip abductors on the supporting side, as shown by abductor tension in <b>Fig. 1</b>. If, for one reason or another, the hip abductors are unable to exert the necessary force, the pelvis has a tendency to drop toward the unsupported side. When, therefore, the above-knee amputee stands upon his prosthesis, his pelvis may tend to drop toward the normal side owing either to inadequate hip abductors or to inadequate support on the lateral side of the stump-support which is necessary to stabilize the femur and to form a firm base for action of the hip-abductor musculature. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Use of the hill abductors for lateral stabilization of the pelvis.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dropping of the pelvis toward the normal side generally results in an increase in pressure in the crotch area. It often allows the pubic ramus to come into contact with the medial wall of the socket and .an therefore be extremely uncomfortable. Anticipating this action, the amputee makes appropriate compensation. He maintains his balance either by leaning over the prosthesis, which results in the familiar amputee list, or by walking with a wide base and swaying from side to side. In the alignment of an above-knee prosthesis, then, one of the most important objectives is to construct the prosthesis in such a way that the hip abductors may be used in a normal and comfortable manner to prevent this tendency toward pelvic drop, torso list, or sidesway, and to allow a reasonably normal and comfortable gait.</p> <h5> <i>The Pelvic Lever</i> </h5> <p> As indicated in <b>Fig. 1</b> <i>A</i>, the center of gravity of the body is defined as the point at which the entire weight would have to be concentrated were it to have the same effect on the body as a whole as does the actual weight distribution. On the strength of this concept, the pelvis can be assumed to act as a lever in the stance phase while the amputee supports his weight on the prosthesis <b>Fig. 3</b>. Using the ischium as a supporting pivot or fulcrum, the pelvic lever supports the body weight (which acts vertically downward through the center of gravity and along the weight line) by the balancing action of the hip abductors, the process being similar to normal hip action in which vertical support is through the hip joint. If this lever action is to prevent dropping of the pelvis toward the unsupported side, the tension in the hip abductors must be sufficient to balance the body weight. The abductor muscle force can perform this function only if abduction of the stump is prevented by firm contact against the lateral wall of the socket. Otherwise the muscle action would simply cause abduction of the femoral stump inside the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Lever action of the pelvis in stabilization of the torso.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Distribution of Lateral Pressure</i> </h5> <p> The necessary stabilization of the stump against the lateral wall of the socket can be accomplished comfortably if the stabilizing pressure is distributed widely over the lateral side. For a stump of average length, stabilization is achieved by fitting the lateral wall snugly over its entire length. A slight flattening of the lateral wall, with relief near the distal end of the femur, usually ensures that the stabilizing forces are not only comfortable but that they are directed medially as required <b>Fig. 2</b>. If, with the stump improperly supported against the lateral wall, an attempt is made to use the hip abductors for pelvic stabilization, the result may be a gap around the lateral brim and a painful concentration of pressure near the end of the stump. </p> <h5> <i>Considerations of Mechanical Advantage</i> </h5> <p> Two other factors enter into the lateral stabilization of the pelvis by the hip abductors. First, in balancing the body weight on the ischial fulcrum, the tension in the hip abductors has greatest mechanical advantage when the lever arm between the abductor tension and the support point is as long as possible. Support of a substantial portion of the body weight by the ischial seat and of a smaller amount by the gluteal musculature gives the abductor tension sufficient mechanical advantage to balance the body weight with little or no conscious effort on the part of the amputee. The characteristics of this lever system are shown in the schematic diagram of <b>Fig. 3</b> , where the required tension <i>T</i> is reduced by decreasing the distance <i>x</i> and increasing the distance <i>y.</i> </p> <h5> <i>Adduction of the Stump</i> </h5> <p> A second factor in making allowance for normal use of the hip abductors is the degree of stump adduction in the socket. The "rest-length" theory of muscle action<a></a> has shown that the muscles of the body act most efficiently when they are at approximately their normal rest length. To make the action of the hip abductors efficient, the stump, when fitted in the socket, must be adducted in such a manner that the outward movement of the femur within the muscle mass of the stump is anticipated and that the normal pelvic-femoral angle is maintained as closely as possible while the body weight is being supported on the prosthesis. For the average amputee, this requirement can be met in a practical way by aligning the medial wall of the socket perpendicular to the floor, the lateral wall being sloped definitely inward. Although exceptions are necessitated on the basis of stump length, the short stump being aligned with less adduction, every effort should be made to adduct the stump as much as conditions permit. </p> <p> An additional advantage of alignment in adduction becomes apparent immediately. As a result of the accompanying decrease in tension of the adductor musculature, pressure in the crotch area is decreased. As a result of this relaxation, the pressure in the crotch or medial area (<b>Fig. 2</b>) is then predominantly lateral rather than vertical and no longer causes painful pressure on stretched adductor tendons or in the region of the ramus. It should be emphasized here that a socket properly fitted and aligned carries little or no weight on the medial wall. </p> <h5> <i>Foot Position</i> </h5> <p> Alignment of the foot in a medial position, a fundamental consideration if the amputee is to walk without excessive sidesway or torso list, helps to ensure that the body weight will be borne chiefly on the ischial seat. The average amputee walks well with the centerline of the foot located directly below the ischium during the time the prosthesis is supporting the entire body weight. But this rule-of-thumb, illustrated by the reference line shown in <b>Fig. 2</b>, must vary depending upon the capacity of the amputee to use his hip abductors. If an amputee with a very short stump attempts to use it for lateral stabilization, he cannot tolerate the increased and usually localized pressure resulting from the short stump length and the concentration of force in a small area. He must, therefore, walk with more limited use of his hip abductors, and compensation is effected by leaning over the prosthesis to shift the weight line closer to the support line and by walking with a wider base, an expedient which increases lateral stability but leads to excessive sidesway. Because of these factors, and because of the probability in such cases of some degree of abduction contracture, the amputee with a very short stump should have his prosthesis aligned to accommodate a gait of wider base. </p> <h5> <i>Recapitulation</i> </h5> <p>In summary, mediolateral stabilization of the pelvis accompanied by a decrease in the amount of sidesway and list can be achieved by alignment of the foot in a medial position relative to the socket, by fitting the stump in an adducted position where possible, and by providing firm support for the stump against the lateral wall of the socket to allow efficient use of the remaining abductor musculature of the hip.</p> <h4>Knee Control</h4> <h5> <i>Involuntary Control</i> </h5> <p> Generally, the tendency of the articulated knee joint of the above-knee prosthesis to collapse under load is controlled involuntarily through alignment or by mechanical devices which lock or restrain flexion while the body weight is being transferred through the prosthesis.<a></a> Although involuntary control is desirable as an aid in achieving a smooth and natural-appearing gait, a proper balance must be obtained between the amount of involuntary and voluntary control of knee stability, taking into account the amputee's coordination and age and the condition of his stump. </p> <p>Involuntary control of knee stability during weight-bearing is made possible by so placing the knee axis that it is at all times posterior to the load line of the prosthesis<a></a>. A prosthesis with the socket placed well forward on the knee block or aligned in hyperextension and with the knee joint located posterior to the ankle joint is said to have a high degree of "alignment stability." That is to say, under load the knee joint is forced to extend until the extension stop makes contact and prevents further motion. This expedient often is necessary for amputees who have a fear of falling or when it is required because of age, insufficient stump power, excessive weight, or the prevailing terrain. But it has the disadvantage of making the prosthetic knee hard to flex under even a light load and thus results in poor gait and difficulty in negotiating stairs and slopes. </p> <h5> <i>Voluntary Control</i> </h5> <p> An attempt should therefore always be made to minimize the amount of involuntary alignment stability and to provide for a maximum of voluntary knee control by stump action because this type of functioning results in the smoothest and most effortless gait possible. The average above-knee amputee has a reasonable amount of strength remaining in his hip flexors and extensors and is able to extend and flex his stump throughout an appreciable range of motion, and it is important that the fullest use be made of this musculature in voluntary control of knee stability. That this control may be exercised in the most efficient manner possible, the stump should never approach the limits of its motion as the amputee performs normal activities. If, for example, the stump is able to extend a maximum of 20 deg. to the rear, then at push-off any forced extension in excess of the 20 deg. results in a forward rotation of the pelvis. To compensate for such a forward pelvic rotation, the amputee must arch his back, an expedient which leads to the development of lordosis. Alignment of the socket in a position of initial flexion, as shown in <b>Fig. 4</b>, eliminates much of this difficulty. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Influence of alignment on control of knee stability, socket aligned in initial flexion to avoid exces. sive pelvic rotation.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Initial Flexion</i> </h5> <p>When the socket is aligned with initial flexion, several other advantages become apparent. Since the length of the hip extensors is increased by the additional degree of hip flexion, the amputee has greater control of knee stability during the entire stance phase of the walking cycle. Since the extensor muscles are thus elongated slightly, they are able to develop the required tension easily. With much less conscious effort on the part of the amputee, therefore, the stump is able to exert the force necessary to keep the prosthetic knee back against its extension stop.</p> <p> Again, in an amputee with overdeveloped hamstring musculature there often is a tendency, as the stump extends at push-off, for the muscles to force the tuberosity of the ischium off the ischial seat, thereby causing pressure on the hamstring muscle and attachments and against the anterior brim of the socket. Initial flexion of the socket reduces this tendency and allows a portion of the body weight to be borne comfortably upon the hamstring attachments.<a style="text-decoration:none;">*</a> </p> <p>If the same degree of alignment stability is to be maintained, initial flexion of the socket must be accompanied by a shifting of the socket anterior to the knee axis. Merely changing the extension stop to decrease knee extension never can achieve the desired end-results. But less alignment stability is necessary under these conditions because of the increased voluntary control of the knee. Anterior positioning of the socket relative to the knee axis allows the prosthetic knee to be flexed a great deal more easily as weight is transferred from the prosthesis to the normal leg at the end of the stance phase. The result is a smoother gait. Although increased use of the hip extensors owing to their greater working length produces some decrease in the power available in the hip flexors, the loss is not serious since during ordinary activities the hip flexors never approach the limit of their range of flexion and since the force requirements are small as compared with those of the hip extensors.</p> <h5> <i>Ankle Position and Toe Break</i> </h5> <p> Another important factor in achieving the proper amount of knee stability is the fore-aft position of the ankle joint relative to the knee joint. For the active above-knee amputee, it usually is desirable to have the ankle joint directly below or slightly posterior to the knee joint, as shown in <b>Fig. 4</b>. Such an arrangement has several effects. First, as the foot is moved to the rear, the distance out to the toe break decreases to give the foot more of a "rocker" action and to allow the knee to flex easily at the end of the stance phase. Second, the major portion of the weight can be carried on the ball of the foot while standing. And third, the amount of toe clearance during walking is greater for a given angle of knee flexion. To move the ankle joint too far to the rear, however, results in instability at heel contact and excessive shortening of the stride. </p> <p> Many of these advantages can be achieved by use of a double toe break <i>(i.e.,</i> a flexible forefoot), which also gives the foot more of a rocker action and decreases the amount of vaulting over the prosthetic foot. But too much flexibility or too short a distance from ankle to toe break causes the leg to feel too short at the time of push-off. </p> <h3>Dynamic Alignment</h3> <p>For the major part of the time that the amputee is supporting himself on the prosthesis during the stance phase, the motions are relatively smooth, and the forces act on the prosthesis in essentially the same way as if the amputee were standing still with all weight carried on the artificial leg. During the swing phase, however, and during the times of transition from stance to swing and from swing to stance, the behavior of the prosthesis is influenced largely by dynamic forces varying rapidly with time. It is often relatively easy to fit an amputee so that he is comfortable in the stance phase, but in many cases it is more difficult to construct the prosthesis so that the amputee is able to walk with a smooth, natural-appearing, effortless swing-through. The first requirement for a smooth swing phase is a smooth transition from stance to swing, since, if the prosthesis is to swing properly, it must be given a good start.</p> <h5> <i>Knee Stability and Toe Break</i> </h5> <p>Of particular importance during these transition periods are knee stability, as affected by alignment and by the stiffness of dorsi-fiexion and plantar flexion at the ankle, and the combined effect of toe-out and orientation of the toe break in the foot. For security, the knee axis should be positioned far enough behind the hip-ankle line so that the amputee is conscious of a stable knee while standing. The amount of security desired depends upon the particular amputee. If, as the amputee attempts to walk, the knee feels insecure, the dorsiflexion position and stiffness in the ankle should be investigated as a possible additional cause of knee instability.</p> <p>In general, placing a stiff dorsiflexion bumper in the ankle and having the foot plantar-flexed in the neutral position, close to the point where the amputee has the sensation of "walking over a hill," produces the most desirable knee stability and allows smooth flexion of the knee at the start of the swing phase. The amount of toe-out usually is adjusted to the individual amputee. In all cases, however, the toe break should be at right angles to the line of progression to prevent insecurity resulting from the rapid shifting of the center of pressure during push-off.</p> <h5> <i>Whip in the Swing Phase</i> </h5> <p> One of the more obvious indications of poor dynamic alignment is the so-called "whip" of the prosthesis during the swing-through (<b>Fig. 5</b>). This lateral movement of the knee accompanied by medial movement of the foot, or vice versa, usually is caused by an incorrect amount of adduction for the particular socket being fitted, an improper angle of the knee axis with respect to the frontal plane, the natural tendency of the femoral stump to twist inward as it is brought forward, or a combination of these factors. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Common indications of incorrect alignment. A, Whip of the prosthesis during the swing phase. B, Mediolateral instability. C, Rotation at heel contact. For specific causes of these difficulties, see Radcliffe (10).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An above-knee prosthesis often is "knocked" at the knee to position the foot laterally for greater stability while standing. Sufficient two-leg standing stability thus can be attained, but a stable, narrow-base gait is not then possible. The tendency of the prosthesis to whip also is aggravated because, as it swings like a pendulum, the leg has a natural tendency to swerve medially after toe-off and then to swerve out again just before heel contact. A prosthesis having the foot aligned medially for a narrow base during the stance phase need only move forward in a straight line from toe-off to heel contact.</p> <h5> <i>Rotation of Knee Axis</i> </h5> <p> Studies of normal human locomotion<a></a> show that the femur rotates an average of 3 to 4 deg. medially as the hip is flexed to bring the knee forward. Medial rotation of the femur causes a lateral displacement of the foot, as can be verified easily by observation of a person standing and flexing the hip while the shank hangs vertically. Accordingly, the knee axis in an above-knee prosthesis usually is rotated laterally to compensate for the tendency of the femur to rotate medially as the hip is flexed.<a style="text-decoration:none;">*</a> When the prosthetic knee axis is aligned in a position laterally rotated with respect to the socket, the foot moves somewhat medially with knee flexion, thus compensating for lateral movement of the foot caused by the medial rotation of the socket during the swing phase and allowing the foot to travel in a straight path. </p> <h5> <i>Ankle Stiffness</i> </h5> <p>The stiffness of plantar flexion at the ankle determines, to a large degree, the stability of the knee at heel contact. A stiff ankle does not allow the foot to rotate forward into the stable flat position and thus tends to cause the knee to buckle forward as the weight is transferred to the prosthesis. An ankle joint with insufficient plantar-flexion stiffness, however, allows the foot to slap at heel contact. A proper balance between these two effects must therefore be attained for the individual amputee. Proper swing-through is achieved by proper dynamic alignment, which, in turn, is effected by a comfortable, stable, and functional prosthesis in the stance phase; a smooth transition from stance to swing phase; proper ankle stiffness; and adjustment of the knee axis in lateral rotation to compensate for medial rotation of the stump during hip flexion.</p> <h4>Socket Shape and Orientation</h4> <p>Considered thus far are the means by which the amputee can make most efficient use of the remaining hip musculature to control body movements and to control the prosthetic knee during the stance and swing phases. There are, however, many functional details of socket shape and fit which make it possible for the amputee to derive these benefits comfortably.</p> <h5> <i>The Lateral Wall</i> </h5> <p>As already indicated, for the amputee having sufficient stump length and power, sidesway and leaning over the prosthesis during the stance phase can be eliminated almost entirely by making provision in the socket for full use of the remaining abductor muscles of the hip, primarily the gluteus medius. This can be achieved in two ways. First, the stump is adducted in the socket so that the lateral wall is sloped downward and inward, the medial wall remaining essentially vertical. Second, a slight flattening of the lateral wall, and undercutting for relief of pressure points where necessary, ensures a comfortable distribution of the pressure directed medially against the stump. The hip abductors then can develop tension as needed because the excursion of the femur is blocked comfortably against the lateral wall of the socket. If, after the fit of the lateral wall is considered satisfactory, the socket is too tight, relief should be provided along the medial wall of the socket to avoid disturbing the fit required to block excursion of the femur.</p> <h5> <i>The Anterior Wall</i> </h5> <p>The lateral pressures, acting with the horizontal counterpressures in the upper portion of the medial wall, tend to maintain the ischium on its seat medially. To hold the ischium in place still more firmly, it is necessary to provide stabilization at the front of the socket. Accordingly, the anterior wall of the socket should fit the stump firmly in the area of Scarpa's triangle, and a very accurate measurement should be made of the distance from the ischial tuberosity to the tendon of the adductor longus so that the anteromedial apex may be fitted snugly around the adductor tendons. The socket brim should be rounded and fitted high on the anterior side. If fitted properly, the anterior brim usually can be brought up to the level of the inguinal crease without producing discomfort when the wearer is seated. The actual height of the anterior brim varies with the individual and is limited by contact with bony prominences. It usually extends from 2 to 2-1/2 in. higher than the ischial seat, but it should extend at least high enough so that the brim will press into the abdominal muscles rather than pinch a roll of flesh near the top of the stump. Distributed over the upper portion of the entire anterior wall of the socket, such anterior counter-pressure easily can prevent the ischium from sliding into the socket and can prevent the discomfort that would result in the crotch area.</p> <h5> <i>The Adductor Region</i> </h5> <p>Incorporation of the proper distance from the adductor tendons to the ischial tuberosity, combined with a well-fitted, high, anterior brim, usually eliminates entirely any unwanted pressure in the crotch area. Some lateral counterstabilization by pressure in the crotch area is unavoidable, but it should be predominantly by lateral rather than by vertical pressure, and it can be tolerated comfortably if distributed over the widest possible area. Flattening the medial wall of the socket is one means of ensuring a comfortable distribution of pressure in the adductor region.</p> <h5> <i>The Anteroposterior Dimension</i> </h5> <p>Weight-bearing in the gluteal region makes it possible to reduce the size of the ischial seat. If the anteroposterior dimension is shortened, the socket may be widened in the mediolateral dimension, a feature having several advantages. First, it allows a greater area for gluteal weight-bearing on the posterior rim of the socket. Second, the ischium is moved laterally, allowing the ramus to be carried within the brim of the socket and thus easing a major source of irritation. Finally, because the ischium bears no weight in the posteromedial apex, there is less tendency for crowding of the adductor and hamstring musculature. Relaxation in this area owing to stump adduction also helps to relieve uncomfortable vertical pressures.</p> <h5> <i>Shape at Ischial Level</i> </h5> <p> As a result of these functional requirements, the socket shape shown in <b>Fig. 6</b> has evolved. When coupled with the proper alignment, it has proved to be extremely beneficial to the average amputee. As with any method of fitting, variations in shape must be made in accordance with the muscular development and condition of the individual stump. The influence of muscular development at the ischial level is shown in (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anatomical features of an above-knee stump in weight-bearing, shown in cross section 1/2 in. below schial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7. Influence of stump muscular development on socket shape at ischial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Entrances of the adductor tendons in the anteromedial apex, shown as <i>A</i> in <b>Fig. 6</b>, can be made more comfortable by a slight flaring of the socket brim in this region. Flaring of the socket brim in the hamstring area <i>B</i> has no function while the amputee is walking, but it contributes remarkably to his comfort while sitting. Many amputees experience a burning sensation while sitting because the hamstring attachments attempt to stretch over an ischial seat located high or medially, especially when the ischial seat has been placed diagonally across the posteromedial apex. The socket shape shown in <b>Fig. 6</b>, however, allows the ischial seat to be placed laterally to provide relief in the hamstring region and does not disturb the functioning of the limb during walking. </p> <h3>Construction of the Socket</h3> <h4>Stump Examination and Measurements</h4> <p>Before construction of an above-knee prosthesis is started, it is essential that a very careful evaluation be made of the amputee and his stump. A prosthesis may thus be planned and constructed to take full advantage of the individual patient's capabilities. Of particular importance is a thorough examination of the stump with regard to its functional characteristics. Answers to the following questions are helpful in planning the prosthesis, and they should be included in the examination data:</p> <ol> <li> What degree of stump flexion contracture is present? </li><li> What degree of stump abduction contracture is present? </li><li> Is the stump musculature soft, average, or hard? </li><li> Is the hamstring group soft, average, hard, or prominent under tension? </li><li> Is the gluteal group soft, average, hard, or prominent with stump extension? </li><li> Is the stump contour along the lateral side convex, concave, or essentially flat? </li><li> Is the rectus femoris muscle prominent with stump flexion? </li><li> Is the adductor longus soft, average, or hard? </li><li> Is the ischium toughened, pressure sensitive, padded with muscle, or prominent? </li><li> Has the amputee been accustomed to ischial-bearing? </li><li> What is the amount and location of redundant tissue? </li><li> What is the extent, location, and adherence of scars? </li><li> Are there areas of prior irritation as shown by blisters, boils, pimples, scars, darkened skin areas, and so forth? </li><li> Are there areas which are sensitive because of bone spurs or other prominences? </li><li> Is there any prior history of edema? </li></ol> <p> In addition to this general information about the condition of the stump, which can be recorded on a form such as <b>Fig. 8</b> <i>8A,</i> the series of measurements indicated in <b>Fig. 8</b> <i>8B</i> should be recorded carefully. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8A. Form used at the University of California for recording stump characteristics and measurements in above-knee fitting.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Planning the Socket Shape</h4> <p>After the information gathered during the examination is recorded, the limbfitter is ready to begin planning the prosthesis, a phase essential to proper fit. The socket contours and the over-all alignment to be incorporated into any lower-extremity prosthesis depend upon the interrelation of many factors. First, the amputee's general physical condition must be determined. Will the amputee be an active walker? Will ease of walking be more important than knee security, or vice versa? Has the amputee developed gait habits that require corrective training? Second, the stump must be evaluated on a functional basis. In terms of its potential usefulness in control of the prosthesis and of body movements, is it classed as short, medium, or long? Is there a normal range of motion in all directions? Are there any sensitive areas that restrict stump function? The answers to these questions affect the alignment of the prosthesis as well as the fit of the socket.</p> <p> It is important to plan for alignment before the socket contours are considered because the orientation of the socket on the stump and the alignment of the socket on the prosthesis may affect considerably the method of fitting the socket. Shown in <b>Fig. 8B</b> are some general features of alignment based upon the functional capacity of the stump-short, medium, and long. There are exceptions, of course, and these illustrations should serve only as a guide. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Figure 8B.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the general type of alignment has been decided upon, the necessary features can be incorporated into the orientation of the socket on the stump, a matter requiring a decision regarding the approximate amount of initial flexion and adduction to be anticipated in the final alignment. The socket contours are determined by reference to the information on stump muscle development recorded during the examination. <b>Fig. 7</b> shows a typical socket shape for an amputee of average musculature and indicates the variations possible with different types of stump muscle development. Undersize patterns for use in roughing out the socket contours are shown actual size in <b>Fig. 9</b> and <b>Fig. 10</b>. The dimensions shown along the medial side of the patterns are typical measurements of the distance from the ischial tuberosity to the anterior aspect of the adductor longus tendon. The perimeter measurements shown correspond to actual stump dimensions. But these patterns may require modification to provide for individual stump characteristics, an example of such a pattern modification being shown in <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Undersize socket patterns (shown actual size) for stump with soft or average musculature,</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Undersize socket patterns (shown actual size) for stump with firm musculature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Materials</h4> <p>The primary features required of a material to be used in making a suction socket are ease in forming to the proper shape, adaptability to a surface finish which is nonirritating and easy to keep clean, and ease in making alterations as required by changes in the stump. Wood and plastic laminates have, so far, proved to be the most satisfactory. But major changes in the size of the stump often take place during the first several months of wear. Hence, wood is recommended for the first socket because it is relatively simple to shape and allows alterations to be made as required. After the stump size is stabilized, a socket can be made of plastic laminates, which seem better than wood because of their flexibility, their ability to stand cleansing with soap and hot water, and their greater resistance to the action of perspiration.</p> <h4>Shaping the Wooden Socket</h4> <p> The three stages in shaping a typical socket are shown in <b>Fig. 12</b>. In the first, the posteromedial shelf is cut after laying out the socket pattern on the top of the socket block. The ischiogluteal shelf is cut in such a way as to be horizontal when the socket is oriented vertically in space. For the average socket, the medial wall is parallel to the vertical reference line ( <b>Fig. 2</b> ), and therefore the horizontal ischiogluteal shelf is cut at right angles to the medial wall of the socket. After the ischiogluteal shelf is cut, the missing portion of the socket pattern line is transferred down to the ischial level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Modification of socket shape to accommodate individual stump characteristics.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second construction stage shows the roughed-out socket, where considerable extra wood has been left above the ischial level to allow for the protrusion and flaring of the anterior brim in this area. The finished socket is shown in the third stage with all areas of the socket brim flared and rounded to prevent irritation of the stump, especially important in the anteromedial apex where the adductor longus tendon enters the socket.</p> <p> <b>Fig. 6</b> indicates the principle muscle groups and other anatomical features considered in preparing the patterns used as a guide in the preliminary layout of the socket outline. Because of the atrophy of certain muscle groups in the above-knee stump, and because the cross section shows the stump in the weight-bearing condition, the shape differs slightly from that of the normal. When the stump is bearing weight, it is necessarily compressed slightly in areas of relatively soft tissue which support load, such as the gluteal channel. </p> <h5> <i>The Lateral Wall</i> </h5> <p>The lateral side is always higher than the level of the ischial seat. In most cases, it is possible to extend it over the trochanter. To do so is especially important when the slump is short and when the height of the socket in this region may be required to maintain suction. If the muscular development requires it, the lateral side of the socket is, in some cases, undercut above the ischial level. Examination of the amputee determines the amount of undercut required, and, if it is necessary, it should be done with caution. The lateral wall should taper in acutely below the ischial level to provide adduction and lateral support for the femur upon weight-bearing above the distal end. Because the femur has been established as the body stabilizer during the stance phase, an undercut below the ischial level may distribute the pressure unevenly and thus allow most of the pressure to be taken at the top of the socket and near the distal end of the stump. The lateral wall should be shaped to fit the stump accurately and should, if necessary, be flattened to distribute the lateral-support pressure over a large area so that it can be tolerated comfortably.</p> <h5> <i>The Medial Wall</i> </h5> <p> The length of the crotch-line area that receives the adductor longus, gracilis, and adductor magnus muscles should be determined accurately by skeletal measurements. As indicated in <b>Fig. 11</b>, the measurement from the anterior aspect of the adductor longus tendon to the weight-bearing portion of the ischial tuberosity, less about half an inch, gives the approximate length of the medial side of the socket. In general, the upper third of the medial wall is flattened, and the superior brim is flared to prevent skin irritation. </p> <p>In almost every case, the crotch-line height varies with respect to the level of the ischial seat, but it should always be as high as is tolerable. In the typical socket, the crotch area is from 1/8 to 1/4 in. lower than the ischial seat. A pelvic tilt lowers the ramus of the ischium and may require a lowering of the medial side of the socket. In a properly fitted ischiogluteal weight-bearing socket, little or no weight should be borne on the medial side. From the ramus to the anteromedial apex, the medial brim can be raised as governed by comfort. If a medial adductor roll is present, the socket is enlarged slightly (never lowered) on the medial side to accommodate the excess tissue, which then is pulled into the socket and eventually diminishes.</p> <h5> <i>The Anteromedial Apex</i> </h5> <p> The socket shape at the anteromedial apex (<b>Fig. 6</b>) should conform to the contour of the adductor longus and gracilis muscles. The shape varies in each case, however, because these muscles form a cordlike tendon which must be fitted accurately. Tightness in this region, a common source of irritation in suction sockets, usually is caused by excessive length of the medial side of the socket. This condition allows the ischium to slide forward into the socket and to wedge the stump into the anteromedial apex. If tightness in the anteromedial apex persists, it is apt to be due to inadequate support of the stump across the anterior brim and down the anterior aspect of the adductor group. </p> <h5> <i>The Anterior Wall</i> </h5> <p>The primary function of the anterior brim of the socket is to maintain the ischium in place on the ischial seat so that ischial weight-bearing causes no discomfort. In many cases of amputees who are unable to tolerate ischial weight-bearing, the trouble can be traced to improper contact between ischium and socket. Ischial bearing on the edge of a flat ischial seat is especially uncomfortable. To maintain the ischium in place properly, considerable counterpressure from the front of the socket is required. Since, by and large, the portion of the stump in contact with the region of the anterior brim is soft tissue, some compression of the stump is necessary. This is accomplished by a flattening and inward protrusion of the anterior brim in the area of Scarpa's triangle.</p> <p>The upper portion of the anterior brim is fitted 2 to 2-1/2 in. higher than the ischial seat and with a generous flare along the superior brim. When the socket is fitted with such a "high front," the anterior brim can hold the ischium in place comfortably. The high front does not interfere with sitting or with the amputee's ability to bend over far enough to tie his shoes. As the stump is flexed, the higher brim of the socket is accommodated by the abdominal musculature and does not pinch a roll of flesh on the upper portion of the thigh. The brim should be lowered only as necessary to prevent contact with bony prominences such as the anterosuperior spine. A channel should be provided below the brim for the rectus femoris muscle, which usually becomes prominent with stump flexion.</p> <h5> <i>The Posterior Wall</i> </h5> <p>The back of an ischial-bearing socket deserves particular attention. Channelization for the gluteus maximus muscle depends on the individual, but, in most cases where there has been little atrophy or distortion, this region of the socket should be kept on the same level as the ischial seat with a gradual enlargement in the posterolateral apex. The gluteus muscle should carry a considerable amount of body weight on a flared socket brim.</p> <p>Relief for the adductor muscles or the crotch line often can be made by relieving the gluteus maximus. Too tight a fit over the gluteus maximus can cause crowding of the adductor muscles in the crotch section. If the space for the gluteus muscle is lowered and widened, the ischial tuberosity can be moved posteriorly and laterally on the ischial seat of the socket. Lowering this section, however, increases pressure on the ischial tuberosity and should, therefore, be avoided. Should additional room be needed within the socket, the lateral side of the gluteal region can be made wider. The gluteal area should be widened instead of cut deeper posteriorly because a deeper section forms a hump or radius on which the leg rotates during sitting and thus causes a burning sensation of the skin over the ischial tuberosity.</p> <p>The outside shape of the socket in the posterior region is important to sitting comfort, but no attempt should be made to complete its shaping until the inside has been made comfortable and until the leg has been aligned properly and tested by walking. After these things are done, the back then is flattened for comfort and alignment while sitting.</p> <h5> <i>The Ischial Seat</i> </h5> <p>The ischial seat cannot be overemphasized. It should be located accurately under the ischial tuberosity, and, in the determination of its location, individual variations in anatomy must be taken into account. The seat should be adequate but not so wide as to cause discomfort while sitting. Slipping of the ischial tuberosity either to the inside or to the outside of the seat, conditions which create a great deal of discomfort, can be prevented by shaping the bearing surface in such a way that the seat slopes slightly toward the inside of the socket to render it more comfortable. Sloping increases the radius of the edge of the ischial seat and lessens the burning sensation of the skin in this region.</p> <p>If the ischial seat is too prominent, or if the ischium rides on the edge of the seat, a jabbing sensation or a marked increase in pressure is felt near the end of the stance phase. Lowering the ischial seat allows more weight to be distributed to the gluteal region and, if the ischial tuberosity is located properly on the seat, results in less discomfort and a shorter break-in period.</p> <p>Amputees with highly developed stump muscles may not require a well-defined ischial seat. In some cases, the muscles may push the ischial seat away from the tuberosity of the ischium and cause the weight to be carried by the muscles around the top of the socket. Such a condition is not objectionable, provided that the socket is designed with proper modification of the ischial seat. Indeed, such a design may be necessary in unusual cases, as for example those with end-bearing stumps.</p> <h4>Special Considerations in the Suction Socket</h4> <h5> <i>Tightness of Fit</i> </h5> <p> In the case of the suction socket, better results are obtained by having proper contours than by having a tight fit .<a></a> If, in the course of donning the leg, much difficulty is encountered in removing the sock, the fit is too tight. The superior brim of the socket should fit the contour of the stump while the muscles are tensed, and the fit should be so accurate that the socket can be suspended for short periods by skin friction without the aid of negative pressure <i>(i.e.,</i> without a valve). </p> <h5> <i>Free Space Below the Stump End</i> </h5> <p>The volume of unoccupied space at the lower end of the suction socket is not critical in obtaining sufficient suction. In most cases, it is convenient to have approximately 2 in. of space below the end of the stump to provide room for installation of the valve and for elongation of the soft tissue. In general, the smaller the volume in the end of the socket the less the excursion, but in itself the amount of free volume has no significant effect on the magnitude of the negative pressure.</p> <h5> <i>End Bearing</i> </h5> <p>If it can be tolerated, end-bearing is recommended because it relieves the load on the ischium. Felt or foam-rubber padding placed in the bottom of the socket permits comfortable end-bearing, the thickness of the padding governing the amount of weight carried on the end of the stump. Although little free space remains in the socket, adequate suction and control are not affected. For example, Gritti-Stokes amputations, which are principally end-bearing, have been fitted successfully.</p> <h5> <i>Inside Finish</i> </h5> <p>No single recommendation is made regarding adequate nonirritating finishes. Industrial and perspiration-resistant lacquers common to the limb industry are being used routinely. Some subjects have reported slipping of the socket because of perspiration. In some cases, perspiration also has caused the lacquer finish to deteriorate and to produce a roughness resulting in skin irritation. In general, however, these industrial lacquers have proved satisfactory when applied according to manufacturers' specifications. In cases of excessive perspiration, the socket may have to be refinished every few months. Whenever perspiration creates a severe problem, the amputee should be referred to a dermatologist for possible treatment.</p> <h5> <i>Bottom Seal</i> </h5> <p>The bottom of the socket should be sealed with a piece of hard wood 1/8 in. thick or more, cut so that the surface goes along the grain, and sealed with a waterproof glue. The bottom may be given additional protection by applying a thin coating of one of the thermosetting plastics common to the limb industry.</p> <h5> <i>Control of Negative Pressure</i> </h5> <p>Several different types of valves have been used in suction sockets with good results. A simple type of plug valve with a manual suction release is satisfactory. Automatic expulsion valves permit some change of air in the socket, a beneficial feature during hot weather and at times when the amputee perspires. They have proved successful in all cases and are now in general use.</p> <p>The valve opening should be positioned for ease in removing the fitting sock when the leg is donned and for convenience in operating the manual control, and it should be placed where the distal end of the stump is least likely to touch the inner face of the valve. The optimum location is toward the front on the medial side below the stump end.</p> <p> The magnitude of the negative pressure or suction required to hold a suction socket in place is only slightly greater than the value given by dividing the weight of the prosthesis by the cross-sectional area of the stump near the distal end-in most cases about 1-1/2 lb. per sq. in. With the additional support given by contracting the stump muscles during each step, a negative pressure of 1-1/2 lb- Per sq. in. is sufficient. Some amputees prefer somewhat greater suction, with its accompanying feeling of security, but excessive suction may cause edema. A negative pressure greater than 1-1/2 lb. per sq. in. indicates the presence of forces tending to pull or push the leg off the stump. This action may occur when the stump muscles are contracted, or it may be caused by an improper fit resulting in constriction of the muscles. Use of a gauge for measuring the maximum negative pressure at the time of the rough and the final fittings serves as a check on the quality of fit and is essential to good and consistent results. </p> <p> Accurate records should be made of the variations in pressure inside the suction socket during normal walking. With the automatic expulsion valve now in general use, these records should show a small positive pressure during weight-bearing and a negative pressure when the leg is in the swing phase. ( <b>Fig. 13</b> ) is a record of the pressure variations in a suction socket during two complete walking steps, the valve used during this test permitting automatic exhaust starting at a positive pressure of 1/2 lb. per sq. in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13. Three stages in the construction of a wooden socket. A, Block cut to form posteromedial shelf. B, Roughed-out socket. C, Completed socket with inside finished and rawhide covering on outside.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stiffness of the spring in the valve has, in itself, no direct effect on the magnitude of the maximum negative pressure. It does, however, allow a greater or lesser amount of air to be expelled with each step and thereby affects the amount of positive pressure developed during weight-bearing. Fairly high positive pressure within the socket during the stance phase generally is found desirable because it increases the pavex action of the socket on the stump, with consequent benefit to the circulation. High positive pressures help to control edema and to give the amputee a sense of "walking on air." But, as already mentioned, too great a positive pressure in the stance phase may tend to push the leg off or to increase the piston action of the stump in the socket. Springs permitting expulsion at a positive pressure of 1/2 <i>, 1-1/2</i> or 2 lb. per sq. in. now are commercially available. The choice should be based upon individual circumstances. Some leakage generally occurs either in the valve or between the socket wall and the stump. A regulated amount of leakage is, however, desirable because it relieves the suction during periods of inactivity. If the leak rate is too great, the leg may fall off or the piston action may be excessive and cause discomfort. If the leak rate is too small, however, edema may result. A good test for leak rate is to measure the time required for the negative pressure to drop to half its initial value while the prosthesis is suspended on the relaxed stump. If the time is 50 to 80 sec, the leak rate is satisfactory, but if it is greater than 100 sec, the manual release should be used during periods of inactivity. </p> <p>Conclusion In summary, then, it may be restated that, in the construction of an above-knee artificial leg, the objective of the prosthetist is to provide the wearer with optimum security in standing and walking, the best possible walking pattern, a minimum requirement for expenditure of energy in usual activities, and a generally comfortable leg that can be used more or less continuously without injuring the stump and without causing undesirable postural deformities. The above-knee prosthesis is called upon to replace as nearly as possible the functions of the normal leg, but it must do so under the influence of a residual motor mechanism deficient in power and sensory control. The necessary features are therefore to be obtained only by observance of certain functional rules established on the basis of anatomical, physiological, and mechanical considerations.</p> <p>Of first importance is that the prosthetist well understand the mutual interdependence of the details of alignment of the various components and of the fit and orientation of the socket. Since, unlike the normal limb, support in the above-knee prosthesis is not through the shaft of the femur but through some other axis, due cognizance needs to be taken of the new set of musculomechanical relationships and of the influence of these relationships on the static and dynamic characteristics of the artificial replacement. When proper compensation for these factors is made by the limbfitter, undesirable compensation by the amputee is avoided, while the requirements of comfort, function, and acceptable gait are satisfied. In no other way can so much satisfaction be afforded the above knee amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Typical pressure variation in an above-knee suction socket during level walking. Body weight: 145 lbs.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> <p>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949).</p> </li> <li> <p>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29.</p> </li> <li> <p>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947).</p> </li> <li> <p>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951).</p> </li> <li> <p>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</p> </li> <li> <p>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff.</p> </li> <li> <p>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953).</p> </li> <li> <p>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110.</p> </li> <li> <p>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</p> </li> <li> <p>Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940).</p> </li> <li> <p>Schede, Franz, Theorelische Grundlagen fur den Bau von Kunstbeinen; insbesondere fur den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</p> </li> <li> <p>Schnur, Julius, Beinbelastungslinie und Schwerlinie, Medizinische-Technik, 5(3):54 (March 1951).</p> </li> <li> <p>Schnur, Julius, Die Aquilibral-Kontakt Prothese, Orthopadie-Technik, 4(2) :36 (February 1952).</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</p> </li> <li> <p>Wagner, Edmond M., and John G. Catranis, New</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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The amount of medial rotation in the stump depends upon the inherent physiological characteristics of the hip joint and upon the loss of muscular function after amputation. Some amputees have even been observed to have lateral rotation of the stump upon hip flexion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Too much initial flexion results in a decrease in stride length, which may be undesirable in some cases.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall"> Wagner, Edmond M., and John G. Catranis, New </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall"> Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall"> Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall"> Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be understood that no new theory of alignment is intended, that the aim is simply to explain logically some of the problems facing prosthetists in the construction of above-knee legs and to provide rational solutions for those problems. The views presented are the combined result of experience gained at the University of California Prosthetic Devices Research Project during limbshop trials of the adjustable leg and alignment duplication jig(8,9,10) of a study of methods presently in use by the artificial-limb industry, and of a survey of information presented in the German literature.(15,16,17)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Acting Assistant Professor of Engineering Design University of California, Berkeley; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-22.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-23.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-24.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-25.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-26.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-27.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-28.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-29.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-30.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-31.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-32.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-33.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-34.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-35.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-36.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 Functional Considerations in the Fitting of Above Knee Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/baa690570cdf9103498cc78a51072780.pdf efeb1aaeccfa288eeec9bc5ecd38a00c https://staging.drfop.org/files/original/02116dc22518c1eb39c68be56eeadcbe.jpg 8a184304fcba8cc4b1780900d847a8a3 https://staging.drfop.org/files/original/5d633c5174ca141632fa4a4f1e21747b.jpg 5e04ded931d40f7f74cd630cd3fa88fd https://staging.drfop.org/files/original/d54d587bc683285e12a948e28325014e.jpg 7ac002016da544b27b8905e5ce7e190c https://staging.drfop.org/files/original/2d411a366a5894b21122ede2a2d07a78.jpg c37bdd60e381a074882dba174d8ebb45 https://staging.drfop.org/files/original/b3276065c28d0d1acc9bd4fbbc1682bd.jpg 161db3ea42e5ab5ea0b8020149c71991 https://staging.drfop.org/files/original/634383156fceaec626e209462b0523ec.jpg 846701e1d084860d18e51ec6f7c5a191 https://staging.drfop.org/files/original/3534840b8b9014b939dcf553b7d798a6.jpg 4ccf1cb63eb1401e3b40b6c3e79e7463 https://staging.drfop.org/files/original/cd15263c33b6e8fe70f3974c54e1df63.jpg 0ea4cec660c63647ee6e63d27d767ee7 https://staging.drfop.org/files/original/5b000331efb05bcdc1dbbad2cfa91b16.jpg 3ca6176c57505618b576214526d5f2fd https://staging.drfop.org/files/original/721dba1469c7361d052d71dc63510353.jpg 45e5a147daaf98d9a8290c41165c37e9 https://staging.drfop.org/files/original/1693caaecd751197fb1a87e816bd59c1.jpg b812afdf152beffe304e924d2710b595 https://staging.drfop.org/files/original/7790ac1614e11c427aa22f45d0c2dd52.jpg 073ddc987fa51b9507a6a6c4ab2381e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_004.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anthropology and Social Significance of the Human Hand</h2> <h5>Ethel J. Alpenfels, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>A definitive study of the anthropology of the human hand has yet to be written. Certain investigators, notably Krogman<a></a>, Schultz<a></a>, Ashley-Montagu<a></a>, Clark<a></a>, and Huxley<a></a>, have done intensive work on specific aspects of the morphology of the human hand. Nevertheless, the paucity of published studies, the fragmentary nature of the research, and the failure to attempt any but the most general conclusions make it difficult to summarize in a short article the present status of the hand in human evolution. Authorities differ both in opinion and in practice as to the value of anthropometric measurements in tracing the lines along which specialization has moved in the evolution of the hand. Published materials on the social significance of the hand are, however, numerous, and the importance of the hand as an organ both of performance and of perception has been recognized in all fields of the social sciences.</p> <p>Man alone has a hand. He uses it as a tool, as a symbol, and as a weapon. A whole literature of legend, folklore, superstition, and myth has been built up around the human hand. As an organ of performance it serves as eyes for the blind, the mute talk with it, and it has become a symbol of salutation, supplication, and condemnation. The hand has played a part in the creative life of every known society, and it has come to be symbolic or representative of the <i>whole </i>person in art, in drama, and in the dance. Students of constitutional types have used the hand as a means of classification, and the correlation between mental ability and manual dexterity has been the subject of much research. At the University of Pennsylvania, Krogman, using x-rays of the hand, currently is demonstrating new and important aspects of the interrelation of a child's growth and mental age. Thus the hand, perhaps because it is also dominant in the world of action, has come to be interpreted and understood best in its social aspects.</p> <p>But in a sense the human hand is a paradox. Although it is said to be the highest achievement of primate evolution, research to date shows it to be no more than a variation of a primitive vertebrate plan. The successive stages of evolution give proof, if proof be needed, that our sensitive and mobile hands, with their opposable thumbs, are part of man's vertebrate ancestry.</p> <p>In the suborder Lemuroidea, both recent and extinct, are found pawlike hands. The fourth digit<a style="text-decoration:none;">*</a> is elongated and, together with the first digit, acts like a pair of pincers to grasp a bough. Hooten<a></a> has pointed out that this is an adaptation found in all the lemurs, enabling them to maintain a more secure hold on boughs of large diameter. In lemurs, all of the digits are flat-nailed (except in the aye-aye, which has kept a number of primitive anatomical features), and several modifications appear in the carpal pattern. <b>(Fig. 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. One conventional method of identifying the digits of the hand. Some authorities prefer to think of the hand as possessing a thumb and four fingers. Both methods of nomenclature occur throughout this issue of Artificial Limbs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suborder Tarsioidea, entirely arboreal, specialization of the hind limbs for hopping frees the hands not only for grasping but for feeding as well. The hind limb is longer than the forelimb, all of the terminal phalanges are flat-nailed, and the terminal digital pads have curious discs, almost like suction cups, enabling the tarsier to support himself on a smooth surface.</p> <p>These and other adaptations foreshadow higher primate development (<b>Fig. 2</b>), but we must look further to find man's place in the primate scheme. The suborder Anthropoidea, the third and highest of the primate group, includes larger arboreal forms. Longer fore limbs, together with a relatively shorter thumb (approaching atrophy in some forms), provide a means of brachiation. It has been suggested that the short thumb is related to the specialization of the hand as a grasping mechanism, permitting a quick release of the hand in swinging from one branch to another. But in this suborder the hands still retain their primitive features, and only in certain of the Old World Monkeys do the proportions of the digits approach those of man. The emancipated hands of the anthropoids, with thumbs that rotate and oppose the other finger tips, are directed by a more complex nervous system and a larger and better developed brain. Liberation of the hand may have been one of the decisive forces in the descent of certain anthropoids to the ground.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparative proportions (not relative size) of the hands of man and of certain related ancestral forms. Top row, left to right, hands of a tarsier, of a lemur, and of a Rhesus monkey. Bottom row, left to right, hands of a chimpanzee, of a human with atypical simian characteristics, and of normal man. In all cases except that of the lemur, the digital formula is 3 &gt; 4 &gt; 2 &gt; 5 &gt; 1. From Jones<a></a>, by permission of Bailliere, Tindall, and Cox, Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Evolution of the Hand</h3> <h4>Links with the Past</h4> <p>Man's hand retains the ancient pentadactyl pattern found in early vertebrates. Geological records show that, during the Devonian period of Silurian times, primitive sharks appeared having typical paired fins corresponding to the paired limbs in man, and these organs were destined to give rise to later and higher forms. But there is a great difference belween the paired limbs of the early forerunners of present-day fishes and the pentadactyl limbs of other vertebrates. All of the steps are not yet clear, and the gap between the ancient fishes and the amphibians has not yet been bridged, but it appears that in the early amphibians the migration from water to land led to adaptations and modifications, especially in the area of the shoulder and pelvic girdles.</p> <p>These early ancestors of the primates had short legs, which grew progressively longer in the mammalian stage<a></a> and they walked flat-footed. The ability of the limbs to rotate brought about changes in the entire body. Striking homologies can be found in the hand and arm of man, the wing of a bat, and the foreleg of the frog. Where there are fewer digits, as in the hoof of the horse or the wing of the bird, the reduction has been due to adaptation to special environmental conditions.<a></a> Such reductions make for greater speed in the specialized limbs of the horse.</p> <h4>Upright Posture and Differentiation</h4> <p>The release of the hand from the requirements of locomotion, accompanied by the specialization of the foot and hind limbs for that purpose, led to upright posture (<b>Fig. 3</b>). Evidences of divergent evolutionary trends in the primate order are clearly distinguishable in the primate hand, especially those relating to limb length and trunk length (<b>Fig. 4</b>). Only the mountain gorilla has a hand shorter than that of man, not only with respect to limb length but in relation to trunk length. The longest hands among the great apes are those of the gibbon, the orangutan, and the chimpanzee. Specialists in the evolution of the hand have attributed the long, slender hands of these genera to brachiation and suspension, behavior that elongates not only the arms but, the hands as well, especially the fingers and the metacarpal bones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The evolution of the hand (top row) and foot (bottom row), as revealed in skeletal structure. A, a primitive reptile; B, C, mammal-like reptiles; D, a lemur, representing a primitive mammalian type; E, man. Note the reduction in the number of joints in the toes, the specialization of the proximal ankle bones in mammals, some reduction in the number of wrist and ankle bones, and the variations in the thumb and great toe From Romer<a></a>, by permission of The University of Chicago Press </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Exact diagrammatic front views of the four largest primates at fully adult age, drawn from detailed measurements on actual specimens, hair omitted, and all reduced to the same trunk height. From Romer<a></a>, by permission of The University of Chicago Press. Originally constructed by A. H. Schultz. Note that, from orang to chimp to gorilla to man, both limb length and hand length generally decrease with respect to trunk height. Only the gorilla has a hand shorter than that of man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for the length of the thumb, man andthe other great apes show sharp divergence, especially when the thumb is considered with respect to hand length. As contrasted with the short thumb of the anthropoid apes, man's thumb is long and well developed. Attempts to explain this difference have led to an either-or position. Either the thumbs of the apes have atrophied as a result of their arboreal life or man's thumbs have lengthened in the evolutionary process.</p> <h4>The Shoulder and Upper Arm</h4> <p>In man the shoulder and upper arm are adapted for strength. As for the other portions of the arm down to and including the hand, the more distal the part the more it is adapted for complex and delicate functions and the less for strength. The pectoral girdle in man consists of three bones. The scapula is directed dorsally, the coracoid process extends forward and downward to meet the sternum, and, anterior to the coracoid, the clavicle connects scapula and sternum. Because the pectoral girdle is not joined directly to the spine, though it may articulate with the sternum, the structure permits great freedom of motion in the shoulder area. Briefly, the human arm, supported and controled by a large number of muscles, together with the elbow and wrist joints, gives freedom to a hand that has become the willing servant of the human intellect.</p> <h4>Man's Opposable Thumb</h4> <p>The powerful and well-developed thumb of man is one of his few uniquely human characteristics. Through successive stages of vertebrate evolution, the thumb has separated from the other fingers and developed specialized musculature. In the Anthropoidea, the feature of opposability led to greater tactile and exploratory facility. Man's thumb, comparatively twice as long as that of some of the anthropoids, reveals a steady increase in absolute and relative length (<b>Fig. 2</b> and <b>Fig. 4</b>) and, at the same time, the steady development of opposability, extensibility, and flexibility. When the "hand" of the ape is compared with the hand of man it becomes, in the words of Krogman<a></a> a "misnomer." In the ape, hands are hands by definition only. Although man's hand, the end-product of our evolutionary development, retains the basic, primitive, pentadactyl pattern common to all land vertebrates, it nevertheless is uniquely human. The earliest animal footprint known (from the Permian of the Tambach in Thuringia) is so similar in appearance to that of the human hand that the animal which left the fossil print was named "Cheirotherium," or the "handbeast" <a></a></p> <h4>Variations of the Human Hand</h4> <p>The morphological pattern of man's hand shows its affinity to the "hands" of other animals. But while man has kept the primitive pattern, other animals have specialized. In birds, for example, the hand has become a wing, in the horse a hoof, in the whale a flipper, in the dog a paw, and so on. According to Hooton<a></a>, Crawford has demonstrated the difference between tool-using, as in man, and tool-growing, as in most animals. Animals use no tools other than those developed out of the materials furnished by their own bodies. Man, however, was<a></a> "the first animal to grow a limb outside himself by making tools out of wood and stone." Furthermore, the limbs of animals are specialized for single purposes only. The horse can run, the mole can dig, but neither can climb; man makes instruments that are imitations of the body tools of other animals a digging stick, an awl, a scraper, or a dagger.<a></a> The power and versatility of the human hand rests, in part, upon its generalized pattern. But it is the human brain, with its intricate and elaborated nervous system, that coordinates man's eye and hand. Thus, man is born with a hand free to do the bidding of his expanded brain.</p> <h3>The Anthropometry of the Hand</h3> <h4>Early Studies</h4> <p>The past fifty years have seen a gradual increase in the literature devoted to the anthropometry of the human body. But until that time, individual investigators had gone their separate ways, and there was little concurrence on standardization of the measurements to be employed, on the way in which these measurements were to be taken, or on the instruments to be used. Furthermore, just as in the osteological studies conducted in anthropological museums, early research on living animals was devoted largely to the head and facial features, and only later was study extended to the remainder of the body. Hence the dearth of anthropometric studies on the hand is easy to understand. Lacking, also, are routine osteometric recordings and systematic measurements and indices that could provide the comparative anatomical data necessary for a definitive work on the evolution of the human hand.</p> <h4>The Lack of Data</h4> <p>Authorities appear to agree that no part of the human body has been as neglected as has the hand.<a></a> The reasons for this situation are many, but perhaps the most important one is the scarcity of fossilized primate hands, probably owing to the fact that these bones are small, fragile, and easily destroyed by the action of the forces of nature. Nor are the anthropological collections of complete hands of the modern anthropoids anywhere near adequate. During the past few years, individual investigators and museums have been attempting to increase the number of complete hands available for study, but the collections still are quite inadequate. Moreover, as was demonstrated at the University of Chicago, skeletons often turn out to be composites of many separate individuals and, therefore, of little use in anthropometric studies.<a></a> These handicaps, together with the complexity and the extreme variations found in the human hand, make it exceedingly difficult to get accurate results.</p> <h4>The New Focus</h4> <p>The early work in comparative anthropometry was devoted entirely lo race differentiation.<a></a> At the present time, however, that interest is lagging, and extensive growth studies of the epiphyseal closures of the metacarpals and the phalanges are being conducted at the University of Pennsylvania.<a></a> The x-ray technique, used for many years, has become the major tool by means of which the anthro-pometrist and anatomist can study living persons. It is dependable and important, especially in studying the highly differentiated parts of the human hand.</p> <h4>Classification</h4> <p>The morphology of the hand has proved useful in classifying hand types. Wechsler's system<a></a> is based upon four hand dimensions (<b>Fig. 5</b>). From all possible combinations of length and three breadths, he derives six index categories, as shown in <b>Table 1</b>. Thus, the long, narrow hand type in man would be, for example, 1-1-1-2-4-3, that of the short, broad hand 4-4-4-4-4-4.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Hand measurements according to Wechsler. From Krogman<a></a>, by permission of Ciba <i>Symposia</i>. </p><ol> <li><i>Stylion radiale, </i>at tip of radial styloid process.</li><li><i>Stylion idnare, </i>at tip of ulnar styloid process.</li><li><i>Interslylion, </i>mid-point of line connecting 1 and 2.</li><li><i>Daclylion III, </i>at tip of third finger.</li><li><i>Metacarpale radiale, </i>at metacarpophalangeal junction of index finger.</li><li><i>Metacarpale ulnare, </i>at metacarpophalangeal junction of little finger.</li><li><i>Proxindicion, </i>at proximal interphalangeal junction of index finger.</li><li><i>Ulnoquintion, </i>at intersection on ulnar side of little finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 7.</li><li><i>Dislindicion, </i>at distal interphalangeal junction of index finger.</li><li><i>Ulnoquartion, </i>at intersection on ulnar side of ring finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 9.</li></ol> <p></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Handedness in Man</h3> <h4>Right and Left - Good and Evil</h4> <p>The cultural world in which man lives, both in preliterate and in technologically advanced societies, tends to be a "right-handed" world. Cross cultural studies reveal that different sides of the body, the left or the right, are associated with different social activities. In India, the right side and the right hand perform tasks considered to be "clean," while the left side and the left hand perform tasks considered to be "unclean." The two types of activities are separated rigidly. The right hand, for example, is used for cooking and eating, whereas the left hand is used in bathing, elimination, or activities associated with sex. Indeed, it is common in many areas of the world to find food related to the right hand, while the left hand is associated with sex.<a></a></p> <p>The right and left hand have come to symbolize good as opposed to evil, gods as opposed to demons. Hence, they are considered as two forces constantly at war with one another. The shadow plays of the Balinese illustrate the widespread association of good and evil with the right and left side respectively. The mystic story teller takes the marionettes out one by one, placing the "good" and "noble" characters at his right side and, at the left, the "evil" and "sinister" characters. In the end, truth and goodness always win, which demonstrates the triumph of the magical powers of the right side. At all important life crisesbirth, death, marriage, initiation ceremoniesthis magic balance between left and right is maintained. Among the Tiv of Nigeria, the afterbirth of a boy child is always buried to the left of the door in order to propitiate the evil spirits residing there. In Bali, a boy's placenta is buried on the right and a girl's on the left side of the entrance to the house.<a></a></p> <h4>Caste and The Hand</h4> <p>The symbolism of the hands in ceremonial rites has, in various ways, come to indicate social class and caste. Among the Balinese, for example, it is a mark of social distinction to wear long nails, but only the priest may wear them on both hands. The giant-god of pre-Hindu times is believed to have carved out all of the caves with the fingernails of his left hand. The Indian caste system is noted for a unique feature in that many of the castes are divided into two sections called the "right-hand" (Balagai) and the "left-hand" (Yedagai) castes. Certain socially lower artisan castes, such as workers in leather, belong to the left-hand subgroup.<a></a> Among the Motu of Papua, the moieties are grouped by the left and right hand. Members of the right-hand moiety have senior status in matters of inheritance, while members of the left hand moiety have junior descent status.<a></a></p> <h4>Other Influences</h4> <p>Music for the piano usually is written in such a way that the melody is carried by the right hand. Threads in bolts, pipes, and even in glass jars are right-handed. Soup and gravy ladles, fish forks, and meat grindersin fact, the majority of our manufactured products are designed for the right-handed individual. Can the custom of men buttoning their coats on the right side and women on the left be a survival from our primitive past when the right was reserved for men because it was "good" and the left for women because it was "evil"? Our society is belatedly recognizing the right of sinistrodextral people to full participation in our culture. Banks are issuing left handed checkbooks, left-handed armchair desks have been introduced in schools, and left-handed scissors and other implements and tools now are available.</p> <h4>Handedness in Early Man</h4> <p>Whatever the reasons for associating right with "good" and left with "evil," the fact remains that man is predominantly right-handed, a fact that appears to have been true even in prehistoric times. Early writers explained the enigma of right-handedness in the Lamarckian sense of "use and disuse." They noted that, since the heart was located on the left side of the body, the warrior carried his shield in his left hand. The right hand was free and, through more frequent use, developed in both size and dexterity. This "acquired" characteristic was passed on to succeeding generations.</p> <p>During the nineteenth century, as the authenticity of plant and animal fossils was established, and with the growth of anthropology as a more exact science, numerous archaeological sites were excavated. By the beginning of the twentieth century, thousands of artifacts had been uncovered, more precise data were available, and the picture of life in prehistoric times began to emerge in greater detail. The oldest implement found in Europe was beveled for grasping between the right thumb and first finger. The implements of primitive Paleolithic sculptors were found to approximate in number and in form those of modern sculptors. All of the tools uncovered in a Spanish cave, said to have been inhabited during Solutrean times, are designed to fit the hand, and, from the almost perfect adaptation of these instruments, we may infer that these ancient artists were right-handed.<a></a> Based upon the frequency of left-handed flint tools found <i>in situ </i>in France, other authorities, Krogman<a></a> for example, note that the incidence of left-handedness increased during the New Stone Age.</p> <h4>Handedness in Apes</h4> <p>During the past three decades, handedness in the apes has been studied extensively in the United States. Yerkes <a></a>, in his classical work on the apes, found that handedness appears in chimpanzees. He points out that they use one hand consistently for certain purposes and the other hand for other activities. He says, however, that right-handed dominance has not been demonstrated and that the three types of motor activity found in man (right-and left-handedness and ambidexterity) occur with about equal frequency.</p> <h4>The Chick Embryo</h4> <p>The problem of left- and right-handedness in chickens has been reported. At about the 38th hour in the chick embryo, certain processes are initiated that result in what may be termed very loosely a "right-handed embryo." In certain chemicals, the molecular structure is "left-handed" in that it is of the nature of the mirror image of the "right-handed" counterpart. After a number of hours of incubation, fertile chicken eggs exposed to such "left-handed" chemicals evidence a "left-handed" type of flexure of the developing brain.</p> <h4>Asymmetry</h4> <p>Yerkes<a></a> holds with the current opinion that asymmetry of the left and right hand (<b>Fig. 6</b>) is related to a general asymmetry of the entire body. The right and left leg in man, for example, also differ in strength and in dexterity. Similarly, the right lung is slightly heavier, the abdominal viscera are heavier on the right side, both the spine and pelvic regions display asymmetry, and hence the center of gravity of the body is slightly to the right. Kahn<a></a> reports a number of experiments which demonstrate that, owing to this asymmetry, every blind wandering ends in a circle. Thus, man cannot write, nor walk, nor drive a car blindfolded without becoming a victim of his physical asymmetry.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Typical difference between the right and left hands of a single individual. The right has a shorter palm and longer fingers, and the long longitudinal line is more marked. From Wolff.<a></a> by permission of Methucn and Co., Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Endocranial casts of the brain cavities of fossil and of modern man support this evidence, and here too asymmetry appears. The left occipital portion of the brain predominates to produce right-handedness, a fact established by Smith.<a></a> One school of thought claims that this asymmetry of the brain represents a primitive character in the higher apes and man. According to Clark<a></a>, however, Keith maintains that, on the contrary, asymmetry represents an evolutionary advance.</p> <p>The general physical asymmetry of the body is associated with a social asymmetry in our human prejudice against the left side. The human preference for right-handed tools and artifacts has, somehow, invaded the social and moral life. There also is a <i>sinistra </i>and <i>dextera </i>view of the world now fixed in our vocabulary.</p> <h4>Handedness in Language</h4> <p>We speak of dexterity (from the Latin "dexter," connoting "right," "favorable") in referring to skill, and this idea has been traced back to Sanskrit, the ancient literary language of India. From the category of physical things, the right hand has reached out to influence many other areas of human life. To be "orthodox" is to follow the "right" or "true" opinion. The concept of legal justice comes from the French "droit," meaning "right" or "law." Contrariwise, the word "left" symbolizes "evil," "weak," "awkward." The word for "left" in French is "gauche," meaning "awkward." The Latin "sinister," meaning "left," rarely applies to that which threatens but, rather, to that which is known to act covertly or insidiously. The bar sinister is the heraldic symbol of bastardy. A man who marries below his social rank gives his left hand, not his right, to his bride. Thus, in our own culture today there survive in our language and customs the social implications that historically have characterized handedness in man.</p> <h3>The Hand as a Sensory Organ</h3> <h4>The Sensory Experience</h4> <p>Although prehension is the major function of the hand, the hand is, at the same time, one of man's primary sense organs. This tactile quality provides sensory experience that may be grouped into four general categories.<a></a> The first consists of "surface sensations" stimulation generated by touching tangible objects. The second is termed "space-filling" stimulation generated by pulling the hand through liquid substance. "Spacelike sensations," comprising the third category, relate to the touch of distinctively shaped objects felt through a heavy material. Finally, there are "penetrable-surface sensations," experienced, for example, by a physician as he palpates some part of the body to locate, through the outer layer of flesh, some abnormal condition in deeper tissue.</p> <p>Movement is indispensable in sensory experience, and experimentation demonstrates that even the "imaginary" touch sensations are located in the finger tips. According to Katz<a></a>, it is quite impossible to call up the image of touch without, in imagination, moving the hand. The moment we imagine our hands at rest, the image becomes uncertain or disappears.</p> <p>When body and ambient temperature are equalized, the hand may be used as an instrument for the perception of the relative levels of heat and cold. Preliminary determination of body temperature can be determined by placing the hand on the forehead. In folk society, for example, where accurate measures of determining fever temperature are not available, a normal hand placed upon the forehead is used to determine the presence of fever.</p> <h4>A Percussive Tool</h4> <p>The human hand can also be used as a percussion instrument. With an apparatus which he called "the percussion phantom,"<a style="text-decoration:none;">*</a> von Gotzen found that vibratory impulses generated by finger percussion can be felt even when the auditory sense is eliminated.</p> <h4>A Vibratory Tool</h4> <p>Vibratory sensations, as perceived by the hand, are of importance in teaching the deaf to speak. By placing one hand on the larynx of a speaker and the other hand on his own larynx, a deaf-mute learns the vibration patterns of speech sounds. When the patterns "heard" by his left and right hand are identical, the student has succeeded in imitating the sound. Helen Keller utilizes the vibratory phenomena when she "hears" music by placing her hand on the piano.</p> <h3>The Human Hand in Art</h3> <p>Through the ages the human hand has appeared in all of the creative arts of every culture.<a></a> A single line, a schematic portrayal, a simple gesture of the hand, and character and personality stand revealed as clearly as they are seen in the human face. Recently, in the Kefauver investigation of crime in New York City, the television camera focused on the hands of a witness, and millions in the television audience watched while hands expressed feelings that man has taught his face to disguise.</p> <p>In the creative arts, the hand speaks, and one senses the tremendous power of the hand to convey human emotions. The hands are the organs of the body which, except for the face, have been used most often in the various art forms to express human feeling. The hands point or lead or command; the hands cry out in agony or they lie quietly sleeping; the hands have moods, character, and, in a wider sense, their own particular beauty. From prehistoric times to our own day, in every society known to science, the hands symbolize cultural behaviors, values, and beliefs.</p> <h4>Painting and Sculpture</h4> <p>Many studies of the hand appear in the traditions of western art. From schematic and conventional hand portraits, the artists of the fifteenth century began to draw anatomically correct hands, and, slowly but surely, the hand was seen as having a personality and a culture of its own. Albrecht Durer (1471-1528) devoted a lifetime to the study of anatomy, and in his studies of hands the lines, the curves, the veins, the wrinkles delineate the complexity of the human hand (<b>Fig. 7</b>). In another medium, the French sculptor Auguste Rodin (1840-1917) deliberately used the hands to create unmatched works of art.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Famed "Hands of an Apostle Praying," by Albrecht Diirer (a.d. 1471-1528). Courtesy The Public Library, Washington, D. C. The original hangs in the Albertina Museum in Vienna. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Prehistoric Artist</h4> <p>Early man left records in shallow caves, in rock shelters, and, in the great period of art during late Paleolithic times, on the walls of the innermost recesses of caves in France and Spain In the ancient engravings and the wall paintings found in caves in eastern Spain, the arms and legs perform animated gestures in running, in drawing a bow, in gathering honey, and in the dance.</p> <p>The human hand appears in quasi magico-religious silhouettes of complete or partially mutilated hands outlined in color on the walls of the grotto of Gargas in the Pyrenees Mountains. The fingers appear to be cut off at the distal end of the first phalanx, with one or more digits missing entirely. Curiously, the thumb never is amputated. The same type of finger mutilation is found in wall paintings in the caves of central Australia. Apparently the practice was customary among the early Aurignacian people of Paleolithic times, and it also is reported in other preliterate tribes. According to Osborn <a></a>, Breuil believes that painting had its beginning in these stencilled contours produced by laying the hands against the limestone walls and spreading red and black paint on the surrounding area. In other examples, the hand was covered with pigment and pressed against the wall.</p> <h4>The Dance</h4> <p>The formal patterns and definite movements of the dance make it one of the greatest of the interpretative arts. It is, apparently, also one of the oldest arts. Whether viewed from a recreational, religious, or aesthetic standpoint, this expression of culture has attained meaning and intensity through movement of the hands. Joint dances between the sexes are rare among primitive tribes, and the hand thus has been liberated for gestures and symbolic movements. In India, the hands can tell an entire story. In Australia, among one of the most technologically simple tribes, the movements of the hands make the dance merge into drama. Indeed, it is difficult to separate the dance from music and from drama, but in each of these art forms it is the hand that gives meaning to words spoken. Perhaps the rhythm produced by the hands in clapping and in slapping the body originally led to music and to the dance.</p> <h3>The Hand in Culture and Society</h3> <h4>Language Abstractions</h4> <p>Because the human hand is an organ of performance, it is not surprising that the hand should "manipulate" ("to lead by the hand") the human vocabulary. The hand receives the "mandate" (from Latin "manus," for "hand," plus "dare," "to give") from the brain, and to "manage" is to govern, direct, or control. Thus, man "commends" (which originally meant "to place in one's hands") and "commands," both words related to "mandate" and, therefore, to the Latin "manus," for "hand."</p> <p>With its basic movements for grasping objects (page 33), the human hand also is "handy" ("dexterous," "to have two right hands") for grasping ideas. To "comprehend" is to "seize" (Latin, "capere," "to seize"), from which we derive such words as "perceive," "conceive," and "receive." Thus, by various shades of meaning, the human hand not only "hands down" information but "picks" it up. The human hand also is an organ of perception and thus lends itself to the most abstract concepts. "Handsome" originally meant "dexterous." "To feel" is connected somehow with the Greek word for hand, "palame." To say in Latin "dicere" means "to point." We touch, feel, handle, finger, thumb, paw, grope, palpate, and stroke objects.</p> <h4>One and One Are Two</h4> <p>Man's hand not only manipulates and grasps, and makes and points, but it counts as well. Counting is very different from what we loosely term "number sense," an attribute that man shares with other animals. In its real connotation, counting appears to be an exclusively human characteristic, and numbers, like so many abstractions, begin with the human body. The old Roman numerals I, II, III, and IIII<a style="text-decoration:none;">*</a> are thought to be representations of the fingers. In certain of the less well-known languages, the word for hand gives us the word for five. "Five" also has come to mean "hand," and in English the slang expression "give us five" once meant "to shake hands."</p> <p>One example of the use of hands in counting is that of the Mafulu mountain people, who do not use pebbles or sticks but instead use the hands and feet.<a></a> Here counting is accomplished by the use of two numerals, "one" and "two." In indicating "one," the hand first is stretched open to indicate "nothing," the thumb then is closed down meaning "one," the first digit closed down meaning "two," and so on, until all of the fingers of one hand are closed. The process is repeated with the other hand, and, to count to 20, the clenched fist points to the feet and to all of the right and left toes. If the count is above 20 (usually only when important occasions demand, such as counting pigs for a ceremony) another man is called to stand beside the first. If the number goes as high as 83, five men join. Four men go through the entire process, and the last man closes the first three digits.</p> <h4>Man the Measuree</h4> <p>Equally important has been the use of the hand as a unit of measurement. Tables showing the use of body organs as units of measure have been established for volume, surface. width, and length (<b>Fig. 8</b>). The earliest records show that the use of the index finger for indicating length was a widespread custom. In Europe the height of a man was estimated by a definite number of finger lengths based upon the measurement of the middle finger. In Latvia, the length of the middle finger was used to measure lengths for women's stockings or woolen socks (three times the length of one's middle finger). Sixteen times the length of the middle finger equals the normal human stride. The hand and thumb were used to measure width, 12 thumb widths being equal to one foot. Tools were made by the eldest member of the family and adjusted to the hand grasp. Thus, a scythe blade for an adult man was as long as nine or ten widths of the clenched hand, eight for an adult woman, and seven or eight for an adolescent (<b>Fig. 9</b>). The same pattern is found through much of eastern and northeastern Europe today.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Natural units of measure, still in use by Latvian and other European peasants. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The method, common among Latvian and other European peasants even today, of arriving at the proper dimensions for farm tools using the hand as the unit of measurement. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Tribal Customs</h4> <p>In the Sun Dance of the Plains Indians of the United States, finger joints were occasionally pledged as a thank-offering for recovery from illness or to ensure revenge for a slain relative.<a></a> Cole<a></a> reports that individual warriors among the tribes of Mindanao carried home a hand as evidence of a successful fight and that at such times festivals were held to celebrate the event. Among the Tinguian tribes of the Philippine Islands, joints of the little fingers were added to ear lobes and brains to make a liquor that was served to the dancers. Here, as in most areas of the world, the brew was consumed not for nourishment but in order to secure that part of the enemies' bodies thought to house strength and valor.</p> <p>Such reports may throw light upon the presence of the mutilated hands found on the walls of the European caves and dating from late Paleolithic times. The scarcity of drawings of the human form in cave paintings may be related in some way to the belief, still found among certain of our "primitive" contemporaries, that realistic portraits might give an enemy magic power. Possibly, through some similar process of sympathetic magic, the hand has already become a symbol to be portrayed realistically in religious ritual.</p> <h4>The Fingerprint</h4> <p>Human hands have been used in various cultures as a means of positive identification. In ancient China, fingerprints were used to sign or to autograph paintings. They are doubly valuable as "signatures" because they cannot be altered or forged, and the intricate patterns of whorls, circular and folded loops, and arches differ from finger to finger and from individual to individual. As the person grows, his individual fingerprint patterns increase in size but do not change in geometric proportions. In 1882, Bertillon, a young French anthropologist, began to develop his famous system for identification of criminals by a physical description based upon eleven anthropometric measurements, deformities, and impressions of lines and markings of the finger tips. The Bertillon system of fingerprints has been used internationally and has proved valuable for physical identification.</p> <h3>Some Other Considerations</h3> <h4>Occultism, Symbolism, and Ritualism</h4> <p>In an anatomical sense, each hand is unique. Every hand betrays its possessor by characteristic mo/ement patterns, by peculiarities of gesture, or by occupational stigmata arising from physical and mechanical causes. From these characteristics, palmistry and a branch of occultism known as "chiromancy" have, for centuries, attempted to read the past, present, and future of individuals. Since early antiquity, numerous scholars of repute have concerned themselves with studies in palmistry. According to D'Arpentigny<a></a>, Plato, Aristotle, Galen, Albertus Magnus, the Ptolemies, Avicenna, Averroes, Antiochus Tibertus, Tricasso (<b>Fig. 10</b>), Taisnier, Belot, and others have handed down lengthy treatises on the subject, and the observations of these early writers still prevail in our own modern times (<b>Fig. 11</b>). Palmists are interested chiefly in the surface of the handlines, stars, crosses, islandsand have divided the life line into seventy parts, each part symbolic of one of man's allotted seventy years of life. Chirognomists study the shape and form of the entire hand, in addition to surface characteristics.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Principal lines and mounts of the hand as charted by Patritio Tricasso da Cerasari (Tricassus the Mantuan), a celebrated chiromancer of the sixteenth century. From Lenssen<a></a>, by permission of The Studio Publications, Inc., New York City. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The mounts and principal lines of the hand and the interpretative functions traditionally assigned to the several areas. Authorities differ in detail, but all follow the same general pattern. In palmistry, which dates from antiquity and which has been the subject of serious discussion by numerous scholars, including Aristotle, the relative development of the mounts and lines is considered to show the comparative ability of the subject to implement the talents and qualities associated with the individual features. Generally the mounts are seven in number, the eighth (Mount of Neptune) occurring in a comparatively small number of cases. Reference to the sun, moon, and planets relates, of course, to the influence which, in early philosophy, these celestial bodies were thought to exercise upon the course of an individual's life. Modern astrology calls upon similar relationships. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>But it is in the realm of quasi magic and symbolism that the hand reaches its highest cultural significance. For the great majority of mankind who think in concrete rather than in abstract terms, graphic representations of superhumanity are related to the human body. The Hindu of India symbolizes this super-humanity by the multiplication of the most important parts of the body, which, to him, are the head, the arms, and the hands. Since arms and hands are extremely useful, a twelve-armed god demonstrates the power and the strength denied a two-armed god. Such thinking may appear grotesque to the Westerner, but the Hindu, accustomed to symbolic thinking, knows that man is not so constructed, nor does he wish that he were. He simply recognizes that power and wisdom and strength may be expressed quantitatively.<a></a>The Moslem often wears a small image of the hand around his neck to ward off the evil eye.</p> <p>Not only in the eastern world does the hand play an important part in the ritual usages but in western culture as well. The pentagram, the five-pointed star, is said to have been derived from an ancient custom of covering the face with the open fingers of the hand. That practice gradually was replaced by invoking the numeral "five," a convention that persists today in countries in central Europe. In Latvia, for example, the pentagram now appears on barns as a protective device.</p> <p>Finally, the hand has become symbolic of human sentiment. We bless and we salute by raising the hand in various ways. The gentle laying on of hands is at once a symbol of benediction and, as among certain religious sects, the means of curing the sick and of drawing out the evil spirits that reside within the body. In legal practice, oaths are taken in court by the simultaneous use of both hands, right hand up and the left hand on the Bible. We close a bargain by shaking hands, we raise our hands in salutation, and a man takes a woman's hand in marriage. Contrariwise, the hand may express condemnation, malediction, and final judgment. In cursing we point the hand at the enemy. In ancient Rome, thumbs down ("pollice verso") sentenced the gladiator to death. Thus, the hand has become an expository of human sentiment. It can express love, hate, doubt, questioning, hospitality, judgment, rejection, or acceptance.</p> <h4>The Hand and Good Health</h4> <p>The handshake may become an index to personality and representative of the <i>whole </i>person. The cold, limp hand, the strong, firm grasp, the moist palm, the dry palm, all help us to create a mental image of personality. To the trained hand of the physician, the cold, moist, flabby handshake often reveals clues relating to physical condition. Such a handshake often is a symbol of physical illness or an indication of an emotional disturbance. To the trained eye of the doctor the hand tells even more. The coloring, texture, lines, and creases sometimes reveal sickness or health. A trembling, warm, moist hand may mean overactivity of the thyroid, redness may indicate gout, a bluish appearance may indicate a certain kind of heart disease, and bad cases of malnutrition and diet deficiency frequently are reflected in the hand. There are many variations in the appearance of each hand, but the danger signals can be read only by the skilled hand and eye of a physician.</p> <h4>The Hand in Expression</h4> <p>The hand has also become associated with certain ethnic and nationality groups, for specific hand gestures have been associated with certain cultural types. Indeed, it has been said of the Italians that they never speak a language, that they caress it. Because movement of the hands serves to emphasize the spoken word, all of us find it difficult to speak while our hands remain perfectly still. A dramatic presentation of the use of the hand in conversation was portrayed through the medium of modern dance in a performance by a group at New York University involving an interpretation of an adolescent the telephone (<b>Fig. 11</b>). talking over No word was spoken, but the wide variety of gestures made clear to everyone what the performer was saying. The cult and the culture of the "teen-ager" in our country was delineated as sharply through the dance as it could have been through the medium of the written word.</p> <h3>Conclusion</h3> <p>From its basic use, prehension, which grew out of anatomical development, the human hand gradually has evolved until it is now also an effective instrument for symbolic and aesthetic interpretation. Man's capable and sentient hand not only serves as a tool but it wields tools as well, and it has in addition the ability to take the place of other body organs. Because of its remarkable adaptability to functional requirements, as compared with the specialization in the forelimb of other animals, the hand is largely responsible for the creative manifestations that characterize the human species and that distinguish it from all other known forms of life. The hands are, as Kant is reported to have said, "man's outer brain."</p> <h3>Acknowledgment</h3> <p>For valued help in obtaining the illustrations which accompany this article, the author is indebted to Marian Blumler, staff member of the Library, National Academy of Sciences National Research Council, who conducted a search of source material and arranged for loan of the necessary documents.</p> <p><b>References:</b></p> <ol> <li>Adam, Leonhard, <i>Primitive art</i>, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</li> <li>Ashley-Montagu, Francis M., <i>On the primatethumb</i>, Am. J. Phys. Anthropol., 16(2):291 (1931).</li> <li>Boas, Franz, <i>Primitive art</i>, H. Aschehoug, Oslo, 1927. pp. 344, 349.</li> <li>Boyd, William C, <i>Genetics and the races of man; an introduction to modern physical anthropology</i>, Heath, Boston, 1950. pp. 16-17.</li> <li>Clark, W. E. Le Gros, <i>Early forerunners of man; a morphological study of the evolutionary origin of the primates</i>, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</li> <li>Cole, Fay-Cooper, <i>Lectures</i>, University of Chicago, 1940-41.</li> <li>D'Arpentigny, C. S., <i>The science of the hand</i>, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</li> <li>Drillis, Rudolf J., <i>Darba riki [Tools]</i>, in <i>Lalviesu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</li> <li>Drillis, Rudolf J., <i>Mcri [Units of measure]</i>, in <i>Latvieiu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</li> <li>Flory, Charles D., <i>Osseous development in the hand as an index of skeletal development</i>, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</li> <li>Hodges, Paul C, <i>An epiphyseal chart</i>, Am. J. Roentgenol., 30(6): 809 (1933).</li> <li>Hooton, Earnest A., <i>Up from the ape</i>, Macmillan, New York, 1931.</li> <li>Huxley, J., <i>From fin to fingers: the evolution of man's hand</i>, Illustrated London News, December 1930. pp. 1138-39.</li> <li>Jones, Frederic Wood, <i>The principles of anatomy as seen in the hand</i>, 2nd ed., Williams and Wilkins, Baltimore, 1942.</li> <li>Kahn, Fritz,<i> Man in structure and function</i>, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</li> <li>Katz, David, <i>On the psychology of the human hand</i>,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, <i>The vibratory sense and other lectures</i>, The University Press, Orono, 1930. pp. 75-78.</li> <li>Krogman, Wilton M., <i>The anthropology of the hand</i>, Ciba Symposia, 4(4):1294 (1942). '</li> <li>Lenssen, Heidi, <i>Hands in nature and art</i>, Studio Publications, New York, 1949.</li> <li>Mead, Margaret, el al., <i>Cultural patterns and technical change</i>, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</li> <li>Mierzecki, H., <i>Symbolism and palhognomy of the hand</i>, Ciba Symposia, 4(4):1319 (1942). '</li> <li>O'Malley, L. S. S., <i>Indian caste customs</i>, Macmilan, New York, 1932. pp. 21-22.</li> <li>Osborn, Henry F., <i>Men of the Old Stone Age, their environment, life, and art</i>, 3rd ed., Scribner, New York, 1919.</li> <li>Personal communication from Margaret Cormack, Brooklyn College.</li> <li>Reininger, W., <i>The hand in art</i>, Ciba Symposia, (4):1323 (1942).</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, University of Chicago Press, Chicago, 1933.</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</li> <li>Rosenstiel, Annette, <i>The Motu of Papua-New Guinea: a study of successful acculturation</i>, Ph.D. thesis, Columbia University, 1953. Microfilm.</li> <li>Schultz, Adolph H., <i>Characters common to higher primates and characters specific for man</i>, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</li> <li>Schultz, Adolph H., <i>The skeleton of the trunk and limbs of higher primates</i>, Human Biol., 2(3):303 (1930).</li> <li>Smith, Grafton E., <i>The evolution of man</i>; essays, 2nd ed., Oxford University Press, 1927.</li> <li>Wilder, Harris H., <i>A laboratory manual of anthropometry</i>, Blakiston, Philadelphia, 1920. pp. 84-109.</li> <li>Wiser, Charlotte V., and William H. Wiser, <i>Behindmud walls</i>, Harper, New York, 1930.</li> <li>Wolff, Charlotte, <i>The human hand</i>, Methuen, London, 1942.</li> <li>Wright, W. B., <i>Tools and the man</i>, George Bell and Sons, Ltd., London, 1939.</li> <li>Yerkes, Robert M., <i>Chimpanzees; a laboratory colony</i>, Yale University Press, New Haven, 1943.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Personal communication from Margaret Cormack, Brooklyn College.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Lenssen, Heidi, Hands in nature and art, Studio Publications, New York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Mierzecki, H., Symbolism and palhognomy of the hand, Ciba Symposia, 4(4):1319 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">D'Arpentigny, C. S., The science of the hand, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Wiser, Charlotte V., and William H. Wiser, Behindmud walls, Harper, New York, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Darba riki [Tools], in Lalviesu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Drillis, Rudolf J., Mcri [Units of measure], in Latvieiu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">IV is a later development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adam, Leonhard, Primitive art, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Boas, Franz, Primitive art, H. Aschehoug, Oslo, 1927. pp. 344, 349.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Reininger, W., The hand in art, Ciba Symposia, (4):1323 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Katz (16) describes the apparatus as a square wooden box, about 60 centimeters long by 8 centimeters deep, and open at the top. Around the top edge a strip of felt is fitted, and over the whole a thick cardboard square is fastened; this side of the box is clamped on with metal clips. The cardboard is strong enough to resist considerable pressure without sagging. On the underside of the cardboard, i.e., inside the box, objects of different shapesfor example, round, elliptical, or heart-shaped objectsare pasted to substantial pieces of lead which appear either as matrices or as patrices, i.e., they are cut into or cut out of lead. The thickness of the plate is chosen according to the degree of difficulty of the percussion task to be presented to the student. In general, the thicker the plate, the easier the task. The plates are so arranged that the figure is located in the middle of ihe underside of the cardboard. Each cardboard is fitted with one figure (if necessary, composed of two parts), so that there are as many cardboards as there are figures required for the test. Students were asked to determine, through percussion alone, the form of figures cut into or out of the lead plates.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Smith, Grafton E., The evolution of man; essays, 2nd ed., Oxford University Press, 1927.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Wolff, Charlotte, The human hand, Methuen, London, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kahn, Fritz, Man in structure and function, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Rosenstiel, Annette, The Motu of Papua-New Guinea: a study of successful acculturation, Ph.D. thesis, Columbia University, 1953. Microfilm.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">O'Malley, L. S. S., Indian caste customs, Macmilan, New York, 1932. pp. 21-22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mead, Margaret, el al., Cultural patterns and technical change, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Boyd, William C, Genetics and the races of man; an introduction to modern physical anthropology, Heath, Boston, 1950. pp. 16-17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Flory, Charles D., Osseous development in the hand as an index of skeletal development, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Wilder, Harris H., A laboratory manual of anthropometry, Blakiston, Philadelphia, 1920. pp. 84-109.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Wright, W. B., Tools and the man, George Bell and Sons, Ltd., London, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Jones, Frederic Wood, The principles of anatomy as seen in the hand, 2nd ed., Williams and Wilkins, Baltimore, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Meaning that digit corresponding to the ring finger in man. Among anatomists generally, at least two systems for identifying hand digits are in accepted scientific usage, often interchangeably by the same writer. A common convention is to number the digits from I to V, beginning with the thumb as digit I and ending with the little finger as digit V (Fig. 1). But many competent writers, thinking of the hand as having a thumb and four fingers, label the fingers as first, second, third, and fourth, meaning the index finger, the middle finger, the ring finger, and the little finger or pinkie, respectively. Throughout this issue of Artificial Limbs, it is considered that the normal hand has five digits, one of which is a thumb, the other four being fingers. A digit is here referred to with the understanding that digit I is the thumb Fingers are referred to as being numbered beginning with the index finger as the first finger.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Schultz, Adolph H., Characters common to higher primates and characters specific for man, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Schultz, Adolph H., The skeleton of the trunk and limbs of higher primates, Human Biol., 2(3):303 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ethel J. Alpenfels, D.Sc. </b></td></tr><tr><td class="clsTextSmall"> Professor of Anthropology, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_004/table1.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anthropology and Social Significance of the Human Hand Creator An entity primarily responsible for making the resource Ethel J. Alpenfels, D.Sc. * https://staging.drfop.org/files/original/89e34b5363a6e2997d50157f759ed25d.pdf be2d67e33fc2cf47d7f30766ca9a7815 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_001.pdf Year 1955 Volume 2 Issue 1 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/1955_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_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>Prelude, Prophecy, and Promise</h2> <h5>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) <a style="text-decoration:none;">*</a><br /></h5> <p> than a dynamic mechanism. The degree of disappointment and measure of failure in these simple objectives, without change in fundamental concepts, is to be seen in the countless empirical modifications of initial designs which bestrew the literature on artificial limbs over the past hundred years and more. </p> <p> Earlier optimisms were gradually replaced by indifference and the inertia of failure, as is well known to those associated with the problem of the amputee after World War I. Locomotion, as we ordinarily understand it, is impossible on a single extremity. But it was realized insufficiently that, unlike the upper extremities, the two lower limbs together constitute but a single organ-the organ of locomotion. Consequently, the complexity of locomotion in relationship to prosthetics design never really was understood, and even where designs were in question the available information was inadequate to support newer developments of principle. </p> <p> Preliminary efforts in the study of human locomotion are to be found in the work, <i>De Motu Animalium, </i>of the Neapolitan mathematician and physician, Giovanni Borelli (1608-1679). As a pupil of Galileo, he was stimulated to take a mechanistic view of bodily function and to study locomotion as a problem in leverage, but his theories and those of his followers soon were reduced to absurdity in the attempt to apply the same mechanistic principles to the whole of medical practice. Continuation of Borelli's approach had to await the nineteenth century and the advent of the Weber brothers, Edward (1806-1871) and Wilhelm (1804-1891), physician and physicist respectively, who with primitive electrical apparatus made the first accurate measurements of gait and undertook its mathematical analysis. The development of photography as a method of recording enabled Etienne-Jules Marey (1830-1904) to avoid previous errors and to correct earlier ideas, and further improvements in photography led to the classical work of Christian Braune and Otto Fischer, <i>Der Gang des Menschen </i>(1895), which has constituted the main source in the formulation of principles for the construction of artificial legs, as in the well-known books of H. von Recklinghausen (1920) and Frederich Mommsen (1932). Over more than a decade (1933-1945) Elftman published the results of extensive locomotion studies. To these and many others we owe a great debt. </p> <p> Despite all these investigations, at the end of World War II our knowledge of human locomotion was still quite incomplete, and such knowledge as existed was only poorly understood. Thus it was that, when approached in September of 1945 by the then Committee on Artificial Limbs of the National Research Council, the representatives of the College of Engineering and of the Medical School of the University of California could point to the necessity of the adoption of a long-term outlook which envisioned the study of the fundamentals of human locomotion, of the amputee who must wear a lower-extremity prosthesis, and of the prosthesis itself. It could be shown that the experience of 400 years in trial-and-error techniques had offered little and that a firm basis for progress could be established only by a systematic approach. It was predicted that at least seven years of study would be required to collect the fundamental data necessary for improved design of artificial legs. </p> <p> That that prophecy was not needlessly pessimistic is revealed in the fact that only today can it be said with a degree of confidence that we are about to enter a period of practical development in the evolution of a truly satisfactory lower-extremity prosthesis. Within the next two or three years we should see the appearance of sound improvements based upon the preceding nine years of pioneering work. </p> <p> But the problems of the leg amputee are not wholly "prosthetic." Such a patient presents a clinical picture of considerable significance. The whole being the sum of its parts, the amputee can scarcely be looked upon as normal in the medical sense, however good general health may be. He is, indeed, quite abnormal, for from amputation of an extremity come changes in skeletal, muscular, and circulatory systems to be dealt with in the design and application of the prosthetic replacement. Complications of pain, real and phantom, and of skin disorders are other matters needing the skills and experience of the medical profession. </p> <p> Taking cognizance of this situation, the Advisory Committee on Artificial Limbs, in the spring of 1953, recommended that the University of California initiate an extensive clinical program to be integrated with the work already under way in the fundamentals of locomotion and in the techniques of lower-extremity fit and alignment. Utilizing space and services afforded by the U. S. Naval Hospital at Oakland and personnel from the University of California Medical and Engineering Schools, the Clinical Study aims to apply to the practical problems of difficult amputee cases the results of the earlier work on the Berkeley Campus. </p> <p> This issue of Artificial Limbs is concerned with two major factors in the management of the lower-extremity amputee-the solution of medical problems associated with the amputated state, and the proper application of the prosthetic replacement on the basis of established biomechanical considerations. In the first of two articles, an orthopedic surgeon and an engineer collaborate in describing the origin, observations, and objectives of the Lower-Extremity Clinical Study. In the second, an engineer develops the principles of alignment and socket fit so indispensable to comfort and function, and hence to the success, of the above-knee artificial leg. In this cooperative effort is reflected the whole basic philosophy of the Artificial Limb Program in approaching the problems of the amputee. </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>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) </b></td></tr><tr><td class="clsTextSmall"> Professor of Anatomy, School of Medicine, University of California, San Francisco. </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 Prelude, Prophecy, and Promise Creator An entity primarily responsible for making the resource John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) * https://staging.drfop.org/files/original/0713435cdc66e5d09afab0bd217b4263.pdf 11665dec8ad20d2b3e67e255dcf4c5e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_001.pdf Year 1955 Volume 2 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/1955_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_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>Engineering Hope of the Handless</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human hand, with its elaborate control system centered in the brain, is doubtless the most widely versatile machine that has ever existed anywhere. Its notorious deficiency lies in its persistent inability to create a similar machine as versatile as itself. This circumstance accounts for the fact that, while there has been from earliest times a great need for hand replacements, all attempts to produce successful hand substitutes have thus far ended in only a rather crude imitation of a very few of the many attributes of the living counterpart. For want of complete knowledge of the natural hand-brain complex, and of the ingenuity requisite even to the most modest simulation of the normal hand, artificial hands have always resembled the natural model in a superficial way only. Voltaire is said to have remarked that Newton, with all his science, did not know how his own hand functioned.</p> <p>But the science of Newton, basic as it was, is itself remote from the advanced technology of our own day. Failure in hand prosthetics, though owing in part to the difficulty of replacing any living organ with an inanimate contrivance, stems also in part from failure to apply intensively the principles of modern science generally, and of engineering in particular, to the problems of artificial-hand design. Because in general the engineering profession had not theretofore been much concerned with the development of improved artificial limbs, the hand prostheses available a decade ago represented no appreciable improvement over those to be had at the end of World War I.</p> <p>In all fields of human endeavor, the problems for which men have found tentative solutions in the past often merit the attention of the engineer of today. A new look by competent technologists usually yields gratifying results, for the solutions found by our forebears, while seemingly adequate at the time, do not reflect the progress made in the development of methods of experimental analysis, in the measurement of behavioral characteristics, in the establishment of criteria, in the development of materials, and in the evolution of forming techniques for application of the materials to the needs of man. Just so in the field of prosthetics, where the problem of matching a device to the human system is particularly acute and where, consequently, the application of new methods holds special promise.</p> <p>Perhaps the most compelling reason today for the importance of engineering in prosthetics research lies in the approach and methodology now implicit in the profession. Introduction of the requirements of man in a quantitative manner without neglect of the qualitative, subjective aspects places design on a rational basis for the first time in history. During World War II there arose the problem of designing numerous complicated systems to be operable within the limits of human capabilities. In that urgent work, a substantial number of engineers had occasion to become acquainted with certain important physiological and psychological characteristics of man, so that by the end of the war the stage was set for the impact of the engineering profession on the development of prosthetic devices, which is, after all, a unique and particularly challenging field of biomechanics.</p> <p>When, therefore, in 1945, the then Committee on Prosthetic Devices undertook to conduct basic studies toward the provision of better hand substitutes, it enlisted the services of engineers to cooperate with the medical profession and others in developing the necessary data and in applying the results to improved hand design. In the Artificial Limb Program, principal responsibility for the development of improved hand substitutes has almost from the beginning resided with the Department of Engineering at the University of California, Los Angeles Campus, and with the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center. Out of this cooperative effort have now come not only new and improved devices but also, and perhaps more important, a set of criteria which lay down the basic principles of hand design toward further improvements in the future.</p> <p>Because of the importance of the hand in all human activities, because of the critical nature of adequate hand replacement in the rehabilitation of upper-extremity amputees, and also because of the rather striking advances that have been made in the design of artificial hands in recent years, this issue of Artificial Limbs is devoted entirely to a little symposium on the hand and its substitutes. The mutual cooperation of the several contributors toward a unified approach to the whole subject is typical of the cooperation that has characterized the Artificial Limb Program since its inception.</p> <p>The work in prosthetics will, it is to be hoped, serve as a pattern for further investigations jointly by the medical and engineering professions wherever developments in materials, controls, and systems in general can be brought to bear to augment human functions which an individual can himself no longer provide. One continuing problem is that of convincing able young people now studying engineering that a satisfying future exists for them in such cooperative ventures with the medical profession designed to rehabilitate the less fortunate throughout the world. Those now engaged in prosthetics development can be of great help in presenting to these young men and women the perspective of the future in such a manner that fresh engineering graduates might elect to carry forward the work now already so well under way.</p> <p>Finally, it ought to be noted that, despite the distinct accomplishments evident at this, the tenth anniversary of the establishment of the Artificial Limb Program, only the first faltering steps have been taken toward the "ideal" prosthetic hand. Structural elements and prehensile function are not enough. It remains to provide some reasonable substitute for the sensory-motor apparatus which, in the living hand, is of such consummate perfection as to beggar description. A problem like this should charge the imagination of any young engineer in search of a field of application for service. To him belongs the future in prosthetics research.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office) Veterans Administration, 252 Seventh Avenue, New York City; member, Technical Committee on Prosthetics, ACAL, NRC.</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 Engineering Hope of the Handless Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/a266195253e839079dde8975e42d8087.pdf c594dc2a840e8199425e981f66117aec https://staging.drfop.org/files/original/7f05ccb8586557cc7b0183cdafe725aa.jpg 63616a4cd1eb71d495e9a1972785cec8 https://staging.drfop.org/files/original/34baa4d0c9f50173d122a1fc9f03237c.jpg 17ba15b4ce63bb3be5f4808d51a3ea39 https://staging.drfop.org/files/original/1c09d56923228c1e807060fe9577bb4b.jpg c44f04d953c3e6e8897a4cd1e4634223 https://staging.drfop.org/files/original/2cc047309ed120bc63aa3b83a308d3fb.jpg 725142c35120be7cfc9eeda3881c00aa https://staging.drfop.org/files/original/616d272e127cadd9ddfd4dfa00a6ada9.jpg aecf21517233b63d0e773199af09d87e https://staging.drfop.org/files/original/d91b0ee4dc2e5f1b5d29d240c9cc5019.jpg e4c5b9f5516409a4f2feb3f7440c342e https://staging.drfop.org/files/original/ab13b0cc1721ab18b7969a2d89777bff.jpg 6dda6cc8254a02d70975f70817cf72de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_025.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 25 - 29 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Arm Checkout Procedures</h2> <h5>Lester Carlye, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The story of civilization's slow but steady march of progress from the days of the Roman Empire, through the Industrial Age, and into the present Technological Age is the story of measurements. The standardization of such common units as the inch and the foot required thousands of years, but once that was accomplished, it paved the way for an almost unbelievably rapid technological advance. One need only compare the developments that have occurred since the metric system was devised in 1793 with those of all the preceding centuries. Replacement of the craftsman's personal art with clearly understood, standard methods has enhanced the lives of all of us my making simple necessities, as well as more luxurious items, available in more adequate quantities and at more reasonable prices.</p> <p>Just as mankind in general profited from measurement standardization, so can those who have lost a limb or limbs and those who devote themselves to replacing lost members. Every person concerned with the manufacture and fitting of a prosthesis-whether he be a prothetist, amputee, trainer, or representative of the paying agency-has felt the need for some set of standards to determine the worth of the prosthesis. Development of such a "yardstick of performance" was just as necessary to the advancement of the prosthetics industry as was the standardization of the inch to the Industrial Age. The so-called "checkout procedures" provide the prosthetist and other members of the clinic team with an invaluable tool for measuring the biomechanical effectiveness of all upper-extremity prostheses. Such questions as "Does this prosthesis fit as well as your last one?" or "Can you work it?" receive only a vague, often uncertain, answer, but such criteria are too often accepted as a measure of performance. One of the first steps in establishing a set of standards is to determine which variable factors can be measured accurately. In upper-extremity prosthetics, some of the measurable factors are ranges of motion with and without the prosthesis, control-system efficiencies, forces necessary to flex the forearm, live-lift of the forearm, socket stability, movement of the terminal device when locking the elbow, plus several others. Once the factors are determined, a test program must be set up and carried out. The results of such a test must first be analyzed, then a trial set of standards must be established, and finally the standards must be laboratory-tested on as great a number of amputee subjects as possible.</p> <p>To this end, a test station was established, and 29 amputees, selected at random from a mailing list, were tested. Approximately 30 tests were applied to these amputees and their prostheses. By combining the test data with research and practical experience, a preliminary set of liberal standards was drawn up. The standards were then applied to more than 70 amputees during the two-year existence of the Case Study Program at the University of California at Los Angeles. Certain modifications and refinements in the tests were made until the procedure attained present form.</p> <p>One of the prime requirements in establishing the tests was that their application be kept simple, with respect both to the equipment and to the procedures to be followed. Sufficient accuracy of measurement can be obtained with a ruler and a spring scale, and the test standards are liberal enough to allow minor inaccuracies without rejecting the prosthesis. The most important concern is, first, that all tests be applied in a similar manner and, second, that the results be compared to a universally acceptable standard.</p> <p>The tests and standards may be conveniently listed in three groups: general tests, applicable to all types of prostheses; tests for below-elbow prostheses; and tests for above-elbow prostheses.<a style="text-decoration:none;">*</a></p> <p>All tests should be performed with the amputee wearing his prosthesis. In the case of a bilateral amputee, each side should be tested separately, but the amputee should have almost complete independence of action on each side while wearing both prostheses.</p> <h3>General Tests</h3> <h4>Test No.1-Compression Fit and Comfort</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Push the prosthesis onto the stump while the wearer resists the push (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Test for compression fit and comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should feel no undue discomfort or pain when the prosthesis is forced onto the stump.</p> <h4>Test No. 2-Tension Stability</h4> <p><i>Test</i>: Straighten the prosthesis at the side (<b>Fig. 2</b>). Hook the scale over the terminal device and apply a force of 50 lb. straight down. (A force of 30 lb. is sufficient for children.) Standard: The prosthesis should not slip more than 1 in. in relation to the stump, and no part of the prosthesis or harness should fail when a 50-lb. distal load is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Test for tension stability. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 3-Hook-Opening Facility (Normal Use)</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Have the wearer actively operate the terminal device.</p> <p><i>Standard</i>: The wearer should be able to obtain full range of terminal-device operation actively with the forearm flexed to 90 deg.</p> <h4>Test No.4-Hook-Opening Facility (At Mouth And Perineum)</h4> <p><i>Test</i>: Flex the forearm so the terminal device is near the mouth (lock if AE). Have the wearer actively operate the terminal device. Repeat this procedure with the terminal device near the perineum.</p> <p><i>Standard</i>: The wearer should be able to obtain at least 70 percent of full range of terminal-device operation actively at the mouth and perineum.</p> <h4>Test No. 5-Control-System Efficiency</h4> <p><i>Test</i>: a) Disconnect the control cable from the terminal device, and attach the scale to hook-operating lever or hand-operating cable (<b>Fig. 3</b>a). Place a 3/4-in. block between the fingers and pull until the block slips out of a voluntary-opening hook or until the fingers of a voluntary-closing hook or hand just close on the block. Note the force at this instant.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Test for control-system efficiency. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>b) Reconnect the control cable to the terminal device, and apply the scale to the T-bar. or terminal, at the other end of the control cable. Pull along the line of the harness unti. the block slips or the fingers touch, as before (<b>Fig. 3</b>b). Note the force at the instant this occurs.</p> <p>c) Multiply the force measured at the terminal device by 100. Then divide by the fora measured at the cable terminal as in the following formula:</p> <blockquote><p>Efficiency = (Force measured at terminal devices X 100)/(Force measured at cable terminal)</p> </blockquote> <p><i>Standard</i>: The control-system efficiency should be at least 70 percent.</p> <h3>Below-Elbow and Below-Elbow Biceps-Cineplasty Tests</h3> <p>All of the following tests apply to the conventional below-elbow prosthesis and to the below-elbow biceps-cineplasty prosthesis.</p> <h4>Test No. 1-Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm flexion with and without the prosthesis.</p> <p><i>Standard</i>: Active flexion with the prosthesis on should be as great as active flexion without the prosthesis.</p> <h4>Test No. 2-Forearm Rotation<a style="text-decoration:none;">*</a></h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm rotation (extreme pronation the extreme supination) with and without the prosthesis (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Test for forearm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: Active rotation with the pros-thesis on should be at least half that obtained without the prosthesis.</p> <h3>Above-Elbow and Shoulder-Disarticulation Tests</h3> <p>All of the following tests apply to the above-elbow prosthesis, and most of them apply to the shoulder-disarticulation prosthesis. Those which do not apply to the shoulder-disarticulation case are marked with an asterisk.</p> <h4>Test No. 1-Ranges Of Stump Motion*</h4> <p><i>Test</i>: Have the amputee straighten the prosthesis and lock the elbow. Then move his stump and prosthesis through the maximum ranges of flexion, extension, elevation, and rotation.</p> <p><i>Standard</i>: The amputee should be able to satisfy the following minimum requirements while wearing the prosthesis: flexion, 90 deg.; extension, 30 deg.; elevation, 90 deg.; rotation, 45 deg.</p> <h4>Test No. 2-Range of Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum active range of prosthetic forearm flexion with the maximum manual range. Note the amount of initial forearm flexion built into the prosthesis.</p> <p><i>Standard</i>: The amputee should be able to flex actively to 135 deg. of forearm flexion, no more than 10 deg. of which should be due to initial flexion.</p> <h4>Test No. 3-Humeral Flexion Required to Flex Forearm*</h4> <p><i>Test</i>: Have the amputee flex the prosthetic forearm actively through its entire range using humeral flexion, and note the degrees of flexion of the humerus required to do so.</p> <p><i>Standard</i>: Humeral flexion required to flex the prosthetic forearm fully should not exceed 45 deg.</p> <h4>Test No. 4-Force Required to Flex Forearm</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Insert the spring scale through the cable attachment, and flex the forearm to 90 deg. while holding the socket stationary. Pull along the normal line of the cable until further flexion of the forearm just starts, and note the force.</p> <p><i>Standard</i>: The force required to start flexion of the forearm from 90 deg. should not exceed 10 lb.</p> <h4>Test No. 5-Live-Lift</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Hook the spring scale over the prosthesis at a distance of 12 in. from the elbow pivot using a leather strap if necessary (<b>Fig. 5</b>). Flex the forearm to 90 deg., and have the amputee actively resist while applying a straight-down pull on the scale. Note the scale reading when the amputee can no longer completely resist the pull and the forearm slips below 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Test for live-lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should be able to resist actively a downward force of at least 3 lb. located 12 in. from the elbow center when the forearm is flexed to 90 deg.</p> <h4>Test No. 6-Involuntary Operation of the Elbow Lock*</h4> <p><i>Test</i>: Face the amputee and have him abduct the prosthesis 60 deg. Note whether or not the elbow lock operates. Then have him walk a short distance swinging the prosthesis in a normal manner, and note whether the elbow lock operates involuntarily or not.</p> <p><i>Standard</i>: The elbow lock should not operate involuntarily when the prosthesis is abducted 60 deg. nor during normal walking. In addition, a natural-appearing arm swing should be exhibited while walking.</p> <h4>Test No. 7-Movement of Terminal Device When Locking Elbow*</h4> <p><i>Test</i>: Have the amputee actively flex the forearm to 90 deg. Then have him actively lock the elbow. Note the movement of the terminal device as the elbow is locked.</p> <p><i>Standard</i>: The terminal device should not move more than 6 in. during active operation of the elbow lock when the forearm is flexed to 90 deg. (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Test for motion of terminal device when locking elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 8-Socket Stability During Arm Rotation*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Have the amputee abduct the prosthesis 60 deg. and rotate his stump and prosthesis. Note any slippage of the socket about the stump.</p> <p><i>Standard</i>: The amputee should be able to control the prosthesis during arm rotation, and there should be no slippage of the socket about the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Test for socket stability during arm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 9-Stability of Socket Against Torque*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Hook the scale over the prosthesis at a distance of 12 in. from the elbow center, using a leather strap if necessary. Have the amputee resist while pull is applied, first laterally, then medially, on the socket with a force of 2 lb. Note any slippage of the socket about the stump, or of the turntable, which may occur.</p> <p><i>Standard</i>: The amputee should be able to resist both lateral and medial pulls of 2 lb. located 12 in. from the elbow center, and the turntable should not turn with this force.</p> <h3>Conclusion</h3> <p>That the test procedure has reached a sufficient degree of refinement to be used successfully in the field is evidenced by its widespread adoption. Such agencies as the United States Veterans Administration, the State Departments of Vocational Rehabilitation of California and Illinois, and others include fulfillment of the standards as a contract stipulation. It must, however, be borne in mind that these test procedures are not to be considered as the final answer. Additions, revisions, and general improvements constitute a never-ending project in the field of prosthetics evaluation.</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">This test need not be applied when the stump is only half the normal forearm length or less.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">These tests and standards may not apply in cases where atrophy, bone blocks, loss of muscles, and the like are in evidence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Lester Carlye, M.E. </b></td></tr><tr><td class="clsTextSmall">Engineer, Artificial Limbs Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-007.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 Artificial Arm Checkout Procedures Creator An entity primarily responsible for making the resource Lester Carlye, M.E. * https://staging.drfop.org/files/original/45936845c560d4d5eebd237d926562f2.pdf 0ea2670a224e26f8a1b36cd756e5f496 https://staging.drfop.org/files/original/1e3bdc3b8dc622982e576909d90687d7.jpg 4c4de5849811d644713ec7230d7d0f02 https://staging.drfop.org/files/original/abf3a4d5ce92c8133b359340480b34ab.jpg 0ceb64af346708b11b688bc9aec46035 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_04_004.pdf Text Any textual data included in the document <h2>Should Functional Ambulation be A Goal for Paraplegic Persons?</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The goal of functional ambulation for paraplegic persons is a subject of long debate in virtually all rehabilitation settings. Such factors as lesion level, motivation, attitude of the clinic team, age, body build and occupation are important determinants when orthoses are prescribed for ambulatory purposes. Despite the various orthotic designs available, and the philosophies that accompany each design, the majority of paraplegic persons will either reject their orthoses or not have them prescribed.</p> <p>Personal experiences and published reports indicate that when a thoracic level lesion is present, only about two percent of patients fitted will reach the level of household ambulation. There are many reasons for this, the main one being the excessive energy expenditure needed to ambulate in an orthosis. The donning procedure for most orthoses is difficult and time consuming, and once the orthoses are on the patient they often interfere with transfer activities. In addition, crutches are needed for stability while standing and ambulating, which limits the use of the hands and arms. Other problems with standing and ambulation for paraplegic patients are the lack of bladder control while standing and obviously abnormal walking pattern.</p> <p>In this brief article, I will review some of the more pertinent articles on this subject, and then present my opinion concerning the provision of lower-limb orthoses for paraplegic persons.</p> <p>The history of the orthotic treatment of paraplegia does not go back much further than World War II, since previous to that time about 90 percent of the spinal-cord-injured persons died from genitourinary infections. The development of antibiotics to combat these infections reversed the fatality rate shortly after World War II.</p> <p>The physiological benefits of standing persons with paraplegia were first mentioned by Abramson <a></a> in 1948, who stated that an hour of standing each day will prevent osteoporosis in the lower limbs and helps to prevent urinary calculi and genitourinary infections. In 1964, Rusk, stated that "circulation and nutrition, as well as morale, are also aided by keeping the patient in the upright position for several hours each day".</p> <p>Rusk also recommended that the tenth thoracic vertebra be used as a landmark when prescribing orthoses; lesions at or superior to this level are usually given double-bar long leg-braces with a pelvic band and Knight spinal attachment (current terminology is LSHKAFO, or lumbo-sacral-hip-knee-ankle foot orthosis); lesions inferior to T₁₀ level are prescribed the same orthoses without the spinal attachment, and lesions inferior to L₁ are fitted without a pelvic band.</p> <p>Hahn <a></a> and Scott <a></a> from Craig Rehabilitation Hospital in Denver, Edberg <a></a> from Rancho Los Amigos Hospital in Downey, and Warren et al., <a></a> from the University of Washington, do not advocate the use of the pelvic band on paraplegic patients. Edberg feels that the pelvic band must apply excessive pressure against the skin to be effective, that it causes difficulty in donning the orthosis, limits flexibility and adds excessive weight. Hahn and Scott state that the two most important considerations for orthotic design for paraplegics are ease of donning and control of ankle dorsiflexion, hence the so-called Craig-Scott design KAFO (<b>Fig. 2</b>) has no pelvic band, only one thigh band, and a fixed but adjustable ankle joint.</p> <p>Hussey and Stauffer <a></a> studied the ambulatory function of 164 spinal-cord-injured patients at Rancho Los Amigos Hospital and stated that "no patient achieved any form of functional ambulation without pelvic control<a style="text-decoration: none;">*</a> and there appeared to be no effective method of bracing patients to overcome this deficit". The nerve supply for the pelvic control muscles is affected by a thoracic lesion.</p> <p>Rosman and Spira <a></a> reported similar problems in ambulating patients with thoracic lesions. In a study of 35 patients with lesions from the T₁ to T₁₁ level who were fitted with orthoses for ambulation, only one patient was ambulating out of the hospital, and five used the orthosis for standing only. The report concluded "that there is an essential difference between the 'occupation' of walking in the 'non-pressured' rehabilitation environment and walking when faced with the problems of everyday life". It further concludes that "some disabled persons with unusual strength, willpower, and motivation for walking will successfully overcome the difficulty, effort, and social strain involved in the continuous use of braces", but that "most will eventually relinquish these goals because the effort proves too great".</p> <p>Pneumatic orthoses (<b>Fig. 1</b>) were developed and first used in the United States, amid great fanfare, in 1973. Three major evaluations by Silber <a></a>, at New York's Bird S. Coler Hospital, Ragnarsson et. al., <a></a> at the Institute of Rehabilitation Medicine, New York University, and by the Committee on Prosthetics Research and Development, National Academy of Sciences <a></a> on a total of 62 paraplegic persons indicate that the orthoses were lighter than metal designs and required less energy for ambulation but severe mechanical limitations, such as donning and inflation problems, outweigh these advantages when the orthoses are used outside of an institutional setting.</p> <p>A study by Cerney, at Rancho Los Amigos Hospital, comparing energy costs for eight paraplegics walking versus using a wheelchair concluded "The average velocity for paraplegic walking was less than half of normal while oxygen uptake per minute was increased by 50 percent. These two factors combine to create an oxygen uptake per meter than is increased six times". Similar data for the same patients using wheelchairs, again compared to normal individuals, showed "only a two to six percent increase in the physiological factors and a ten percent decrease in velocity".</p> <p>Despite the poor track record I have documented, ambulation is still considered a goal for paraplegic patients in most rehabilitation settings. Obviously, the patient will fail to reach this goal in most cases, so why do most of us expend our energies in this area? I feel there are benefits to be gained by providing ambulation training. For one, nearly all new paraplegic persons believe they will walk again, and it is virtually impossible to convince them otherwise. These patients feel that they are being deprived of their chance for complete rehabilitation if they are never given the opportunity to try to walk. Psychologically, they must prove it to themselves. After these patients are convinced that walking is impractical, they will concentrate more heavily on becoming wheelchair-independent.</p> <p>A physician I worked with in Chicago told the story of an obese, bilateral above-knee amputee who wanted to be fitted with prostheses so he could walk again. They physician refused to prescribe a prostheses as he knew that the patient could never use them, and told the patient he would not be able to walk again. The patient immediately suffered a nervous breakdown in the clinic and required hospitalization. From that day on, the physician prescribed prostheses for patients with similar problems so they could convince themselves of the impracticality of ambulation and, more important, have a longer period of time to accept reality.</p> <p>A small percentage of patients do ambulate in orthoses (<b>Fig. 3</b>), especially those patients with pelvic or hip control or sensation. It is impossible to predict successful ambulators, and patients should be given a chance to succeed. Obviously, patients who lack motivation, are very obese, or who lack strength and endurance will never succeed and should be dissuaded from trying to ambulate.</p> <p>In this article I have attempted to back up my personal experiences with information from published reports, and then to justify why most paraplegics are given ambulation training despite the poor prognosis. We would appreciate your thoughts on this subject and therefore encourage you to complete the attached questionnaire.</p> <p><b>References:</b></p> <ol> <li>Abramson, S. A., <i>Bone disturbances in injuries to spinal cord and caude equina (paraplegia)</i>. J. Bone and Joint Surg. 30-A:982-987, October 1948.</li> <li>Edberg, E., <i>Bracing patients with traumatic paraplegia</i>. Phys. Ther. 47:9:818-823, September 1967.</li> <li>Hahn, Harry, Personal communication, March 1975.</li> <li>Hofstra, Peter C, <i>The clinical engineer and the spinal-cord-injured person</i>. Bull. Pros. Res. 10-22:37-40, Fall 1974.</li> <li>Hussey, Robert W., and E. Shannon Stauf-fer, <i>Spinal-cord injury: requirements for ambulation</i>. Arch. Phys. Med. Rehab. 54:12:544-547, December 1973.</li> <li>Ragnarsson, K. T., G. Heiner Sell, Margaret McGarrity, and Reuven Ofir, <i>Pneumatic orthosis for paraplegic patients: functional evaluation and prescription considerations</i>. Arch. Phys. Med. Rehab. 56:11:479-483, November 1975.</li> <li>Rosman, N., and E. Spira, <i>Paraplegic use of walking braces: a survey</i>. Arch. Phys. Med. Rehab. 55:7:310-314, July 1974.</li> <li>Rusk, Howard A., <i>Rehabilitation Medicine, Second Edition</i>. C. V. Mosby Co., St. Louis, Missouri, p. 503, 1964.</li> <li>Scott, Bruce A., <i>Engineering principles and fabrication techniques for the Scott-Craig long leg brace for paraplegics</i>. Orth. and Pros. 25:4:14-19, December 1971.</li> <li>Silber, Maurycy, Tae-Soo Chung, George Varghese, Catherine Hinterbuchner, Milton Bailey, and Nancy Hirvy, <i>Pneumatic orthosis: pilot study</i>. Arch. Phys. Med. Rehab. 56:1:27-32, January 1975.</li> <li>Warren, C. G., J. F. Lehmann, and B. J. DeLateur, <i>Use of the pelvic band in orthotics for adult paraplegic patients</i>. Arch. Phys. Med. Rehab. 56:5:221-223, May 1975.</li> <li>Cerney, Kay, R.P.T., <i>Walking and wheelchair energetics in spinal cord injury</i>.</li> <li>National Academy of Sciences, <i>Evaluation of the ortho-walk type B pneumatic orthosis on thirty-seven paraplegic patients. Washington, D.C., 1976, pp. 1-5</i>.</li> </ol> <strong>Footnote</strong><br />The Term 'pelvic control' used here refers to the ability of the abdominals to move the pelvis when body weight is on the crutches.<br /> <div style="width: 400px;"><br />*Michael J. Quigley, C.P.O.<br />Rehabilitation Engineering Center, Rancho Los Amigos Hospital, Downey, California.</div> Page Number(s) 4 - 6 Year 1977 Volume 1 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1977_04_004/1978_04_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_04_004/1978_04_005-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello 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 Should Functional Ambulation be A Goal for Paraplegic Persons? Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/646807426d786878263060044f860bb5.pdf a91cea6354ddf7b14de92ba2bb2c720d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_04_001.pdf Text Any textual data included in the document <h2>Partial Foot Amputation</h2> <h3>Results of the Questionnaire Survey</h3> <p>There were fifteen replies by mail to the questionnaire on management of patients with partial foot amputation that appeared in the Summer 1977 issue of the NEWSLETTER. Ten came from prosthetists, one from a physical therapist, and four from physicians.</p> <p>The answers and remarks from all but one prosthetist are given below. One prosthetist, Lewis Meitzer of Miami, Florida, took the time and trouble to write a very thoughtful letter which is printed in full after the tabulation of the questionnaires.</p> <p>Prepared by the American Academy of Orthotists and Prosthetists, 1444 N Street, N.W., Washington, D.C. 20005. Editor: A. Bennett Wilson, Jr., B.S. M.E.; Editorial Board: Joseph M. Cestaro, C.P.O., Charles H. Epps, Jr., M.D., Robert B. Peterson, R.P.T.</p> <ol> <li> <p>Do you feel that patients with partial foot amputations require prostheses that extend higher than the distal third of the tibia?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>No. Ankle high only.</p> </li> <li> <p>The prosthesis should not be higher than maleoli.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Very seldom</p> </li> <li> <p>Especially true for active people. Low activity people without deformities seem to function well with the least amount of appliance.</p> </li> <li> <p>Not in all cases, for example, we're using C. Fillauer's AC &amp; PLIC socket w/posterior (6) split for a great percentage of our partial foot amputees.</p> </li> <li> <p>No.</p> </li> <li> <p>I basically avoid terminating a prosthesis on the lower tibia. Often a shoe insert with the filler works fine. If a rigid ant. is used, I definitely do not stop at any point on the tibia.</p> </li> <li> <p>Transmetatarsal or longer - No. All others - Yes.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>If hand users.</p> </li> <li> <p>Yes.</p> </li> <li> <p>No.</p> </li> <li> <p>If full, pain free, weight bearing is possible on the remaining part of the foot - No. If not, then weight needs to be taken higher.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Yes.</p> </li> </ol> </li> </ul> </li> <li> <p>Do you feel that most patients who receive partial foot amputations would function better with a Syme's amputation?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>No.</p> </li> <li> <p>No, as long as the plantar surface can tolerate weight bearing, a partial foot is better than Syme's.</p> </li> <li> <p>No.</p> </li> <li> <p>No.</p> </li> <li> <p>Again active people and children who can possible avoid bone spurs and eventually develop an endbearing cosmetic BK. Surgery is important. Good padding over bones is very beneficial.</p> </li> <li> <p>Yes, the large majority would increase their function and be relatively pain-free.</p> </li> <li> <p>No.</p> </li> <li> <p>No. I have seen too many patients function beautifully with partial foot and only a toe filler.</p> </li> <li> <p>For P.V.D. patients a Symes amputation usually has a better chance to heal and the prosthetic fitting is better. For traumatic amputations as much length should be preserved to increase weight bearing surface and lever arm.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Yes, but not all.</p> </li> <li> <p>Not necessarily.</p> </li> <li> <p>Yes, at least psychologically.</p> </li> <li> <p>No. A Syme's is much more radical than is often necessary and will not necessarily result in better function.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Yes.</p> </li> </ol> </li> </ul> </li> <li> <p>Do you agree with the author's list of advantages and disadvantages of this amputation?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>Some.</p> </li> <li> <p>-</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>I feel amputation sites for children should take bony overgrowth and foreshortening into account, i.e., disarticulation rather than partial foot types.</p> </li> <li> <p>Not in its entirety, but generally speaking, yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Some of them.</p> </li> <li> <p>Yes we do, however, prosthetic breakdown will still occur regardless which type is fitted.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>No. They are not the indication for the procedure.</p> </li> <li> <p>?</p> </li> <li> <p>Yes.</p> </li> <li> <p>Partially.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Yes.</p> </li> </ol> </li> </ul> </li> <li> <p>Do you feel that the sole or shank of the shoes or prosthesis should be rigid or flexible?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>Flexible.</p> </li> <li> <p>Flexible, to provide easy roll over the often tender distal anterior foot.</p> </li> <li> <p>Rigid to metatarsal break, flexible distal from this point.</p> </li> <li> <p>Rigid except for toe flexibility.</p> </li> <li> <p>The sole should extend the toe break past the end of the amputation, rigid slightly past this point.</p> </li> <li> <p>We think in terms of the SACH foot function using rigid soft tissue support w/flexible forefoot.</p> </li> <li> <p>Flexible.</p> </li> <li> <p>Depends on patient's gait, toe off phase especially. Generally rigid to the ball of the shoe and flexible in the toe area.</p> </li> <li> <p>Usually, a rigid shoe and/or prosthetic foot functions better. However, we do have success using a modified Winnipeg Symes Prosthesis, which is partially flexible.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Rigid.</p> </li> <li> <p>Rigid.</p> </li> <li> <p>Do not know.</p> </li> <li> <p>It depends largely on the level of amputation, the shoe control which is achieved and the residual ankle function. In general it needs to be rigid proximal to the metatarsal heads and capable of flexing to about 15° under the metatarsal heads when loaded.</p> <p>Sometimes, e.g. when the metatarsal heads are painful or in a very proximal level amputation, it needs to be rigid throughout and with a rocker base. If there is adequate ankle function, and reasonable shoe control on the residual foot, the prosthesis should flex at the ankle too.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Rigid.</p> </li> </ol> </li> </ul> </li> <li> <p>Please comment if you have experience with the "ankle-foot orthosis" type of treatment mentioned here and described by Fillauer.</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>I have been using the same basic idea for several years with good success.</p> </li> <li> <p>I have used this on one patient and he was quite pleased.</p> </li> <li> <p>-</p> </li> <li> <p>No experience.</p> </li> <li> <p>No experience. I added another approach to my repertoire.</p> </li> <li> <p>No experience.</p> </li> <li> <p>Yes.</p> </li> <li> <p>I have used the AFO with a toe filler attached a few times recently and am very satisfied with the results.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Yes, only very limited.</p> </li> <li> <p>Yes, occasionally useful.</p> </li> <li> <p>No.</p> </li> <li> <p>-</p> </li> <li> <p>No experience.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>No experience.</p> </li> </ol> </li> </ul> </li> <li> <p>Would you be willing to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes, although my experience is limited (which is probably the situation 90% of the time). A ready reference such as this may help us all solve the unique problems each of these amputees present.</p> </li> <li> <p>Enthusiastically.</p> </li> <li> <p>Yes.</p> </li> <li> <p>At present I have nothing new to contribute.</p> </li> <li> <p>Yes, we would.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Yes.</p> </li> <li> <p>No.</p> </li> <li> <p>Do not feel qualified to do so.</p> </li> <li> <p>Yes.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>No, not enough experience.</p> </li> </ol> </li> </ul> </li> </ol> <h3>Conclusions</h3> <p>It can be seen that although there is a wide variation of opinion about partial foot amputations and prostheses, more than half of the practitioners feel that partial foot amputations can provide better function than the Syme's.</p> <p>Nearly all of the respondents would be glad to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations.</p> <p>Mr. Meltzer's letter, which follows, seems to sum up the state of the art and is reproduced here in full.</p> <p><i>September 27, 1977</i></p> <p><b>Newsletter Questionnaire</b><br />AAOP<br />1444 N Street, N.W.<br />Washington, D.C. 20005</p> <p>The following are the answers to your questions as per your request from the Newsletter Questionnaire, copy enclosed.</p> <p>NAME: Lewis N. Meltzer, C.P.O.</p> <ol> <li> <p>Do you feel that patients with partial foot amputations require prostheses that extend higher than the distal third of the tibia?</p> <blockquote> <p>It has been my experience that patients with partial foot amputations occasionally cannot tolerate the Fillauer type orthosis. Yet, for cosmetic purposes, they prefer it rather than something extending above the shoe. I have fitted a few and only succeeded with one. This is after extended trials by myself and the patient. Yet, the two who were not satisfied, preferred to wear nothing and have been lost to follow up. Several years ago I worked with polypropylene or similar AFO's with toe fillers and steel shanks in the shoe, and those seemed to work satisfactorily. I think that Mr. Pritham's idea merits trials. My only concern is cosmetic acceptance when compared to the Fillauer type.</p> </blockquote> </li> <li> <p>Do you feel that most patients who receive partial foot amputations would function better with a Syme's amputation?</p> <blockquote> <p>This seems like an ambiguous question which I feel I can only answer by saying it would depend on the individual. At the same time, all else being equal, partial foot amputation would be my choice were I to need that type of amputation as I could more easily walk without a prosthesis either around the house or at night.</p> </blockquote> </li> <li> <p>Do you agree with the author's list of advantages and disadvantages of this amputation?</p> <blockquote> <p>Yes.</p> </blockquote> </li> <li> <p>Do you feel that the sole or shank of the shoes or prosthesis should be rigid or flexible?</p> <blockquote> <p>Here, again, this would depend on the patient as I have seen patients desiring no prosthesis.</p> </blockquote> </li> <li> <p>Please comment if you have experience with the "ankle-foot orthosis" type of treatment mentioned here and described by Fillauer.</p> <blockquote> <p>The Fillauer method I have tried has included a section of Silastic R.T.V. in the anterior distal socket for comfort and total contact. This is laminated over the cast rather than after the prosthesis is made. With this, I still have had only one satisfied patient. The other two required several attempts at fitting and yet the patients were not satisfied.</p> </blockquote> </li> <li> <p>Would you be willing to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations?</p> <blockquote> <p>I would be willing, if I felt I had something specific to offer as an alternative, but I have not found it to date.</p> </blockquote> </li> </ol> <p>Sincerely,<br />Lewis N. Meltzer, C.P.O.</p> Page Number(s) 1 - 3 Year 1977 Volume 1 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot Amputation https://staging.drfop.org/files/original/d1e6d37381974afea447207e5e2dcbe4.pdf 098f55530355bceeb283da47fcc350e7 https://staging.drfop.org/files/original/0666e268b5cec1356b0b7c65cbfadb51.jpg 34526111ef1e2eb773fafce8d671b491 https://staging.drfop.org/files/original/cc9fd87e23971d5b30a0750aca41f5a3.jpg 63bf988ca05ee052c35c60bac08961ea https://staging.drfop.org/files/original/85d3b8a378a156a011e468adb5269da1.jpg 5bf92dc7bf504dcff53808541d517251 https://staging.drfop.org/files/original/227e6156213f99f0da1e50d223dee8a0.jpg 3db61f11e3ba6a4f7e34e896d5442696 https://staging.drfop.org/files/original/9a578284ee6908603aea1c033d17b00a.jpg e8da77889765cbddc376316eae272fe9 https://staging.drfop.org/files/original/2cdd2bdc87a91cc20b1bd2e2c8de8fdb.jpg bc32bfecba3ba120e95537d67188be8d https://staging.drfop.org/files/original/08887b5a399d3835a423a7465e92c363.jpg b49025384d7feb416227e5c087356179 https://staging.drfop.org/files/original/3bdc683c4fd3a3b01dd291dcc05442a7.jpg dc3f77f6a7dc6e8f10d15f57a79b4bd5 https://staging.drfop.org/files/original/baa8c678a811a389abfecf5c63ec394a.jpg fadb2fb86dfab8eae20656c2668c41bf https://staging.drfop.org/files/original/8af81fcc4e2a1200c4b3ebacefd7dcdc.jpg 71e21b708994bac32da23d1191b72f33 https://staging.drfop.org/files/original/df8f5de5f6e51604721fe6c8eac18d00.jpg daf7122151ce6dea1bd294319637ca83 https://staging.drfop.org/files/original/fc36c0b09aa6f3af1a634440b2895b0c.jpg 737f8f6f58dd6ce0aa0bafb5bc333f08 https://staging.drfop.org/files/original/f23de5b7227d292fd049b5c53370ad5e.jpg 322c5646d98f492326ba9b2ad1189f10 https://staging.drfop.org/files/original/12807becbc364793ce64139f3ed19ca0.jpg 76b2ffd63899936900e983217326addb https://staging.drfop.org/files/original/c7c004b4cacc9f9a708a3486dc137efa.jpg d1ecb9180a51ca39aec2e6a1a746c16d https://staging.drfop.org/files/original/0b96ee4588a2a50ba8ae866ee38bd212.jpg 9ce093f92ed02602e5a59abd344d72a8 https://staging.drfop.org/files/original/6dca045beee9acf9d8ca40d95e842f26.jpg 261149ab340dc088401ee1852c05995d https://staging.drfop.org/files/original/1dfabfd667493e59ce35c164c328039a.jpg d22c081e2b4704fdbf8a951a6c62136a https://staging.drfop.org/files/original/70bc99ba51deb9adc1649fc859b83790.jpg 1315b524e4b6252efd9c727af36bddc5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_015.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 15 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Upper-Extremity Prosthetics Armamentarium</h2> <h5>Maurice J. Fletcher, Lt. Col., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The word "armamentarium" is defined as "the equipment, instruments, apparatus, or paraphernalia used by the practitioner of medicine." As applied to artificial limbs, it refers to the array of components necessary for the prescription fitting of prostheses in relationship to the site of amputation.</p> <p>In the prosthetics armamentarium, it is desirable that a complete range of components be available in order to provide satisfactory prostheses for all sites of upper-extremity amputations. A few gaps still remain in the present armamentarium of devices, but such temporary inadequacies are in the area of special cases, such as in transcarpal and fore-quarter amputations and in children's prostheses. The few remaining gaps are being rapidly filled, and supplementary components for fortifying the present armamentarium, such as additional hand sizes, are under consideration at the present time. The fact that devices now exist in each category of necessary arm components does not necessarily mean that they are the ultimate. They might even be interim devices, but they do permit prescription fitting of arm prostheses to a degree of efficiency heretofore unattainable. As a device is made available for each category of the armamentarium, improve-ments are attempted in these individual devices to increase their efficiency and useful-ness to the amputee. New models and methods of operation are being exploited in the hope of providing, eventually, even more efficient restorative prostheses. It is the purpose here to provide brief descriptions of the functions provided by the basic units of the present upper-extremity armamentarium. For a more detailed treatment of the devices and the philosophy underlying their design, reference may be had to <i>Human Limbs and Their Substitutes</i> (McGraw-Hill, in press) and to the <i>Manual of Upper-Extremity Prosthetics</i> (University of California at Los Angeles, 1952).</p> <h3>Terminal Devices</h3> <h4>APRL Model 4c Voluntary-Closing Hand and Cosmetic Glove</h4> <p>As the name implies, in the APRL voluntary-closing hand (<b>Fig. 1</b>) prehension force is obtained voluntarily by the amputee. Tension applied to a control cable closes the index and middle fingers against the thumb in a three-jaw-chuck pattern. These one-piece, hollow, metal fingers move through a 1 1/2-in. range, but since the thumb tip can be set in either of two positions 1 1/2-in. apart, objects up to 3 in. wide can be grasped. Finger angles are such that a grasped object is forced inward toward the palm. Security of grasp is further increased by the use of felt pads on the inner surfaces of the fingers and thumb. Any degree of prehensile force up to about 35 lb. can be obtained. The ring and little fingers are of cast latex and are attached so that they roughly conform to the shape of the object being handled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. APRL model 4C voluntary-closing hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The actuating mechanism, shown in <b>Fig. 1</b>, consists of a cam-quadrant type of clutch which automatically locks the index finger and middle finger in place when tension in the control cable is released. Reapplication of tension automatically unlocks the mechanism, and a spring forces the fingers to the fully open position, at which point the mechanism is recocked and ready for another cycle. Backlash is eliminated in the lever system by incorporation of an auxiliary spring-and-lever system. In fact a certain amount of frontlash may be introduced into the system. The voluntary-closing type of mechanism permits fuller utilization of the potentialities of a cineplasty tunnel than any device heretofore available.</p> <p>The APRL hand is covered by a cast polyvinyl chloride glove of extremely natural appearance (<b>Fig. 2</b>). Developed especially for the APRL hand, it has been designed with particular regard to eliminating as much as possible the resistance to operation of the fingers. In order to reduce the necessarily high cost of coloring each glove on a custom basis, after careful experimentation six Caucasian and six Negroid shades have been provided. They satisfy the majority of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. APRL model 4C voluntary-closing hanc covered with APRL cosmetic glove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Voluntary-Closing Hook</h4> <p>The APRL voluntary-closing hook (<b>Fig. 3</b>) contains essentially the same mechanism employed in the APRL hand. One hook finger is closed against a stationary hook finger, the two designed to accommodate objects up to 3 in. in size. A control button permits the engagement of a stop to limit hook opening to 1 1/2-in. so that the hook finger does not have to move through its full range before recocking of the locking mechanism takes place. Moreover, locking action in the l 1/2-in. open position can be eliminated at the will of the amputee when this is desired for repetitive tasks. The rubber-lined, lyre-shaped, aluminum hook fingers are specially designed to provide maximum function. The smooth exterior surfaces present the least amount of friction to aid in entering pockets, while the rubber linings provide friction to aid in handling objects. Duckbill finger tips lend facility in handling small objects. By removing the fingers and reinstalling them 180 deg. from the original position, a right hook can quickly be converted to a left, or vice versa.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. APRL voluntary-closing hook in open and closed positions. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Northrop-Sierra Voluntary-Opening Two-Load Hook</h4> <p>In the Northrop-Sierra voluntary-opening two-load hook (<b>Fig. 4</b>), designed primarily for bilateral amputees, tension on the control cable causes one hook finger to open against a spring force, which in turn provides prehensile force between the hook fingers when there is no tension on the control cable. The spring force is provided by two identical coil-type springs. When both are engaged, a prehensile force of approximately 7 lb. is available at the ringer tips. When only one spring is engaged, 3 1/2 lb. of force are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Northrop-Sierra voluntary-opening two-load hook. Schematic diagram (above) shows arrangement of hook thumb and enclosed coil springs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lyre-shaped fingers are the same as nose used in the APRL hook.</p> <h4>Dorrance Voluntary-Opening Hook</h4> <p>Prehension in the Dorrance hooks is provided by rubber bands which force the hook fingers together. Adjustment of the prehension force is accomplished by adding or removing bands. Hook fingers are available in many different sizes and shapes of both steel and aluminum. Dorrance hooks offer the extreme in ruggedness and simplicity. The model known as Utility #5, shown in <b>Fig. 5</b>, is very popular.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Dorrance #5 utility hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Length Adapters and Fairings</h4> <p>To provide a constant effective prosthetic length when terminal devices of different lengths are interchanged, as in the case of the APRL hook and hand, length adapters and fairings (<b>Fig. 6</b>) have been made available. The length adapter is simply a stud with male threads at one end and female threads at the other so that it may be inserted between terminal device and wrist unit. Also available is a plastic fairing which covers the length adapter and provides a smooth transition between the oval end section of the APRL hand and the circular section of the wrist unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Wrist fairing and length adapter for APRL model 4C hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wrist Units</h3> <h4>Manual Friction-Type Wrist Units</h4> <p>Female threads receive the stud of the terminal device, the wrist-flexion unit, or the length adapter to permit attachment of these units to the arm. Compression of a rubber washer between the terminal device and the wrist unit provides sufficient friction to permit a certain amount of adjustment in the rotation of the terminal device without slippage under average operating conditions. SierraEngineering Company supplies the friction-type wrist unit in one size, 2 in. in diameter, suitable for the average adult male, while Hosmer supplies essentially the same unit in three sizes-2 in. in diameter for the average male, 1 3/4-in. in diameter for women and large children, and 1 3/8-in. in diameter for small children. All these units are designed to facilitate incorporation into plastic-laminate arms.</p> <h4>Manual Lock-Type Wrist Units</h4> <p><b>Hosmer F-M Wrist Unit</b></p> <p>Rapid interchange of terminal devices and positive locking of the terminal device in the pronation-supination plane are afforded by the Hosmer F-M (Fletcher-Motis) unit (<b>Fig. 7</b>). A serrated steel adapter with an annular groove is attached to the stud of the terminal device by threads. To connect the terminal device to the arm, the stud is forced into the wrist unit until a locking yoke and gear segment are engaged. To adjust the amount of rotation of the terminal device, the control button is depressed to the first detent, which releases the gear lock and permits rotation since the terminal device is retained by engagement of the locking yoke in the annular groove on the adapter. Further depression of the control button disengages the locking yoke and permits removal of the terminal device. A coiled compression spring attached to the end of the adapter facilitates operation of the F-M unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Hosmer F-M wrist unit, with exploded view showing arrangement of parts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Quick-Change Wrist Unit</b></p> <p>The Hosmer quick-change wrist unit provides essentially the same function as the F-M unit but is not quite as rugged and is more difficult to operate in some instances. The adapter and terminal device are released by rotating the forward portion of the wrist section, which disengages a detent-type lock. The quick-change unit is lighter in weight than the F-M unit and is used when weight is an important factor.</p> <h4>Northrop-Sierra Wrist-Flexion Device</h4> <p>The Northrop-Sierra Model B wrist-flexion device (<b>Fig. 8</b>), when used, is installed between the terminal device and the wrist unit. Consisting of a simple detent-type lock with three positions, it permits manual positioning and locking of the terminal device at 0, 25, and 50 deg. of flexion. Depression of a control button at the base of the unit disengages the lock to permit a change in the amount of wrist flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Northrop-Sierra model B wrist-flexion device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bilateral amputees find this device especially useful for working in areas close to the face and body, and some unilateral amputees have found it helpful in certain tasks necessary to their particular occupation.</p> <p>The APRL-Sierra below-elbow wrist-rotation unit (<b>Fig. 9</b>) has been developed to step up or multiply the residual pronation-supination of below-elbow amputees. A given rotation of the inner socket by the stump produces, through a planetary gear system, 2.3 times that amount of rotation in the terminal device. A locking mechanism, actuated by relative motion between the forearm and upper arm, and by which the unit is unlocked upon full extension of the forearm and locked upon flexion, is provided when desired.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. APRL-sierra wrist-rotation step-up unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Below-elbow amputees with little or no pronation-supination and nearly conical stumps have been fitted successfully with this unit, since rotation of the inner socket can be produced by rotating the humerus. In this case the lock must be provided so the stump may rotate relative to the socket upon flexion.</p> <h3>Below-Elbow Hinges</h3> <h4>Robin-Aids Flexible Hinges</h4> <p>Where no wrist-rotation step-up unit is used, the Robin-Aids flexible hinge (<b>Fig. 10</b>, bottom) is employed between the socket and arm cuff or triceps pad to impart axial stability to the entire prosthesis and yet to permit maximum use of the residual pronation-supination. The Robin-Aids hinge consists of a metal cable covered with a wrapped-wire housing and having flat terminal plates designed for firm anchoring in the plastic-laminate forearm and for fastening to the upper-arm cuff.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-elbow hinges. Top, Sierra insert hinge; center, Hosmer variable-ratio step-up hinge; bottom, Robin-Aids flexible hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Leather-Strap Hinges</h4> <p>Nylon-coated leather straps may be fabricated in the shop and used in lieu of the Robin-Aids flexible hinge.</p> <h4>Single-Axis Hinges</h4> <p>Metal single-axis hinges specially designed for plastic fabrication are available from several manufacturers. This type of hinge is used where maximum stability is required, such as in short below-elbow cases and in heavy-duty arms.</p> <h4>Polycentric Hinges</h4> <p>Polycentric hinges may be substituted for the single-axis hinges. They are preferred by many prosthetists because less care is required in location to give the same amount of comfort to the patient. Instead of a single axis, two hinge points are provided in this unit, thereby exerting less pressure on the stump through the socket when the forearm is flexed and when some slight misalignment exists.</p> <h4>Northrop-Sierra Insert Hinges</h4> <p>Insert-type hinges might be classified as semiflexible hinges, since they provide a degree of stability somewhere between that offered by the flexible Robin-Aids hinge or the leather strap and the solid steel hinges. They are generally used on medium below-elbow prostheses where sufficient stability cannot be obtained with the flexible hinge but where the stump is long enough to provide sufficient stability so that the metal-strap hinges are unnecessary. Insert hinges are installed in "ears" on the distal end of a leather arm cuff so that the cuff may be hinged about the proximal end of the forearm socket. The method of assembly is illustrated in <b>Fig. 10</b>, top.</p> <h4>Step-Up Hinges</h4> <p><b>Hosmer MA-100 Hinges</b></p> <p>The Hosmer MA-100 step-up hinge (<b>Fig. 11</b>) was developed to permit full flexion of the prosthetic forearm when flexion of the stump is limited to 90 deg. or more. Step-up action is provided through two gears so that flexion of the stump 90 deg. results in 135 deg. of forearm flexion. The multiplication in motion results in a corresponding decrease in torque about the prosthetic forearm, and often an assistive lift is required for forearm flexion. This is accomplished by employing one of the above-elbow harnessing systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer MA-100 step-up hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Variable-Ratio Step-Up Hinge</b></p> <p>The Hosmer variable-ratio hinge (<b>Fig. 10</b>, center) provides approximately the same function as the MA-100 hinge but is usually preferred because the changing ratio of stump action to forearm action provided by the sliding lever system results in easier operation. This ratio in the fully extended position is 1:1.8, increases to 1:1.3 when the forearm is flexed 90 deg., and decreases to 1:1.8 at the 135-deg. position. Furthermore, because of the sliding action of the hinge, the stump does not extend as far below the forearm in flexion as in the case of the MA-100 hinge, a fact which in many instances eliminates the necessity for enlarging the sleeve of the garment covering the artificial limb.</p> <h4>Robin-Aids Stump-Actuated Elbow Lock</h4> <p>The Robin-Aids elbow (<b>Fig. 12</b>) was designed for short below-elbow cases where flexion of the forearm is limited to less than 90 deg. or for those cases where the torque about the elbow is too weak to offer sufficient stability. Full extension of the stump forces a lever into a detent on a segment about the elbow axis, locking the forearm in flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Robin-Aids stump-actuated elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Units for Above-Elbow Cases</h3> <h4>Northrop Model C Elbow</h4> <p>An alternating-type control for the locking mechanism is the prominent feature of the Northrop Model C elbow (<b>Fig. 13</b>). The first pull on the control cable drops a lever into a detent on a sector, resulting in a positive locking action about the elbow axis. The next pull on the control cable removes the locking level from the detent, thereby making the forearm free to rotate about the elbow axis. Eleven locking positions are available. In the average above-elbow case, the control cable is generally actuated by humeral extension, leaving the other hand or prosthesis, as the case may be, free. The excursion required, about 3/8-in., is so slight that after some practice most amputees are able to operate the locking unit with a motion that goes unnoticed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Northrop model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attachment to the upper arm is afforded by a single bolt in a turntable arrangement which permits the amputee to select at will the plane of forearm flexion and extension. A specially designed saddle for lamination into plastic is used for attaching the unit to the forearm.</p> <p>The Northrop elbow is presently available in one size only, 3 in. in diameter.</p> <h4>Hosmer Elbow Unit</h4> <p>Locking action of the Hosmer elbow unit (<b>Fig. 14</b>) is accomplished by permitting two tightly wound coil springs to wrap themselves around a shaft. Such an arrangement permits an infinite number of locking positions. Attachment to the arm and forearm and operation by the amputee follows the same pattern as in the case of the Northrop Model C.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Hosmer elbow unit, without turntable or forearm saddle attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Hosmer unit is available in two sizes, approximately 2 and 3 in. in diameter. Recently Hosmer has added to its line a smaller elbow designed for children.</p> <h4>Elbow-Disarticulation Prostheses</h4> <p>The APRL-Sierra side-locking elbow hinge (<b>Fig. 15</b>) was developed expressly for elbow disarticulation and for very long above-elbow cases where insufficient room exists for the fully enclosed type of elbow unit. An alternating-type locking unit on the outside of the inner hinges permits locking and unlocking of the elbow by humeral extension, as in the case of the standard above-elbow amputee. This unit may also be used on short below-elbow cases where use of the Robin-Aids forearm-actuated lock is not feasible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. APRL-Sierra outside-locking elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Control Systems</h3> <p>For terminal-device operation and forearm control, Bowden-type controls, along with such parts as retainer and terminal fittings specially designed for use on artificial arms, are available from a number of sources for both the harness and cineplasty applications. This type of control system (<b>Fig. 16</b>), consisting of high-strength woven wire cable enclosed in a wrapped-wire housing, has proven infinitely more satisfactory than anything else used to date, mainly because of its resistance to stretching and its relatively high power-transmission efficiency.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bowden-type control cable and attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-Elbow Biceps Cineplasty Control Systems</h4> <p>Special control-system kits are available for below-elbow amputees with biceps cineplasty tunnels. The twin-cable system (<b>Fig. 17</b>), often referred to as the UCLA system, is available with either straight or ox-bow acrylic tunnel pins reinforced with a copper core. Provisions have been made for quickly attaching or removing the control cables with respect to the pin. Rapid selection of the initial tension on the muscle tunnel is made possible by the incorporation of a turnbuckle type of unit which controls the effective cable length. A single-cable system using a sheave-type equalizer and known as the APRL system is also available (<b>Fig. 18</b>). Cable-tension adjust-ment is provided by a single cable-length ad-juster installed between the sheave and the terminal device. Each of these systems is considered merely as a replacement for the shoulder-operated control system, since all other portions of the prosthesis are the same whether operated from the shoulder or from the muscle tunnel.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Twin-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. APRL single-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nudge Control</h4> <p>For the shoulder-disarticulation case, in which it is impossible to provide from shoulder movement force and excursion necessary to operate the Northrop Model C or Hosmer elbow, there is available the Nudge Control, which permits the elbow lock to be controlled by chin movement. The nudge control (<b>Fig. 19</b>) is especially useful for bilateral shoulder-disarticulation cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Nudge control for operation of elbow lock in shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusion</h3> <p>This, briefly, completes the basic items of the armamentarium of devices available for prescription fitting relative to sites of amputation. There are, however, many supplementary devices, available in the field and well known to the industry, which are used with the devices described.</p> <p>With the existence of the many devices now on the market, it is possible to custom-build prostheses to rare or irregular cases, and to increase the number of items in the armamentarium makes such custom-building more feasible. A number of improvements are constantly being made in the research establishments on existing devices, and these, of course, will be fed into the industry as they are developed to the point where they are considered commercially marketable and necessary items of the armamentarium.</p> <p>Needless to say, each existing armamentarium item is being accorded careful study by the various research groups in an effort to increase efficiency and utility. Many new devices are now in the research stage; some are approaching the transitional period; others are known to be necessary and steps have been taken to prove such devices and to production-engineer them to the point where they will be marketable from the standpoint of increased efficiency, decreased maintenance, and economics. To mention a few items, the goals sought include improved terminal devices, both hand and hook; the cosmetic glove; improved elbow-lock mechanisms and elbow mechanisms themselves; the cosmetic approach to the entire prosthesis, up to and including the shoulder; and improvement of the over-all control systems to make them more efficient and more durable than are those now available. Already existent items of the armamentarium, such as harnesses, harness materials, and fittings, have been passed by purposely in this discussion, since they are well known to the industry. The use of some of the new synthetic materials, such as nylon, orlon, and dacron webbing, is standard practice in most limbshops. These new webbings are perspiration-resistant and possess adequate strength to meet the requirements of modern prosthetic devices. New webbings of various types and structures are constantly under study and test. Steady improvement has been made in the process of weaving these materials to prevent stretching.</p> <p>It is hoped that, through the gradual improvement of all items of the armamentarium, the comfort and utility of upperextremity prostheses will be increased to the point where an amputee will continuously wear and use a prosthetic device and will no longer be considered by society as a handicapped person. It may then be realized that the amputee can perform his job as well as can the normal person. The prescription fitting of each individual case may become so precise and so efficient that there will no longer be a question as to the value of the prosthesis to the amputee in returning to his place in society. The continuous development of new items for the armamentarium, and improvement in items existing in the present armamentarium, will make available to the prosthetist a variety of components permitting the satisfactory fitting of each amputee in conformance to his own individual pattern of life and will permit the new amputee to resume many jobs without loss in efficiency.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Maurice J. Fletcher, Lt. Col., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Director, Army Prosthetics Research Laboratory, Walter Reed Army Hospital; member, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Upper-Extremity Prosthetics Armamentarium Creator An entity primarily responsible for making the resource Maurice J. Fletcher, Lt. Col., USA (MSC) * https://staging.drfop.org/files/original/f4a0dba11dbd83d1386ccb0e624bc090.pdf cdd8923abdae6f28e1a9d8d1fe8755c4 https://staging.drfop.org/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg ae65dd03b074faa805393f2bb2cca1eb https://staging.drfop.org/files/original/b3f368a835f52e8d59db880235d53694.jpg 64a7ad3c59294b4014476742e34ee741 https://staging.drfop.org/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg 40b7c14dc32d98e7f4de52e02a7bd7aa https://staging.drfop.org/files/original/8377ac015b32853159b839d4e215bde5.jpg ebb48fe686c96a27f8944c39a7ea1994 https://staging.drfop.org/files/original/568455a545a488a7582cc67a53f4e0ff.jpg 39633f73e9a88bef0976b0d0d921dcb5 https://staging.drfop.org/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg 56a7734fbe443f9e90a5a81715258054 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_03_005.pdf Text Any textual data included in the document <h2>Partial Foot Amputation - A Case Study</h2> <h5>Charles H. Pritham C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Traditionally amputations through the foot have been held in poor repute for a variety of reasons<a></a>, chief among them being the equinus deformity that can result from an imbalance between the intact triceps surae and the severed anterior muscles. In addition, the poor quality of socket fit that often occurs with older styles of fabrication can be cited as a contributing factor for the low esteem in which tarsal and mid-tarsal amputations are held.</p> <p>In recent years there has been an ever increasing emphasis on more distal level of amputation for peripheral vascular disease and the advantages to be accrued. Thus, today, below-knee amputations and disarticulations at the knee have supplanted to a large measure above-knee amputations. In a similar fashion Syme's and partial foot amputations are being performed by some <a></a> to ensure the patients the advantages of full limb length, distal end-bearing, retention of proprioception, and a long lever arm. The trend has gained impetus from such improved methods of predicting successful amputation levels as Xenon Radiography, and differential pulse ratios to predict accurately stump viability <a></a> as well as such improved methods of surgical technique as fixation of the pretibial muscles for Chopart and Lisfranc amputations, heel pad fixation for the Syme's, and the use of rigid dressings for all levels of amputation <a></a>.</p> <p>It, thus, seems correct to conclude that an increasing number of partial foot amputations for vascular insufficiency will be seen by prosthetists in the years to come. The challenge to the prosthetist, therefore, is to maximize the advantages cited by using the best products of the latest available technology. One example of this can be found in the use of a modified plastic ankle-foot orthosis with a toe filler distal to the stump in those cases where stump length is adequate to ensure proper control and fit of the shoe <a></a>. Numerous variations of the basic theme exist, and are well known. Karl Fillauer has reported recently on his experience with a prosthesis that totally encompasses the stump below the malleoli and permits free motion of the ankle <a></a>. To the extent of the author's knowledge, neither of these designs have ever been subjected to formal evaluation and while experience has been gained by many prosthetists with the first design, little is known objectively about the latter. Both designs appear to work well in selected cases, but neither design appears to provide for the broadest possible distribution of pressure (or in the case of a modified AFO, the most accurate distribution) to protect the fragile, sensitive, and often partially anesthetic skin over the dorsal surface of the remainder of the foot <a></a>. The purpose of this paper is to discuss one possible solution to this problem.</p> <h3>Case Report</h3> <p>W.M. is a 62-year-old male Caucasian, who sustained a right Chopart amputation in 1972, secondary to peripheral vascular disease and necrosis of the forefoot (<b>Fig. 1</b>). He was subsequently fitted with a prosthesis which he wore until April 1977 (<b>Fig. 2</b>). The prosthesis was fabricated of polyester lamination with a posterior opening and metal reinforcing elements. Because of subsequent failure an additional steel armature was added externally, and the weight of the unit when seen by us had crept to 5 lb. 4 oz. Over the years sufficient change had taken place in contour of the stump so that W.M. was experiencing pain on the distal-lateral and anterior aspects of the stump, and he walked slowly with the use of a cane. Our initial attempt to fit the patient was made with a molded ankle-foot orthosis with a toe filler, but the patient obtained no relief from the pain, and the situation was re-evaluated.</p> <strong><a href="/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg">Fig. 1.</a> W.M.'s Chopart Amputation</strong><br /><br /><strong><a href="/files/original/b3f368a835f52e8d59db880235d53694.jpg">Fig. 2.</a> W.M.'s "Conventional" prosthesis</strong><br /> <p>After due deliberation, the patient was cast in the weight-bearing position, tracings were taken of both feet and vertical reference lines drawn (<b>Fig. 3</b>). With the tracing as a guide, a proper sized SACH foot was selected for the forefoot extension to the positive model of the stump, overwhich a polyethelene form of the heel and sole could be vacuum molded. The positive model of the stump was positioned inside the polyethelene form and the tracing and reference lines were used as guides to establish proper alignment. After plaster had been poured in the form and blended into the stump model, 1/4-in. thick polypropylene was vacuum formed about the extended model and subsequently modified to establish an AFO-type of socket with maximum rigidity about the ankle and anterior lever arm. A Plastizote interface was molded to the anterior aspect of the stump model and mated to a toe filler shaped from SACH-foot heel-cushion stock.<br /><br /><strong><a href="/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg">Fig. 3</a>. Outline of feet during weight-bearing to provide references for fabrication and alignment of the molded prosthesis.</strong></p> <p>The semi-completed prosthesis was fitted to the patient so that adequacy of fit and alignment could be checked. Ambulation by the patient revealed that he still experienced some pain, which was relieved by using adhesive tape to strap the shin firmly into the prosthesis and thus distribute the pressure over a broader area. While the patient was standing, strapped in the prosthesis, splints were used to cast the limb for an anterior shell that would match properly with the posterior element. Polyethelene was vacuum formed over the model to form an anterior shell that was lined with Plastizote. The two elements were then fitted to the patient and fastened proximally with "PTB-type" buttons in a fashion identical to the tibial fracture orthosis reported by Stills <a></a>. The finished prosthesis (<b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>) weighed 18 ounces and fitted more loosely in the shoe than the older prosthesis. The patient reported total comfort in the prosthesis during walking and considered the vastly decreased weight an important advantage.</p> <strong><a href="/files/original/8377ac015b32853159b839d4e215bde5.jpg">Fig. 4.</a> The molded prosthesis on the patient.</strong><br /><br /><strong><a href="/files/original/568455a545a488a7582cc67a53f4e0ff.jpg">Fig. 5</a>. Lateral view of the molded prosthesis.</strong><br /><br /><strong><a href="/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg">Fig. 6.</a> Three-quarter anterior view of the molded prosthesis.</strong><br /> <p><b>References:</b></p> <ol> <li>Alidredge, R. FF, and E. F. Murphy, <i>The influence of new developments on amputation surgery</i>. In: Human Limbs and their Substitutes. New York, McGraw Hill Co., Inc. 1954.</li> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessey, <i>The construction and fitting of lower-extremity prostheses</i>. In: Orthopaedic Appliances Atlas. Ann Arbor, ). W. Edwards, 1960.</li> <li>Bingham, J. <i>The surgery for partial foot amputations</i>. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970.</li> <li>Condie, D. N. <i>Biomechanics of the partial foot amputation</i>. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970,</li> <li>El-Sharkaw, A., H. Abdel-Farrar, H. El-Hadidi, and M. Abdel-Hafez, <i>A reconsideration of tarsal amputations with a new approach to the problem of equinus deformity</i>. In: Proceedings of the International Conference, Cairo and Alexandria, Egypt, May 1- 1 1, 1972. Sponsored by Social and Rehabilitation Service, DHEW, USA and International Society-tor Prosthetics and Orthotics.</li> <li>Eillauer, K. <i>A prosthesis tor foot amputation near the tarsal-metatarsal junction</i>. Orthotics and Prosthetics 30 (3): 9-11, September 1976.</li> <li>Rubenstein, H. J., G. J. Sweeney, P. Strong, and C. Durrett, <i>A foot amputation orthosis-prosthesis</i>. Inter-Clinic Information Bulletin 14(4), April 1975.</li> <li>Rubin, G., and M. Daniso, <i>Functional partial foot prosthesis</i>. Bulletin of Prosthetic Research 10-16: 149-152, Fall 1971.</li> <li>Rubin, C, and M. Daniso, <i>A functional Chopart prosthesis</i>. Inter-clinic Information Bulletin 11(6), March 1972.</li> <li>Stills, M. <i>Vacuum-formed orthoses for fracture of the tibia</i>. Orthotics and Prosthetics 30(2): 43-55, June 1976.</li> <li>Wagner, W. <i>Instructional Course in Amputation Surgery and Post-Op Care</i>. ISPO World Congress. New York, May 1977</li> </ol> <strong>*Charles H. Pritham C.P.O. </strong><strong>Staff Prosthetist, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, 12th St. &amp;Tabor Rri., Phila., Pa. 19141<br /><br /><br /></strong> Page Number(s) 5 - 7 Year 1977 Volume 1 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-6.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 Partial Foot Amputation - A Case Study Creator An entity primarily responsible for making the resource Charles H. Pritham C.P.O. * https://staging.drfop.org/files/original/627090118e7550aef32b928f5cfc5097.pdf c7c3671e2f62151182aae56f91f5d70f https://staging.drfop.org/files/original/c7e92f6d5fe85c8d6ef8544614a97aa3.jpg e468493086048ce57199f393dee24774 https://staging.drfop.org/files/original/04ce23f2e2248f3d1d49330516618203.jpg 5ad71da0cd2407e65b1be1093f9dad0d https://staging.drfop.org/files/original/37a6c5bccac772225e463355b7ce5b99.jpg 5fdd10eb7e82869440f88ddc8281c621 https://staging.drfop.org/files/original/1df47c562dff18af23aea5737e89ad4f.jpg d057a4335966a37fed05ecf311b6fa49 https://staging.drfop.org/files/original/66602a6f594faa462098d6e7eae66228.jpg b1e3ac1eed82d64494c9acf1af76bd6f https://staging.drfop.org/files/original/beceed2ac3ba9eecfcc08cf2abe51169.jpg 9ae2a1c0df624061372096332c5fce03 https://staging.drfop.org/files/original/d308ea30b792e6fb6e57c9d43f2f66f5.jpg 8be6fb5bd0b864a1f0104a3e23affdd6 https://staging.drfop.org/files/original/5e8c8f8672d073a25e049c5a392e5ef1.jpg 5774196adae9a8c9364a6e9134b7bde9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_029.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 29 - 39 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_029.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Status of the Above-Knee Suction Socket in the United States</h2> <h5>Chester C. Haddan <a style="text-decoration:none;">*</a><br />Atha Thomas, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The above-knee suction socket constitutes a means of attaching an artificial leg to the stump of an amputee without necessity for the conventional pelvic band, a metal hip joint, or other types of suspension harness (<b>Fig. 1</b>). The leg is held on by the slight vacuum created in the socket each time the leg is lifted from the ground, the pressure usually being controlled by a valve installed in the lower portion of the socket. Accurate functional fit of the socket, as distinguished from the conventional "plug" fit, permits the creation of negative pressure, gives a wider range of muscular control of the leg, and provides comfort while walking or sitting. Because the conventional belt and hinge joint are eliminated, the suction socket gives the above-knee amputee more freedom and less interference with clothing. The leg feels more like an integral part of the body, a feature which tends to decrease the sensation of dead weight and to improve sense of position. Reduced piston action of the stump in the socket results in greater toe clearance during walking. No stump sock is necessary. Any adductor roll is corrected. And finally, active use of the stump muscles causes them to develop instead of becoming atrophied. For a complete discussion of the prescription, fabrication, fitting, alignment, and use of the above-knee suction-socket prosthesis, reference may be had to Bechtol,<a></a> to Eberhart and McKennon<a></a>, and to the so-called "suction-socket brochure" of the University of California.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical above-knee suction-socket leg before application of the usual rawhide finish. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Early History</h3> <p>The earliest known reference to the suction socket is in the form of a patent issued by the United States, February 10, 1863, to Dubois D. Parmelee<a></a> of New York City. Subsequent patents have been issued to George Beacock and Terence Sparham<a></a> of Brock-ville, Ontario, Canada, in 1885; to Justin K. Toles<a></a> of Stockton, California, in 1911; and to Ernest Walter Underwood<a></a> of Birmingham, England, in 1926. The fundamental principles of the Beacock and Spar-ham suction socket differed but little from those of the Parmelee method. Toles' description was basically the same but with the addition of a rubber lube and bag lining which could be inflated by air to assist in holding the socket on. The socket described by Under- wood had smooth helical grooves, which he claimed ventilated the stump as well as assisted in holding the socket in place.</p> <p>A search of the literature on above-knee suction sockets has revealed only a few articles prior to the last few years. In 1925 Muirhead Little<a></a> of England reported favorably on 11 amputees fitted with the suction socket after the design of Blatchford,<a></a> made of metal, and containing a smooth helical groove of a little more than one turn around the circumference of the socket. Some 30 cases were reported as fitted at Roehampton, England, following World War I using a metal socket with a helical groove as described by Blatchford.<a></a> It is not known whether these 30 cases included the 11 reported by Muir-head Little, but it is considered doubtful since during this period several different groups were using the suction socket in England. Use of the suction socket has been practically dormant in England since that time, although it has been revived in recent years.</p> <p>Pfau<a></a> of Berlin says the suction socket has been known in Germany for 30 years but that it was not popularized until Oesterle, in Ulm, started his work in the early '30s. Felix,<a></a> a surgeon of Diisseldorf, reported on above-knee sockets in 1941. He stated that the suction socket had been used in Germany to some extent since World War I but that it was not popularized until a satisfactory suction-socket valve had been developed in 1932. After this accomplishment, numerous selected cases were successfully fitted in Germany.</p> <p>As a result of the apparent reported success with artificial limbs in Germany, early in 1946 the Surgeon General of the United States Army sent to Europe a "Commission on Amputations and Prostheses" to observe foreign practice. One principal item of interest was the successful use in Germany of suction sockets for above-knee prostheses. Because of the favorable report<a></a> issued by the commission, the Advisory Committee on Artificial Limbs instituted, as one activity of its general plan of providing information on the best possible prostheses, a program to determine the possibilities and limitations of the suction-socket type of suspension for the above-knee leg.</p> <h3>Clinical Research in the United States</h3> <p>After extensive trials and studies in their own laboratory, workers at the University of California, Berkeley, prepared instructional material and started a nation-wide program to determine the feasibility of use of the above-knee suction-socket technique under field conditions in the United States. By September 1947, 52 subjects had been fitted in 10 widely separated localities by local prosthetists in their own shops with materials and devices normally employed but making use of supplementary information and supervision by University personnel.</p> <p>The success of this program led the Advisory Committee on Artificial Limbs, in October 1947, to recommend to the Veterans Administration the use of the suction-socket technique for above-knee amputees, its use being limited for the time being to further field tests within the VA under the direction of qualified surgeons. The recommendation was accepted and, from December 1947 through January 1949, 20 schools, each of one week duration, were held throughout the country to provide 250 orthopedic surgeons and 200 prosthetists with sufficient knowledge of the fabrication and application of the suction socket to introduce it on an experimental basis.</p> <p>By October 1949 comprehensive records had been made of over 500 cases, and ACAL felt that sufficient experience had been gained in the use of the suction socket to warrant its general application. Accordingly, a recommendation was made to the Veterans Administration, and the above-knee suction socket has since been in use routinely. The Orthopedic Appliance and Limb Manufacturers Association and the Veterans Administration, in a cooperative effort, have sponsored suction-socket schools from time to time to permit surgeons and limbfitters to gain sufficient knowledge in this field to qualify them to prescribe and fit the suction socket.</p> <h3>Surveys Of Amputee Acceptance</h3> <p>The enthusiasm with which the suction-socket above-knee leg has been accepted in the United States is indicated by the results of a number of surveys. Among them are the surveys of selected groups made by Thorndike and Eberhart <i>, </i><a></a> by Mazet, McMaster, and Hutter <i>, </i><a></a> and by Canty and Asbelle.<a></a> Results of three surveys, two by the Orthopedic Appliance and Limb Manufacturers Association, are shown in <b>Table 1</b>. The earliest data are from a University of California report<a></a> of April 1948. The 52 cases reported at that time had been carefully screened, selected, and fitted under the supervision of representatives of the Advisory Committee on Artificial Limbs. The results were carefully recorded. At the termination of this initial experimental program on April 15, 1948, of the 52 subjects fitted, 40 had been wearing their suction-socket legs routinely for 4 to 20 months. All were satisfied and had no intention of returning to the type of prosthesis worn previously. Six of the subjects, owing to improper fittings, nervous disorders, or lack of cooperation, were still alternating between the suction-socket leg and their previous legs. Six had been dropped from the program and were considered as failures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In February 1949, the Orthopedic Appliance and Limb Manufacturers Association, in an effort to determine the extent of acceptance of the suction-socket leg in the United States, mailed questionnaires to approximately 200 limbshops. Of these, 159 shops reported. Eighty of those reporting had made no suction sockets at all; 79 shops had at that time fitted 1262 men, women, and children, with an amazingly small number of complete failures. A comparatively small group of 46 were converted to pelvic-belt-controlled legs, but many of these continued to use the suction-socket shape and some the suction valve, thus retaining many of the advantages of the suction-socket leg. The 1954 survey, also conducted by OALMA, with 72 firms reporting on 5882 cases, indicates similar conclusions. The 1954 OALMA questionnaire includes those firms reporting as few as three cases fitted and those reporting as many as 500 cases or more.</p> <p>Many of the limbshops reporting in both the 1949 and the 1954 OALMA questionnaires indicate that they have adopted the suction-socket method of fitting (that is, ischial bearing) as standard practice even though the amputee cannot actually wear the suction socket as such. Auxiliary supports, such as the Silesian bandage (<b>Fig. 2</b>), are used almost routinely by some limbshops. One of the most widely known and reputable shops in the United States reports the use of auxiliary supports on 300 out of 322 cases fitted. Another reports auxiliary supports applied in 300 out of 373 cases fitted. Another highly successful shop, in fitting 181 cases (of which 91 were children), used auxiliary supports on 90 cases. It is interesting to note that the firms reporting the largest number of cases also report the largest percentage of cases fitted with auxiliary supports.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two forms of the Silesian bandage commonly used as an auxiliary support for the suction-socket leg, both in the United States and in Europe, particularly in Germany, where, according to Pfau, Hepp, and others <i>(13), </i>it is used almost routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The surveys indicate that over 96 percent of all suction sockets fitted since the introduction of the program were fitted to stumps over 3 in. long. In the one shop that reported 90 children fitted, not a single one was fitted with a stump shorter than 3 in. It is to be noted that most of those fitted with the stump shorter than 3 in. were women; and some reported that, although they did not believe the fitting of a stump shorter than 3 in. to be practical, they were almost forced at least to attempt it because of pregnancy, a condition which precludes wearing the conventional pelvic belt.</p> <p>It may therefore be assumed that, except in very rare instances, generally it is impractical to prescribe the suction socket for stumps less than 3 in. long. A further observation is that of the large number of apparently quite successful cases of Gritti-Stokes amputations fitted, no failures whatever being reported in the case of amputation at this level.</p> <p>Another interesting feature brought out is that, while in 13 percent of the cases reported edema was present in the early stages of fitting, in only two cases did the edema persist and become a contributing cause of failure of the suction-socket leg. It is obvious from these data that, while edema may be common, it need not be considered a serious problem.</p> <p>An effort was made to determine the number of bilateral above-knee amputees fitted successfully with suction sockets, but reliable data were not obtained on this question. From the information received in the survey, however, it is believed that the number will probably be about 100, the percentage of failures being approximately the same as in the case of unilaterals.</p> <p>The overwhelming reason given for failure in the use of the suction socket comes under personality factors. An effort has been made in the surveys to obtain reliable data as to the definite reasons for failure. Personality factors are found to be predominant, with physical factors next in line, the condition of the stump third, and social and economic considerations fourth in importance. Thus tabulated, the causes of failure look about like this:</p> <blockquote><p> <i>1. Personality Factors</i><br />Unfavorable temperament<br />Poor cooperation<br />Inability to adjust<br />Discouragement<br />Lack of interest<br />Low order of intelligence<br />Insecurity<br /><i>2. General Physical Factors</i><br />Skin trouble<br />Age<br />Change in weight<br />Circulatory difficulties<br />Inability to bear weight on ischium<br />Buerger's disease<br />Overweight<br />Perspiration<br />Allergy<br />General weakness<br />Loose abduction<br />Unsocial noises<br /><i>3. Slump Characteristics</i><br />Inadequate length<br />Bone spurs<br />Interfering scars<br />Undue length<br /><i>4. Social and Economic Considerations</i><br />Insufficient time for proper fitting<br />Excessive distance from shop<br />Undue sales influence<br />Employer disapproval<br />Occupational requirement </p> </blockquote> <p>Another question asked the reporting firms was: "What percentage of above-knee amputees could, in your opinion, be fitted with a suction socket?". While the answers to this question range from a low of 30 percent of all amputees to as high as 100 percent, the average is 73 percent, a figure thought, in the opinion of the authors, to represent a realistic approach.</p> <p>Another question, asked because of the unusual amount of interest in children and the older age group on the part of the Committee on Artificial Limbs, was: "Is the socket suitable for amputees under five and over seventy?". Almost without exception the suction socket was said not to be suitable for the very young or the very old.</p> <p>Again, the question was asked: "When is the suction socket a practical approach to prosthetic fitting?". The following list of conditions, in the order of frequency with which they were mentioned, indicates the thinking prevalent among the reporting firms on this particular question:</p> <blockquote><p>Right personality factors and willingness to cooperate<br />Healthy, unscarred stump over 3 in. long<br />Under 65 years of age<br />New amputees not conditioned to suspenders or pelvic control<br />Easy access to facility<br />Good muscular reaction<br />Patient's enthusiasm<br />Good circulation<br />Good balance and coordination<br />Available training and therapy<br />Reasonable occupational demands</p> </blockquote> <h3>Factors in Suction-Socket Technique</h3> <p>Accumulated experience with fitting the suction-socket above-knee prosthesis over a period of seven years has clearly demonstrated its many advantages and its desirability over the conventional belt- or shoulder-suspended leg. On the other hand, the experience of the authors during the same period has convinced them that the suction socket is not suited for all above-knee amputees. This belief has been confirmed further by reports of survey studies previously conducted by others and by the results of the surveys reported here. In our opinion, there is considerable question as to the validity of the statement made by some to the effect that the suction socket can be used profitably by any thigh amputee who can wear the conventional type of prosthesis successfully. Experience has shown that there are certain amputees who cannot wear a suction-socket prosthesis successfully. If failures are to be avoided, all cases should be studied and screened carefully before a suction socket is prescribed.</p> <p>The factors to be considered are divided roughly into two groups, each often affecting the other-those relating to characteristics of the prosthesis itself, and those relating to the characteristics of the amputee. Chief among the mechanical considerations of the leg are alignment and socket shape. Factors relating to the amputee are the general physical and mental condition, the condition of the stump, and the condition of the opposite extremity.</p> <h4>Factors Relating To The Artificial Leg</h4> <p><i>Alignment</i></p> <p>With the suction-socket leg, which is controlled entirely by the stump muscles, alignment becomes much more critical than in the case of the pelvic-band suspension and therefore must be correct for proper control and comfort. If alignment is incorrect, there is a definite whip or rotation of the prosthesis during the swing phase. The problem of alignment has not yet been solved completely, and opinions differ a little as to what constitutes the ideal alignment of the prosthesis. Theoretically, it is desirable to incorporate as much adduction of the stump within the socket as is possible mechanically, since to do so tends to suppress body sway and to place the iliotibial band (or that portion of it which may remain intact) under tension.</p> <p>In the normal, the centers of hip, knee, and ankle joints coincide in the frontal plane with the mechanical axis of the lower extremity as a whole (<b>Fig. 3</b>). After amputation through the femur and fitting with a prosthesis, however, the body weight is no longer borne through the center of the hip joint but on the ischial tuberosity, which lies medial to the center of the hip joint. This would indicate, then, that the mechanical axis of the well-aligned above-knee prosthesis would more nearly coincide with a vertical line extending from the ischial tuberosity through the centers of the knee and ankle joints (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Normal alignment in the frontal plane, showing how centers of hip, knee, and ankle joints coincide with the mechanical axis of the lower extremity as a whole. From Thomas and Haddan (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Forces acting on the stump and pelvis of an above-knee amputee during the stance phase. In the well-aligned prosthesis, the heel of the foot and the center of the knee should fall approximately on a vertical line (A-A') through the point of contact of the ischium (a). The tendency of the pelvis to rotate downward on the normal side owing to the body weight can be reduced by keeping the dimension (b) as small as possible. This is accomplished by an upward force through the ischium (a). Lateral rotation of the pelvis and side-sway in the shoulders and torso can both be minimized if the force in the abductor muscles (c) is sufficient to balance the body weight by lever action about the ischial seat <i>(a). </i>The stump must be anchored firmly and comfortably by pressure along the entire lateral side <i>(d). </i>Failure to do this results in discomfort at the crotch (e). From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Posterior view of the above-knee prosthesis showing position of the socket in relation to the rest of the leg. The medial line (a) should be approximately vertical. The lateral line (b) is sloped downward and inward. From Had-dan <i>(8).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the sagittal plane, the weight line in the normal person is a vertical line drawn through the centers of the shoulder, hip, knee, and ankle joints (<b>Fig. 6</b>, left). After amputation and fitting of a prosthesis, however, this vertical weight line must be shifted forward in order to obtain alignment stability (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Normal posture and two postural deviations which must be compensated for in fitting and aligning the prosthesis. Left, normal; center, slight deviation from normal presenting few difficulties in prosthetic fitting; right, extreme postural abnormality which, unless corrected by postural exercises, would present almost insurmountable alignment problems. From Gocht (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Alignment in the sagittal plane. The stump should be oriented in the socket with several degrees of initial flexion <i>(a) </i>to allow the stump to control knee stability over the widest range of hip motion possible. The ankle may be positioned either in front of or behind the knee. The dimension (i) will depend upon the individual amputee, his age, range of motion in the stump, stump musculature, and prevailing terrain. From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee is young and agile, with no stump deformities and with strong and well-developed muscles in the back of the stump, the dimension <i>b </i>in <b>Fig. 7</b> may be reduced to zero. On the other hand, in the presence of flexion contracture in the stump, or weak musculature, this dimension may have to be increased to give sufficient stability. But to do so may result in the sacrifice of a normal gait and cause a tiring and awkward one. Similarly, postural abnormalities (<b>Fig. 6</b>, center and right) can make proper alignment very difficult to achieve.</p> <p>Such deviations in the weight line have upon postural stability and body alignment a biomechanical effect that is obvious. To complicate matters further, the amputee is deprived of a number of those sensory cues upon which every normal human being depends for the autonomous control of posture and motion. These include touch and pressure sensations from the soles of the feet and the never-ending bombardment of proprioceptive impulses that emanate from sensory receptors in the muscles, tendons, and joints of the weight-bearing limbs and sweep upward to the cerebellum. In the aggregate, these physiological and biomechanical deviations from normal appear formidible. Yet with proper fitting and alignment of his prosthesis, and with adequate training in the proper gait and posture, the average amputee can compensate for them to an amazing degree.</p> <p><i>Socket Shape</i></p> <p>Exactly what constitutes the most successful socket shape has not yet been fully determined owing to the many variables involved in the use of this technique. Several successful designs have been fully described in the literature <i><a></a><a></a><a></a><a></a>. </i>In these designs, weight-bearing occurs chiefly about the top posterior portion of the socket, particularly in the region of the ischial tuberosity, with a lesser amount on the gluteal muscle. The addition of a well-defined . . ischial seat reduces pis- ton action of the stump in the socket to a minimum and allows for a looser fit at the top of the socket. Incorrect shape, size, or location of the ischial seat leads to definite discomfort and frequent loss of suction, particularly when the wearer is sitting. In some very muscular stumps, the ischial seat may be reduced in size and in some cases removed entirely. Such amputees bear weight on their well-developed muscles, with the load distributed around the top portion of the socket. The socket is shaped the same except for the reduction or removal of the ischial seat.</p> <h4>Factors Relating To The Amputee</h4> <p><i>General Physical and Mental Factors</i></p> <p>A complete history and physical examination is the first step in determining the desirability of fitting the suction socket. Age is an important consideration, and as a rule elderly amputees are poor candidates for the for this reason it requires considerably more effort and muscular skill to learn to use it. If, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has indicated that children as young as seven years can be fitted successfully.<a></a> The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to suction socket. But old age <i>per se </i>is not a contraindication. Amputees over 70 years of age have been fitted successfully. As already noted, the suction-socket prosthesis is activated almost entirely by the muscles of the stump, and for this reason it requires considerably more effort and musulcar skill to learn to use it. if, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has Indicated that children as young as seven years can be fitted successfully<a></a>. The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to psychological or emotional difficulties. Learning to wear and use a suction-socket prosthesis requires cooperation, effort, patience, and perseverance. If the amputee is impatient, resentful, undependable, easily discouraged, unreasonable, or otherwise emotionally unstable, he most likely will be uncooperative and is apt to be a poor subject for the suction socket. Many failures can be attributed to the fact that the amputee is either unwilling or unable to devote the necessary time and effort to obtain a satisfactory fitting. As experience has been gained by the prosthetists, and with the additional aid of the recently developed alignment devices (page 23), the time required for construction and fitting has been considerably lessened in recent years. The interesting observation has been made that, when an amputee has to purchase his limb himself, he is likely to be much more cooperative than if he is given one by some agency.</p> <p><i>Slump Considerations</i></p> <p><i>Length. </i>Stump length is not so important a consideration as might be thought. Contour, muscle tone, and mobility are important determining factors in deciding whether or not a short stump can be fitted. Naturally, the longer the stump the better is the muscular control and the easier is the fitting and training problem. But stumps as short as 3 in. (measured from the crotch) have been fitted successfully. Usually the shorter stumps require the addition of an auxiliary suspension belt (such as the Silesian belts shown in <b>Fig. 2</b>) in order to stabilize the socket on the stump.</p> <p>End-bearing supracondylar and Gritti-Stokes amputation stumps can be fitted successfully with the suction socket, although in such cases the mechanical knee joint usually has to be placed at a level slightly below that of the opposite knee.</p> <p><i>Stump Contour. </i>With the conventional socket, a conical-shaped stump has always been considered desirable. Such is not the case with the suction socket. A stump of more cylindrical shape, with only slightly tapering sides and a fairly broad end, seems to maintain better suction and friction than does the conical or pointed stump. Most undesirable is a long, redundant, flabby mass of skin and fat extending beyond the bone end. Such a mass of tissue not only offers fitting problems but is prone to become edematous and swollen, thus making it difficult to don the leg or to remove the stump from the socket. In such cases, surgical revision is advisable before a suction socket is prescribed.</p> <p>Excessive subcutaneous fat or extreme flabbiness of stump muscles frequently results in marked changes in the contour of the stump after the suction socket has been worn for a while. Repeated modification of the socket thus becomes necessary. With excessive subcutaneous fat, the stump may shrink considerably after wearing the socket, necessitating the insertion of leather liners or even the making of a new socket. Muscles that are atrophied and flabby and of poor tone will develop and increase in size with the use of the suction socket, necessitating enlargement of the socket.</p> <p><i>Muscle Control and Strength. </i>Good muscular control and mobility of the stump are essential for successful use of the suction socket. Fixed deformities due to muscle contracture are very common in amputations above the knee, particularly in the older age group, and they not only present very serious fitting and alignment problems but also handicap the amputee in walking. Flexion and abduction deformities are the usual ones, and the shorter the stump, with resulting greater muscle imbalance, the more likely are they to occur. Once they do occur they are very difficult to correct. It is imperative, therefore, that every effort be made postoperatively to prevent such deformities. Studies in alignment conducted at the University of California<a></a> indicate that the most efficient gait with the suction-socket prosthesis is obtained by fitting the socket with the stump in adduction and slight flexion (<b>Fig. 7</b>). Severe flexion-abduction deformity of the stump makes such alignment very difficult, if not impossible, without producing marked tilting of the pelvis and excessive pressure on the stump.</p> <p>The adductor and hamstring muscles are important not only in controlling the limb but also in preventing flexion-abduction deformity by overcoming muscle imbalance. The shorter the stump, the less power remains in these muscles and the greater the tendency to deformity. It is well known that, in order for muscles to function at maximum efficiency, they must have a fixed insertion. In amputations through the thigh, the major muscles are sectioned well above their insertions, and all too often these muscles are allowed to retract upward, no attempt being made to fix their cut ends to fascia or over the end of the bone. Failure thus to fix the free ends seriously impairs muscle function in controlling the stump. In considering an amputee for a suction socket, the stump should be carefully examined to determine how well the thigh muscles are functioning and whether there are any fixed deformities. If any are present, active and passive exercises should be carried out to correct them as much as possible before the socket is fitted.</p> <p><i>Scars. </i>Deep linear scars near the socket brim may interfere with maintenance of suction. Tender, adherent scars in the weight-bearing area beneath the ischial tuberosity and over the buttocks may cause pain sufficient to prevent the wearing of a suction socket. Deep, folded, adherent, or puckered scars over the end of the stump, which so often cause difficulty with the conventional socket, rarely offer any problem with the suction socket. In fact, it has been observed repeatedly how often these scars smooth out and become more pliable after a suction socket has been worn for some time.</p> <p><i>Ulceration and Infection. </i>Open ulcers, draining sinuses, and active deep infection of the soft tissues of the stump, as well as active osteomyelitis, are definite contraindications to the use of the suction socket. With adequate surgery and use of antimicrobial drugs, these conditions can usually be eradicated readily.</p> <p><i>Bony Spurs. </i>Although in many thigh stumps bony spurs develop at the end of the femur, they rarely offer any difficulty in the fitting or wearing of a suction-socket prosthesis. Occasionally, however, a large spur will develop on the lateral side of the bone in a stump with a fixed abduction, thus producing painful pressure against the side of the socket. Relieving the socket at point of pressure, realigning the socket, or surgical removal of the spur usually solves such a problem.</p> <p><i>Skin Disturbances. </i>Skin sensitivity, irrita- tion, and infections are not uncommon in amputation stumps, and there appears to be considerable variation in the skin's resistance to pressure, friction, and irritation among individual amputees. Some are constantly troubled, while others have no difficulty. Der-matological complications are cited as a fairly common cause of failure in the use of the suction socket. Usually they can be prevented by proper hygienic care of the stump and good fitting, or else they can be relieved by derma-tologic treatment. Skin allergy and contact dermatitis, of rare occurrence with the suction socket, usually can be controlled readily. The troublesome adductor roll, with recurring "pressure boils" (suppurative hydroadenitis and folliculitis), so commonly encountered with the use of the conventional socket, rarely if ever occurs with the well-fitted suction socket. In fact, when such a condition exists with a conventional socket, and the socket is converted to a suction one, usually the roll and cysts rapidly disappear. This is one of the great advantages of the suction socket.</p> <p><i>Perspiration. </i>One troublesome problem occurs in individuals who perspire excessively and who also have a high bacterial count in their perspiration. Irritation or skin friction in such a situation leads to suppurative hydro-adenitis and furunculosis. Excessive perspiration is not uncommon when the suction socket is first worn, but it usually subsides after varying lengths of time. In alleviating these superficial skin infections, x-ray treatment is often of value. Autogenous vaccines have also been used with some success. Before any suction socket is discarded as a failure, every possible effort should be exerted to treat and eradicate such troublesome skin conditions. Some of them can be anticipated from previous history and careful examination and can be eliminated by proper treatment before the socket is fitted.</p> <p><i>Condition of the Opposite Extremity</i></p> <p>During the experimental program, and in the early suction-socket schools, abnormalities and disabilities in the opposite extremity were considered as constituting an important factor—and even as a probable contraindication—in determining the suitability of the amputee for a suction socket. Subsequent experience has shown that abnormalities in the opposite extremity, while still to be considered, are not necessarily contraindicative. Amputees with disabilities so great as to require permanent bracing of the opposite limb have been fitted successfully with suction sockets; many persons with below-knee amputations on one side are wearing above-knee suction-socket prostheses with ease and comfort on the other. In fact, in such cases the suction-socket leg appears to have several advantages over the conventional above-knee leg. Survey studies also reveal that some bilateral above-knee amputees have been successfully fitted with suction-socket prostheses. But of course it is apparent that all such cases must be selected only after a very thorough analysis of individual problems.</p> <p>Peripheral vascular disease which has necessitated amputation is in itself no contraindication to use of a suction socket, provided the opposite limb is not too seriously affected by the disease.</p> <h3>Conclusions</h3> <p>On the basis of the surveys reported upon, it appears quite definite that the suction-socket prosthesis has many advantages over the conventional belt- or shoulder-suspended leg. Approximately 75 percent of all above-knee amputees can be fitted successfully with the suction socket. Chief causes of failure, listed in decreasing order of importance, are psychological difficulties, general physical factors, stump abnormalities, and social and economic factors. Teamwork between physician, prosthe-tist, therapist, and amputee is an essential requirement in the successful fitting and wearing of the suction-socket prosthesis. Meticulous attention to fitting and alignment techniques is important, as is also adequate training.</p> <p>Research studies in gait and principles of alignment, and the development of new alignment devices and duplicating jigs, have been of great value in reducing the time involved in construction and fitting by eliminating, to a great extent, trial-and-error methods. Although many limb manufacturers in this country still do not appreciate the advantages of the suction-socket above-knee limb and make no attempt to fit it, the wide acceptance of the above-knee suction-socket prosthesis in the United States today indicates that it can no longer be considered an experimental device, its use limited to a few selected amputees. Use of the above-knee suction socket is now so prevalent that it can be safely stated—and fairly stated-that the majority of above-knee amputees can successfully be fitted with the suction-socket prosthesis.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>The juvenile ampu-tee, </i>J. Bone and Joint Surg., 35A:659 (1953).</li> <li>Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</li> <li>Bechtol, C. 0., <i>The suction socket, </i>J.A.M.A., <b>146:625 (1951).</b></li> <li>Canty, T. J., and C. C. Asbelle, <i>Above knee suctionsocket prosthesis. </i>Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954,</li> <li>Felix, W., <i>Praktische Erfahrungen mil der Saugpro-these, </i>Ztschr. f. orthop., 72:352 (1941).</li> <li>Gocht, H., <i>Kunstliche Glieder, </i>Berlin, 1920.</li> <li>Haddan, C. C, <i>Alignment principles, </i>paper readefore a meeting of AAAS, Sec. M., Philadelphia, 1951.</li> <li>Little, E. M., <i>A new method of fitting artificial legsockets, </i>Brit. Med. J., 2:896 (Nov. 14, 1925).</li> <li>Mazet, R., P. E. McMaster, and C. G. Hutter<i>Analysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, </i>J. Bone and Joint Surg., 33A:618 (1951).</li> <li>OALMA Journal, 3(3) :36 (Spring 1949).</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</li> <li>Pfau, Heintz, personal communication.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation pros-thesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thorndike, A., and H. D. Eberhart, <i>Suction socketprosthesis for above knee amputations, </i>Am. J. Surg., 80:727 (1950).</li> <li>Toles, Justin K., U. S. Patent 980,457, January 3,1911.</li> <li>Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</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>20.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (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">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (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>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Canty, T. J., and C. C. Asbelle, Above knee suctionsocket prosthesis. Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Mazet, R., P. E. McMaster, and C. G. HutterAnalysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, J. Bone and Joint Surg., 33A:618 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Thorndike, A., and H. D. Eberhart, Suction socketprosthesis for above knee amputations, Am. J. Surg., 80:727 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Felix, W., Praktische Erfahrungen mil der Saugpro-these, Ztschr. f. orthop., 72:352 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Pfau, Heintz, personal communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Toles, Justin K., U. S. Patent 980,457, January 3,1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Atha Thomas, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, University of Colorado School of Medicine, Denver; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Chester C. Haddan </b></td></tr><tr><td class="clsTextSmall">President, Gaines Orthopedic Appliances, Inc., Denver, Colorado; Past-President, Orthopedic Appliance and Limb Manufacturers Association; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-25.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-26.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-27.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-28.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-29.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-30.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-31.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-32.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 Status of the Above-Knee Suction Socket in the United States Creator An entity primarily responsible for making the resource Chester C. Haddan * Atha Thomas, M.D. * https://staging.drfop.org/files/original/30c31f3ab0a1bb7bf6b2fed3d44ab98e.pdf 1b4c13b6fe4572542d88a4b6b1765e21 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_03_001.pdf Text Any textual data included in the document <h2>"The Geriatric Amputees" - Results of the Questionnaire</h2> <p>There were twenty-three replies by mail to the questionnaire on management of lower-limb geriatric amputees that appeared in the Spring 1977 issue of the NEWSLETTER. Ten were signed by prosthetists, five came from M.D.'s and two from therapists. The remarks included on the six unsigned forms appear to have come from prosthetists.</p> <p>The raw results, question-by-question, are shown below:</p> <ol> <li> <p class="kapow"><b>Should the prosthesis weigh less than conventional prostheses?</b></p> <p class="kapow"><i>PROSTHETISTS</i></p> <blockquote> <p class="kapow">AK yes: 15, No: 1<br />BK yes: 14, No: 2</p> </blockquote> <p class="kapow">Comments made by the prosthetists:</p> <ul> <li> <p>They cannot be made too light.</p> </li> <li> <p>We use endoskeletal AK set ups and light feet as often as possible to reduce weight.</p> </li> <li> <p>Yes. Unless "conventional" prostheses are already very light. BK's should weigh between 1 1/2 - 3 lbs. and AK's from 4 1/2 — 6 1/2 lbs. Decreases energy consumption, eases suspension. Soon, however, new materials and techniques should allow all prostheses to weigh about the same. Major difference for geriatrics is not weight but socket comfort and cost.</p> </li> <li> <p>A major complaint from the geriatric patient is the weight of the prosthesis.</p> </li> <li> <p>In most cases conventional prostheses are prescribed and the geriatric patient has trouble with them usually because of the weight. But age and strength are the difference.</p> </li> <li> <p>This is debatable, each case should be considered individually. I feel that most geriatric males would prefer a conventional prothesis.</p> </li> <li> <p>As much weight as you can knock off the better. The old story of the leg being so light that in a strong wind it is hard to control, just a tale.</p> </li> <li> <p>Whenever possible, a light-weight prosthesis is desirable for geriatric patients.</p> </li> <li> <p>Patients' resources less and need for strength not important,</p> </li> <li> <p>I do not feel that this is a very major issue as far as function is concerned. Most patients complain about weight early but those who do function do not continue these complaints,</p> </li> <li> <p>It is generally desirable that prostheses be as light as possible.</p> </li> <li> <p>Light limbs seem to be tolerated much more than the heavy limb.</p> </li> <li> <p>An attempt is always made to maintain lightness in all prostheses, however, especially AK geriatrics who are fighting quite a lever arm in regard to weight.</p> </li> <li> <p>The decrease in energy out-put during ambulation is very important for the geriatric amputee. Decrease in weight decreases energy out-put which in turn decreases the stress on the cardiovascular system.</p> </li> <li> <p>Even where a geriatric has not experienced an amputation, there is loss of muscular strength. This is the primary-reason for a lighter prosthesis.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>AK Yes: 5, No: 1<br />BK Yes: 4, No: 2</p> <ul> <li> <p>If the geriatric amputee is unable to manage the conventional prosthesis, making a lighter limb increases his difficulties when walking in a high wind or deep snow. In these cases I fit the geriatric amputee with an articulated peg leg invariably with a successful result.</p> </li> <li> <p>Initially they do quite well, however, a lighter, especially AK prosthesis would help.</p> </li> <li> <p>I think <em>all</em> prostheses should weigh less, particularly for geriatrics. The prosthetists should go to extra lengths to thin out the shell of exoskeletal limbs as thin as possible and consistent with durability. This is just not done enough with the shins of AK and BK prostheses.</p> </li> <li> <p>If there is sensory loss, a heavier prosthesis for sensory feedback may be necessary.</p> </li> </ul> <p><i>THERAPISTS</i></p> <ul> <li> <p>One therapist felt that both the AK and BK prosthesis should weigh less than the conventional and commented that "Patients seem to prefer an extremely lightweight prosthesis." The other therapist did not check any of the boxes but wrote in "Individualized Adjustment" and commented that "A neurophysiological functional evaluation should determine if the patient responds better to heavier or lighter sensory bombardment."</p> </li> </ul> <p style="margin-left: auto; margin-right: auto;"><i>DISCUSSION</i></p> <p>The great majority of clinicians seem to feel that lower-limb prostheses that weigh less than those generally available are desirable for the older patient.</p> </li> <li> <p><b>What type of knee do you generally use for above-knee cases?</b></p> <p style="text-align: center;"><i>PROSTHETISTS</i></p> <table style="border-style: none; width: 338px; margin-left: auto; margin-right: auto;" height="120"> <tbody> <tr> <td>Manual lock</td> <td>6</td> </tr> <tr> <td>Weight-bearing (Safety Knee)</td> <td>10</td> </tr> <tr> <td>Other (please specify)</td> <td>11</td> </tr> </tbody> </table> <p>Prosthetists' comments were as follows:</p> <p><i>Manual Lock:</i></p> <ul> <li> <p>Treatment for the dysvascular amputee should always be separated from geriatric amputees with other causes for amputation at Rancho, well over 90 percent of amputations are secondary to vascular problems. Manual lock knees have cut down PT time by two weeks, and, combined with an adjustable socket, have made it possible to convert nearly all of our dysvascular AK's into prosthesis wearers and more importantly, they use them.</p> </li> <li> <p>At our clinic either the adjustable AK "Rancho design" or conventional AK have locking knees.</p> </li> <li> <p>We have not been pleased with the various "safety" knees. The only really useful one is the SHS — we do not use it for geriatric patients, but it's the best.</p> </li> <li> <p>Balsa Lock knee, wherever possible, light weight foot with soft heel. Polypropylene joint and band (where stump is long)</p> </li> </ul> <p><i>Weight-Bearing (Safety-Knee):</i></p> <ul> <li> <p>The friction lock type of knee will work for 80% of the AK's.</p> </li> <li> <p>The weight-bearing knee seems to be the most easily managed by elderly amputees.</p> </li> <li> <p>Manual lock knees only when safety knee is inadequate.</p> </li> <li> <p>I prefer endoskeletal.</p> </li> <li> <p>About 90% of our geriatric patients are fitted with friction locking knees and 10% are fitted with manual locks.</p> </li> <li> <p>Aside from poorer musculature, the evidence of less proprioception illustrates that the AK geriatric has difficulty knowing where his knee and foot are. Only in extreme severe muscular weakness is a manual lock prescribed.</p> </li> </ul> <p class="kapow"><i>Manual lock &amp; Weight-bearing (Safety) Knee:</i></p> <p class="kapow">Varies with patient need.</p> <p class="kapow"><i>All three types marked:</i></p> <ul> <li> <p>Depends on needs of the patient and his ability to control the knee with his own efforts, as well as his expected level of performance.</p> </li> </ul> <p><i>Other:</i></p> <ul> <li> <p>Constant friction knee for the elderly. Not much maintenance problem. Variable gait is not an important factor. Mauch S-N-S for the younger amputee.</p> </li> </ul> <p><i>None Marked:</i></p> <ul> <li> <p>My approach is to evaluate each person individually. Our primary knee is the Bock Safety knee, relying primarily upon alignment stability and fast plantar flexion of S/A foot. I use Kolman only when absolutely necessary due to noise problems.</p> </li> </ul> <p style="text-align: center;"><i>PHYSICIANS</i></p> <table style="border-style: none; width: 390px; margin-left: auto; margin-right: auto;" height="116"> <tbody> <tr> <td>Manual lock</td> <td>2</td> </tr> <tr> <td>Weight-bearing (Safety Knee)</td> <td>3</td> </tr> <tr> <td>Other (please specify)</td> <td>0</td> </tr> </tbody> </table> <p>The physicians comments were as follows:</p> <p><i>Manual Lock:</i></p> <ul> <li> <p>Bock Geriatric. Most often. Weight-bearing (Safety) knee, seldom. Often knee lock with option to give constant friction if open, as a trial.</p> </li> <li> <p>Safety is very important. There is more energy required to operate a safety knee (Bock). I reserve it for the younger amputee.</p> </li> </ul> <p><i>Weight-Bearing Safety Knee:</i></p> <ul> <li> <p>We need a manual lock that is sturdier than the Bock geriatric knee. Ideally someone should manufacture a lock that could be placed on the outside of the prosthesis so that if patient finally confident enough with free knee after practice he could remove it.</p> </li> <li> <p>I usually use the Otto Bock Safety knee which stands use by the geriatric amputee well. However, have run into breakdown problems with this knee in my younger patients.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>The comments from the two therapists were:</p> <ul> <li> <p>Knee usually depends on patient's functional demands, equipment cost, prosthetist convenience in non-standard set-ups in that order.</p> </li> <li> <p>My training is deficient in the prosthesis — but excellent in observation of physiological response.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>Opinion on use of manual lock versus the weight-bearing (Safety) knee is slightly in favor of the weight-bearing (Safety) knee. Certainly the weight-bearing units provide more function and better appearance when they can be used. It is gratifying to find that so many prosthetists and physicians are being successful with the more functional units.</p> </li> <li> <p><b>In your opinion is the use of stubbies for bilateral AK cases desirable?</b></p> <p>PROSTHETISTS</p> <p>Yes: 7<br />No: 8<br />No experience: 1</p> <ul> <li> <p>No, Have not used them for 5 years — patients would not wear them after six months.</p> </li> <li> <p>No. We have used them, however, the cases were to prove to the patient the difficult task it is to master bilateral AK prostheses. The stubbie is a substitute but not a good one.</p> </li> <li> <p>No. Much trouble and expense for very little benefit. Most should not be fit at all. If fit, shorten slightly but include knee joints for sitting purposes. Stubbies cause problems in wheelchairs, look horrible and do not convert non-users of prostheses into users.</p> </li> <li> <p>No. In most cases the bilateral AK patient has had extensive vascular surgery and scars in abdomen and scarpas are too much of a problem.</p> </li> <li> <p>No. Most would rather sit in a wheelchair.</p> </li> <li> <p>No. We have not had the occasion to use them. Geriatric amputees, with therapy, are able to use light-weight prostheses with weight bearing knees.</p> </li> <li> <p>No. We've tried stubbies in a few cases where we thought the patient could eventually go to regular legs. A better idea is pylons — you can adjust them. No one uses stubbies permanently — a wheelchair is much more functional.</p> </li> <li> <p>No. Stubbies make patients look like "freaks", they think. Patients are more functional in wheelchairs.</p> </li> <li> <p>Yes. Only if there is a good P.T. program.</p> </li> <li> <p>Yes. To permit A.D.L. in the home — We have 2 cases of short A.K.'s who did so well they demanded full length prostheses and did fair.</p> </li> <li> <p>Yes. As temporaries to define the patient's functional potential both to him and to the clinic team.</p> </li> <li> <p>Yes. If bilateral amputation occurs simultaneously.</p> </li> <li> <p>Yes. It is a way to allow an individual independence and mobility without the problems of knee control.</p> </li> <li> <p>Yes. There are amputees that can walk with stubbies and not walk with bilateral A/K prostheses therefore it is desirable in obtaining an accurate assessment of prosthetic potential.</p> </li> <li> <p>Yes. Bilateral stubbies offer safety that no AK with knees can offer. The CG is closer to the earth, and there is less weight to be manipulated. I would recommend stubbies for the desirable active AK.</p> </li> <li> <p>No opinion. I have no experience in this area.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>Three physicians were opposed to the use of stubbies and two felt that their use is indicated.</p> <p>The physician's comments were:</p> <ul> <li> <p>No. Stubbies are unsightly ugly things, besides (they) cost as much as prostheses. I very seldom prescribe bilateral AK prostheses to geriatric patients. The few knees I did, the prosthesis ended up in the closet. However, an occasional patient may do well, however, when the prostheses are made several inches shorter than patient's original height. Each patient is pretested with pylons.</p> </li> <li> <p>No. I do not believe in fitting bilateral AK's with vascular disease. If young and vigorous and traumatic — and candidate for limited walking with bilateral AK prostheses — should be fitted with full length.</p> </li> <li> <p>No. Not in the geriatric, but useful in young adults.</p> </li> <li> <p>Yes. Useful around the house if patient wants them. Cosmesis bad. Useful for training.</p> </li> <li> <p>Yes. I regard this as an essential if the bilateral amputee is to learn to walk satisfactorily.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>Both therapists felt that use of stubbies is desirable. Their comments were:</p> <ul> <li> <p>Yes. Stubbies are desirable to demonstrate to most patients that the amount of energy expended is usually not worth the effort, from a functional point of view.</p> </li> <li> <p>Yes. Any reasonably balanced device helps maintain balance and muscle strength. Prevention of disuse atrophy.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>The respondents were almost equally divided on the issue of stubbies, and without exception each respondent offered a comment. The comments seem to indicate that in spite of drawbacks stubbies can be used successfully in certain settings, and that a careful, thorough evaluation of this procedure is needed.</p> </li> <li> <p><b>In your opinion, is immediate postsurgical fitting of prostheses desirable for geriatric cases?</b></p> <p><i>PROSTHETISTS</i></p> <p>Eleven prosthetists felt that immediate postsurgical fitting is indicated for geriatric patients; five felt that the procedure was contraindicated, while one felt that it would probably be useful if orthopaedic surgeons performed the amputations.</p> <p>Their comments are as follows:</p> <ul> <li> <p>Yes. We only recommend a rigid dressing. Only after wound healing has been ascertained do we apply a pylon.</p> </li> <li> <p>Yes. If there is a good P.T. program; otherwise only the rigid dressing should be used.</p> </li> <li> <p>Yes. This treatment doesn't allow the geratric amputee to become comfortable in a wheelchair thus losing strength and endurance.</p> </li> <li> <p>Yes. The PT Department starts working with the patient within 24 hours and the chances are (that) contractures and depression won't occur.</p> </li> <li> <p>Yes. BK's only. AK's too much trouble for benefit accrued.</p> </li> <li> <p>Yes. Immediate fitting is good for everyone. But its hard to do — hard to supervise, takes a lot of effort so its not done.</p> </li> <li> <p>Yes. For below-knee patients who have the ability to coordinate the post surgical dressing and pylon.</p> </li> <li> <p>Yes. I feel immediate post surgical fittings minimize loss of strength which is very critical in the geriatric cases.</p> </li> <li> <p>Yes. I.P.S. fittings are desirable for any amputee, aside from trauma cases. The less muscle tone the geriatric loses the better his chances are of becoming a successful prosthetic candidate with I.P.S.F. This is possible.</p> </li> <li> <p>No. The results I have witnessed have been mostly unfavorable. Perhaps if the orthopedic surgeons did more of the amputations it would be more advisable.</p> </li> <li> <p>No. Rigid dressings for BK's should be used for 10-14 days then a temporary prosthesis for 2-4 weeks. Immediate post-surgical fittings encourage too much activity and it is too hard to control the stress the patient is placing on the wound.</p> </li> <li> <p>No. We never use immediate postsurgical fitting. Stumps should be healed before shrinkage is attempted. After stump is healed, we use laminated plastic sockets on temporary units for definitive shrinking.</p> </li> <li> <p>No. Low tolerance.</p> </li> <li> <p>(Nothing marked) It depends on the patient's prior medical history. We would not recommend it for diabetic patients.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>Two physicians felt that immediate postsurgical fitting had a place in management of geriatric patients; two felt otherwise; and one had no experience on which to base an opinion.</p> <p>Their comments were:</p> <ul> <li> <p>Yes, <em>If</em> you have full team approach including nurses who fully understand principle. Otherwise early temporary fitting with good control of stump edema may be second best alternative. Two months is still a <em>long</em> delay.</p> </li> <li> <p>Yes. I do not feel that a differentiation need be made unless there are other conflicting medical factors, e.g. heart disease.</p> </li> <li> <p>No. But I prefer rigid dressings with early fitting when wound is fully healed.</p> </li> <li> <p>No. No benefits except psychological, and many dangers. Use of cast is OK in many cases, but adding prosthesis courts disaster.</p> </li> <li> <p>(Nothing marked) I cannot express an opinion since in our institution immediate post surgical fitting is not being done at all.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>Both therapists felt that immediate post surgical fitting is useful.</p> <p>Their comments were:</p> <ul> <li> <p>Yes, . . . but please see abstract of article to be published in American Journal of Surgery {<em>which will be publishing in a future issue. Ed</em>.). I feel that very few people now are using the prosthesis on an immediate basis, but our prospective study well documents the value of the rigid dressing in the postoperative care of the BK amputee.</p> </li> <li> <p>Yes. Normal physiology maintained at maximum potential.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>The replies to this question indicate that the use of a rigid dressing is used widely and that immediate postsurgical fitting is used more than is generally expected. Perhaps the reports on the study at Iowa will encourage others to adopt these advanced techniques. Other clinics with experience should publish results of their clinical program.</p> </li> <li> <p><b>In your opinion what is needed to improve the function of geriatric amputees?</b></p> <p>All of the respondents commented on this question.</p> <p>Their comments were as follows:</p> <p><i>PROSTHETISTS</i></p> <ul> <li> <p>The lightest prosthesis with the safety factor at the knee system (being) the main factor.</p> </li> <li> <p>A better method of suspending the AK prosthesis. Total suction does not work, rigid pelvic belt is a fair substitute, but (is) heavy. Something better is needed.</p> </li> <li> <p>Vascular surgery is often indicated but compounds our fitting problems. After several surgical procedures — physiologically and psychologically the patients require more professional service — let us all hope that more orthopedists would become more involved in amputation surgery.</p> </li> <li> <p>An adjustable BK socket that is permanent. It can be fit(ted) instead of a "temporary" and will adjust throughout the "maturing" process. (It) will save time, as patient can adjust it and since a temporary is not needed, it will save dollars. Most physicians are looking for a cheap geriatric prosthesis, although they will state "light duty" or "lightweight" or "sitting prosthesis."</p> </li> <li> <p>I believe the prosthetic components that we have now are all we need: However the P.T. program needs to be reevaluated.</p> </li> <li> <p>Better pre-op and initial post-op care.</p> </li> <li> <p>This is where the total team is so very necessary. Pre-surgical consultation, pre-prosthetic care and post prosthetic training and followup. Outpatient care for the amputee is practically overlooked by the doctors and the subsidizing agencies, the insurance companies, Medicare and Medicaid. The patient can only receive adequate care as an inpatient. Usually his funding is exhausted by the time he is ready for prosthetic fitting.</p> </li> <li> <p>A lightweight single axis foot. More training for surgeons (general and vascular) to give the patient a chance for a BK, when the problem is in the toes or ankle; also teach them how to bevel and round the tibia.</p> </li> <li> <p>Articles such as this help spread information that geriatric patients can utilize a prosthesis. Motivation is an important factor. Two days ago we fitted a 91-year-old man with a prosthesis and his initial attempts have been excellent.</p> </li> <li> <p>Lighter prostheses, greater emphasis on use of temporaries in early phase of rehabilitation.</p> </li> <li> <p>Quicker fabrication and more adjustable prostheses. We use Polysar sockets and pylons. We can make adjustments easily and get (out) the prosthesis quickly.</p> </li> <li> <p>The limiting factors in geriatric amputees are motivation, coordination, and endurance. The therapist has the best chance to do something about these things.</p> </li> <li> <p>Patient compliance and patience with the amputee.</p> </li> <li> <p>Better post-surgical physical therapy. Some method to decrease the long periods of inactivity and confinement to a bed prior to amputation.</p> </li> </ul> <p>Follow-up programs.</p> <ol> <li> <p>Successful therapy program (before and after fitting)</p> </li> <li> <p>A competent prosthetist — follow-up necessary</p> </li> <li> <p>A sound instillation of confidence to the geriatric</p> </li> <li> <p>A good exoskeletal safety knee (needs) to be developed.</p> </li> </ol> <p><i>PHYSICIANS</i></p> <ul> <li> <p>Enthusiastic team work and total care of the patient to include medical, socioeconomic and vocational aspects.</p> </li> <li> <p>Immediate referral to a rehabilitation department to teach necessary conditioning exercise, range of motion exercise to prevent contracture and stump conditioning.</p> </li> <li> <p>More interest and concern of plight of elderly person with vascular disease by surgeons in particular, but also by physicians in general. And I don't mean simply interest in the pathophysicology and surgical approaches to arteriosclerosis.</p> </li> <li> <p>Improved sensory feedback</p> </li> <li> <p>Improved training procedures</p> </li> <li> <p>Improved knowledge of what the patient <em>really </em>needs</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>My concern is the bracing needed for C.V.A.'s. Our suggestion to our Medical Chief of Staff is to invite your representative to hold a seminar in our hospital.</p> <p>Generally we need to sell the success of fitting the geriatric AK from the standpoint of requiring less in terms of third-party paid institutionalization or purchased services. An AK patient on a walker is much easier to deal with than a one-legged wheelchair-bound patient. In short, we need to emphasize the 4 successes of 10 attempts, and demonstrate this success in a cost-effective manner. This is the only language cost conscious bureaucrats will understand. Additionally, many patients report positive attributes of independence in gait, so they "don't have to depend on or bother their family or friends." At the same time, we need to strive to improve our care package so as to raise the percentage of AK's who become independent with their prostheses.</p> </li> </ol> <p><i>SUPPLEMENTARY DATA</i></p> <p>To augment the data provided by the 23 questionnaires returned through the mail, prosthetists attending the instructional course in molded plastics sponsored by the American Academy of Orthotists and Prosthetists and held in Kansas City, Missouri, July 15-16, 1977, were asked to fill out the questionnaire. Forty-one did so. The results are given below:</p> <ol> <li> <p>Should the prosthesis weigh less than conventional prostheses?</p> <p>AK Yes: 41 No: 0 No mark: 0<br />BK Yes: 39 No: 0 No mark: 2</p> </li> <li> <p>What type of knee lock do you generally use for above-knee cases?</p> <table style="border-style: none; width: 402px; margin-left: auto; margin-right: auto;" height="116"> <tbody> <tr> <td>Manual lock:</td> <td>15</td> </tr> <tr> <td>Weight-bearing (Safety Knee):</td> <td>22</td> </tr> <tr> <td>Other:</td> <td>3</td> </tr> <tr> <td>No mark:</td> <td>5</td> </tr> </tbody> </table> <br /> <p>(Four people marked two places. Most of the 5 not marked made some kind of comment.)</p> </li> <li> <p>In your opinion is the use of stubbies for bilateral AK cases desirable?</p> <table style="border-style: none; width: 401px; margin-left: auto; margin-right: auto;" height="123"> <tbody> <tr> <td style="text-align: left;">Yes:</td> <td style="text-align: left;">21</td> </tr> <tr style="text-align: left;"> <td>No:</td> <td>19</td> </tr> <tr style="text-align: left;"> <td>No mark:</td> <td>2</td> </tr> </tbody> </table> <br /> <p>(One person checked both yes and no.)</p> </li> <li> <p>In your opinion is immediate postsurgical fitting of prostheses desirable for geriatric cases?</p> <table style="border-style: none; width: 400px; margin-left: auto; margin-right: auto;" height="121"> <tbody> <tr> <td>Yes:</td> <td>25</td> </tr> <tr> <td>No:</td> <td>14</td> </tr> <tr> <td>No mark:</td> <td>2</td> </tr> </tbody> </table> </li> <li> <p>In your opinion what is needed to improve the function of geriatric amputees?</p> <ul> <li> <p class="kapow">Improved knees and feet of lighter weight.</p> </li> <li> <p>In hospital prosthetic facilities so therapists and prosthetists could give combined and closer supervision to walking training, etc.</p> </li> <li> <p>Suspension in geriatrics seems to cause weight and cosmetic problems.</p> </li> <li> <p>A good pre-prosthetic program, a qualified P.T. and a well fitting lightweight prosthesis.</p> </li> <li> <p>Proper post surgical supervision and gait training with prosthesis. Lighter prosthesis that is more comfortable.</p> </li> <li> <p>A good sound Rehabilitation program: 1. Good Amputation; 2. Good prosthesis; 3. Good P.T.</p> </li> <li> <p>Simple donning procedures — less weight, uncomplicated mechanics to understand.</p> </li> <li> <p>Closer observation and good rehabilitation work after surgery so the patient will have the best chance possible of becoming self-sufficient.</p> </li> <li> <p>Reduced weight/energy consumption.</p> </li> <li> <p>Getting them in better physical condition prior to prosthetic fitting.</p> </li> <li> <p>Better physical therapy and PT follow-up.</p> </li> <li> <p>Better materials other than plaster, transparent materials perhaps, lighter weight, orthoplast possibly.</p> </li> <li> <p>More the patients can do for themselves, less care needed by other people.</p> </li> <li> <p>Feather weight prostheses, and 2) team approach management.</p> </li> <li> <p>You can put a safety knee and a two way ankle.</p> </li> <li> <p>(I don't know) I have been fitting AK prosthesis for only a year therefore the above information may not be of value due to my personal lack of experience.</p> </li> <li> <p>Lighter materials.</p> </li> <li> <p>Better communication between the doctor, therapist, prosthetist and patient.</p> </li> <li> <p>Most patients need one person, as overseer, who can control his rehab program, — a coordinator.</p> </li> <li> <p>Immediate post-operative fitting.</p> </li> <li> <p>Lighter prosthesis.</p> </li> <li> <p>Increased physical therapy, —early as possible.</p> </li> <li> <p>More lighter and durable prosthesis and exercise.</p> </li> <li> <p>Exercise.</p> </li> <li> <p>Lighter weight and a more positive attitude about age and life in the future.</p> </li> <li> <p>Proper instruction in wrapping, exercise, etc.</p> </li> </ul> </li> </ol> <p><i>DISCUSSION</i></p> <p>The supplementary data agrees remarkably well with that received through the mail, and only reinforces any conclusions that can be reached from the information supplied by the original 23 respondents.</p> <p>It seems that geriatric patients are receiving considerable attention throughout the country and while the results are good considerable refinement in devices and techniques will be welcomed. Reduction in weight of artificial legs for all levels of amputation through the lower limb seems to be indicated, and improved knee control units are needed by above-knee (and hip-disarticulation) cases. The use of stubbies certainly needs clarification, probably through a well-ordered study.</p> Page Number(s) 1 - 5 Year 1977 Volume 1 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource "The Geriatric Amputees" - Results of the Questionnaire