Prosthetic and Orthotic Devices for Nonstandard Prostheses in the Management of Limb Deficiencies
Charles H. Frantz, M.D. *
During the past decade great interest in the child amputee has been manifested by the development of many amputee clinics in this country that devote their efforts exclusively to the child. Paralleling this interest, industry has made an increasing number of prosthetic components available for the child amputee both by miniaturization of standard devices and by special components designed specifically for the child.
In the last ten years, two phenomena have occurred:
- A tremendous increase in the number of young children wearing standard types of prostheses. (Most clinic teams have become very adept at prescription-writing and training these young children.)
- The appearance of many young children with anomalous extremities at child amputee clinics. Usually their problems cannot be answered by the application of standard appliances or prostheses. These anomalous extremities present problems to the prosthetist and orthopedic surgeon because of gross variation in limb contour, substandard muscle power and serious underlying skeletal deficiencies.
In this evergrowing group of anomalous extremities, restoration of function usually cannot be obtained with the so-called standard prosthetic prescription. The preparation of the mold of the anomalous extremity for socket fabrication requires careful technique to obtain an accurate positive model of the limb (see Fig. 1A, Fig. 1B, Fig. 1C).
The standard joints which are currently available may not be suitable. The difficulty of suspending prostheses on or across a substandard joint presents complex problems. Many times the team is 'hard-put' to obtain functionally significant power in the transmission system.
In many instances to obtain a comfortable socket or bucket, techniques in mixing the polyester resins must be varied to obtain the desired degree of flexibility and at the same instant maintain durability. Perforations in buckets, large or small, for abnormal contours and relief from underlying bony pressure areas may be frustrating. Energy expenditure and heat dispersion are important considerations when large areas of the body must by necessity be covered.
The multihandicapped child with a plurality of limb deficiencies challenges the skill of the prosthetist. He may be called upon to work in close cooperation with the orthotist. The orthotist may be required to modify upright braces and joints in a nonstandard manner to allow for laminations in the plastic sockets. It is quite evident that these "nonstandard" situations will call for a considerable breadth and depth of knowledge.
The detailed variations in body contour and lack of power and mobility of proximal joints must be appreciated by all members of the team (see Fig. 2A, Fig. 2B, Fig. 2C, Fig. 2D). With an understanding of the basic deficiencies, the necessary modifications in techniques of fabricating a socket and applying a suspension system may proceed (see Fig. 3 A,B). The orthotist may provide crutch modifications to permit ambulation in the lower extremity amelia (see Fig. 4 A,B ).
Frequently the orthopedic surgeon will elect to manage an anomalous extremity during the early years with a standard type of orthopedic appliance (see Fig. 5A). This appliance of course falls within the field of the orthotist. At a later stage, the knowledgeable surgeon who is well acquainted by experience with the life history of llie abnormal limb may amputate or disarticulate to obtain a "fitable" slump (see Fig. 5B, Fig. 5C ). The emphasis therefore has shifted to the prosthetist who possibly may fit a standard appliance, or more likely a nonstandard socket. These changes in the management of a child with an anomalous extremity may involve either fool, knee, hip, forearm or elbow levels.
a variety of complex nonstandard appliances have been fabricated to meet the needs of many bizarre limb deficiencies when the trunk musculature is substandard. Here a Williams type of backbrace may be attached to two below-knee thigh cuffs ( see Fig.6-A, Fig. 6B, Fig. 6C). There may be the classical aluminum double upright braces fabricated into a pelvic bucket with droplocks (see Fig. 3 A,B ).
With these complex situations it is very evident that the orthopedic surgeon, prosthetist and orthotist must combine their skills and judgments to produce satisfactory and functional appliances for the multihandicapped child (see Fig. 7A, Fig. 7B, Fig. 7C, Fig. A ).