A Problem Of Prosthetic Fabrication

Earl E. VanDerwerker, Jr., M.D. John C. Allen, M.D. Josef Rosenberger, CP.

The case study presented in this report is an attempt to describe our method of handling a complex problem involving congenital deficiencies of three limbs, and to detail the progress of fabrication of the prosthesis and habilitation.

R.J. is a white male delivered prematurely on March 24, 1959, the first living child of a woman who had previously had several spontaneous abortions. In addition to the limb deficiencies, a deformity of the skull at birth was noted. Otherwise, the child's development appeared to be relatively normal.

The patient was first seen at our clinic at the age of 13 1/2 months, having had no prior prosthetic replacement or habilitation. He appeared to be a bright child with normal reactions, in spite of the skull deformity. There was (1) a partial hem-imelia left upper limb; (2) distal phocomelia with partial adactylia left lower limb; and (3) paraxial fibular hemimelia, right, with partial adactylia (Fig. 1 and Fig. 2 ).

R.J. was fitted initially with a single walled AE prosthesis with a pre-flexed elbow and passive mitt. No attempt was made to fit the lower limbs at that time. Progress with the upper limb prosthesis was satisfactory and the patient wore it throughout the day.

When the child began to try to pull himself to a standing position, bearing weight primarily on the right lower limb at the age of about 21 months, fabrication of the lower limb prosthesis was started. The right lower limb was to be fitted as a below-knee amputation, while the left was fitted as an above-knee amputation. Fabrication presented a problem because of the marked deformities.

Completed plastic laminated sockets were attached to temporary tripods for fitting of sockets, establishing lines of alignment and determining proper length and joint axes (Fig. 3 ). Temporary jigs that were adjustable vertically and horizontally were then made to adjust alignment during weight bearing and swing phase (Fig. 4 ). The sockets were then attached to the alignment jigs (Fig. 5 ). A duplicating device was made from a drill press so that the positions established during the fitting could be maintained exactly during the process of finishing the prosthesis (Fig. 6 ).

Completed Prostheses

The completed prostheses are depicted in Fig. 7 . They consisted of: Right B/K -- Plastic laminate socket and shank, SACH Foot, long thigh lacer, standard B/K hinges, fork strap to toddler type harness; Left A/K - Plastic laminate socket and shank, SACH Foot, standard B/K hinges, fork strap to toddler harness.

The completed prostheses were delivered with the knee hinges locked for stability during initial training (Fig. 8 ). During the training period, the patient ambulated with crutches using a "plumbers helper" as a crutch for each tip for greater stability. By the time he reached the age of 32 months, he was wearing the prosthesis nine hours a day and was independent. At that time, the right knee was unlocked and ambulation continued satisfactorily

It is planned to free the left knee hinge and subsequently replace the left upper limb prosthesis with a split socket mechanism with step-up hinge and an activated hook. At a later date, the feet will be ablated to allow fitting with more conventional prostheses.

The successful outcome of this case underscores the experiences of others, indicating that even markedly atypical limb deficiencies can be fitted satisfactorily with the aid of an ingenious prosthetist and non-standard equipment.

The Newington Hospital for Crippled Children, Newington, Connecticut