Crutches for the Quadrimembral Amputee
FIORINO D'ONOFRIO PATRICIA C. COPE, O.T.R.
During his lifetime the congenital quadrimembral amputee faces innumerable challenges but as a child the desire to walk is often his most pressing need. From the standpoint of those involved with his habilitation, however, independent ambulation is often considered impractical or unattainable and is therefore not stressed as a major goal. If the effort is made it usually involves a long series of trial-and-error improvisations the testing of which requires much patience on the part of the child, his family, and the staff.
J.B. ( Fig. 1 ) was first seen at the age of 14 months at which time his deficiencies were diagnosed as terminal transverse hemimelias of all four limbs. Anatomically and prosthetically his upper limbs are bilateral elbow disarticulations; his lower, a right hip disarticulation (with a small rudimentary femur), and a left knee disarticulation. Sitting balance was poor at that time and the boy was placed in a socket resembling that of a Canadian hip-disarticulation prosthesis to improve his head and trunk control. At 18 months J.B. was fitted with a right standard above-elbow prosthesis with an inside locking elbow and a Hosmer 12P hook. He was trained in the use of this arm over a period of a year and a half and became fairly proficient in manipulating and grasping various objects. He learned to operate his elbow-lock at the age of two and a half years and had refined his elbow-locking operation considerably by the age of three years. At the age of two and a half years he received his first pair of lower-extremity prostheses. He rapidly learned to balance on the legs but despite a year of training he was never able to take more than a couple of steps alone.
The family moved away from the area for a period of two years but the boy was closely followed in another clinic and training was continued during that time. When he returned he was ambulating in a walker but this situation was not very satisfactory since he had to be placed in the device. Once in it, he leaned too far forward causing some concern about his posture.
Until the age of seven years no attempt had been made to teach him to use crutches. He was wearing bilateral upper-extremity prostheses at that time and was unable to manage any conventional type of crutch. The first pair made for him were pylon-type appliances (above-elbow sockets with crutch extensions) and were worn in place of the upper-extremity prostheses. He was highly motivated at that time and became an independent walker in a relatively short period of time.
Having to remove and replace his upper-extremity prostheses several times a day became a major problem and the next task for the prosthetist was to design some type of crutch which could be worn over the upper-limb prostheses; and which could be put on and taken off by the child. Those described in this article are relatively easy to construct and have proved to be highly satisfactory.
A mold of the prosthetic forearm is taken and a cuff is constructed of rigid polyester resin over six layers of stockinette. Prior to lamination a half-inch-wide piece of 1/8-in.-thick stainless steel is inserted around the upper rim as reinforcement. A one-inch-wide opening is cut out on the front side to accommodate the operating lever of the hook ( Fig. 2 ). A strip of stainless steel 1/8-in. thick connects the cuff to the crutch. On completion the upper rim of the cuff is lined with 1/8-in. Kemblo to afford better holding power on the prosthetic forearm.
To don the crutches, the boy slides his arms into the cuffs, extends and locks his elbows, and then taps the crutches hard against the floor to secure them to the prostheses. To remove the crutches the child first sits, and then forces the cuffs off by hitting them against the edge of the chair ( Fig. 3 ).
J.B. still needs assistance to get into an upright position but he ambulates independently at home and at school. He uses a wheelchair for traveling long distances.
Juvenile Amputee Clinic Handicapped and Crippled Children's Services District of Columbia General Hospital Washington, D.C.