The Use of Stubbies for the Child with Bilateral Lower-Limb Deficiencies
BY LEON M. KRUGER, M.D.
Prosthetic fitting of the child with bilateral lower-limb deficiencies poses a distinct challenge when one or both limbs terminates at or above the knee. The bilateral below-knee, Syme's, or ankle-disarticulation patient on the other hand can be fitted with prosthetic limbs and will walk without a great deal of difficulty, assuming his upper limbs are normal.
Almost 25 years ago we observed the use of "stubbies" in the treatment of a child at the Kessler Institute in New Jersey, and since that time we have had the opportunity to use this technique on the three patients presented in this report.
In reviewing the literature it is noted that the Orthopaedic Appliances Atlas3 devotes less than one page to "stubbies," and that this discussion contains no suggestion of their use as a transitional stage in the treatment of the limb-deficient child. Georgi, Davis, Warner, and Alessi1 have reported on the treatment of two bilateral above-knee amputees and have commented on the difficulties involved in ambulating these patients. Both patients appeared to have been ambulated with standard prostheses and crutches rather than with stubbies. In the Technical Notes section of the Spring 1972 issue of Artificial Limbs 2 , a description and photograph of a tie bar for use with bilateral AK sockets also mentions its use with bilateral "stubbies." Otherwise there is an extreme dearth of information in the literature regarding the use of these truncated devices.
In each of the three occasions we have had to use "stubbies" for limb-deficient children the child was seen very early in life. In each instance the child had normal trunk and hips (except for one with a congenitally dislocated hip which had been reduced), as well as normal upper limbs.
It was felt that a young child could gain balance more easily with "stubbies," and that subsequent lengthening of the devices would serve as balance training prior to a fitting with full-length articulated limbs.
The fabrication of "stubbies" might be described simply as being the construction of quadrilateral sockets with foot pieces. The sockets are best carved out of willow wood, but may also be fabricated of plastic material by the usual laminating technique. The foot pieces may simply be soles glued or nailed to the bottom of each stubby, or may be rocker bottoms slightly elongated posteriorly. Suspension may be obtained by Silesian bandages or, if the stump is short, a pelvic belt with hip joints may be used. In our experience auxiliary shoulder-strap suspension has not been necessary.
It is important to provide a few degrees of preflexion in these sockets to prevent the development of lumbar lordosis. This requirement is particularly important in the bilateral AK fitting. If a few degrees of flexion are not built into the sockets, the patient will hyperextend his hips and definitely develop a lumbar lordosis.
Case 1 -B.K. was born on August 16, 1956, and was first seen in the clinic at the age of one year in August 1957. At that time a diagnosis of lower-limb hemimelia, left, and a partial hemimdia, right, was made. The knee of this right limb was described as having 45 deg. fixed flexion deformity, and the tibial fragment was so small that it was referred to as a "small bony prominence."
In April 1958 soft-tissue nubbins were removed from this boy's stumps, and an effort was made to release the contracture at the knee. However, only about 10 deg. of extension was gained by this surgery. The wounds were allowed to heal, and the boy was measured for stubbies which, in effect, were modified University of California at Berkeley (UCB)-type sockets, elongated and broadened at the bases. The right limb had a posterior opening through which the stump could protrude. He was actually fitted with the knee in the flexed position. He immediately achieved balance and independent ambulation ( Fig. 1-A,B ).
Three months later he was still doing satisfactorily, and it was felt that the stubbies might be elongated by four inches. Again, he experienced no difficulty in achieving balance and was fully ambulatory. It was decided, therefore, to attempt correction of the right knee deformity by supracondylar osteotomy and then to fit him with articulated prostheses.
The surgery was carried out in January of 1960, and three months later the boy was fitted on the left side with a UCB quadrilateral socket with a single-axis knee joint and a SACH foot; and on the right side with a standard below-knee prosthesis, a thigh corset, and an auxiliary suspension toddler's harness. He could ambulate almost immediately.
His knee-flexion deformity recurred, and in October of 1961 Z-plasty of the skin and a posterior release of the knee were carried out following which permanent correction of the knee-flexion deformity was attained. Since that time he has been completely independent in ambulation without crutch or cane, fully active and attending regular school with no concessions made to his impairments ( Fig. 1-A,B ). When seen at his most recent visit in 1973, B.K. was 17 years of age. He is now riding a motorcycle in dirt fields, very upset that the Registry of Motor Vehicles has been reluctant to give him a license to drive on the highway ( Fig. 1-C ).
Case 2.- E.M. was seen in March of 1964 at which time she was two years of age. She was born with bilateral terminal transverse hemimelia of her lower limbs, but had normal upper limbs, back and hips. She had been under the care of another institution where she had been filled with a pair of long-leg caliper braces with shoes attached and suspended from a chair-back brace making her rigid from the nipple line to the feet ( Fig. 2-A,B ). With these devices she was ambulatory with crutches or in parallel bars. With normal trunk and hip joints, it was fell that stubbies were indicated to gel her ambulating independently with later progression to articulated limbs. She ambulated on her stubbies immediately. These were lengthened a month later, and in July 1964 articulated limbs were prescribed ( Fig. 2-A,B and Fig. 2-C,D,E ). She ambulated immediately without any difficulty and has never used crutches or canes. She attends regular school in New York City and travels by public transportation despite the fact that she wears bilateral AK prostheses with quadrilateral sockets, single-axis knee joints, and SACH feet ( Fig. 2-A,B and Fig. 2-F,G,H ). She has learned the technique of climbing stairs and is able to get on and off public buses. At the present time E.M. is 11 years of age, continues to be fully ambulatory with the same prescription- bilateral quadrilateral sockets with single-axis knees, SACH feet, and Silesian-bandage suspension ( Fig. 2-F,G,H ).
Case 3.-V.E. was born September 19, 1970. This child was first admitted to the Springfield, Mass., Shriners Hospital in January 1972, with a diagnosis of left lower terminal transverse hemimelia, right terminal transverse partial hemimelia (complete fibula absence) and with the status of post-open-reduction of congenital dislocation of the right hip ( Fig. 3-A,B ). The hip had been treated elsewhere and appeared to be well reduced. At admission it was felt that the child had normal trunk musculature, that her congenitally dislocated hip had been reduced and that she was functioning well. Although her left AK stump measured only 3 in. from pubis to tip, it was believed that she could be fitted with bilateral stubbies. These limbs were essentially quadrilateral sockets which, because of her extremely short left stump, required pelvic suspension with hip joints. With these stubbies in place, the child was started on ambulation ( Fig. 3-C,D ). Initially, it was extremely difficult to keep the very short left AK stump in the stubby. However, when this was accomplished, the child became ambulatory and was discharged home to Quito, Ecuador.
Very shortly thereafter, a communication from her father indicated that she was completely ambulatory on her stubbies. She was maintained in this manner until March 1973, when she was readmitted to the Springfield Shriners Hospital for articulated limbs. At that time it was noted that her right hip seemed to be subluxing. A Salter-type osteotomy was carried out with improvement in the status of the hip joint and she was then measured for articulated limbs in the form of a quadrilateral socket with single-axis knee and SACH foot on the left and a plastic laminate PTB with side hinges and thigh corset on the right. These limbs have just been delivered ( Fig. 3-E ).
In each of the instances reported it was felt that the child was too young and balance too insecure to attempt a primary fitting with conventional articulated limbs. We therefore turned to "stubbies" as the initial prescription. The importance of a trunk exercise program to maintain the erect posture and the normal spinal curves must be stressed. Also the importance of hip-extension exercises to prevent the development of hip-flexion deformity is emphasized.
Each of the three children fitted quickly became independently ambulatory in "stubbies" and was even able to master stairs. None of the three children was permitted at any time to resort to crutches or canes. As a matter of fact the reverse was true. Patient No. 2 (E.M.) had previously been fitted with caliper-type limbs attached to a chair-back brace, and was ambulatory with crutches and a typical swing-to gait. With the fitting of her first "stubbies" she immediately became ambulatory without any support and since that time has continued to be ambulatory with her articulated limbs without the need for external support.
When the children were converted to conventional articulated limbs all were ambulated without crutches or canes. All achieved independent gait and maintained it. Speculating as to the future it may be predicted that the patient with a BK-AK combination would remain independent through adult life. However, the independently ambulatory status of the bilateral AK patient may well be affected by unknown variables. Specifically we are concerned about weight, feeling that excessive obesity will not only make bilateral AK socket fitting a problem, but will also require a high expenditure of energy for ambulation. Patients No. 1 and No. 2 have remained independently ambulatory 17 and 10 years postfitting. Patient No. 3 has just become ambulatory and there is no reason yet to be concerned about her status.
The use of "stubbies" as a preliminary prescription for children with bilateral lower-limb deficiencies is recommended. Three cases are presented. Emphasis is placed on the development of trunk and hip musculature in order to maintain an erect posture and to prevent hip-flexion deformity. It is further emphasized that external support in the form of crutches or canes is not needed by these children.
Shriners Hospital for Crippled Children Springfield, Massachusetts
1.Georgi, W. H., B. P. Davis, R. Warner, and D. F. Alessi, Initial fitting of bilateral lower-extremity prostheses in the teen-ager. Inter-Clin. Information Bull., 9:3:1-5, December 1969.
2.Hubbard, Sheila, and C. A. McLaurin, AK Tie Bar. Artif. Limbs, 16:1:54-59, Spring 1972.
3.Orthopaedic Appliances Atlas, 2:239-240, J. W. Edwards, Ann Arbor, 1960 Descriptors: Bilateral; children; limb deficiencies; lower limbs; stubbies