A Standing Frame for Paraplegic Children
RICHARD ROSENBERGER, C.P. MARGARET STEWART, R.P.T. WILTON BUNCH, M.D.
The development of the "Parapodium" at the Ontario Crippled Children's Centre in Toronto, Canada, provided a novel and practical means of maintaining a standing position for paraplegic children. In our experience, however, the Toronto appliance has two major drawbacks. It is difficult to place on a child with significant knee contractures or pelvic obliquity. The kit is expensive and the device itself cannot be fabricated from material commonly found in the average orthotic establishment.
This paper reports on an attempt to surmount both of these difficulties with a standing frame designed at the University of Virginia. All parts of the device are standard items which are available in any shop manufacturing above-knee orthoses (hip-knee-ankle-foot orthoses or HKAFOs) thus eliminating the need for special assemblies. Because of the method of attachment of the pelvic and knee pads in this appliance, the child may be placed in the standing frame without the need for hip or knee motion. This feature facilitates use of the frame by the therapists and the child's mother.
The fabrication begins with a tracing of the child's lower torso and extremities, much like that for an HKAFO. The legs are abducted until a line perpendicular to the soles of the feet would pass through the lateral border of the foot and the greater trochanter. Locations of the knee centers, the trochanters, And the tops of the iliac crests are marked on the tracing.
The mold for the knee pad is taken with 12 layers of 3-in. plaster-of-Paris splints which are formed just below the patellae of both knees with a space between, similar to the knee bar of the Parapodium. It is not necessary to make a positive cast from this mold.
Standard drop locks are selected for the hip and knee and are connected with about 1 in. allowed for "growth potential" at each joint. The aluminum pelvic band is 11 2 in. wide and is curved from above downward so that at its lowest point the lower edge is midway between the level of the trochanter and the perineum. This band is covered with felt and plastic (Figure 1 ). The abdominal pad is a standard three-buckle item and extends from the tip of the xiphoid process to the trochanters.
The base is cut from 34-in.-thick plywood. It is slightly wider than the distance between the trochanters. The depth of the base is three-quarters the width. It is covered with Neoprene to prevent damage to the floor. The heel clips are cut from aluminum and shaped to fit the back of the shoes. It is not necessary in all cases to have spring-loaded anterior shoe clips such as we formerly used
and which are shown in the illustrations. A 6-by-6-in. square of 1 8 in. aluminum is bent and riveted to the platform, and the uprights are attached with screws. As will be noted from the illustration, we use an open A-frame which gives excellent strength without excessive weight. However, other designs could be used.
The Orthoplast knee band is molded directly over the outside of the plaster mold and is lined with ~ 2 in. felt. The felt compensates for the size of the mold as well as provides padding. The Orthoplast is riveted to a band of metal which is attached to one of the uprights with a butt hinge. The other end of the band is slotted to receive a screw and nut of the Milwaukee neck-ring type which is attached to the other upright by a hinge. Figure 2 shows the details of this device. The knee band then swings open widely to allow the child easy entrance (Figure 3 ). To complete the assembly, T-straps may be added to support the feet if necessary.
The standing frame is applied with the child lying supine. The child is laid into the frame and the shoes slipped into the clips. The knee support and the abdominal pad are then secured, hips and knees are locked, and the child is ready to stand. Removal is simply a reversal of this process.
Figure 4 shows a happy child in the completed standing frame. She could not be fitted with a standard Parapodium because of hip and knee contractures. Note that the pelvic band is well below the area of precarious skin. Despite a T8 paraplegia, this girl is now stable in the standing position and both hands are free for play.
When contemplating the application of any orthosis for a severely disabled child, ease of application becomes a paramount consideration. Mothers simply will not take the time to use devices which are difficult to place on the child and to remove. This does not reflect on their love and devotion to the child but is a manifestation of their responsibilities to other children and to household tasks. Therefore, the simpler the device and the less time required in applying and removing it, the more likely it is that the child will obtain the inherent benefit.
With the constant escalation of medical costs the price of an appliance cannot be ignored. The fact that an insurance company or state agency may be paying a portion of the charge for an orthosis does not relieve the medical team from the responsibility of making reasonable decisions. The total fabrication time for the standing frame is about one half the time required for a pair of HKAFOs. The exact cost will vary with the local facility but generally will be considerably less than that of a Parapodium.
We have accepted as true without proof the concept that it is good for these children to stand. It is our impression that the incidence of femoral fractures is less but we do not have data to document this feeling. What is clearly evident is the psychological effect of standing. It is amazing to see the sudden change in a fussy, irritable child when he is able to stand and play. This benefit in itself would make such a device worthwhile.
Even more pleasing is to see the number of children who go on to ambulation with conventional orthoses after a period of standing; it seems that the standing episode has facilitated the attainment of this next, more functional, phase.