Prostheses for Hockey-Playing Upper-Limb Amputees
John B. Redford, M.D.
A number of case reports in the literature on artificial limbs have presented devices which enable amputee children to participate in sports. Hockey is a very popular sport among Canadian children and many of our child amputees play regularly. Playing this game presents few problems to the unilateral upper-limb amputee fitted with a conventional prosthesis incorporating a voluntary-opening hook. The player grasps the hockey stick with his terminal device or inserts the hook into a hole bored through the stick handle. About the only problem that has come to our attention involving the use of a single upper-limb prosthesis in playing hockey was experienced by a 14-year-old boy who is a very active user of a below-elbow prosthesis for a congenital mid-forearm deficiency. He found that the usual hook-type terminal device constantly caught on the boards at the side of the rink and was somewhat of a menace to other players. Therefore, he welded a piece of metal to each tine of the hook to make it a closed loop. This modification is illustrated in Fig. 1 . Other juvenile hockey players might find this alteration of assistance in improving their game.
Bilateral upper-limb amputees on the other hand have an almost insurmountable problem in controlling a hockey stick. Nevertheless, a unique new prosthesis developed by Mr. W. Stauffer, chief prosthetist at the Edmonton Artificial Limb Company, has enabled a 13-year-old boy with bilateral phocomelia of the upper limbs to become a skilled forward on his local hockey team. The report which follows discusses this case and describes these special prostheses.
K.H. was born June 1, 1960, in Sarnia, Ontario. His birth was at full term, and his birth weight was 9 lb. 13 oz. The mother had a normal pregnancy with no history indicating the taking of thalidomide or any unusual drugs. The father and mother were both in good health at the time of the pregnancy and had had three normal children previously.
At birth it was immediately apparent that K.H. had bilateral upper-limb phocomelia. The left upper limb showed absence of the forearm with a vestigial finger attached to the distal end of a shortened humerus. On the right side there was a shortening of the humerus and a partial hand with two terminal digits. The forearm bones and some wrist elements were absent. Both shoulders were relatively normal. No other congenital abnormalities were evident.
Fig. 2 shows the boy's appearance today at the age of 13 years. The anomalous wrist and fingers of the right limb can be moved strongly and actively in several planes. The vestigial digit on the left lacks any muscular control.
The boy passed through infancy and childhood with no particular behavioral problems. He was well accepted in a stable, middle-class family. He related well to other children and to his own brothers and sisters. In 1961, his father, who was employed in the oil industry, moved his family to Alberta.
K.H. was first seen in our center at the University of Alberta in October 1963, when he was 3 and 1/2 years old. At the age of 4 years he was fitted with a specially designed prosthesis. On the left phocomelic remnant a standard above-elbow unit with an elbow lock, activated by a chest strap, and a voluntary-opening terminal device was applied. On the right side he was supplied with a nonstandard prosthesis which had a distal opening in the upper arm portion through which the digits protruded. These digits activated a locking device on external elbow hinges. As the distal segments on the right stump grew, the prosthesis was changed so that the elbow was locked with a shoulder (humeral) extension movement. The vestigial wrist and fingers were used to flex the forearm portion of the prosthesis. The boy learned to operate the prostheses readily and after extensive practice in occupational therapy, he became very proficient with these devices. Fig. 3 shows his present prostheses.
This patient has now been followed in our clinic for 10 and 1/2 years. Many subsequent adjustments and changes have been made in his prostheses since childhood, but K.H. has continued to wear all of them well. In 1969, he developed an exostosis with an overlying ulcer over the tip of the left humerus. This was excised in September 1969, but he required two further revisions for bony overgrowth in this stump in the succeeding two years. As a result of many months of practice and the use of adaptive devices for dressing, etc., he has become totally independent in self-care activities. He has attended regular school and does well scholastically. For some activities, such as writing, the right prosthesis is not as useful as the vestigial wrist and hand. At present, the possibility of discarding the right prosthesis for regular school activities and using only the left above-elbow device is being considered.
During a clinic visit in 1972, it was mentioned that K.H. was trying to play hockey. He was grasping the hockey stick with his prostheses but having little success because of the restriction of shoulder and elbow movements imposed by the sockets. Therefore, a special pair of limbs, as shown in Fig. 4 -A and Fig. 4 -B, was designed.
He was fitted with a simple prosthesis without an elbow joint or cable control on the right side. A #5 Dorrance hook with a flexion wrist unit and enough rubber bands to grip firmly a layer of friction tape wrapped around the hockey stick completed the prosthesis. To enable the boy to grip the top of the stick, a special sleeve of 1/8 in. sheet metal with an opening on two sides was designed and attached to a foreshortened left prosthesis. The hockey stick can be pushed in from below and jammed against the top, closed end of the sleeve for a firm grasp. This sleeve was welded to a universal joint with a 2 in. diameter ballbearing that allows the stick to swivel in all directions. The whole unit is attached to a hinge-type flexion wrist unit and held securely by tape and screws to the end of the laminated above-elbow socket. The wrist unit could be turned slightly to find the most satisfactory setting before the unit was taped in place. Fig. 5 -A and Fig. 5 -B show the details of this special unit.
Our young amputee has been most pleased with this set of prostheses. Some minor modifications were necessary initially to make the prostheses the correct length. Some problems were experienced also with the top of the stick slipping out of the sleeve; but these problems have now been corrected. If K.H. loses his stick in rough play, the game has to be stopped so that he can be assisted in reattaching the device. However, this requirement has not proven to be a significant problem.
By reporting on these special hockey-playing prostheses it is our hope that prosthetists in other programs may be encouraged to make similar devices for their patients. Obviously, any juvenile amputee will get a great emotional boost by being able to wear a prosthetic device that permits him to compete in sports with children of his own age.
University of Kansas Medical Center, Kansas City, Kansas; Formerly Co-Chief, Juvenile Amputee Clinic, Glenrose Hospital, Edmonton, Alberta, Canada.