The Principles of the "Toronto Standing Brace" Applied to Prosthetics
In the rehabilitation of the paraplegic infant a primary aim is to provide him with the wherewithal to achieve the standing position as a prelude to ambulation. Without doubt, the standing brace developed in Toronto has been of great value in simplifying the bracing of these children.
To brace paraplegic patients with conventional long-leg braces connected, through lockable hip joints, to an abdominal corset is a complicated, tedious, expensive and time-consuming job. In addition to the usual problems of bracing, paraplegic infants present additional difficulties because of their special sensitivity, the absence of communication, and their inability to cooperate actively. Moreover, the need for frequent adjustments because of rapid growth at this age is of importance. In addition to the advantage of crutchless standing, the standing brace provides the outstanding advantage of simple and rapid adjustability.
The principles of the Toronto Standing Brace can be applied to the solution of prosthetics problems in the young child. Two unusual rehabilitation challenges were solved in this way.
Case No. 1-A five-year-old boy suffered a D-10 paraplegia as a result of multiple arteriovenous fistulae in the cord. Progressive painful enlargement of the right lower limb also attributable to this vascular anomaly led to a disarticulation of the right hip (Fig. 1 ). The multiple arteriovenous fistulae caused severe hypertension and mild heart failure.
Even if the use of a hip-disarticulation prosthesis with a long-leg brace attached to the opposite side of the socket through a hip joint were found to be possible, it would have made tremendous energy demands on the patient. In view of his cardiac condition, the achievement of the erect position was considered a reasonable goal as a first stage in the boy's rehabilitation.
The appliance consisted of a hip-disarticulation plastic socket connected at the appropriate height to the vertical bars of the standing appliance (Fig. 2 ). To stabilize the remaining leg a posterior band was fitted on the left side with an anterior fastening at the level of the knee. A foam-rubber cosmetic leg was used on the disarticulated right side.
The child rapidly achieved the treatment goal of crutchless standing (Fig. 3 ), and eventually developed a very satisfactory swing-through gait between parallel bars.
Case No. 2-A 14-month-old boy was admitted to the hospital for prosthetic rehabilitation. He had suffered from bilateral, congenital, very-short above-knee amputations. These AK stumps were too short to permit above-knee fittings at that time. The elaborate process of fabricating conventional disarticulation prostheses was considered unnecessary, and a modified standing appliance was designed to allow first the achievement of an erect posture, and later some degree of ambulation if possible.
A "bucket" was fitted as for a bilateral hip-disarticulation prosthesis. Care was taken to place the posterior bars of the standing appliance parallel to each other. A clamping attachment was adapted to the back of the "bucket" to fit between the parallel bars in such a manner as to allow vertical adjustment along the upright bars. Fixation of the "bucket" at any desired height could be achieved by means of a fastening handle. The height-adjustability feature of the appliance enabled us to bypass the process of fitting the child with "stubbies" initially, then fabricating prostheses and lengthening them by stages, until eventually the permanent height was achieved (Fig. 4 ).
Swivel walkers for cases of tetramelia due to thalidomide, and for spina bifida with high paraplegia, have been designed. In our case No. 2 the swivel walker was considered unnecessary in view of our subject's strong trunk and upper limbs. In fact, he first developed mobility using a walker for support and later achieved an independent swiveling gait on the appliance, with no upper-limb support.
The technique used here for adjusting the height of the "bucket" consisted of a simple screw-handle clamp. This, however, is not essential; and any other form of height adjustability can be used, depending on the material and tools available in the orthotics laboratory in which the appliance is made.
It is also noteworthy that, although the standing brace deprives the patient of the sitting position, had he been supplied with conventional prostheses he would in fact have always remained sitting, whether or not the prostheses were set in the flexed position or extended for standing.
For the daily activities required at the child's present age, the mechanism needed to permit sitting would be a nuisance and would hardly ever be put to use. As it is, the boy now attends kindergarten, eats at the table standing while other children sit, and can "ambulate" around his wardroom at will.
Jimmy Saltiel is Chief Orthotist/Prosthetist at Hadassah University Hospital, Jerusalem, Israel
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