Independence in Toileting for a Patient Having Bilateral Upper-Limb Hemimelia


Case Description

T .,a black male, was born in January 1966. He has a diagnosis of bilateral upper-limb partial hemimelia with two functioning digits on the right and one on the left. He also demonstrates torsion of the left tibia, asymmetric head, and low-cervical spina bifida occulta. Toileting has continually been a major problem for T. and requires that he have special assistance at home and at school.

Corrective Measures

Since the spring of 1973 various clothing and mechanical adaptations have been developed to enable T. to remove and replace his trousers for toileting.

Pants-Zipper Modifications

Velcro replacement zippers were tried to adapt the pants zippers so that T. could zip and unzip. When the zipper was adapted with Velcro, the trousers opened to the left. T. has range of motion only from his body midline to the right. Therefore, if Velcro was to be used the front of the trousers would have to be reconstructed. The complexity of the reconstruction caused us to eliminate this method as a practical solution for the problem.

A metal ring was placed through the zipper tab to enable T. to pull up the zipper. However, he still was unable to unzip it. By using a long wire with a hook on the end he was able to push the zipper down with his right flipper. This method proved unsatisfactory because function was dependent on the particular zipper in use and because the pants sometimes bunched during the unzipping process.

Trouser Modifications

Trousers were adapted by adding elastic at the waist side seams. It was hoped that T. would be able to remove these pants without unfastening them. To aid in lowering his pants, a rounded wooden drawer knob was attached to a small piece of wood which was mounted on the wall at waist level. This allowed him to push his pants waist against the knob and thus lower his pants. However, the elastic placed in the side seams held his trousers so firmly that T. could not push them over his hips.

Next, suspenders were attached to loose-fitting pants to allow T. to lower his pants without unfastening them. Even after continued practice, the suspenders proved unsatisfactory. If the suspenders were adjusted tightly enough to hold the trousers properly, they were then too tight for T. to slip them off his shoulders.

We felt that if the waist of the trousers was large enough the pants could be lowered without unfastening them. A leather belt was made with a Velcro closure. T. was able to unfasten the belt but was unable to push the end of the belt through the buckle ring and pull it tight enough to hold up his trousers.

Finally a coverall type of trouser (overalls) was chosen. The overalls selected ( Figure 1 ) had a low, scooped back allowing easy removal, and they were one size larger than T. usually wears. T. slides each strap off his shoulders and moves his trunk laterally in quick motions until the trousers slip to the floor. He then is able to move the leg opening of his undershorts aside and urinate. After completing his toileting, T. pulls up each shoulder strap with his upper limbs while maneuvering the trousers up his trunk. He then places one shoulder strap onto the knob of the bathroom door and is able to place his shoulder into the strap, thus properly positioning one side of his trousers ( Figure 2 ). He is able to free the strap by rotating his trunk backwards from the doorknob. He then places the other strap of his trousers over the doorknob and repeats the process, thereby completing his dressing. Using the overall type of trousers appears to be the most satisfactory method for T. to raise and lower his trousers. The overalls do not require an unfastening, and if necessary the straps can be adjusted as he grows taller. The difficulty with this particular low-scooped-back style is that often the straps slip off T.'s shoulders even though they are adjusted as tightly as possible. Different styles of overalls will he studied in the future in an attempt to alleviate this problem.

Toileting-Device Stand

Because of the high level of his congenital amputations, T. also requires special assistance for bowel movements. The toileting device described by Friedmann1 was built so that T. could wipe himself after a bowel movement. Often, however, he had a bowel movement during school hours, necessitating assistance by an attendant. We designed and built a sturdy structure to hold this toileting device so that it did not have to he placed on a bathtub edge ( Figure 3 ). The stand ( Figure 4 ) has a wooden base on which T. stands, thus giving stability to the toileting device. The device sits on a 1.3-cm (1/2-in.) diameter steel pipe which can be replaced with longer sections as the child grows taller. At present this stand appears to be working well in meeting his needs.

It is hoped that by the Fall of 1976, T. will be totally independent in toileting. Through the aid of his overalls and his toileting device we hope that T. will be able to attend a regular school in his community.


The toileting-device stand was designed by George Ackerman, and the diagram was drawn by Roger Will.

1. Friedmann, Liesl, Toileting device for high-level upper-limb amputees. Inter Clin Inform Bull, 14:7-8:25-27, 1975.