Juvenile Upper-Limb Amputees: Early Prosthetic Fit and Functional Use
R. C. TERVO, M.D.,* AND J. LESZCZYNSKI, M.D.*Saskatoon, Saskatchewan
When is the best time to fit a prosthesis to a child who has an upper-limb amputation? Does early fitting influence prosthetic acceptance or enhance function? These central questions concerning juvenile upper-limb amputees have been contentious issues for many years. In 1953 Frantz and Aitken stated that children with lower-limb amputations are best fitted at about the age a child normally learns to walk, and that children with upper-limb amputations should be fitted one year prior to entering school1. The recommendations were made by extrapolating from Gesell's observations of child development and concluding that the 4-to-5-year-old child has the motor skills needed to operate a prosthesis and use it purposefully2. Since then, experience has indicated that children who have been fitted earlier than 4 years seem to do better functionally, and most clinicians now believe that fitting an artificial limb within a year after birth or traumatic loss is optimal. In the upper-limb amputee it allows the opportunity to develop bimanual skills at the prosthesis into the body image and into useful prehensile activities at an earlier age. Early fitting may also contribute ultimately to better prosthetic tolerance and wearing patterns and may prevent an asymmetrical posture and spinal curvature3-8.
The purposes of this study were to record observations regarding the timing of fitting and the relationship between early fitting, prosthetic acceptance and functional gains; and to formulate recommendations for optimal management of upper-limb amputees in a juvenile amputee clinic.
Patients and Methods
Thirty-nine juvenile amputees, 31 male and 8 female, ages 0.04 to 17.9 years (z ±S.D. = 10.5 ± 5.39 years), were reviewed by retrospective chart audit to describe their clinical presentation and to identify management plans leading upper-limb amputees to become prosthetic wearers. There were 28 upper-limb amputees. One child had congenital upper- and lower-limb amputations.
The 28 patients with upper-limb amputations presented six levels of disability: partialhand, hand, wrist- disarticulation, below-elbow, above-elbow and forequarter (Table 1 ).
Age, sex, race, location of residence, time of fitting and adaptation to the prosthesis were surveyed; information was recorded on standardized data collection sheets. Two children under 2 years of age with upper-limb amputations were excluded from the calculations as these children had not worn their devices for periods long enough to ascertain their wearing pattern. Associations were assessed by odds-ratio9-10.
Children were considered prosthetic wearers when they demonstrated spontaneous semi-skilled or skilled bimanual activities and if their devices showed evidence of wear or a record or repairs, modifications or replacement. Early fitting was defined as the provision of a prosthetic device within one year of congenital or traumatic limb loss. Urban children lived in a regional center of commercial activity, generally in areas with a population greater than 5,000, and the fathers had an occupation other than farming, ranching, or trapping. Rural children lived on a farm or ranch, distant from a regional center of commercial activity.
An occupational therapist conducted a detailed functional assessment of prehension which evaluated the skills needed to perform four activities of daily living; eating, dressing, toileting and playing at an age-appropriate level. Completely independent children did not need assistance in any activity, while partially independent children required assistance in one of these activities and dependent children had to have help in two or more activities. Children 6 years of age or older were expected to have mastered bimanual functional skills such as tying laces and eating with a knife and fork. Ageappropriate levels were determined according to Sheridan11.
Selected characteristics of upper-limb amputees related to time of fitting are given in Table 2 . Any amputee who is fitted early is likely to become a prosthetic wearer (w = 27.5, p < 0.05), and in this group the congenital amputees who were fitted early were most apt to wear and use a prosthesis (w = 18.67, p < 0.05).
Single or multiple limb loss in a child, whether due to congenital or traumatic causes, must be referred for evaluation immediately. Juvenile upper-limb amputees are more likely to develop effective bimanual skills and become consistent wearers if fitted with a prosthetic device within one year of limb loss. Conversely, the children with upper-limb amputations who are not fitted early are not good prosthetic wearers. In upper-limb amputees, early fitting appears to facilitate the development of spontaneous, bimanual skills.
Regardless of the functional benefits of early fitting, the psychological importance is considerable. Parents) in the delivery suite see their infant's congenital amputation as an emergency and should receive immediate care to help them deal with the impact of their baby's impairment.
The dramatic nature of a traumatic limb loss (mainly in lower-limb amputees) and the obvious need for prompt surgical treatment lead to earlier fitting (within 0.27 years of injury). Traumatic amputees tend to be better wearers than congenital amputees. The time from limb loss to the first clinic visit, however, was about the same for both traumatic (1.66 years) and congenital (1.84 years) amputees.
Clearly the setting of the juvenile amputee clinic affects the way in which the etiology of an amputation influences the patterns of practice and referrals; this variable could influence the time when a prosthesis is prescribed. Congenital amputees, mainly upper-limb, were fitted within 2.63 years of birth. Such children must be referred to a multidisciplinary clinic within the first four months of life for a detailed assessment and evaluation so that good wearing patterns can be established.
Easy access to rehabilitation services may be one reason why urban upper-limb amputees are better wearers than rural upper-limb amputees (w = 2.85, p < .10). Children living in rural areas often help with heavy physical work on the farm and to do this may have to discard their prostheses. The play activities of urban children may require finer movement skills leading to prosthetic acceptance and wear.
Those fitted early tend to be prosthetic wearers and, if equally independent with or without a prosthesis, usually choose to wear one.
Is prosthetic use and function in upper-limb amputees a central issue in a juvenile amputee clinic? Children in the clinic seem to be able to achieve some degree of independence regardless of whether they wear a prosthesis or not. Additionally, function and wear may occasionally be far less important than appearance, especially to the adolescent with an upper-limb amputation. The preoccupation of physicians with function may not reflect patient needs totally. Interviewing the families attending the clinic disclosed 3/7 of the upper-limb amputees over the age of 12 placed primary importance upon appearance rather than function. Concern about prosthetic appearance in adolescence is reflected in use. Only half the children over 12 were prosthetic users. Ultimately, one must ascertain whether an upper-limb amputee who is a prosthetic wearer as a child continues a good wearing pattern through adolescence and adulthood when the individual is no longer accountable to parental guidance. Only the results of a long-term follow-up could justify the enthusiasm for early intervention and early fitting. If upper-limb amputees are fitted early, establish good wearing patterns and then discard prostheses once they are old enough to make their own decisions, the emphasis on early fitting has limited advantages. While early fitting may not enhance independence, it will prevent secondary physical disabilities during growth, such as scoliosis, and will also enhance bilateral functional skills. In addition an early clinic visit should be encouraged for the psychological benefit it gives the parents. In a telephone survey, 15 of 34 parents stated that their child's early appointment at the juvenile amputee clinic definitely helped them adjust, by allowing them to see and interact with other parents and amputees attending the clinic12. Parents were reassured by the experience of the team, supported by the early habilitation provided by community resources, such as itinerant therapists and day-care centers; reassured by genetic counselling when necessary; and comforted by the early delineation of a long-term multidisciplinary management plan for their child.
A retrospective chart review of 39 patients attending the juvenile amputee clinic in Saskatoon has clarified pertinent attributes of these children and allows the following recommendations to be made:
- All children with limb loss, particularly upper-limb amputees, should be fitted within one year of limb loss.
- Early referral (within the first four months of life) to a multidisciplinary team is imperative for the successful habilitation of congenital amputees, including the resolution of family concerns. This is critical for the upper-limb amputee.
- In rural settings, primary prevention, particularly of farming accidents, must be advocated.
- Further study should be undertaken to assess long-term compliance of good juvenile upper-limb amputee prosthetic wearers.
We thank Ken Betts and Val Suderman, medical students, and Audrey Salkeld, occupational therapist, for their help with this manuscript. This project was supported as a Dean's Project, University of Saskatchewan, with financial assistance from Health and Welfare, Canada.
*Children's Rehabilitation Centre, University Hospital, Saskatoon, Saskatchewan S7N 0W8, Canada
- Frantz, C. H., and G. T. Aitken: Management of the Juvenile Amputee. Clin Orthop 14:30-49, 1959.
- Gesell, A.: The First Five Years of Life: A Guide to the Study of the Preschool Child, in MacDonnell, J.: Age of Fitting upper Extremity Prosthesis in Children. J Bone Joint Surg 40-A:655,1958.
- 3. Angliss, V. E.: Rehabilitation of Upper Limb Deficient Children. Am J Occup Therap 28:407-414, 1974.
- Brooks, M. B., and J. Shaperman: Infant Prosthetic Fitting-A Study of the Results. Am J Occup Therap 19:329-334, 1965.
- Dennis, J. F.: Infant and Child Upper Extremity Amputees: Their Prostheses and Training. J Rehab 28: 2628, 1962.
- Fisher, A. G.: Initial Prosthetic Fitting of the Early Congenital Below-Elbow Amputee: Are We Fitting Them Early Enough? Inter-Clin Inform Bull 15:7-10, 1976.
- Guerrero, V., and C. H. Epps: Early Prosthetic Rehabilitation of the Child with a Unilateral Below-Elbow Congenital Deficiency. Inter-Clin Inform Bull 11:9-14, 1972.
- Hall, C. B.: Recent Concepts in the Treatment of the Limb Deficient Child. Manitoba Med Rev 44:554555, 1964.
- Miettinen, O.: Estimability and Estimation in Case Studies. Am J Epidemiol 103: 226-235,1976.
- Fleiss, J. L.: Statistical Methods fur Rates and Proportions. New York: John W iley and Sons, 1973.
- Sheridan, M.: From Birth to Five Years: Children's Developmental Processes. Atlantic Highlands, New Jersey: Humanities Press, 1975.
- 12. Suderman, V., R. C. Tervo and J. Leszezynski: Patient and Family Perceptions of a Juvenile Amputee Clinic. Inter-Clin Inform Bull 18: 1-4, 17, 1982.