Report Concerning Typical Prosthetic Applications To Armless Children
Kurt Lindemann, M.D. Ernst Marquardt, M.D.
(The following article by Drs. Lindemann and Marquardt, of the University of Heidelberg's Orthopedic Clinic, appeared in the August, 1962 issue of Die Rehabilitation, a publication of the German Association for the Rehabilitation of the Disabled.)
This report presents a condensed discussion concerning the provision of prostheses for armless children.
Leading authorities have stated that physical power potential is inadequate for actuating a prosthesis in case of a missing arm or the presence of small buds. This is pointed out in the Annual Report of the Child Amputee Prosthetics Project, University of California at Los Angeles, in 1959.
Since these children do not possess adequate physical strength of their own, their prostheses must be actuated by external power. The pneumatic prosthesis is, of course, one of the proven sources of external power. Our experience is based on 80 bilateral arm amputees who have been provided with pneumatic prostheses in our clinic since 1949. This group includes 11 bilateral shoulder-disarticulation cases (several armless), four with little fingers directly attached to the shoulder (phoco-raelia), and 25 bilateral above-elbow amputees.
Our personal experience leads us to believe that we may safely discuss a "standard" externally powered prosthesis for the upper-extremity juvenile amputee. We have found that application of such a "standard" prosthesis has produced successful results in children only two and three years of age. Within a period of from two weeks to two months, the toddlers have learned to utilize their prosthetic arms and hands for playing and eating.
In these cases a sound basis for rehabilitation has been established. It is our plan to follow up these early steps with what we hope will be successful provisions for the schooling, professional education and social integration of the children. By using the prosthesis on an increased and varied daily basis, the repeated performance of the grasping act serves to improve the child's intelligence (sic).
There can be no doubt that severe limb malformations have increased remarkably in Germany as well as in other European countries (Sweden, England). Consequently, it must be expected that many children who are completely without arras, or whose remaining limb segments are insufficient for the performance of necessary acts, will require prosthetic care. During a child's first year following birth, training measures are necessary for the limb buds, the musculature of the shoulder girdle, the feet and the toes, and also to create flexibility of the lower extremities. If prosthetic application is required, it should be initiated as soon as possible. Fitting and subsequent efficient operation of the prosthesis will be very difficult, however, if the stump or the limb buds are excessively short.
We began to fit small children with prostheses in 1957. The initial fitting took place in the spring of that year-a right-side pneumatic prosthesis for a five-year-old child. At the age of four, the patient had received an active grasping arm from H. Kessler of New Jersey. The arm enabled him to grasp and hold light objects but not to play and eat. In referring the child to us, the Kessler representative inquired if improved performance could be achieved by a pneumatic method.
We were able to answer the question affirmatively. The hook was replaced with a pneumatic child's hand and the passive wrist unit with one that was pneumatically controlled. The child experienced no difficulties in operating the prosthesis and was able to eat with a regular spoon after three days. This favorable outcome encouraged us to continue the provision of pneumatic power for armless children.
Our observations of children playing, eating, writing and painting while wearing a pneumatic prosthesis and our experience with contact valves in the muscle control of below-elbow prostheses motivated us to substitute pulling valves for the pressure valves originally used. Through this substitution, the application of harnesses for pneumatic prostheses was considerably simplified and, significantly, improved control was achieved by utilizing the sensitivity of the skin and the muscle to which the valve control was attached.
With the new arrangement of valves, elevation of the shoulder controls hand rotation and forward motion controls grasp in a natural appearing manner. Both motions - rotation and opening, and closing of the hand - remain under separate control and forced linkages are avoided. Compared with a prosthesis controlled by body forces, this presented a decisive advantage .
Short limb buds (segments), even those which are only loosely attached to the shoulder, can be profitably utilized to provide impulses for control of the pneumatic prosthesis. This can be achieved by systematic training. Clothing should be altered so that grasping of the little fingers will not be obstructed by cloth bulges. The child's parents should be thoroughly instructed as to what is taking place and should be advised from time to time on the development of the child.
The first child supplied with a prosthesis of this type was able to perform the necessary functions at the age of one and three-quarter years. Depending on the age of the child, it was found that two passive "clapping" hands could become an automatic grasping organ by synchronized motion and contact. This was brought about by coupled inner rotation of both arms (sickle motion) and flexed elbow joints. In this connection, it is advisable to view the photographs appearing with the article on "Pneumatic Arm Prostheses in Children." (Editor's Note: This article, by Dr. Marquardt, was reprinted in the January, 1963 issue of the Inter-Clinic Information Bulletin.)
If a child is four or five years old, the genuine grasping function of one artificial hand, or two, can be developed with the aid of pneumatic power. At the present time, we are supplying a five-year-old boy with a prosthesis of this type with which he will have the advantage of utilizing his little fingers for the control of such important prosthetic functions as grasp and hand rotation (Fig. 1 ).
Fig. 2 , Fig. 3 , Fig. 4 , and Fig. 5 depict the technical application of the prosthesis and the procedures followed during training. The boy learns to use the prosthesis as well as his feet for all types of functions. He also learns to pass objects between his prosthesis and his feet in the manner of a "link-to-link" connection. It is interesting to note that the child prefers to eat with the aid of his prosthesis although he learned to use his feet at the same time as the prosthesis.
In this phase of rehabilitation, it is gratifying to learn again and again that a child regards a prosthesis as part of his body as soon as he becomes familiar with its functions. This attitude makes it considerably easier for us to achieve successful results. We cannot claim, however, that we have fully completed the development of this prosthesis. There are still many questions requiring solutions, especially those involved in providing prostheses for bilateral armless children.
We believe that we have developed useful standard methods for initiating the rehabilitation of armless children from the beginning of their second year of life with the application of bilateral "clapping" hands, followed by the provision of unilateral prostheses at the ages of four or five. In view of the increase of malformations, understanding of these methods and their dissemination is desirable.
In 1917, K. Biesalski, writing in Zeitschrift Fuer Orthop. Chirurgie, Volume 37, page 240, reported on the outstanding bilateral application of prostheses for a nine-year-old boy. These prostheses, with bilateral active hooks, operated in free suspension and independent voluntary control of both elbow joints and hooks (according to Fischer). The boy had undergone a bilateral above-elbow amputation after an accident.
Continued development since that time has led to the successful introduction of independent external power and it is hoped that a basis has been established for the ultimate complete rehabilitation of children.
It would be a mistake to cling to the view that children can only be supplied with a prosthesis after the completion of their growth period. Biesalski, in his time, showed the way; and today the continuing progress of prosthetic technique constantly enables us to improve our procedures. The experience acquired in the fitting of prostheses to children in the United States has given us many valuable suggestions.
But technical knowledge and application alone cannot do the job. Sympathetic understanding and systematic training of the children and their parents is also very essential.
This article translated from the German by Maurice M. Schweizer, Ph.D., New York University-Child Prosthetic Studies.
Orthopedic Clinic, University of Heidelberg