Survey of Juvenile Hand Amputees

DENISE REID, M.ED., B.Sc., OT(C)* ANDLINDA FAY, B.Sc., OT**


The Juvenile Amputee Clinic and its associated prosthetic service at The Hugh MacMillan Medical Centre traditionally has fitted hand amputees with conventional prostheses. Recent developments, such as myoelectric prostheses, are options readily available to children.1,2Little research has been conducted investigating prosthetic use and attitudes among juvenile amputees.1,3,4 The purpose of this study was to identify the current prosthetic device(s) worn by congenital hand amputees and the extent of their use, and to determine children's and parents' satisfaction with specific prostheses.

Literature Review

The Centre has a long established multidisciplinary clinic which provides clinical care and rehabilitation to juvenile amputees.5 Review of the literature revealed that rehabilitation varies according to the level of amputation and whether it involves one or both hands. 6,7

Hand amputees of either congenital or acquired origin can be classified as:

  1. Achiria: Distal radial and ulnar epiphyses are present, but there are no carpal bones. Complete congenital achiria is rare. More common is the presence of a carpal remnant of variable size, which, if large enough, is classified as adactylia.8
  2. Adactylia: Carpal bones of varying number and configuration are present.
  3. Aphalangia: Metacarpals are present, but are invariably fewer than normal and attenuated.

According to Kostuick,8 a large mobile carpal remnant of a unilateral adactylia effectively used may contraindicate any form of prosthetic fitting because increases in function will be minimal. Others,6,9,10 have demonstrated that children with adactylia or aphalangia, who have a large and mobile enough amputation limb have been fitted successfully with an opposition palmar-pad prosthesis, often referred to as "spatula". It provides crude palmar prehension which allows the child to use whatever sensation is available in the hand and to control the strength of grasp voluntarily, by varying the action of the wrist flexors.

The standard below-elbow prosthesis has been prescribed when there is marked forearm shortening in an effort to compensate for the length discrepancy.1,6 The terminal device, either hook or hand, is activated by shoulder movements through a harness. With the advances in electrically powered prostheses both switch-controlled and myoelectric appliances have become available. In the switch-controlled prosthesis, opening and closing of the terminal device is achieved by a switch which is activated by moving the amputation limb into extension or flexion within the socket.

The myoelectric prosthesis is controlled by surface electrodes placed over the extensor and flexor muscle bellies of the forearm. Electrodes transmit the electrical activity of contracting muscle groups to an amplifier. The signal is processed to control the on/off state of the motor of the hand which produces prehension.2 Electrically powered prostheses have good appearance and easy operation.1

In spite of advances in prosthetic development, the issues surrounding prosthetic use among children remain unclear. Several factors have been identified as significant for successful prosthetic use. Firstly, studies indicate that the incidence of prosthetic use and acceptance among children increases with fitting at an early age.11,12 Secondly, researchers have found that appearance of a prosthetic device has significant impact on prosthetic use .3,7,13 Recent reports suggest that myoelectric prostheses provide a profound cosmetic advantage over conventional prostheses.1,14 Finally, other research has concluded that the impairment in sensory function, often associated with wearing a prosthetic device, is a major reason for children abandoning the use of their prostheses.3

A questionnaire was sent to families of children with hand amputations currently on active prosthetic rehabilitation program. Information obtained would provide insight into the types of prosthetic devices prescribed, the extent and manner of their use, and the degree of satisfaction parents and children have with regard to the prosthesis.

Method

Thirty-eight children living in metropolitan Toronto were surveyed. They met the following criteria: (1) on an active prosthetic rehabilitation program, (2) diagnosed as achiria, adactylia, or aphalangia amputee, and (3) were prescribed a prosthesis. The questionnaire was sent to the families, and parents were requested to complete it if children were too young to do so.

Respondents were asked background information, including date of birth, sex, and whether the child attended a school or day care program. Next, they indicated the level of amputation. Three categories were presented: (1) partial fingers, (2) below wrist, and (3) at wrist. They were asked if there was any wrist movement, and whether the movement was useful for performing functional activities. Respondents specified whether the amputation was unilateral or bilateral, and congenital or acquired.

Respondents were asked if they owned a prosthesis currently. Four choices were presented: (1) body-powered below-elbow, (2) spatula (conventional), (3) electric switch-controlled, and (4) myoelectric (Table 1 ).

They reported the length of time they owned the prosthesis, and listed all devices owned previously, including the ages at which the device(s) were fitted, the extent of use, and any problems.

They compared their present prosthesis on a three-point scale ("better", "the same", and "worse") with their previous prosthetic device(s), in terms of (1) appearance, (2) functional use, (3) comfort, and (4) maintenance. They noted the number of hours per day the prosthesis was worn, and whether it was worn willingly or they needed encouragement to wear it. From a list of seven choices, respondents were asked to indicate reasons the prosthesis was worn (Fig. 1 ), and if it was used primarily as: (1) an active device (for grasping objects), or (2) a passive device (for stabilizing objects). They rated the extent to which the prosthesis improves function on a four-point scale ("a great deal", "somewhat", "not at all", "impedes function").

Finally, respondents stated their satisfaction on a three-point scale ("like a lot", "like", and "dislike"), and specified reasons for the ratings. They were also asked whether or not there was anything they would like changed, or "made better" about their prosthesis.

Results

The questionnaire return rate was 58 percent; of the 38 sent, 22 were received. Of these 22, three were returned with letters indicating the questionnaire was not appropriate since the criteria could not be met. Thus, the study sample was 19 patients.

Most respondents, 16 (84%), were male with a mean age of 12 years. Three female respondents had a mean age of 9 years. All attended a daycare or school program.

All had congenital amputations, 18 (95%) involving only one hand; 16 had amputations of the left hand. Three (18%) had "partial fingers", six (31%) "below the wrist", and ten (53%) "at the wrist". Sixteen respondents reported the existence of wrist movement, and of this group, eleven stated that the movement was useful in stabilizing and holding objects.

All respondents owned a prosthesis currently. Table 1 shows the types of prostheses.

Over 80 percent had the current prosthesis for less than three years.

Eight (42%) respondents initially received a spatula prosthesis. Over half were fitted at 1 year of age or younger and reported that the prosthesis was either not used at all or only occasionally. Eleven (59%) had a standard below-elbow prosthesis, with most fitted over the age of 1 year. Eight claimed regular use. The problems with a standard prosthesis included poor appearance and discomfort. Only four (21%) of the total sample had an electrically operated prosthesis, (i.e.. two electric switch and two myoelectric prostheses) prior to being fitted with their present prosthesis; three had the electric prosthesis fitted after 2 years of age and used it on a regular basis. One subject had an electric switch-controlled prosthesis at 15 months of age and reported never having used it. The common problem cited by electric prosthesis owners was mechanical breakdown.

Over 70 percent of respondents rated their present prosthesis "better" in terms of appearance, functional use, comfort, and maintenance as compared to past prostheses.

More than half of the children reported using their current prosthesis willingly for a minimum of eight hours a day. Two, however, did not wear their current prosthesis.

Figure 1 outlines the most frequent reasons prostheses are worn.

Of the seventeen currently using a prosthesis, nine wrote that it was used primarily as an active device, while the others used it passively.

The extent to which prostheses improved function was: six (35%) had increases in function to be "a great deal", eight (47%) "somewhat", two (12%) "not at all" and three (15%) reported that the prosthesis impeded function.

Six (35%) respondents said they "liked their prosthesis a lot", nine (53%) that they "liked it", and four (21%) that they "disliked it". Reasons for satisfaction included cosmetic value, increases in function, comfort, and enhancing body image. The primary reason for dissatisfaction was interference with function; some respondents actually felt more functional without it. Suggestions for improvements included lessening weight, increasing durability, making the cosmetic glove less susceptible to discoloration and tears, and finally, developing a prosthesis which could provide both internal and external sensory feedback.

Discussion

The prototypical child amputee in the sample has a congenital amputation involving one hand, at the level of the wrist (achiria), and has owned a myoelectric prosthesis for less than three years. The most popular prosthesis currently used by the sample is the myoelectric prosthesis, confirming the trend toward successful application of this device with juvenile hand amputees.1,14,15,16

The finding that most "regular" prosthetic users were fitted with a prosthesis at an early age (under 3 years) is in accord with frequent reports that have suggested early fitting might influence prosthetic acceptance and enhance function among child amputees positively. 3,11,12,16,17,18,19

Many prosthetic users cited increases in function; this disagrees with Kostuick's8 results which suggest that functional gains may be minimal among unilateral hand amputees. The reason for the discrepancy might be that most subjects in the current study wore a myoelectric prosthesis, and research's has shown that functional use of the myoelectric limb is much greater than that of the standard prosthetic limb. Prostheses are worn primarily for performing specific functional tasks such as holding and carrying objects and playing sports, rather than as a cosmetic device.

Although most myoelectric wearers were satisfied with prosthetic comfort, function and appearance, a few indicated that a recurring problem was mechanical breakdown, consistent with other reports.1,2,14 The practice of wearing a prosthesis "willingly" for at least approximately eight hours a day by the majority of the sample suggests that earlier fittings influenced acceptance and tolerance.

Finally, although most respondents were pleased with their current device as compared to an earlier one, several complained about the loss of sensory function associated with wearing a prosthesis. This problem has been implicated as significant in determining whether or not a prosthesis will be worn or abandoned.3

Conclusions and Recommendations

This survey questionnaire presents information regarding current prosthetic use and satisfaction among nineteen children with congenital hand amputations treated at The Hugh MacMillan Medical Centre. Early prosthetic fitting might have helped them accept their current device. Furthermore, the survey supports observed trends of successful application of myoelectric prostheses in children.

Acknowledgments

We thank Dr. D. Gibson, Medical Director; Dr. H. R. Galway, Clinic Chief Prosthetic Team; and Ms. S. Hubbard and Ms. E. Hamilton, OccupationalPhysical Therapists, all of The Hugh MacMillan Medical Centre, for their cooperation and support in conducting this study.

*Division of Occupational Therapy, University of Toronto, 256 McCaul Street, Toronto Ontario M5T 1 W5

**Saint Michael's Hospital, Toronto, Ontario

References:

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