Symposium on the Limb-Deficient Child: A Report
JOHN R. FISK, MD
Professor Doctor Ernst Marquardt, under the sponsorship of the International Society for Prosthetics and Orthotics, directed the Symposium on the Limb-Deficient Child in Heidelberg, Germany, August 27 to September 1, 1988. Physicians, therapists, prosthetists, engineers, and others interested and involved with limb-deficiency clinics represented countries from North and South America, Asia, Australia, and eastern and western Europe. A dozen members of the Association of Children's Prosthetic-Orthotic Clinics participated in the meeting at the University of Heidelberg, the third oldest in Europe, founded in 1386. Its setting in the historic district of a thriving city stimulated the very provocative conference. Leon Kruger, MD began the program with an historical perspective that recalled the outstanding child prosthetic efforts which existed in the United States from the late 1930's to the present Association of Children's Prosthetic-Orthotic Clinics. He reminded the audience of the Thalidomide tragedy of the mid 1950's. Of greater importance, however, is the realization that limb-deficient children present a contemporary problem for which many goals have yet to be realized.
Dr. Lenz of Muenster spoke on genetic concerns. Although a few inherited conditions include limb deficiency, most congenital limb anomalies are sporadic. Teratogens, such as Thalidomide, most certainly do not cause hereditary effects because their influence is not on the genetic code, but on the developing embryo.
Professor Marquardt always taught the value of a broad perspective of care and services provided to limb-deficient individuals. In keeping with this dictum, he invited Harold Wilke of White Plains, New York, himself an amputee, to speak on psychosocial aspects of disability. Wilke noted that one tends to view the handicapped with subconscious repressed fears and embarrassment. Consequently, interacting with the disabled liberates one's emotional responses, hopefully in a constructive manner. He further suggested that parents of handicapped children need to be encouraged to go on living, to have additional offspring in order to show the handicapped child that they were not so overwhelmed as to curtail their family plans.
Bo Klasson of Stockholm, Sweden gave an engineer's perspective on device evaluation. One must consider the patient and the environment, the care providers and their capabilities, and, most important, the patient's economic resources. Advantages and disadvantages must be weighed at each point. Klasson emphasized that the child must be loved the way he or she is, otherwise any device will fail.
One of the most significant presentations was that of H. J. B. Day, MD, of Manchester, England. He has been representing the International Society for Prosthetics and Orthotics (ISPO) to the International Standards Organization. Day reported that the ISPO classification of congenital limb deficiencies had been accepted internationally. This will ease communication and computerization of patient statistics. He observed that the ISPO classification, although exacting, is sometimes clumsy. In everyday conversations in the clinic setting, he expects that some old common terminology will still be used.
Although several speakers discussed their experiences with myoelectric below-elbow prostheses, little new was revealed. Some individuals, even the very young, derive benefit from myoelectric prostheses; nevertheless, each clinic will find wide variation in myoelectric appropriateness and acceptance.
Professor Marquardt chaired a discussion on "The Hook Versus the Hand." One of his patients who lost both hands in a laboratory explosion said, "Now I have two machines. It is not what they look like that counts, but what I can do with them. " Of particular interest is the fact that he used a body-powered hook on his dominant side and a myoelectric hand on his nondominant side.
Alfred Swanson, MD, from Grand Rapids, Michigan, noted that prehension is more than pinch. It is "strong grasp with sensation." He described his experience with the Krukenberg procedure.
In addition to bringing together a well qualified and diverse faculty, Prof. Marquardt contributed greatly himself. Registrants heard of his techniques and experiences, saw his patients, and, most impressively, heard from a wide gamut of his former students now practicing in many universities and clinics throughout Germany. All are making contributions to the care of limb-deficient children. They reported on a combined experience with many techniques, among them angulation osteotomies and limb capping. Their experience corroborated the reports of Dr. Marquardt at many ACPOC meetings.
Much time was spent discussing radial club hand. Dr. Charles Bukrey and Dr. Levett from Grand Rapids, Michigan reported their experience with associated conditions. Others spoke on surgical as compared with nonsurgical management. Speakers emphasized three points. First, careful individual evaluation must be conducted of each child in order to detect associated abnormalities. Second, early treatment is of paramount importance; stretching and appropriate night splinting are especially helpful. The child must be allowed to use the hands during the day. Third, function should not be sacrificed for appearance. The hand must remain sufficiently flexible, especially for the patient with a stiff elbow so that the child may eat independently.
One topic which always creates controversy is proximal femoral focal deficiency. Speakers from Springfield, Massachusetts; Toronto, Ontario; Heidelberg; and Muenster, among others, came to no agreement. Ablation, turnaround, and custom shoes all had their advocates. Old world shoe cobblers displayed exceptional ingenuity creating leather shoes to cover limbs which, in other clinics, would have been modified surgically. It is likely that alternate approaches will continue to be developed for this very dffficult limb deficiency.
Much admiration and attention was evinced from European, Asian, and Australian delegates for the activities and organization of the Association of Children's Prosthetic-Orthotic Clinics. The aspect which received the most credit was the multiple discipline approach to membership and meeting format. I was very proud to represent you. Many individuals from other countries inquired about associate membership. I will encourage their attendance at our meetings.
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