The Use Of Brace-Type Devices In The Treatment Of Children With Congenital Malformations
Milton J. Wilder, M. D. William Neill, III, R.P.T.
The primary goal of a prosthetic clinic team is to provide a child amputee with a comfortable, functionally efficient and cosmetically acceptable prosthesis. There are times, however, when it is impractical to prescribe a standard prosthesis for a child and it becomes necessary to utilize a nonstandard item. At the Kernan Hospital Amputation Clinic, we have made extensive use of non-standard prostheses, where they were considered desirable or necessary, with particular emphasis on the utilization of brace components in the construction of such devices.
It should be pointed out that the use of the brace-type prosthesis is not new or novel. Devices of this type have been prescribed for congenital amputees for many years with various types applied to the treatment of numerous disabilities if need and patient motivation are present.
A definite pattern in the use of the brace-type prosthesis has been established at our clinic. Selected patients with congenital malformations are fitted with the devices and are guided through a period of training and development until they are believed ready for a standard or a near-standard prosthesis. In these cases the brace maker works in close association with the doctor, physical therapist and other members of the clinic team. Two models of brace-type prostheses which we have frequently used are depicted in Fig. A .
Our experience indicates five important advantages in the prescription of a brace-type prosthesis for a growing child:
Availability: A brace-type prosthesis can be fabricated and delivered in a shorter time than a regular prosthesis.
Cost: The cost of a brace-type prosthesis is approximately one third that of a standard prosthesis.
Ease of Maintenance: The brace-type device is made of durable material. It can take considerable abuse and requires little maintenance.
Provision for Early Ambulation: A lengthy period of formal gait training is not required. Standing balance and walking patterns are usually developed rapidly.
Testing for ambulatory potential is achieved more rapidly than with a standard prosthesis.
In considering the prescription of a brace-type prosthesis, cognizance must be taken of two possible disadvantages -cosmesis and adverse effect on later gait patterns. We have found, however, that adequate comfort and function more than compensate for cosmetic considerations during the early stages of a child's development. Adverse effects on later gait patterns can be prevented by training the child in the pattern of walking that will be appropriate for the standard prosthesis he may eventually receive.
The particular type of device to be utilized is determined, of course, by the requirements of the patient. Once the prosthesis has been chosen, rehabilitative and training measures, based on the age and motivation of the patient and the type of device, are formulated. Training is usually initiated with standing balance and advances ultimately to step taking. The children are permitted to employ canes, crutches and other supporting devices in the preliminary stages and, whenever possible, are directed to independent walking. The parents are encouraged to observe the physical therapist working with the child and frequently they become proficient enough to continue the youngster's training themselves.
The first four cases presented here are representative of patients with congenital deficiencies who have been fitted initially with brace-type replacements and have progressed to near-standard prostheses. Their histories indicate that, with proper timing and judicious use of components and modified sockets, a brace-type device can be used very effectively as a precursor to a standard prosthesis.
Subject R.H., male.
Classification: Terminal Transverse Hemimelia (K/D) Bilateral (Fig. 1A ).
R.H. was first seen in our clinic at the age of three months. He began to pull himself erect on his stumps in the crib at the age of 13 months. A month later, we fitted him with two pylons with leather sockets and brace calipers anchored to rocker bases.
In subsequent months, the following adjustments were made: The rockers were changed to platforms (Fig. 1B and Fig. 1C ), the pylons were lengthened to accommodate growth, and a more rigid pelvic belt was added (Fig. 1D ). The patient was ultimately fitted with standard prostheses -leather lacer sockets with outside hinge knee joints, a wood shin and a SACH foot (Fig. 1E and Fig. 1F ).
Subject S.G., female.
Classification: Proximal Femoral Focal Deficiency, Left (Fig. 2A ).
This patient was seen initially in February 1959, at which time she was three months old. At the age of one year, she was fitted with an elevated shoe (Fig. 2B and Fig. 2C ) so that she might learn to stand. Shortly afterward, she was given an ischial weight-bearing leather socket, a caliper-type brace with a platform, and a pelvic belt (Fig. 2D , Fig. 2E , and Fig. 2F ). Numerous lengthenings were provided at later stages (Fig. 2G and Fig. 2H ).
In October 1963, the clinic team decided that S.G. was ready for a near-standard prosthesis. She is now in the process of being fitted with a prosthesis with a modified socket, an outside hinge knee joint, a wood shin and a SACH foot.
Subject J.S., male.
Classification: Proximal Femoral Focal Deficiency, Right (Fig. 3A ).
J.S. was first seen in February 1956, at the age of 14 months. At that time he was fitted with a partial ischial weight-bearing pylon-type extension brace with a leather lacer socket and a pelvic belt (Fig. 3C ). In April 1963, he had progressed sufficiently to be fitted with a modified socket with the foot in equinus. The prosthesis incorporated an outside hinge knee joint, a wide pelvic belt and a SACH foot (Fig. 3D and Fig. 4A ).
Subject V.P., female.
Classification: Complete Paraxial Hemimelia Fibular, Left.
V.P. was examined for the first time at our clinic in September 1956, when she was 32 months old. She was fitted with a brace-type pylon and a stop lock knee (Fig. 4A ). In January 1958, 16 months later, she was given a standard below-knee prosthesis, the components of which were a leather thigh lacer, an outside hinge knee joint, a wood socket and a SACH foot (Fig. 4B and Fig. 4C ).
Functional Aids to Athletic Participation
Cases Five and Six differ from the previous four. Two highly motivated boys expressed a strong desire to participate in competitive sports despite the presence of limb malformations. In response to their needs, we provided several unusual devices solely for athletic participation and achieved gratifying results.
A.L., an adolescent boy, was very eager to improve his baseball and tennis skills. After careful consideration, we fitted him with several unusual devices to enable him to play baseball in a satisfactory manner (Fig. 5C and Fig. 5D ). In order to catch the ball, he had to learn to position the glove on his left hand. This unusual boy strove for proficiency and, fortunately, possessed inherent alert reactions. By developing a rapid sensory feedback accommodation, he refined his skill to the extent of becoming a catcher on the junior varsity team at his school.
In response to his desire to play tennis, we provided a ball-holding support to be used for serving. By utilizing his thumb (Fig. 5E and Fig. 5F ), he was able to maintain pressure on the ball and release it.
J.S. was also extremely interested in sports. He first came to us at the age of 11 years and was fitted with a plastic foot filler (Fig. 6C ). He could not run well with this arrangement, however, and his un-happiness was quite apparent. A Velcro supporting strap was added to the foot filler but he still could not run to his satisfaction.
Finally, a filler with a stabilizing strap, a toe break and an essential heel support were added (Fig. 6D and Fig. 6E ). This arrangement provided the lad with better "take off" and his running ability markedly improved. He is now a member of his high school soccer team.
The first four cases presented demonstrate the satisfactory results that can be achieved when a child is fitted initially with a brace-type device and is gradually brought along to the stage where a standard or near-standard prosthesis can be employed.
The final two cases illustrate the value of special devices which may be designated to meet the needs of patients.
These six cases indicate clearly that the conventional routine prosthetic method is not necessarily the only road to follow in the treatment of the child amputee. There is ample scope for intelligent experimentation and trial ventures. New ideas and concepts should be welcomed, discussed and developed since it is only in an atmosphere of this type that a child amputee clinic can satisfy the varying needs of its patients.
Amputation Clinic, Kernan Hospital and University Hospital, Baltimore, Maryland. Milton Wilder is Clinic Chief.