Observations And Findings Concerning Upper-Extremity Prosthesis Wearers
J. Leonard Goldner, M.D.
Our observations over the past eight years have led us to several generalizations concerning the management of children with upper-extremity amputations. Two facets of treatment have been of particular interest. One is the apparent effect of growth and development, and the influence of a changing personality, on the child's acceptance or rejection of the upper-extremity prosthesis. The other, and closely related, is the adequacy of our resources to meet these changing needs. In this regard, I believe it is generally recognized, that despite the advances of the past decade, gaps in our resources do exist, either in relation to a given stage in a child's development or to his total problem.
In the light of these two considerations we must (1) encourage the development of new and improved devices commensurate with the needs; and (2) attempt to find practical solutions to the problems that arise in the day-to-day management of the upper-extremity amputee, by all means now available.
This article presents several examples illustrative of the type of problems encountered, together with a brief interpretation of the factors involved in each case. The six case histories which follow are based on long acquaintance with each patient, and considerable available information pertaining to the home environment, parents, and school situation.
A three-year-old girl with bilateral congenital shoulder-disarticulation amputations was comfortably and satisfactorily fitted with a unilateral shoulder-disarticulation prosthesis. At the time of the initial fitting, she was proficient with her feet and toes and was able to feed herself, draw, and satisfy her play needs as long as her shoes were off. The single prosthesis did not interfere with her foot activities, and no effort was made to limit these activities in any way. She eventually learned to feed herself with the prosthesis and used it for carrying objects draped over the forearm. Maintaining body coolness was a moderate, but not a severe, problem.
We were gratified by the relative success of her first prosthesis and a second unit was added one year later. This did not create any complicated problems, although body cooling was difficult and the second prosthesis was not as functional as the first. Nevertheless, the child indicated that she felt more "whole" when she wore the two limbs.
The girl now attends school, and in this environment the limbs are bulky and a definite handicap, according to both the child and her mother. Attempts at learning to write with the prostheses were frustrating, and were discontinued. Feeding with the prostheses was also given up because of the time involved. Total use of the prostheses was limited.
It would thus appear that regular wear of the prostheses was detrimental to the accomplishment of her daily tasks and her happiness, when she reached school age, despite acceptance and some degree of use in the pre-school years.
An additional influence operative in this situation was that the child and her mother had talked with a 40-year-old woman with bilateral congenital shoulder-disarticulation amputations. This woman had reared two children, accomplishing all her housework and other chores, without any kind of prosthetic assistance. She sewed, cooked, changed diapers, and performed various household cleaning activities with her feet and with adequate speed.
Accordingly, the girl abandoned her prostheses and began a program to become self-sufficient without them. She is now able to put on her dress, using both feet. She manages her other dressing needs with the help of blunt metal extensions which project from the wall, and is able to take care of her personal hygiene.
A change in need and attitude with the advent of school attendance, and the limitations of the prosthetic assistance we could provide, combined to negate attempts at prosthetic restoration. There is a possibility that this child will ultimately return to prostheses in order to fill out her clothes, but the chance that she will actively use artificial hands, unfortunately, is slim.
This little girl came to us in 1957 at the age of five years, with a left elbow-dis-articulation amputation. She was fitted with a hook and did satisfactorily for two years, but was happy to transfer from the hook to the APRL-Sierra No. 1 Hand. However, she grew too large for the No. 1 Hand and during the following months withdrew, declined to participate in group activities, and finally gave up the prosthesis. She experienced little difficulty in carrying out all her functional activities without a prosthesis and was reasonably content.
At a routine clinic visit, we reviewed the problem with her again and came to a decision to seek a minimal functional-cosmetic replacement with a Robin-Aids Hand matched to the size and configuration of her opposite hand. She has now accepted the Robin-Aide device, and uses it for appearances in public, as a sleeve filler, and for certain types of grasp. Other than that the hand is non-functional.
In this case, a high level of cosmetic orientation was involved. The child's problems and discontinuance of prosthetic wear might never have arisen if a size No. 2 Hand had been available to replace the No. 1 at the appropriate time.
Our third case is a boy who lost a hand and the distal two-thirds of his forearm in 1955 when he was 10 years old. He was fitted with a below-elbow prosthesis and a two-load hook as soon as the stump was in good condition, and this proved satisfactory for almost three years. He wore the arm to school and used it for work around the home, but rarely wore it during the summer, because he swam most of the time.
When he reached adolescence, he requested a hand. The APRL Hand (No. 4) was slightly larger than his normal hand, but it was applied and he found it useful functionally and a good replacement from the cosmetic standpoint. However, he gradually went longer periods of time each day without the prosthesis, and discovered that he could perform his work without it. (He was a member of the recreation staff of a public unit.)
Currently, he does not wear the hand during the summer, when he is a lifeguard, and uses it only for special events during the winter. He reverts to the hook when he has outside work to do or when he washes his automobile. The present pattern indicates that he is unlikely to ever go back to the hook as a permanent device. The APRL Hand is his first choice, supplying the cosmetic appearance he desires for special occasions, and providing adequate function for his needs.
In this instance a reasonably adequate adjustment to a hook-type prosthesis was apparently disrupted by the onset of adolescence, leading ultimately to part-time use of both the hook and the cosmetically more acceptable hand. The dearth of adequate prosthetic equipment was not a major factor, since it is not likely that he would wear a prosthesis regularly, even if an intermediary hand (No. 3) had been available at the earlier stage.
The fourth case is a ten-year-old girl with a very short below-elbow stump. She has worn a below-elbow prosthesis with a pre-flexed forearm and an APRL-Sierra No. 1 Hand, which replaced a cosmetic hand, for the past two years. The prosthesis is worn constantly, but she uses the hand only for specific activities.
In this case also, appearance is of primary importance. It is our hope that the Size No. 2 Hand will be available when it is needed in a year or two. Otherwise, conflicts and difficulties may well ensue, as was experienced with the second case in this series.
A 14-year-old girl with a mid-forearm amputation was fitted with a standard below-elbow prosthesis three years ago. A hook was unacceptable, the APRL-Sierra No. 1 Hand was too small, and the size No. 4 Hand was too large, A Robin-Aids Hand was used solely for cosmetic purposes and this proved to be satisfactory for approximately one year. During the second year, the girl did not use the prosthesis during the warmer periods of Spring, Summer and Fall and by the third year she used it only for dress occasions. Since cosmetic requirement was our goal, the question of function never arose.
The problem again appeared to derive from two sources - lack of a sufficiently satisfactory device at the time of initial fitting and aggravation of the inadequacy by the approach of adolescence.
This boy had triple congenital "amputations" (short below-elbow, high above-knee and Syme).
When he was 11 years old, the APRL-Sierra No. 1 Hand became available and an arm acceptable to the boy and his parents was fitted. The prosthesis was worn on Sundays and for dress but not for functional activities at home or at school. The lad was able to ride his bicycle, play ball and perform other essential activities without the prosthesis.
When the first limb became too small, the entire prosthesis was discarded. However, he subsequently requested a prosthesis that would have a hand showing and serve as a coat filler. Now, at the age of 13, he is wearing a new prosthesis with the No. 1 Hand. The hand is small and we anticipate that he will reject the prosthesis until such time as he is able to wear an adult-sized APRL Hand, unless a hand intermediate in size between the No. 1 and No. 4 items can be provided.
This case also illustrates the dual problem of less than optimal equipment at the critical adolescent period.
The accommodations and compromises involved in these six cases were necessary and perhaps "practical", but as solutions to the problems encountered they are less than satisfactory. However, they do underscore some of the needs still existing in the child amputee treatment program.
All of these children showed similar patterns of acceptance and rejection in relation to growth and development. Appearance seemed to be the basic motivation for wearing the limb rather than any specific functional advantage, even though the latter does exist. It is essential that the relative importance of these two factors be given due consideration in the prosthetic management of children with upper-extremity amputations.
In summary, our experiences emphasize the need for clinic team members to understand the problems of growing children, particularly those arising at critical stages in their development. One such stage is that related to school attendance, particularly the initial exposure. Another, and perhaps even more potentially disruptive, is associated with the onset of adolescence. The stresses normal at these times, even for non-amputee children, are accentuated by a limb deficiency.
It is essential, therefore, that the team maintain close contacts with its patients through the medium of regularly scheduled clin ic visits. In this way, incipient problems may be recognized at an early stage and steps taken to arrive at solutions that are in the best interests of the children, within the limits of available knowledge. Hopefully, the efficacy of these solutions will increase with time, and with the emergence of new and improved prosthetic devices and fitting techniques .
J. Leonard Goldner is Professor, Orthopedic Surgery and Chief, Child Amputee Clinic, Duke University Medical Center, Durham, North Carolina