Some Observations On Upper Extremity Prosthesis Applications
James M. Hunter, M.D. David Subin, M.D. Adaline J. Plank, A.B., O.T.R.
The children's amputee clinic was inaugurated at the State Hospital for Crippled Children in 1959. Since that time a total of 53 upper extremity amputees has been evaluated. Thirty-nine of these patients became prosthetic users and are available for inclusion in this study.
Upper extremity amputees represent 36.3 percent of the total number of patients currently being followed in our amputee clinic, to which children are referred from sixty-seven counties through state nursing and welfare agencies. They are eligible for inpatient and out-patient care until 21 years of age.
Following their initial clinic visit, the majority of the children in this group were admitted to the hospital for complete evaluation. All children receive a complete social and psychological evaluation and a period of pre-prosthetic training. All necessary surgery and prosthetic fabrication is done at the state hospital. After final checkout of the prosthesis and discharge from the hospital, the children continue to make periodic out-patient visits to the hospital clinic. There is a further follow-up of these patients by state nurses and physical therapists in their home community.
39 Patients Evaluated
This report will highlight some of the interesting patterns which have emerged during the management of these 39 juvenile upper extremity amputees over the past five years. Two cases will be discussed to illustrate our approach to the management of the very young amputee and an attempted solution to a difficult adolescent amputee problem.
Distribution by Sex and Etiology
Of 39 patients evaluated in this study, 21 were male and 18 were female, representing 26 congenital, 11 traumatic and 2 surgical (malignancy) amputations. The subdivisions of the male sample were 11 congenital, 9 traumatic and 1 surgical, while those for the female group were 15 congenital, 2 traumatic and 1 surgical (Table 1 ). Thus, at this early stage, the pattern at Elizabethtown seems to follow that of other amputee clinics, with congenital amputations more common in females and traumatic amputations occurring more frequently in males.
The distribution by amputation levels of the 39 patients trained and followed in our clinic is outlined in Table 2 . All patients studied in this series were unilateral amputees. Short and very short below-elbow congenital amputations are even more preponderant in our sample than other studies have reported.
In reviewing the etiology of traumatic amputations in our males, it appears that the hand is likely to be lost from a homemade bomb or rocket explosion; while the arm may be burned in the railroad yard from contact with the high tension rail or amputated by the wheels of a freight train.
Distribution by Age
The ages of the children fitted with prostheses ranged from 7 months to 15 years. Nine children were fitted with their first prosthesis at age 2 or under. The congenital amputees were fitted with their first prosthesis at an average age of 5 years, while traumatic amputees were fitted with their first prosthesis at an average age of 6 years.
Intelligence Related to Prosthetic Adaptation
Standard psychological intelligence evaluations were satisfactorily obtained on 3k of the 39 patients. Twenty children were classified as above-average, 6 as average, and 8 as below-average.
An attempt was made by our occupational therapist to correlate the intelligence of the prosthetic candidate with his ability to use his prosthesis. Based on his performance in four specific situations used to evaluate the basic functions of transport, position and grasp, the prosthesis user was classified as Excellent, Good, Pair or Poor. A brief discussion of the classification categories follows, and the results of the study are presented in Table 3 .
If at all possible, the child grasps objects with the hook as an assist to the normal hand in two-handed activities. The object is never held against the body by the forearm.
The prosthetic arm reaches out to assist the sound hand.
The amputee pre-positions the hook and elbow voluntarily and properly for grasp.
Prosthetic action Is accomplished smoothly and naturally.
If at all possible, the child grasps objects with the hook as assist to the normal hand in two-handed activities. The object is rarely held by the forearm.
The prosthetic arm usually reaches out to assist the sound hand.
The amputee does not always preposition the hook and elbow.
Occasionally, prosthetic action may be awkward.
Part of the time the child grasps objects in two-handed activities. Object is sometimes held by the forearm.
The prosthetic arm seldom reaches out to assist the sound hand.
Amputee seldom pre-positions the hook and elbow.
Prosthetic action may be jerky or awkward.
The hook is used passively, rarely opened and rarely assists the sound hand. Objects are usually held by the forearm, when held at all.
The prosthetic arm never reaches out to assist the sound hand.
Hook is never pre-positioned and elbow is positioned only when absolutely necessary.
Prosthetic action, if any, is awkward. The prosthesis is worn mainly for cos-mesis.
Table 3 indicates a clear correlation between above-average intelligence and a child's ability to manage an upper extremity prosthesis efficiently. Of the 20 children whose intelligence ratings were above average, 10 were "excellent" users; while none of the 8 children whose intelligence was rated below average fell in this category.
All below-elbow amputees achieved "excellent" ratings except one. Below-elbow and above-elbow amputees were equally represented in the "good" user category. It is interesting to note that in the younger age group girls showed good adaptation and used their hooks about as well as boys.
In all we encountered seven children who rejected the use of their prosthesis. One child rejected the hook because of its objectionable appearance; the families of three children were apparently not able to resolve feelings of guilt and rejection and the children were not returned to the amputee program. In three cases we were unable to determine the reason for the rejection of the prosthesis.
The amount of In-patient training required was determined for thirty-two of our patients. On the average, 40 hours of training were necessary before the patient could use the prosthesis effectively. Patients under five years of age required, on the average, approximately 42 hours; while those over the age of five required approximately 28 hours. Thus, on average, there was a 14-hour difference in the amount of prosthetic training time required for the older versus the younger patient. We were unable to correlate training time required with the intelligence of the individual.
Case #l - The Very Young Child
L.D., a female, was first seen in our clinic at the age of 7 1/2 months with a left very short congenital below-elbow amputation. The initial examination revealed that the child had good sitting balance, could stand with support, and use both shoulders and arms normally. No other abnormalities were present. X-ray confirmed the presence of a normal elbow joint and short radial and ulnar bones. Range of motion of the elbow was 0-120° under active control. Standard intelligence testing revealed an I.Q. of 110 plus. The family situation and home environment were considered excellent, and at 9 months of age, L.D. was fitted with a "banana" arm and passive mitten (Fig. 1 ). The parents were instructed to encourage the use of the prosthesis during crawling and for two-handed grasp.
By the age of l6 months, L.D. had outgrown her first arm, but she had learned gross grasp and seemed quite attached to her prosthesis. She was fitted with a new "banana" arm, figure-8 harness, and a 12P hook without a cable. Miss Plank showed the parents how to place objects; e.g., a small doll, blocks, etc., in the hook. During play activities manual operation was to be encouraged to develop an assistive pattern for the normal hand.
At 22 months of age a new "banana" arm was fitted with a single control cable added to the figure-8 harness and 12p hook. Because of the interest and understanding shown by the parents, a program of home training under clinic guidance was conducted. The patient soon learned to pick up toys and place them in the hook. At 2 years of age she was using two hands to put on her own bib, put on and zip her house slippers, and remove her socks and underpants.
By 27 months of age the patient had learned to manage her hook so well that she was given a new prosthesis with a split socket, stëp-up hinges and a 10X hook.When this patient was 2 1/2 years old, her parents submitted home pictures of her training progress (Fig. 2 , Fig. 3 , Fig. 4 , Fig. 5 ). Our occupational therapist wrote the following note on her last clinic visit:
"Even at her tender age, Lisa is slowly but surely getting the idea of flexing her elbow. She is now a bright-eyed, sturdy little body who is busily exploring every corner of her environment with four very active extremities. She shows evidence of much better than average intelligence. The parents have been a big factor in Lisa's rapid learning of active hook use. They are a well-adjusted and happy young couple who have taken Lisa's deformity in stride. They are most cooperative in the home training program and in returning to clinic. Now that the father's graduate studies are almost completed, he is looking for work in an area near one of the Child Amputee Research Clinics so that they can continue with Lisa's prosthetic program."
Case #2 - The Emotionally Disturbed Child
The second case presentation is that of T.M., an 11-year-old emotionally disturbed boy with a right short below-elbow amputation resulting from an automobile accident at age 4 1/2 years. Because of his low I.Q. and seriously withdrawn personality, the decision was made to begin rehabilitation slowly, in the Children's Hospital environment. He was fitted with a double wall socket, with leather hinges, figure-8 harness, and a passive cosmetic hand. His response to the pre-school and occupational therapy program showed that he would require considerable physical training and psychological help before he would be ready for active prosthesis fitting. The boy was assigned to a children's protectory and followed in the amputee clinic.
During the months that followed, positive behavior changes and a warm attitude toward his prosthesis developed. A trial with a 99X hook was encouraging, and on the advice of psychiatric counsel he was also given a new Dorrance #2 Hand with a long cosmetic glove to use interchangeably with the hook.* Although it is too early for a final opinion, the Amputee Team has noted positive interest by the patient in his new prosthetic program (Fig. 6 and Fig. 7 ).
Thirty-nine patients with upper extremity amputations from the amputee clinic of the Elizabethtown State Hospital for Crippled Children have been reviewed. A discussion has been presented regarding the amputation levels encountered, the amount of time required for training as well as the age, sex, and intelligence levels of patients. A correlation between ability to use the prosthesis and the patient's intelligence level has been shown. The rating system used for evaluation of the prosthetic wearer has also been presented. Two cases illustrating the Elizabethtown approach to interesting upper extremity prosthetic problems have been discussed.
James M. Hunter, M.D., David Subin, M.D. and Adaline J. Plank, A.B., O.T.R. are associated with Child Amputee Clinic State Hospital for Crippled Children Elizabethtown, Pennsylvania