Writing Aids For Children With Severe Malformations Of The Arms

Dietrich Petersen, M.D.

Translated from the German by Maurice M. Schweizer, Ph.D., New York University. Originally published in Die Rehabilitation, Vol. 4, No. 2, May 1965 (Georg Thieme Publishing Company, Stuttgart). This article is reprinted with the permission of the author.

In general, prostheses for children with bilateral malformations of the upper extremities are necessary only if the mouth cannot be reached and the arms cannot be actively crossed in front of the chest. If these movements are possible, emphasis should be placed on intensive physical and occupational therapy in order to gain a maximum of functional ability and thus obtain a far-reaching independence in the activities of daily life.

In the occupational therapy program at our clinic, painting exercises are started early, to promote general dexterity of the arms and hands. These exercises are also intended to prepare the child for later school attendance, since it is our aim to have as many children as possible sufficiently advanced by the sixth or seventh year of age to be able to attend public school.

Sometimes these exercises create difficulties. Actually, quite a strong grip is necessary to hold and to wield a peg (pencil) firmly. Furthermore, due to their short arms, the sitting posture of these children is frequently very unfavorable, the distance between eyes and paper being so small that disturbances in vision and posture may result.

Preventive measures must be instituted as early as possible. If inability to grasp the handle of the peg firmly is the only problem, it is sufficient to alter the pencil shaft to conform to the malformed hand. This can be done with a piece of cork into which the peg is inserted; plastoid-foam (plastic) is also suitable.

If these simple remedies are insufficient, and especially if they do not guarantee a good sitting posture and an adequate eyes-paper distance, special aids are used. We developed these aids in cooperation with our special school for disabled children, and they were partially built by the occupational therapists in our research shop under the direction of Helmut John. The material used was nyloplex (Plexidur); it is lightweight and can be easily handled and kept clean.

Special Aids

The child shown in Fig. 1 was unable to hold the peg firmly enough; sitting posture and eye distance were also very unfavorable. The writing aid was made as simply as possible: A crossbar is held with the fingers; the counterpressure which results from applying pressure to the peg in writing is controlled by a strap at the upper arm. Fixation at the arm is achieved with a rubber band. The peg rests in a hollow groove in order to prevent a lateral displacement and it also is held with a rubber band. Fig. 2 shows only the writing aid, in order to demonstrate the technical details.

The second child (Fig. 3 ) can hold the hand only in a supinated position; active pronation is not possible. This child was completely unable to wield a peg. Furthermore, because of the short arms, eye distance and sitting posture were highly unfavorable. The writing aid was shaped according to prevailing conditions. The two existing fingers grasp U-shaped holders and in this way have a firm support. The splint is supported under the upper arm, around which it is fastened in a semicircular fashion and is attached only by a rubber band. The splint only is shown in Fig. 4 , to demonstrate the details of construction.

The third child illustrated has a left-side amelia. In this case a pneumatic prosthesis with an active elbow joint, as well as a pneumatic hand, was applied. The right side has a peromelia-type above-elbow stump with one long well-developed finger. Holding a peg at the right side for writing was only possible if the end was squeezed between chin and shoulder and the center of the peg was grasped with the finger. This condition necessarily caused a very unfavorable sitting posture and a short eye distance. It would have been possible to retrain the child to be left-handed and to grasp the peg with the prosthesis. However, in agreement with the teachers at our special school, we did not consider this retraining appropriate in view of the child's strongly entrenched right-handedness.

Therefore Mr. John constructed a writing aid (Fig. 5 and 6 ) whereby the arm is put through a ring, the single finger holds the writing aid, and the counterpressure occurs at the shoulder girdle. Again the peg is in a groove and held with a rubber band in order to make a fast interchange possible. The child is able to put on and to take off the writing aid without any other assistance, and is today a student in the second grade of a public school.

Based on the experiences gathered to date, the value of these writing aids has been proven again and again, and we hope has assisted the children on their way to independence.

Congenital Absence Of The Tibia. Acta Orthop. Scand. XXXIV, 337-358, 1964.

Sulamaa, M., and Ryoppy, S. (Surgical Department, University Children's Hospital, Helsinki, Finland.)

Since considerable difference of opinion exists regarding treatment possibilities in congenital absence of the tibia, the authors present their experience with a total of seven such defects, involving four patients (one unilaterally and three bilaterally). Four of the defects involved total absence of the tibia and three, partial absence. All the patients were presented when less than six months of age. All had other malformations, usually severe, although the femur was within normal limits in most cases. The observation periods ranged from six and a half to twelve years.

Three patients and five limbs were treated surgically. In four instances operations were performed to correct the varus position and to stabilize the ankle by implanting the distal end of the fibula in the ankle bone. In three instances of partial defect, the fibula was successfully united with the tibial remnant: the knee is stable, the leg is firm and straight, and no significant progressive shortening has occurred. All the patients can walk well with braces. In a case of total defect, however, this procedure did not fulfill the surgeon's expectations. Although the tibialized fibula constitutes a firm continuation of the femur, the arthrodesis was not quite successful. Further, the pronounced shortening of the tibia makes lengthening by an orthopedic boot imperative. The authors believe that a better walking capacity can be obtained for this case at a later time by an above-knee amputation and appropriate prosthesis.

Exarticulation of the knee joint was successfully carried out in another case of total defect: despite normal growth of the femur the stump is well preserved. The authors believe that amputation is the method of choice for total tibial defects, but suggest that above-knee amputation be postponed until growth is complete. They do not recommend amputation in cases of partial defect.

Some Aspects Of Orthopaedic Surgery In Childhood. Trans. Coll. Phys. Surg. Gynaecol. S. Africa. 9(2):39-50, Sept. 1965.

Lloyd-Roberts, S.C. (Hosp. Sick Children, Great Ormond St., London, England

This lecture includes discussion of congenital vertical talus and the primary treatment of clubfeet. The importance of genetic factors is discussed in relation to congenital dislocation of the hip and the origin of contracture of the quadriceps. The natural history of septic arthritis of in fancy, congenital dysplasia of the femur, idiopathic structural scoliosis of infancy, ectopia vesicae, and Perthe's disease are also covered with respect to experience in management.

Dietrich Petersen, M.D. is associated with the Orthopaedic Clinic Annastift Hannover-Kleefeld, Germany