Follow-Up Experiences With Muenster Prostheses
William E. Gazeley, M.D. Mildred C. Ey, O.T.R. William Sampson, CP.
Since we first began fitting children with Muenster sockets in this center five years ago, we have had a variety of experiences and have had some successes and some failures. A review of four of our cases may be of benefit to others.
C.W., a female, was born on September 25, 1953. When she was 2 1/2 years of age, she sustained traumatic amputations of both forearms, which left her with two very short below-elbow stumps. She received prostheses and training at various centers, and was eventually referred to us on June 30, 1961. At that time, her second pair of prostheses had become worn out. New ones were constructed, and in August she was admitted to the hospital for a period of inpatient training. This training included instruction in such simple household activities as cooking, sewing, and ironing. At discharge, six weeks later, she was using the prostheses well and was essentially independent for her age level. Her parents were instructed in home care.
The family situation proved to be very poor, hygiene being a major problem. When C.W. was next seen in our clinic in April 1962, stump irritations, which had been present when she was first seen, had recurred. We believed this condition was related to poor hygiene, and requested the District Health Office to follow up the family. Also at this time the child's skills had diminished because the parents found it easier to do some things for her than to allow her sufficient time to do them herself. The importance of hygiene and independence in self-care was reiterated to the parents.
The child was next seen in August 1962, by which time she had been placed in a foster home. The hygiene problem seemed to be considerably reduced. The importance of independence in self-care was explained to the foster parents, who seemed very interested and cooperative.
By January 1963 C.W. had outgrown her prostheses. New ones were prescribed with triple-wall sockets1, and she was given a brief refresher training program. The inner sockets were removed in October 1963.
Muenster Sockets Prescribed
When C.W. was seen in August 1965, it was decided that new prostheses were needed, and Muenster sockets were prescribed. These arms were checked out the following November. At that time, the clinic team felt some apprehension as to how well the patient would be able to function with them. However, by using substitution patterns, she was able to reach the area of her mouth with either terminal device. It was felt that, with practice, she would quickly adapt to the Muenster prostheses.
A letter from the county caseworker in February 1966 indicated that C.W. was having mechanical difficulties with her Muenster prostheses and consequently was wearing her old ones. The caseworker also felt that C.W. was not accepting the new prostheses because of the restrictions they imposed. The child had been in the habit of frequently removing her stumps from the sockets, and this was no longer possible. Necessary repairs were made, and C.W. did start wearing the new prostheses.
A letter written by the caseworker in March 1966 indicated that C.W. was having difficulty with such activities as writing and eating while using her Muenster prostheses. She was seen in clinic in April, five months following receipt of the Muenster prostheses. They were badly worn and in need of repair. She had recently been wearing her old ones, which were also in need of repair. The Muenster prostheses were repaired and returned to the patient, following which the old ones were repaired.
The child was again seen in October. We had hoped to see her sooner, but she had been hospitalized with a serious illness. In the interim, she had been returned to live with her own family. The Muenster prostheses were being used only as spares. It was decided to modify the sockets to standard below-elbow types, and C.W. was seen again in April and October 1967. Although many repairs have been made, new prostheses have not been necessary. C.W. has matured sufficiently so that she is very conscious of her appearance, and she has been provided with functional hands (Fig. 1 ). She was given a brief training period with her new hands and uses them well for most activities. She is delighted with them.
B.S. was first reported upon in the January 1966 Inter-Clinic Information Bulletin2. The child has multiple congenital skeletal limb deficiencies, but we will discuss only his left upper extremity-a terminal transverse meromelia (partial hemimelia), below-elbow. Born in January 1962, B.S. received his first prosthesis when he was 16 months of age. Because the below-elbow stump was extremely short, this prosthesis consisted of a triple-wall laminated above-elbow "banana"-type socket, with the elbow preflexed 45 degrees. A Northwestern University ring harness and passive mitt were used (Fig. 2 and 3 ).
Following one month of inpatient training, the child was discharged and his parents were instructed in a home training program. Regular clinic visits were scheduled, so that a close liaison could be maintained. This prosthesis was worn until April 1964, when a functional elbow-disarticulation-type prosthesis was applied. This limb consisted of a triple-wall laminated socket with outside elbow lock, laminated forearm, constant friction wrist unit, 10P hook, manual control cable for elbow lock, and a figure-eight harness with a dual control cable for elbow flexion and terminal device operation. It should be noted that the stump disappears completely at 90 degrees of flexion. Four outpatient training periods were conducted with the mother present, during which time the child learned to operate the terminal device. He continued to make good use of the prosthesis in bilateral activities.
Muenster Socket Fitted
When a new prosthesis was needed, it was decided to attempt a Muenster fitting. Because the stump was so short (Fig. 4 ), it was necessary to take the cast with the elbow flexed to just 45 degrees. B.S. received his Muenster prosthesis in November 1965 (Fig. 5 ). He readily adapted to it and immediately started using the 30 degrees of natural elbow motion allowed. His mother was very pleased with the simplicity of the prosthesis.
The child was seen in the clinic at regular intervals. Because circumferential growth did not occur, it was never necessary to remove the inner socket of his prosthesis. Eventually, longitudinal growth and general wear necessitated a new Muenster prosthesis. This was given to the patient in February 1968, and he will continue to be seen at regular intervals.
M.L. was first seen in our clinic in November 1962 at the age of 3 years. A prosthesis was prescribed incorporating a split socket with step-up hinges, a constant friction wrist, Northwestern University ring-type harness, triceps pad, and 10P hook. This arm was delivered, and a training program started in January 1963. An inpatient program was selected because the child's home was nearly 200 miles from Sunnyview. He was discharged in February 1963, and his parents were instructed in home activities. Regular follow-up visits to the clinic indicated that M.L. was using his prosthesis well. In September 1964, he was fitted with a modified Muenster socket. Although the child used his prosthesis well, this fitting was only partially satisfactory, as the boy's stump would frequently pop out of the socket.
In April 1965, it was decided to fit M.L. with a new Muenster prosthesis with a figure-nine harness. This was applied in July, 1965.
M.L. has been followed regularly in the clinic. He has continued to be a good prosthetic user, wearing the device regularly during all his waking hours. Occasional repairs have been necessary because of wear. Eventually growth and wear necessitated a replacement, and a new Muenster prosthesis was applied in September 1967. When last seen in March 1968, the child was still functioning very well. He participates in all school activities and seems to have made an excellent adjustment.
We first saw C.O. in March 1963, when he was 2 1/2 years old. He had a short below-elbow stump and was fitted with a Muenster prosthesis with a triple-wall laminated socket, flexible elbow hinge, triceps pad, Northwestern University ring harness and cable system, friction wrist, and 10P hook. He immediately started active use of his terminal device and was seen for only one training session with his mother. Use of the prosthesis in all bilateral activities seemed to come naturally to this child, and both he and his family accepted it unusually well.
When seen at follow-up visits to the clinic, C.O. continued to use his prosthesis satisfactorily. Occasional repairs were necessary. The inner wall was removed in January 1965, and a new prosthesis was prescribed in March. However, fitting was delayed, at the mother's request, so that the prosthesis would be new when school started in the fall. In September checkout was done on the new prosthesis, which consisted of a Muenster socket, figure-nine harness and cable system, WE-200N wrist unit, and 99X hook.
Initially very cooperative, CO.'s mother failed to keep several clinic appointments after her June 1966 visit. Ä baby sitter related to one of the clinic personnel informed us several months ago that C.O. was no longer wearing his prosthesis. The school nurse encouraged his mother to return to the clinic, and C.O. was again seen in February 1968. He had outgrown his prosthesis, and a new one was prescribed. The importance of regular clinic visits was reemphasized to his mother.
We have presented four case studies of patients fitted with Muenster prostheses. The first, C.W., proved to be an unsuccessful wearer because of a bilateral amputee's need for complete elbow flexion and general freedom of movement. The clinic believes that it may be possible to fit the nondominant side with a Muenster socket, but that bilateral fitting is not feasible.
In the case of B.S., who has an extremely short below-elbow stump, the fitting was successfully changed from an elbow disarticulation type of prosthesis to a Muenster type. B.S. now has considerably more freedom of motion.
M.L. was changed from a split socket prosthesis with step-up hinges to a Muenster-type limb. This prosthesis has been very satisfactory to the patient and his parents.
CO. has always worn a Muenster prosthesis and has been a good user. Recent lack of parental cooperation has been the only problem.
Except in the case of the bilateral amputee, we have been very pleased with the use of Muenster prostheses. We believe that proper selection of patients is important, and when this is done, results will be satisfactory.
We would be interested in hearing of the experiences of others who have used Muenster-type fittings.
William E. Gazeley, M.D., Mildred C. Ey, O.T.R. and William Sampson, CP. are associated with the Child Amputee Clinic Sunnyview Hospital and Rehabilitation Center Schenectady, New York
1. Gazeley, William E., M.D., Ey, Mildred C, and Sampson, William, "Use of Triple Wall Sockets for Juvenile Amputees," ICIB, December 1964.
2. Gazeley, William E., M.D., Hoffman, Robert S., Ey, Mildred C., and Sampson, William, "Problem Solving for the Multiply Handicapped Child," ICIB, January 1966.