Treating The Quadrimembral Ampute: An Illustrative Case Report

Robert E. Tooms, M.D. Ronney Snell, CP. Elizabeth Speltz, R.P.T.

Although quadrimembral amputees comprise a small percentage of the total amputee population, most juvenile amputee clinics will have one or more of these severely involved children on their clinic roster. Little published information is available to assist the clinic team in the prosthetics fitting, training, and care of these patients; or in evaluating their developmental progress. While it is recognized that these cases must be treated on a highly individualized basis, we feel it worthwhile to add to the general knowledge on this subject by reporting our experiences with one of the quadrimembral amputees under treatment in our clinic. This patient was the subject of a preliminary report in the January 1965 Inter-Clinic Information Bulletin1

T.C. was first seen in the Memphis Child Amputee Clinic in 1962 at the age of five months. Roentgenograms confirmed the physical findings of bilateral lower-extremity amelias and bilateral upper-limb transverse terminal hemimelias-above-elbow-type (Fig. 1 ). At this time the child's parents were instructed in appropriate exercises to help strengthen his trunk and upper extremities. When the child attained adequate sitting balance at the age of eight months, both upper extremities were fitted with passive above-elbow prostheses. These devices were of tremendous assistance to the patient in improving his sitting balance. The terminal devices on these prostheses were activated when T.C. was 15 months old. At the same time he was placed in a bilateral hip-disarticulation socket which was mounted on a platform with casters attached. The child rapidly became proficient in propelling this platform across the floor with his upper-extremity prostheses and it soon became necessary to add extensions to the platform, both front and rear, to avoid tipping. At the age of 18 months elbow locks, controlled by the mouth, were incorporated into both upper-extremity prostheses, and T.C. rapidly became quite skillful in manipulating them.

Lower-Extremity Prostheses

When T.C. was 2 1/2 years old, wooden pylons with SACH feet were attached to his hip-disarticulation socket with standard hip joints. His balance was excellent and he rapidly learned to walk across the floor at a slow pace using a side-to-side swaying motion of his trunk. This child's coordination, agility and mental alertness have been exceptionally good and in large part have been responsible for the degree of skill which he has attained.

Further Progression

When T.C. reached the age of 3 years, he was fitted with standard above-elbow prostheses with dual harnessing. Hinged knees with manually controlled knee locks were inserted into the lower-extremity pylons to allow him to sit in a chair without having his feet stick straight out in front of him. This arrangement made a marked improvement in the child's sitting appearance and did not compromise his standing safety.

At the age of 4 1/2 years, the patient's present lower-extremity prosthesis was fabricated for him (Fig. 2 and 3 ). Since his waist was larger in circumference than his pelvis, the bilateral hip disarticulation socket was fabricated of a plastic laminate which was made flexible in the upper portion and rigid in the lower half. This combination made donning the prosthesis much easier and yet afforded sufficient stability for weight support and for the attachment of the lower-extremity pylons. The hip joints used were standard in construction and hip-joint placement was according to standard techniques, but a soft, easily compressible hip bumper was incorporated into the prosthesis to facilitate a smooth forward progression during walking.

True knee joints were felt to be desirable for both cosmetic and functional reasons, but at the same time it was felt that they should be positive locking to provide standing safety. Since all currently available knee locks are difficult to operate through clothing, a new type of knee lock was designed for this patient. This knee lock is spring-loaded and is activated by a control cable attached posteriorly on the hip-disarticulation socket. It is designed to allow automatic unlocking of the knees when the patient's hip joints are flexed beyond 35 degrees (Fig. 4 ). A more detailed paper on the design of these knee joints is in preparation and will be published soon.

Single-axis ankle joints were used to help maintain a foot-flat position.

Present Status

At the present time, T.C. is 6 years old and is now able to feed himself with minimal assistance. He uses an adult-size swivel spoon and a flat knife as a pusher and is able to eat from an ordinary plate without a rim (Fig. 5 ). He writes and colors well for his age and has developed considerable dexterity in assembling toys and puzzles and also in throwing balls. He is still unable to dress himself independently, although he can don and doff a slip-on shirt when not wearing his prostheses. He can unzip his trousers by using a Velcro fastening at the waist and a zipper with a key ring attached to the pull tab.

Although he can remove his upper-extremity prostheses, he cannot put them on without assistance and is unable to get into his lower-extremity prosthesis unassisted. T.C. can propel a wheelchair quite well by himself and is able to sit down in a stable chair without assistance but cannot arise without help. He walks amazingly well on level surfaces by using a lateral sway motion of his trunk. Distance walking is limited by the time required as well as by the effort demanded. He is able to walk on grass and uneven surfaces with the aid of a walker attached to wheels. His stride length is between four and six inches. He pivots, turns, and can walk backwards for short distances. He does not negotiate steps but can walk over doorsills unassisted.

T.C. plays an integral role as a member of his family and engages fully in all family activities. He plays games with his brothers and sisters and is rarely to be found sitting idle or inactive. He learned to rollerskate with the aid of crutches and this activity helped him perfect his stride. He is quite fond of boating and fishing and engages in these activities with his family wearing an especially designed life preserver which is weighted at its lower border. T.C. is an avid horseman and rides his pony using a special saddle to which a bilateral hip-disarticulation socket has been bolted (Fig. 6 ).

One of the most important assets in this child's training program has been the understanding and complete cooperation of his entire family. This is particularly gratifying in view of the fact that he is an adopted child and is also a member of a very large family. Since his parents live in town, he has been trained exclusively on an outpatient basis and during all of his extensive training sessions the assistance and cooperation of his family have been excellent.

Robert E. Tooms, M.D., Ronney Snell, CP. and Elizabeth Speltz, R.P.T. are associated with the Child Amputee Clinic Crippled Children's Hospital Memphis, Tennessee

1. Stewart, M., "The Importance of Early Evaluation of the Whole Child," ICIB, Vol. IV, No. 3:1-10, January 1965.