Reflections On The Shortcomings Of Conventional Prostheses: A Case Study
Felice Celikyol, O.T.R. Ki Ho Kim, M.D.
T.M., a native Bolivian, born in La Paz on December 28, 1949, sustained above-the-elbow amputations to both upper extremities at the age of 13 months, when she was run over by a train.
The child's father is unknown and her mother was a destitute Indian who has been unable to support T. Consequently, from the age of 5 to 15 years, she lived in a home for handicapped children in La Paz. She was then sent to the United States to live with a foster family through the efforts of Mrs. W., who had established the home in La Paz. Meanwhile, Mrs. W. wrote to Dr. Kessler, seeking assistance in obtaining arm prostheses for the girl and training in their use. T.M. had never been previously furnished with prostheses.
T.M. was admitted as an in-patient at the age of 16 years.
Examination of the right upper extremity revealed a short, well-formed stump measuring 2-3/4 inches from the axilla to the stump end. The left upper stump was longer, measuring 5 inches from the axilla to the stump end. However, palpation of the lateral aspect of the distal stump revealed an exostosis which acted as a spear point. It was covered by a thin fragile scar. The range of motion and strength characteristics of both stumps were within normal limits. A surgical revision was performed to ensure a more satisfactory fit, and after removal of the sutures a routine pre-prosthetic training program was begun.
Exceptional Abilities with Feet
As a young child, T.M. had instinctively developed adeptness with both lower extremities. She had to fend for herself in an environment which was certainly far from being overly protective. While at the "home," she was encouraged to be independent in daily pursuits - dressing, toileting, and feeding, as well as in painting and crafts (Fig. 1 ).
Fitting of Prostheses
In mid-February, casts were taken for bilateral prostheses which were received at the beginning of March, 1966. They consisted of bilateral plastic double-wall above-elbow sockets, a bilateral figure-eight harness with an "O" ring and lateral support straps, internal-locking elbow units and spring assists bilaterally, two Sierra wrist flexion units, and two Dorrance 88X hooks. Dorrance hands were also provided.
Prosthetic-control training plus training in activities of daily living were stressed during the remaining month of T.M.'s stay at the Institute. Since the left stump was longer, it became the dominant extremity. However, quite interestingly, she demonstrated a strong right-sided dominance-the quality of her writing was decidedly better when she used the right arm! (She is also right-footed.) The left side was used for all unilateral activities with the exception of writing and drawing. Emphasis was placed on those functions that she might be called upon to perform in public, such as feeding, communication skills, desk activities, and some household chores. Prosthetic tolerance had to be increased gradually, and by the time of discharge T.M. was wearing the prostheses for eight hours per day. She was discharged to another foster family located in Virginia, and prior to her discharge, contacts were made with personnel at the Department of Vocational Rehabilitation of that State so that they would follow her progress with regard to vocational plans and programs.
A Visit from T.M. Two Years Later
T.M., now 18 1/2 years of age, visited the Institute while vacationing in the area (Fig. 2 ). In letters to us subsequent to discharge, she had stated that she was doing well with her arms. However, it was discovered that she was not, in fact, using her prostheses for many activities that she was capable of performing, and the hooks had been almost completely discarded in favor of the hands because of cosmesis (Fig. 3 , Fig. 4 , Fig. 5 , Fig. 6 ). Further analysis revealed that since 1966 she has lived with six different foster families (not including two additional families during two summer vacations). Hence, there was poor continuity of direction and encouragement in these various situations. During the few days of her visit, she was brought into the training kitchen, with emphasis placed on the value of using the hooks, particularly in kitchen activities (Fig. 7 ). In addition, appraisal of her potential for driving revealed that she did not have complete control using the arm prostheses, whereas with her feet she showed excellent potential (Fig. 8 ). Where T.M. will be living this coming year is uncertain (it may be California) . She has a year of high school to complete, and there is much uncertainty as to her future vocational goals because of the unsettled social situation.
Some Thoughts in Retrospect
One cannot help but reflect on the merits of conventional prostheses for a girl such as T.M., who is so expert with her feet after using them for 16 years. We know, in all honesty, that her upper-extremity prostheses were provided in order that she might be more readily acceptable in the eyes of society. There is no comparison between her performance with prostheses and her adeptness with her feet. T.M. reminds us--"I use my feet as you use your hands." But, of course, she was highly motivated to wear the prostheses and look "normal."
The ideal solution in this case would be more highly sophisticated externally powered arms of relatively light weight which would afford numerous arm and hand functions in a smooth, coordinated manner.
Felice Celikyol, O.T.R. and Ki Ho Kim, M.D. are associated with the Kessler Institute for Rehabilitation West Orange, New Jersey