The Limb-Deficient Child [Reprint 2020 ed.] 9780520318588

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T h e Limb-Deficient Child

THE CHILD AMPUTEE PROSTHETICS PROJECT / D E P A R T M E N T OF PEDIATRICS S C H O O L OF M E D I C I N E

/ U N I V E R S I T Y OF C A L I F O R N I A , L O S

ANGELES

The Limb-Deficient Child Edited by B E R T O N BLAKESLEE Photography by M A R Y LOUISE HISTON

UNIVERSITY OF CALIFORNIA PRESS B E R K E L E Y A N D LOS

ANGELES

1963

University of California Press, Berkeley and Los Angeles Cambridge University Press, London, England © 1963 by T h e Regents of the University of California Library of Congress Catalog Card No. 63-16210 Printed in the United States of America

Contributors

Milo B. Brooks, M. D., medical director, Child Amputee Prosthetics Project, and Professor of Pediatrics, Department of Pediatrics, School of Medicine, University of California, Los Angeles. Lila Beal, M. S. W., medical social worker, Child Amputee Prosthetics Project. Berton Blakeslee, staff editor, Child Amputee Prosthetics Project. Harry Campbell, C. P . , research prosthetist, Child Amputee Prosthetics Project. Jeannine F. Dennis, O. T. R . , research occupational therapist, Child Amputee Prosthetics Project. Wilma Gurney, M. S. W., Chief of Medical Social Service, School of Medicine, University of California, Los Angeles. Cameron B. Hall, M. D . , Assistant Clinical Professor of Surgery (Orthopedics), School of Medicine, University of California, Los Angeles. Mary Louise Histon, staff photographer, Child Amputee Prosthetics Project. Gilbert Motis, R. E . , research engineer, Child Amputee Prosthetics Project. Lorraine Ogg, R. P. T . , research physical therapist, Child Amputee Prosthetics Project. Julie Werner Shaperman, O. T. R . , research occupational therapist, Child Amputee Prosthetics Project. Carl Sumida, C.P.& O . , research prosthetist, Child Amputee Prosthetics Project. Joan Thue, O. T. R . , research occupational therapist, Child Amputee Prosthetics Project.

Preface

Habilitation of the limb-deficient child involves problems that are unique: a complex of skeletal, neuromuscular, learning, and psychosocial factors not encountered in the treatment of adult amputees must be considered in the planning and execution of a successful prosthetic program for the child with a limb deficiency. In selecting the material to be included in this volume, no attempt has been made either to review or supplement standard techniques for the treatment of adult amputees; these are already well-documented. It is, rather, the intent of the authors to consider only those aspects of prosthetics which are pertinent to the problem of the child with an amputation—aspects which in themselves are numerous, and often baffling. Essential orthopedic and pediatric considerations are discussed, as well as principles of prosthesis design and fitting for children, the psychosocial problems always present to some degree in the case of the child with a limb deficiency, and the physical and occupational therapy techniques that are presently in use at the Child Amputee Prosthetics Project. It is hoped this information will be of value to the orthopedist, pediatrician, psychiatrist, psychologist, therapist, prosthetist, or medical social worker who, with little or no previous experience in this field, may be called upon to apply his professional skills to the care of children with limb deficiencies. For this reason, treatment and training procedures are outlined in considerable detail. In addition, the experiences of the Child Amputee Prosthetics Project clinic team in striving for a wellfunctioning interdisciplinary staff and the best possible clinical procedure are offered as a guide for new clinics of a similar nature. Although this volume is not intended for use as a textbook, it is hoped that it may serve as a source of reference for teaching. The evaluation methods, fitting techniques, medical, surgical, therapeutic, and training vii

viii

Preface

procedures are in all instances those presently being employed at the Project, and essentially are joint recommendations of the Project's interdisciplinary clinic team. These techniques are a result of the combined research and service efforts of the staff since the Project's inception in 1955. THE INTERDISCIPLINARY TEAM: ITS FUNCTION AND OPERATION

If the child with an amputation is to function with satisfaction to himself, his family, and his community, he needs not only a welldesigned prosthesis, properly fabricated and fitted, but also careful training to achieve skillful and spontaneous use. He requires the assurance of good medical care for maximum health, skillful surgery for all possible restoration of function, and in addition a careful analysis of the psychodynamics of the child and his family. In many instances the limb-deficient child's greatest problems are not those imposed by the limb deficiency or its mechanical replacement but by the attitudes and feelings of the patient as reflected from those around him about his physical difference. Most importantly, he needs the emotional strength to make constructive use of his abilities in coping with the daily problems of living, for in addition to the problems that result from his disability, he must face all the problems of the normally constituted child growing up in this complex and bewildering world. Thè primary goal of the Child Amputee Prosthetics Project clinic team is that of providing the child with function: to bring him, as much as possible, into the mainstream of the race, rather than leaving him to the cruel process of natural selection. In the effort to accomplish this, the Project utilizes the skills of orthopedists, pediatricians, medical social workers, prosthetists, engineers, physical therapist, and occupational therapists, as well as consultants in the fields of psychiatry and psychology. This is, perhaps, an ideally constituted staff, and although the services of each of these specialists are of great value, a child amputee clinic may be required to function with a more limited staff. This can be done successfully. In the absence of skilled psychiatric aid, an understanding and perceptive medical director can be of great help in assisting the family to comprehend and deal with the psychosocial aspects of their problem; an astute and creative prosthetist, working closely with the child and his parents, can often solve seemingly insuperable problems of prosthesis design and fitting. Also, through referral to agencies which may be available in the community,

Preface

ix

such as the Public Health Service, Crippled Children Services, or volunteer organizations, the clinic team may obtain services for the child which the clinic itself is not equipped to provide. It must be remembered that whatever the size of the clinic team, the child's problems remain the same, and cannot be disregarded simply because of lack of personnel. It is essential that the limb-deficient child and his family be carefully introduced and oriented to a proposed prosthetics program, regardless of the time interval between birth or surgical amputation and the initiation of the program itself. This orientation period provides the family with an opportunity to learn about the program and their responsibilities in it, and at the same time allows them to become acquainted with the members of the staff and the ways in which each staff member will endeavor to meet the child's needs.

The Medical Social Worker

From the referral source and the medical director's communications with the child's physician, the staff has already received some information about the family before they appear at the clinic. When the family arrives at the clinic for the first time, they will need to be guided to an understanding of what is involved in a prosthetics program. There is also a need to express and relieve some of their feelings about their child who is different from most other children. Their recognition of the implications of this difference and the possibility of a mechanical substitute for the missing or ineffective limb begins to be an actuality, often for the first time. This orientation is initiated by a preliminary interview with the medical social worker, who attempts to guide the family to a realistic understanding of these problems.

The Orthopedist

The orthopedic surgeon (if his function on the clinic team i s that of consultant) works closely with the medical director in the direct care of the patient, observing closely the strengths and range of motion of the child, and searching for any surgical procedures that will make the limb more useful, whether this be casting, physical therapy, or extensive surgery, and he will determine the time at which these can be most advantageously done. The orthopedist also participates in research studies pertaining to surgical and other orthopedic procedures.

X

Preface

The Prosthetist

The prosthetist talks with the family during their first visit to the clinic, and shows them the ways in which a mechanical device can provide function within the limits of the existing physical conditions. The prosthetist is frequently confronted with disbelief that this is the best device available: this most often happens when a considerable period of time has elapsed between the birth or the amputation and the family's first appearance at the clinic. The parents may have heard that medical science and engineering achievements have produced artificial limbs which are almost superior to the real thing; they have been referred to the clinic as a place of authority, only to discover that apparently there is not as much knowledge here as among their own associates. Parents with this misconception are not among the majority, but they do pose problems to the entire staff and particularly to the prosthetist when this misinformation or wishful thinking is deeply implanted. The Therapist

The family also talks with an occupational or physical therapist, who watches the child to determine his readiness for fitting, and observes how he operates without a prosthesis. The therapist discusses with the parents the ways in which a child learns to make use of a prosthesis, and the sequence of training at the clinic and in their community. In this discussion the therapist and the parents examine realistically the expectations for participation in training sessions. The Medical Director

It may be preferable for the medical director to be the last member of the clinic team to see the child and the parents. This allows him an opportunity to talk briefly with those staff members who have already seen the family and to hear their recommendations. During the course of his discussion with the parents and his medical examination of the patient the medical director conveys to the parents his interest in the total development of the child and the ways in which a prosthesis may or may not contribute to that effective development, for there are instances in which the malformation is of such a nature that a prosthesis will not provide sufficient advantage of function to warrant its application.

Preface

xi

The medical director tries in different ways to orient the parents to the clinic and to a prosthesis program, if one i s indicated. He advises them that although they will have the opportunity to talk again with any member of the staff they have already seen, there is no obligation to make an immediate decision. It has been found that a prosthesis i s of value only when the parents are able to make the kind of decision they can later support firmly and consistently. From the time of referral, the medical director maintains close communication with the family's physician or clinic. He encourages and strengthens the family's ties with their own physician while serving essentially as a specialist in the field of prosthetics but with a profound interest in the child's growth and development. Other Consultative Personnel

The Psychiatrist. Some parents may be so confused and overwhelmed by their problem they cannot admit its existence and therefore cannot accept any proposed solution to it. Family conflicts or personal blocks may interfere with acceptance. These persons may need psychiatric care before any prosthetic program can be initiated. The Psychologist. Either at the beginning of a prosthetic program, or during its course, psychological testing and evaluation may be necessary to guide the staff in its decision as to the method of approach, or to expose areas of conflict which may need treatment before a program can be successfully continued. The Engineer. Many of the more complex types of anomalies are so difficult to fit satisfactorily it may be necessary in the early stages of planning to have the advice and skills of an engineer, who, when the design criteria are furnished, may help devise approaches that will render prosthesis possible. PLANNING THE PROSTHETIC PROGRAM

The members of the clinic staff jointly consider their evaluations and impressions before seeing the patient and his family again. This second interview may be on the following day, or a few days later.

xii

Preface

The parents should be allowed sufficient time to absorb and consider what they have seen and heard at the clinic. If a prosthesis is indicated, the types of suitable prosthetic designs are considered, and the most advantageous selected. The most appropriate time for prosthesis fitting and training is agreed upon—a decision based on a realistic estimate of the family's capacity to participate in and make use of a comprehensive prosthetics program, previous experience with children of this age group, and the present clinic work load. The staff's decision is then discussed with the parents, and the parent's readiness to participate in the proposed program i s determined. If the parents are not ready to make a decision, appointments may be made for them to return to the clinic within the next few weeks for further discussion with staff members. *

It should be emphasized that the procedures outlined above, and the recommended techniques in the chapters to follow, will not be applicable in all instances either to the individual treatment problem or to the facilities of a particular clinic. Undoubtedly, problems will arise to test the experience, skill, and ingenuity of any clinic team, and the methods offered here are admittedly inadequate to solve them all. It is, however, hoped that the Project's research and service experience will be of value to others working with limb-deficient children, and a stimulus to all those engaged in research into the problems of their habilitation—a field in which there is still much to be learned. *

From its inception in 1955 until 1959 the Child Amputee Prosthetics Project was financed entirely by a contract with Crippled Children Services of the California Department of Public Health with funds made available from the United States Children's Bureau. In 1959 an additional grant from the National Institute of Health permitted an expanded program of design studies and use testing of additional experimental equipment. The Project now operates under Grant No. 12:HS, Project No. 204, from the Children's Bureau of the United States Department of Health, Education and Welfare, and Grant No. USPHS GM-06026-04 from the United States Public Health Service, Division of Research. Berton Blakeslee, Editor

Contents

PREFACE I.

vii

THE ROLE OF THE MEDICAL DIRECTOR

1

The Medical Director's Function as a Member of the Clinic Team

II.

1

The Referral

2

The Preliminary Interview

3

The Medical Examination

5

Growth and Development of Normal Children

15

Growth and Development of Limb-Deficient Children

20

The Problem of Limb Dominance

21

The Traumatic Amputee

22

The Etiology of Congenital Limb Deficiencies

23

The Role of the Medical Director in the Prosthetic Program

35

ORTHOPEDIC CONSIDERATIONS

37

Nonsurgical Aspects of Treatment

39

Surgical Aspects of Treatment

41

Congenital Skeletal Deficiencies of the Extremities: Classification and Fundamentals of Treatment

55

xiii

xiv

Contents

III.

THE PSYCHOSOCIAL PROBLEMS

79

The Parents' Reactions to the Impact of the Event

IV.

V.

81

Assisting the Parents in Periods of Crisis

83

The Child's Attitude Toward His Difference

87

The Preadolescent and Adolescent Periods

89

The Problem of Competition

90

The Child's Ways of Handling Anxiety

90

The Traumatic Amputee

91

The Role of the Social Worker

92

PREPROSTHETIC EVALUATIONS

95

The Therapist's Contribution to the Prescription

95

Evaluating Developmental Status in the Infant Amputee

96

Evaluating Developmental Status in the Preschool and School Age Child

100

Evaluating Range of Motion and Motor Development

101

Preschool and School Age Interests

109

The Teen-Ager and Young Adult

109

Determining Functional Needs

110

Translating Functional Needs to Prosthetic Needs

112

PREPROSTHETIC THERAPY

114

Postoperative Care of the Traumatic Amputee

114

The Use of Crutches

116

Contents Postoperative Bandaging

117

Physical Conditioning for the Traumatic Amputee

128

Physical Conditioning for the Congenital Amputee

131

VI. CHILD PROSTHESIS DESIGN AND FITTING

VII.

xv

136

Design Criteria

136

Harnessing

143

Harnessing for Above-Elbow Amputees

145

Experimental Harnessing Techniques

151

Designing the Phocomelia Prosthesis

153

Fitting Upper Extremity Amputations

171

Fitting Lower Extremity Amputations

180

Prostheses for Children with Multilateral Deficiencies

188

The Check-Out

197

THE TRAINING PERIOD

200

Initiating the Training Program

200

Clothing for the Child Amputee

202

Stump Hygiene

207

Maintenance and Care of the Prosthesis

208

Putting on the Prosthesis

225

Building Tolerance to Wear

236

VIII. TRAINING THE UPPER EXTREMITY AMPUTEE

240

The Training Area

240

Training the Infant Fitted with Passive Controls

241

xvi

Contents Follow-up Training for the Infant with Passive Controls

245

Readiness for Active Controls

251

Activation of Controls

252

Active Operation of the Prosthetic Components

253

Operation of Controls: The Above-Elbow Amputee

255

Operation of Controls: The Shoulder Disarticulation Amputee

262

Training with Active Controls

266

Teaching Hook Operation

268

Sequence of Learning Grasp and Release Patterns

271

Refinement of Grasp and Release Patterns

275

Toys and Training Aids for the Child with Active Controls

276

Training Activities for Bilaterals

283

Suggested Activities for Developing Prosthetic Skill

284

Playground Activities

290

Household Activities

293

Schoolroom Activities

296

Sports

299

Musical Instruments

302

Card Games

304

Special Equipment

305

Eating and Drinking

307

Dressing

316

IX. LOWER EXTREMITY TRAINING The Training Area and Training Equipment

335 336

Contents

xvii

Initial Training

339

Control Motions for Lower Extremity Prostheses

342

Preliminary Weight Shifting and Balance

346

Gait Deviations in Reference to Therapy

348

Ambulatory Activities for the Unilateral Lower Extremity Amputee

353

Training the Bilateral Lower Extremity Amputee

359

Ambulatory Activities for the Bilateral Lower Extremity Amputee

363

APPENDIX

375

INDEX

387

I The Role of the Medical Director

A prosthetics program for the limb-deficient child involves a number of people, both at the clinic and in the community. The functions of the personnel comprising the clinic team were described in the Preface; specialists in the community who may participate are: commercial prosthetists near the patient's home, occupational and physical therapists, the family physician, public or special school teachers, and school nurses. An important responsibility of the clinic's medical director is that of a s s u r ing satisfactory liaison between the clinic and the community. THE MEDICAL DIRECTOR'S FUNCTION AS A MEMBER OF THE CLINIC TEAM

The extraclinic specialist with whom the medical director is most likely to have first direct communication is the family physician. The family physician may or may not have been the one who directed the family to the clinic; in either case, the medical director must determine whether he is agreeable to having the clinic assume full prosthetic care of the child, or whether he wishes only a consultation. The clinic may provide either service; however, it is seldom satisfactory to have divided responsibility for the child's prosthetic care. It is most important to have a valid understanding with the family physician on this point: it should be made clear to him that the clinic does not wish to assume complete medical care of the child, although it is essential for the clinic to assume full responsibility for the entire prosthetic care. A close and friendly working relationship with the family physician is mutually beneficial: it provides him with an opportunity to learn about prostheses and the prosthetic program planned for this child, and at the same time it allows the clinic team to enlist his cooperation for proper medical and surgical care, immunization, diet, dental care, and discipline. 1

The Limb-Deficient Child

2

THE REFERRAL

A referral can originate from a number of sources other than the family physician. Referrals are made by other clinics, hospitals, the family or their friends, or from a government agency or social service source. Referrals may also come from teachers and school nurses. More often than not the referral is incomplete—in the sense of giving all the information the medical director and the other members of the clinic team must have before they can begin to plan any prosthetic program. The following information is generally needed: 1. Names, address, and telephone number of the parents. 2. Name, age or birth date of the child, and the type of limb deficiency. 3. Name of the family physician. 4. Availability of x-rays and photographs, if taken. 5. Type of service desired by the parents (or the child, if he is old enough), and the family physician. 6. Any previous prosthetic program or advice received. Often some of this essential information can only be obtained during the interview with the parents when they come to the clinic for the first time. It is essential for the clinic team to determine as early as possible whether the family has any real interest in a prosthetic program. The clinic staff is extremely interested in the family's motives: whether, for example, they may have been cajoled or even forced into seeking help, and whether they want to get function or only hide the deformity. This makes a great difference in the way the clinic team will approach the problem, and what action will be taken. It is important to assess the attitudes, the inhibitions, and any phobias or fixations the parents might have. Usually it is most revealing to learn how the parents adjusted to the initial shock; the first twenty-four hours after the birth of the child or the loss of his limb may be more important to the success of the prosthetic program than any other single factor. The occurrences during these crucial twenty-four hours, and the attitudes and advice of medical personnel (especially if this advice was confusing or contradictory) are most important. The attitudes and advice of other members of the family or even of friends may also have an important effect.

The Role of the Medical Director

3

It is also necessary to determine whether the child really needs a prosthesis. Not all limb-deficient children can benefit from a prosthetic device; a child may have a partial limb that is merely shortened or with the absence of one or more digits, and with the remaining portion of the extremity functional—at least more functional than any mechanical replacement might be. THE PRELIMINARY INTERVIEW

The parents are almost certain to experience a variety of emotions as they approach the preliminary interview with the medical director. It is likely they will be somewhat confused by the information they have received from the other members of the clinic team. Feelings of guilt, shame,or reluctance to deal with their problem may make them reticent, uneasy, or even inwardly hostile. At the very least they will be defensive, although probably not admittedly so. They may even demonstrate anger at being forced to deal with the situation in which they have been placed. Therefore it is essential that the parents be made to feel at ease and unthreatened. They need to be assured early that the clinic team is not trying to sell them something, but attempting only to provide the most complete life possible for the child; that the clinic team wants to understand their problem and also to give them a chance to express their feelings about the tremendously powerful and shocking experience they have undergone. If some time has elapsed since the birth or amputation, the parents may find it difficult to express these feelings that have been repressed for so long. It is not likely that this can be accomplished with complete success in the first interview. The shock of the birth of a. child with a limb deficiency is far greater than many members of the medical profession realize. It is less difficult to understand the mother's reaction than to realize that the father is also profoundly shocked. (This is illustrated by the fact that several fathers have revealed that long after the event they still have, unopened, the box of cigars they had bought to pass out when their child was born.) Nor are physicians immune to the trauma of this experience. Congenital limb deficiencies are sufficiently rare that the average physician may not see one during a lifetime of practice. Thus if it should happen it can

4

The Limb-Deficient Child

be a shock, and he may be unable to cope with the situation adequately. (This problem is discussed in more detail in Chapter III, which deals with psychosocial problems.) At the birth of a limb-deficient child the parents are almost certain to be extremely disturbed, with a feeling of being totally alone, and with no possible solution to their problem. They urgently need the opportunity—within the first few hours, if possible—to discuss the problem with someone from a child prosthetics center. The medical director and medical social worker have found it well worthwhile to make themselves available for immediate consultation with the parents, even if this requires a trip of a hundred miles or more. Although this may seem like a great deal of trouble to take, especially when the amount of disability is small, it can save many hours, weeks or months of difficult and laborious work later on; it may shorten the many days and nights of frustrated anguish for the parents, and most of all may even make the difference between a successful prosthetic program and a complete failure. In these consultations, any attempt to minimize the problem by such statements as, "You should be glad it is not worse," only tends to create in the minds of the parents a feeling that the medical profession does not understand or has no interest in their griefs and suffering: the parents are not in a position to be glad for anything at this point. Also, a lesser amount of disability does not necessarily lessen the amount of shock. This kind of preparation and help to the parents is needed long before any kind of prosthetic program is actually initiated, and it devolves on the medical director and the medical social worker to provide it. If the parents have already talked with the medical social worker, they have had an opportunity to reveal their feelings. They may, however, find that with the physician they can discuss matters they were reluctant to reveal to the social worker (although there may be cases in which the opposite is true). The social worker may have discovered attitudes and areas of feeling that the parents are reluctant to discuss, and the medical director may be able to persuade the parents to talk about them. Because the parents' emotions are so deeply involved in this situation, it is important to establish a direct and friendly relationship and understanding with them, in an atmosphere in which they can talk frankly.

The Role of the Medical Director

5

For one reason, the medical director must know why they have come to the clinic, and what they think a clinic of this sort can or should do for their child. The medical director cannot expect to receive clear-cut answers to his inquiries; he must, however, determine some essential facts before the prosthetic program can be initiated. Perhaps the most important thing to be determined is how the parents feel about their child, and the idea of a prosthesis for their child. The most beautifully constructed and fitted prosthesis may be worthless if there are unresolved family conflicts, and the reason for its nonuse later on may be baffling if the family's attitudes are not understood. It is ordinarily the function of the medical social worker to determine what these attitudes are, but this is something an astute physician can do, and in some situations may be required to do. THE MEDICAL EXAMINATION

However the continuing medical care of the limb-deficient child is handled, it is particularly necessary to have his general health up to a maximum. The prosthetics engineering laboratories can measure the multiplication of effort required for the amputee to perform even simple tasks such as tying his shoe or walking up an incline (for example, it has been determined that it requires up to nine times as much effort for the above-knee amputee to walk as it does the intact person), but there is no way of measuring the fatigue and frustration involved in many simple tasks multiplied over and over in a day's ordinary activities. Also to be considered is the frustration of having to accept the possibility that there are many things everyone else does which the amputee can never do—for himself or others. For this reason it is imperative that careful and continued attention be paid to the child's general health. A complete medical and surgical examination is of course essential at the outset. A precise knowledge of the nature of the anomaly or anomalies is important for all the members of the staff; for example, the prosthetist must know what anatomical structures are absent or deficient, and what sources of power are available before he can design a functioning prosthesis. This is also essential knowledge for the therapist; there may be bizarre skeletal and muscular structures present which contraindicate the use of conventional therapy techniques.

6

The Limb-Deficient Child

An accurate analysis of the general health and strength of the child is equally important, for it is useless to burden a child with equipment he is physically incapable of operating or which would be too great a physical strain. Also, it is not uncommon for one or more associated anomalies to be present in addition to the deficient or absent limb (see p. 27). The associated anomaly may or may not require medical attention, but perhaps must be considered in the decision for prosthesis prescription. Body Measurements

It is essential to obtain and r e cord detailed physical measurements. These are important in helping to determine the child's developmental level (information of prime importance to other members of the clinic team) and also because they provide specific guides to the prosthetist in his planning for the design and fabrication of the prosthesis. A chart similar to the one shown on page 7 is of value in recording these measurements. The following body measurements should be r e corded: Body length: measured with the child supine. The measurement is taken at right angles to the soles of the feet and crown of the head. Body height: measured in the standing position. Sitting height: in infants is measured by calipher pressure against the ischial tuberosities to the top of the crown. In older children, the measurement is made with the child seated on a firm surface (such as a tabletop) and measured from that surface to the crown. Head circumference: measured at the greatest protrusion of the occiput to the crown of the forehead, usually near the hairline. Chest circumference: measured at mid-respiration at the substernal notch and across the nipples. Maximum inspiration and expiration measurements may at times be helpful. Waist measurement: made with light pressure at the level of the umbilicus.

CHART 1

CHILO ANTHROPOMETRIC RECORD CASE NO.

NAME AGE:

Yrs.

DATE

Mos. PROS. NO.

UPPER LOWER

»••-I

Measured by

8

The Limb-Deficient Child

Pelvic breadth; the distance between the lattermost points of the iliac crest of the pelvis. Using caliphers, the measurements should be made by pressing firmly without producing pain. Upper Extremity Measurements

The humeral section is measured from the acromium (felt through the deltoids) to the point of the lateral condyle of the humerus, with the arm held loosely at the side.

The forearm is measured from the lateral condyle of the humerus to the styloid process of the ulna, with the forearm horizontal. The distance from the humerus to the tip of the thumb is also measured; this measurement is used for the length of the prosthesis to the hook end (fig. 1). Lower Extremity Measure ments The upper leg is measured Fig. 1 from the ischial tuberosity to the medial tibial plateau. (The medial tibial plateau can be easily located if the patient, while seated, rotates his foot outward.) The lower leg is measured from the medial tibial plateau to the floor. The ankle is measured at its narrowest circumference, and the calf at its widest. By comparing these individual measurements with average measurements of children of the same chronological age (see tables 1-5, pp. 9-14, for some examples), the child's level of growth and development can be assessed. However, it should be remembered that the normal values for an individual child may not be the same as the average.

The Role of the Medical Director

9

TABLE 1 WEIGHT AND LENGTH (The 50 Percentile Group) From Birth to Five Years AGE

BOYS WEIGHT

Birth 3 mo. 6 9 12 15 18 2 years

2i

3 3i 4 4* 5*

Lbs.

Kg.

7.5 12.6 16.7 20.0 22.2 23.7 25.2 27.7 30.0 32.2 34.3 36.4 38.4 40.5

3.4 5. 72 7. 58 9. 07 10.07 10. 75 11.43 12. 56 13.61 14. 61 15. 56 16.51 17.42 18.37

GIRLS LENGTH In.

Cm.

19.9 50.6 23.8 60.4 66.4 26.1 71.2 28. 0 75.2 29.6 30.9 78.5 32.2 81.8 34.4 87.5 92.1 36.3 96.2 37. 9 99.8 39.3 40.7 103.4 42. 0 106.7 42.8 108.7

WEIGHT Lbs. 7.4 12.4 16.1 19.2 21.5 23.0 24.5 27. 1 29.6 31.8 33.9 36.2 38. 5 40.5

3.36 5. 62 7.26 8.71 9. 75 10.43 11.11 12. 29 13.43 14.42 15.38 16.42 17.46 18.37

LENGTH In.

Cm.

19.8 23.4 25.7 27.6 29.2 30.5 31.8 34.1 36.0 37.7 39.2 40.6 42.0 42.9

50.2 59. 5 65.2 70.1 74.2 77.6 80.9 86.6 91.4 95.7 99.5 103.2 106.8 109.1

*The measurement figures for the 5-year-old group differ slightly from those given in table 2 for this age because they were obtained from a different population of children.

Source: Studies of Child Health and Development, Department of Maternal and Child Health, Harvard School of Public Health.

10

The Limb-Deficient Child

TABLE 2 WEIGHT AND LENGTH (The 50 Percentile Group) From Five to Eighteen Years AGE

5* si 6 «* 7 7' i2 8 8i 9 9i 10 10j 11 Hi 12 12i 13 13i 14 14i 15 15i 16 16i

BOYS

GIRLS

Lbs.

Kg.

In.

Cm.

Lbs.

Kg.

In.

Cm.

42.8 45.6 48.3 51.2 54.1 57.1 60.1 63.1 66.0 69.0 71.9 74.8 77.6

19.41 20.68 21.91 23.22 24. 54 25.9 27.26 28.62 29.94 31.3 32.61 33.93 35.2 36.74 38.28 40.23 42.18 45. 5 48.81 51.66 54.48 56.65 58.83 60.33

43.8 45.0 46.3 47.6 48.9 50.0 51.2 52.3 53.3 54.3 55.2 56.0 56.8 57.8 58.9 60.0

111.3 114.4 117.5 120.8 124.1 127.1 130.0 132.8 135. 5 137.9 140.3 142.3 144.2 146.9 149.6 152.3 155.0 158.9 162.7 165.3 167.8 169.7 171.6 172.7

41.4 44.0 46. 5 49.4 52.2 55.2 58.1

18.78 19. 96 21. 09 22. 41 23.68 25. 04 26.35 27.67 28.94 30.44 31.89 33.79 35. 74 37. 74 39.74 42.37 44.95 47. 04 49.17 50.35 51.48 52.3 53. 07 53. 57

43.2 44.4 45.6 46.9 48.1 49.3 50.4 51.4 52.3 53. 5 54.6 55.8 57.0 58.3 59.8 60.7 62.4 62.8 63.1 63.4 63. 7 63.9

109.7 112.8 115.9 119.1 122.3 125.2 128.0 130.5 132.9 135.8 138.6 141.7 144.7 148.1 151.9 154.3 157.1 158.4 159.6 160.4 161.1 161. 7 162.2

63.9

162.4

81.0

84.4 88.7 93.0 100.3 107.6 113.9 120.1 124.9 129.7 133.0

61. 0

62.6 64. 0 65. 1 66. 1 66.8 67.8 68.0

61.0

63.8 67.1 70.3 74.6 78.8 83.2 87.6 93.4 99.1 103.7 108.4 111.0 113.5 115.3 117.0 118.1

61.8

The Role of the Medical Director

11

TABLE 2 (continued) BOYS

AGE WEIGHT

17 17i 18

GIRLS LENGTH

WEIGHT

LENGTH

Lbs.

Kg.

In.

Cm.

Lbs.

Kg.

In.

Cm.

136.2 137.6 139.0

61.78 62.41 63.05

68.4 68.5 68.7

173.7 174.1 174.5

119.1 119.5 119.9

54.02 54.2 54.39

64.0 64.0 64.0

162.5 162.5 162.5

*The measurement figures for the 5-year-old group differ slightly from those given in table 1 for this age because they were obtained from a different population of children.

Source: The measurements in this table are from studies by and are reproduced courtesy of Howard V. Meredith, Iowa Child Welfare Research Station, University of Iowa.

12

The Limb-Deficient Child

TABLE 3 PELVIC BREADTH (The 50 Percentile Group) From Birth to Five Years AGE Birth

BOYS 8.1 cm.

GIRLS 7. 7 cm.

AGE

BOYS

GIRLS

2 years

14.4 cm.

14.1 cm.

3 mo.

10.6

10.4

¿2

15.1

14.8

6

11.6

11.3

3

15.8

15.4

9

12.3

12.0

H

16.3

16.0

12

12.8

12.4

4

16.9

16.5

15

13.3

12.9

4i

17.3

17.0

18

13.7

13.3

5*

17.8

17.5

*The measurement figures for the five-year old group differ slightly from those given in table 4 because they were obtained from a different population of children.

Source: Studies of Child Health and Development, Department of Maternal and Child Health, Harvard School of Public Health.

13

The Role of the Medical Director TABLE 4 PELVIC BREADTH (The 50 Percentile Group) From Fifteen to Eighteen Years AGE

BOYS

GIRLS

AGE

BOYS

GIRLS

5*

18.3 cm.

18. 0 cm.

12 years

23. 5 cm.

24. 9 cm,

5*

18.7

18.4

12*

24.1

25. 5

6

19.1

18.8

13

24.6

26.0

«4

19.5

19.2

13*

25.2

26. 5

7

19. 9

19.6

14

25.8

26.9

H

20.3

20.1

14*

26.3

27.2

8

20.7

20. 5

15

26.7

27.5

8*

21.1

20.9

15*

27. 1

27.8

9

21.4

21.3

16

27.4

28.0

9i

21.7

21.8

16*

27.6

28.2

10

22.0

22.2

17

27.8

28.3

io£ li n*

22.3

22.9

17*

27.9

28.4

22.6

23. 5

18

28.0

28.4

23.1

24.2

*The measurement figures for the five-year old group differ slightly from those given in table 3 because they were obtained from a different population of children.

Source: The measurements in this table are from studies by and are reproduced by courtesy of Howard V. Meredith, the Iowa Child Welfare Research Station, the State University of Iowa.

14

The Limb-Deficient Child

TABLE 5 SITTING HEIGHT (Stem Length) AGE

BOYS

6 mo. 1 year 1* 2 21 ¿2 3 3i 4 4* 5

44. 8 cm. 48.7 51.6 53.8 55.6 57. 1 58. 6 60.0 61.3 62.6 63.9 65.2 66.4 67.6 68.8 70.0 71. 2 72.2

5i 6 *h 7