Management of the upper-limb-deficient child with a powered prosthetic device.

A long-term survey of a large number of children fitted with an electrically powered upper-limb prosthesis seems not to have been reported in the literature. Children with upper-limb deficiencies (congenital or traumatic) were fitted with an electrically powered upper-limb prosthesis in Ontario during the 18-year period of 1965-1983. Seventy-eight patients responded to a questionnaire or were interviewed by telephone. The dropout rate in children with a below-elbow amputation was similar to that reported in below-elbow child amputees wearing a conventional body-powered prosthesis (10% vs. 13%). The acceptance rate in children with above-elbow amputations was higher in those wearing an electrically powered prosthesis than in those using the conventional prosthesis, testifying for improved prosthetic function in the former group.

Prosthesis with electric elbow and hand for a three-year-old multiply handicapped child.

The usefulness of wisely prescribed powered components in the rehabilitation of upper extremity amputees has long been recognized (Schmidl, 1973). Their value is especially evident in the prosthetic rehabilitation of high level adult and child amputees (Heger et al, 1985). In recent years, manufacturers of prosthetic hardware have provided practitioners with a wide selection of either myo-electrically or switch controlled electromechanical components and systems. As a rule, however, most commercially available components are designed to serve the adult amputee and do not lend themselves for use in the prosthetic rehabilitation of children. One current exception is the availability of child-size electric hands. The availability of the world's first child-size electric hand in 1970 at the Ontario Crippled Children's Centre later known as the Variety Village 105 hand, gave tremendous impetus to the fitting of younger children with externally powered components and myoelectric control systems. However, this trend served to benefit the young below-elbow patient only (Sorbye et al, 1972). The successful fitting of higher amputation levels in this age group stopped at the elbow level. Existing artificial elbows such as the Variety Village and Hosmer elbow with their necessary powerpacks are simply too bulky and too heavy for pre-school age children. The need for a lightweight compact electric elbow, suitable for 3-8 year old children, still has not been addressed. This single case report illustrates an innovative and successful conversion of a 6-3/4 Otto Bock hand into a small electric elbow. The idea was first proposed by Schmidl (1973).

Myoelectric training methods for the preschool child with congenital below-elbow amputation. A comparison of two training programmes.

The Ontario Crippled Children's Centre has completed a two-year research project designed to develop effective strategies for training the preschool child to use a myoelectric prosthesis. Two programmes were developed: one home-based with the parent as primary trainer, and the other Centre-based with a therapist as trainer. Seventeen children were successfully trained and fitted with myoelectric prostheses. Both training programmes appear to be equally effective, proving that informed parents can assume responsibility for the training of their children. Economic implications are self-evident. The functional assessment of the children's skill with the myoelectric prosthesis is very encouraging so far. However, long-term studies are indicated for adequate assessment of the cost-effectiveness of early myoelectric fitting. As a result of this study, effective training methods can now be used in routine clinical service; a manual is available to provide guidelines.

Triaxial electrogoniometric examination of the pivot shift sign for rotatory instability of the knee.

The precise nature of the motion of the knee during a pivot shift is of interest when types of knee instability are correlated with specific injuries. Ten subjects with anterior cruciate ligament injuries and demonstrable pivot shift instabilities were examined with a triaxial electrogoniometer to detect angular motion at the joint during the performance of a pivot shift test. By varying the method of test performance and observing the patterns of motion by eye and in the electrogoniometric data, the pivot shift was shown to be a dominantly translational event during nonstressed knee testing and a dominantly rotational event during stressed knee testing.

Studies of dynamic ligamentous instability of the knee by electrogoniometric means.

Ligamentous injuries to a knee joint increase the risk of post-traumatic degenerative changes. Successful early diagnosis and treatment of such injuries remains a challenging and controversial task. There are a variety of clinical tests available and some of these are difficult to perform and interpret. These clinical tests are really static in nature and may not reveal the presence of what is essentially a dynamic event. A complete assessment would need to be "dynamic" and by its application during ambulation, incorporate the effects of ground-foot forces, joint motions and muscle activities. At the Ontario Crippled Children's Centre (OCCC) a triaxial electrogoniometer system (extensively modified CARS-UBC) has been used, together with complementary gait laboratory instrumentation, in order to study the knees of 16 male subjects. Ten subjects had knees without evidence of injury and six had a variety of cruciate and menisceal tears. The purpose of the study was to investigate if a subject's knee could be classified as "normal" or "unstable" by using just the data provided by the electrogoniometer during walking trials. These data are difficult to interpret in their time series form because they are multidimensional and in all subjects likely to exhibit subtle stride to stride variations. The method described allows the mapping of this data into an abstract two dimensional co-ordinate system, resulting in a set of trajectories which cluster together for data belonging to the "normal" group. Only two subjects, with grossly unstable knees, were judged different from normal using a level walking test protocol. Some potential reasons for this are discussed.

A long-term review of children with congenital and acquired upper limb deficiency.

A long-term review of 131 children fitted with upper limb prostheses at the Ontario Crippled Children's Centre between 1965 and 1975 is reported. There were 116 children with congenital deficiencies and 15 who had had amputations. Follow-up ranged from 7 to 17 years. A total of 42 children had abandoned their prostheses, 37 of whom had congenital deformities and five were amputees. The level of deficiency was of fundamental importance in determining whether the prosthesis would be accepted; in the forearm, the longer the stump, the more likely it was that the child would discard the prosthesis. Overall, 50 per cent of children fitted over the age of two years abandoned their prostheses compared with only 22 per cent of patients who had been fitted before the age of two years. The highest drop-out rate was at the age of 13 years when the children became more conscious of their cosmetic appearance. Suggestions for reducing the high drop-out rate in the early teens are put forward.

The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency.

The lateral pivot shift(LPS) is a special form of lateral compartment instability arising from anterior cruciate insufficiency. It is characterized by anterior subluxation of the tibial plateau out from beneath the lateral femoral condyle. As a consequence of this form of instability, deleterious changes of the knee joint take place, including meniscal tears, and articular cartilage erosions. The eventual result of continued symptomatic instability is late osteoarthritis of the knee. LPS is the most prominent form of instability of the knee in patients complaining of "giving way" of the knee, and recovery from severe soft-tissue injury to the knee joint.