Summary of responses on pediatric prosthetic patient

Summary of responses on pediatric prosthetic patient

Stephen Fletcher

2/16/2000

Listed below is the original posting and then the summary of responses.
Thank you all for the great assistance.
We are planning on going with a Proflex inner socket, with supracondylar socket design. TRS infant hand and a custom made neoprene elbow sleeve to aid in suspension.
Thanks again.



I am looking for advice in regards the a patient. Here are the specifics:
11 month old male
congenital R mid level trans radial level residual limb.
full ROM at the elbow and shoulder
no other health issues.

Patient was referred by their Orthopedic M.D. for fitting of a prosthesis.
My experience with this young of a patient is limited. My questions are the following:
What age is it most appropriate to initiate treatment?
How about suspension of the prosthesis?
Passive hand type of terminal device? Specific reccomendations of brands?
Thank you in advance for your assistance.
Steve Fletcher, CPO
Shands Hospital at the University of Florida


Responses:

Lots of options on this one. I'd probably start with a passive BE, using
Steeper's (Liberty Mutual) foam-filled passive hand. The socket can be
self-suspending, Muenster style, sort of. It often is more of a soft
tissue suspension. Some use a donning hole and sock, others use lotion,
others like to use a small cocktail straw along the side or back of the
socket with lotion on the child's residual limb (the straw lets air wick
out, and is then removed, thus creating a form of suction socket.) After a
test-socket, you may want to vacuum form or laminate a small inner socket
that can be removed later to allow for growth.
        I won't get into the myoelectric option, because I feel it's a little early
to go that route. I'd rather wait until around age two before switching to
an active td (cable or myo), because by then the child has acquired some
language, will have gotten used to having something on, and understands
cause-and-effect, so is more amenable to being trained to use the device.
        There's also the option of not fitting at all, and waiting until the child
is old enough to show interest and have some defined goals. If everyone's
pushing for a prosthesis, this may not be an option.


 have a tremendous amount of experience with pediatric upper extremity
patients I was a life long member of AAPOC clinic # 13 for 22 years.
The answer is you fit with sit!
The most appropriate terminal device is a passive mitt because they like to
chew on these and they are easy to keep clean
These kid work very well with supracondylar suspension, and seldom with a
Velcro strap to assist
Any further help I can give just call me, Good Luck


Steve,

Contact Carl Brenner CPO
Brenner Orthotic and Prosthetic Labs and Michigan Electonic Limb Institute
32975 8 Mile Rd.
Livonia, MI 48152-1337
248-615-0601

He specializes in upper extremity prosthetics for children. Particularly
myoelectrics.
He has more experience in this, than any one in the field that I know.
Give him a call.


Stephen
We deal with this type of patient all the time here at Shriners Hospital in
St. Louis. We usually fit Young Pt. when they can sit independently. We than
fit them with a passive system ( us use TRS infant hand with sleeve
suspension, This easier for the parents to don and doff the prosthesis. If
they have allot of baby fat so to speak you will have to use a pull sock. We
do a proflex type inner socket and either laminated or pulled plastics for
the outer skin. If we do have to pull the Pt. in We will drill a hole in
distal end of the socket. Using a nylon that has both ends cut out, I put
one end onto the Pt. Residual limb and the other end through the hole. I
pull the Pt. into the socket but I do not pull the nylon out of the socket.
I reflect the nylon up onto the socket then put the socket into the arm. The
sleeve will hold everything together. We do not put an active system onto a
Pt. until they are eighteen months or older. Any question write or call.



Start now or it will be too late very quickly because of the innate ability
for young humans to adapt. Use of the prosthesis will impede their learned
activity so will not be accepted.


Steve,

Several years ago, I treated a pediatric patient who was about the same
age. This child was a long transhumeral amputee, but I think the same
design could be utilized. We had been requested to address what turned
out to be a three fold-outcome plan. First we wanted the child to begin
to develop his spacial proprioception using a prosthetic hand. Previous
to the prosthesis, the child would pick objects up (ie bottles...toys...)
with his hand, and his distal residuum. After we fit the prosthesis, the
child picked objects up with the same technique at first, yet after about
ten minutes of coaching he started using the prosthetic hand in
opposing grasp. Second we wanted to aid the child in his attempts to
hold himself up, walk, (moving along tables chairs etc). Having two
extremities of the same length to assist him made it less awkward. Third
we wanted to address the mothers image issue's.

I fabricated the terminal device out of a five finger glove for a
pediatric passive hand (I believe it was from Hosmer). I did not utilize
the hand because of overall prosthetic weight required to include it.
Instead I used a rigid foam, used for making shoe lasts, and poured it
into the glove to just proximal the level of the styloids. I reinforced
the fingers with wire so he couldn't bite the fingers off. I molded an
inner and outer socket (the inner socket was removable to accommodate
growth) with a threaded delrin plate molded into the outer socket. (The
distal socket plate was very similar to the distal tooling plates Cascade
includes in the Iceross locking liner fabrication kits). The rigid foam
hand was tapped to the same threading as our distal socket attachment
plate, and a delrin rod was used to set the length and connect the
terminal device and the socket. For our patient, I bent the rod into a
functional angle to provide some elbow flexion. Any space between the
proximal terminal device and distal socket was filled with plastazote,
and the glove rolled proximal over the foam and socket. We used a
Y-strap and figure 9 harness for suspension. You might be able to
fabricate the proximal socket tight over the epicondyles to provide
suspension, and use removable flexible hinges and a harness for auxiliary
suspension if needed. Velcro strips could be attached under the glove,
so the glove could be rolled back the flexible hinges attached or
detached, and the glove rolled back up.

I was able to follow the patient for about a year before they moved, and
we were ecstatic over the positive outcomes.

hope it helps



Steve:
I will give you information based on my experiences working with pediatrics
at the Child Amputee Prosthetics Project (CAPP) at Shriners Hospital in Los
Angeles. We fit young children when they have developed good sitting
balance, preferably when they can transition in and out of the sit position.
So, your 11 month old is probably ready for fitting. We generally fit a
passive infant prosthesis. Since our clinic mainly fits body powered
prosthesis at a later time, we will fit young ones with a standard socket,
full cuff, and a chest harness. We let the parents decide if they would like
a passive hand (we generally use a Hosmer or Century) or our CAPP TD (it
gives the child passive grip - parents could insert an object into the TD.
it's very function but not very cosmetic). We have found that the short
BE's do well with the forearm pre-flexed to 30-45 degrees - it puts them in a
good functional position.

I have also seen young ones fit with a self suspending type socket (mainly if
they will be fit with a myo later) and a passive hand. It will be important
to have good suspension so that the child cannot easily remove it.

Whatever the little one is fitted with, it is important that the parents
develop a full time wearing pattern (all waking hours) and encourage gross
motor use with the prosthesis on. The child should include the prosthesis to
stabilize large objects and do other activities requiring two hand/arms.

Children usually need an active TD around 18 months to 2 years. We recommend
our CAPP TD or an electric hand. We have not had good experiences with a
mechanical hand or TRS adept for the 2 year old.


Hi Stephen. I see lots of patients with congenital deficiencies of the
forearm/hand. The earlier a congenital child is fit the better. I fit the
first prosthesis (uaually around 3-4 months of age) as a passive. Self
suspending socket, using string casting technique described by Staats in either
Clinical Prosthetics & Orthotics or JPO. It is a modified Muenster design. Use
the foam filled passive hand available from Liberty Technology.....it is
flexible in case the child might still crawl some. When the child outgrows the
passive, move on to a single site, voluntary opening auto closing myo system
(cookie cruncher).

I consult on cases like this for various prosthetists around the country. I
have worked with Michael Tompkins of Animated Prosthetics and we have developed
a micro-computer myoelectric system. It works great on congenital kids because
it is menu driven in terms of control options, and you can literally grow the
prosthetic options with the child's development.

Feel free to phone me (number posted below) if you like and I can explain in
detail both the casting technique and myo options for later. As I mentioned
above, I am available as a consultant (on site if needed) for these types of
fittings. Keep in mind, that a child well treated early, is a patient for life.



Mr. Fletcher:

a good place to start would be working with a clinic that sees a lot of
kids this age. check out the ACPOC.org website to find one near you. at
minimum find and occupational therapist in one of these clinics who can
work with you and the family.

your questions:

if you can get a hold of a copy of Setoguchi's The Limb Deficient Child to
answer all of your questions. it is out of print. the AAOS has published
a newer version, but i have not read all of it and won't assure you that
it answers all of your questions.

when to fit: runs the whole range from 3 months on. conservatively at
sitting (6 mos), preferably before 12 mos as it only gets harder to take
away their function and sensation.

suspension/components: everything available for adults is available for
kids. and everyone does it differently. it is important to have at least
an OT working with you and the family to achieve optimum sucess and it all
depends on what you all are comfortable with. fitting what you are best
at is better than trying to make something work that you do not do often
or very well. everything works/fails at about the same percentages. i
use the CAPP system with passive components unless there is an economical
issue, then i fit passive use of components that can be activated (usually
at 15-24 months)

TDs: depends on the family. i use mittens from hosmer, passive hands from
hosmer, CAPP, 12P, TRS, all the way to Otto Bock 2000 myo systems. you
probably don't have room for a lot of gadgets, but Liberty Technology has
some very nice flexion wrist stuff from VASI used with VASI hands.

i emphasize that you will get your best outcome with a good OT working
with you and the family or getting a good ACPOC OT to do one consult and
work with a more local OT.

have fun, they are delightful kids to work with


Steve, I can comment on our protocol here at the Texas Scottish Rite
Hospital for Children. The main developmental milestone we look for is when
the child is able to balance independently and sit up on their own. You can
think of it as fit when they sit! We usually will fit a supracondylar type
design on the patient if the length is sufficient. Sometimes we might add a
sleeve to aid in suspension. Some centers definitely fit patients a lot
earlier than this though. It also depends on what type of therapy is
available for training purposes. As far as td's available, you can use
passive ones from Hosmer, Liberty Mutual,TRS, and Otto Bock. Hope this helps
in any way. If I can help you further, just let me know.



Dear Stephen:

I think you can introduce the prosthesis as soon as 3 months or when the
child begins to sit upright and reach for objects. The TRS Mitt or Baby
Mitt from Hosmer are some options that are flexible. at 11 months though a
more active device is needed. Perhaps a 12P or 10P hook or a CAPP Device
which may be left uncabled for initial passive use. Voluntary closing
devices by TRS also look like a hand. Also at 11 month you may consider a
Myo option. Suspesion can be supracondylar or flexible hinges if pronation
and supination is to be preserved. I hope this helps.


In my experience working with Shriners Hospital and innumerable such
fittings, we fit as early as 4-5 months with a passive prosthesis. This
consisted of a Liberty Mutual glove filled with O-Bock duplicating foam,
super glued to an optiflex self suspension socket. This method would
sufice for suspension if they weren't always trying to pull it off, so
we suplemented with a size 0 or 1 Daw power suction sleeve. I had
Stuart Marquette create this size especially for this purpose, they
worked great, although we usually cut them in half.
Usually we would fit them with an activated terminal device(either self
actuated or with a mommy loop) when they no longer could wear the
passive at around 12 - 18 months of age. This is not a valid time frame
though ( we were fitting activated arms earlier and earlier) and a
qualified OT should be consulted for an evaluation of the child's
abilities. I can put you in touch with Kristi Kyte, OTRL, who is in my
opinion one of the best. She would be able to tell you what you should
be looking for. A child this age is also a prime candidate for a
myo-electric arm, assuming there is/are suitable site(s) available for
control and the child is not physically too small. Training is also an
issue and myo should not be considered unless it is available. Again
Miss Kyte is an extraordinary resource in this area.
Please feel free to cal me with any questions.


Steve,

I have had similar aged patients, and have been successful fitting the
following: polyetheline socket (sometimes doubled when growth anticipated).
polypropline forearm with foam removed after pulling, and CAPP mitt type TD.
I have suspended them in a variety of ways including a figure 9 harness made
of 1 Velfoam, or an elastic sleeve. I have resisted fitting with any
functional terminal device until the developmental age of fine prehension,
usually 3 years old.

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