Chapter 35B - Atlas
of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation
Deficiencies: Prosthetic and Orthotic Management
G. Oglesby, Jr., C.P.O.
Carmen Tablada, C.P.
prosthetic and orthotic care for the limb-deficient
child involves more than simply supplying the proper
componentry. The psychological impact on the parents
and family must also be considered. In most cases the
very young child has no awareness of being different
from his peers. It is only from the reactions of his
parents and others that he learns about his disability.
prosthetist is often able to help the family deal with
these issues by discussing their concerns openly and
calmly and by providing prosthetic care that encourages
a normal developmental sequence for the child. Fitting
and delivery of new devices must be timely to avoid
adding to the child's feelings of being unable to keep
up with his family and friends. Referral to a local
support group can often help the family faced with the
new challenge of limb deficiency. Only occasionally
is referral to a professional for counseling necessary.
the child with an acquired limb loss due to tumor or
accident, there may be the added factors of fear of
death or guilt over the circumstances of the amputation.
The emotional scars can be even more devastating than
the physical loss. The prosthetist's role is to help
keep the child actively involved in normal daily activities.
A well-fitted fully functional prosthesis can help keep
the child and the family focused on constructive adaptation.
DEVELOPMENTAL STAGING OF COMPONENTRY
basic principle in pediatric prosthetics is to provide
components that are appropriate to the child's developmental
stage. Although sophisticated mechanisms have a role
in prosthetics, children's devices usually emphasize
simplicity and reliability. General guidelines based
on experience with many children over time can be given
for when to provide a particular level of complexity.
The optimum time to utilize a component for a specific
child, however, must be individually determined by the
Birth to 6 Months
centers do not provide lower-limb prostheses prior to
6 months of age because the child is growing so rapidly
that it would be quickly outgrown. Furthermore, the
child must master sitting balance and other developmental
tasks before standing and walking become realistic goals.
On occasion, the family may insist on prosthetic fitting,
and very lightweight materials can be used. Such fittings
probably have more to do with the parents' or grandparents'
idea of "body image" than the child's.
7 Months to 14 Months
centers recommend fitting when the child is almost ready
to pull to stand, which varies among individuals. The
major prosthetic considerations are as follows:
- A socket that allows for rapid linear growth
- A suspension system that does not encumber the child
- Regular checkups to monitor growth and proper prosthetic
chief biomechanical function of the foot at this age
is to fill the shoe. The child is so lightweight and
the gait pattern so primitive that commercial feet are
optional. Many prosthetists fashion infants' feet from
lightweight and flexible polyethylene foam material
that provides good balance without stress on the residual
limb or next proximal joint. Knee mechanisms are unnecessary
for children of this age. Most infants' prostheses are
fashioned from one solid piece of balsa wood or rigid
foam and covered with a lightweight plastic shell. Endoskeletal
construction is also possible; one solid tube from socket
to foot reduces weight by omitting the knee mechanism.
When the infant with a hip disarticulation is fitted
with a prosthesis, a hip joint permitting flexion is
necessary to allow sitting. Once again, the knee joint
is customarily omitted, and the foot is often formed
of lightweight foam materials.
15 to 36 Months
the period from 1 to 3 years of age, limb growth is
the most evident change. There are several ways to accommodate
the need for a longer prosthesis. At the time of initial
delivery, children's prostheses are sometimes made 1.5
cm (½ in.) longer than is correct with an equivalent
buildup on the opposite shoe to level the pelvis. When
the parents purchase new shoes in a few months (without
a lift attached), the effective length of the prosthesis
is increased. It is also possible to place spacer blocks
between the ankle and foot mechanism up to a point;
eventually, it may be necessary to cut the prosthesis
in half and add material to the shin plus relaminate.
Endoskeletal designs can add longer tubes until the
cosmetic cover no longer stretches any further. Although
foot size will seem to lag behind as the uninvolved
foot grows, this is seldom significant for the growing
child. Most prosthetists advise selecting the largest
possible foot size for the initial fitting in anticipation
of the child's future growth.
the musculoskeletal system matures, the family may notice
variations in the toe-in or toe-out of the prosthesis.
This seldom affects the child's gait significantly and
can be simply observed. Only rarely will it be necessary
to realign the prosthesis due to significant postural
or structural changes in the maturing child. Through
careful prosthetic planning and follow-up adjustments,
it is common for pediatric prostheses to remain serviceable
for a full year or more despite the rapid growth that
37 to 72 Months
the child's preschool years, from ages 3 to 6 years,
manufactured components become available in simple and
basic styles. The preschooler's active lifestyle commonly
results in lost or tattered clothing after a hard day
at play. The prosthesis is subjected to similar rigors
and must therefore be simple, rugged, and repairable.
functional knee is commonly introduced at this age,
often with a manual locking option initially. As the
child masters the prosthesis, the knee can be unlocked
at home and later at preschool. An extension assist
aids knee stability but may need repairs from time to
time. Endoskeletal designs are readily available, and
the components generally fare well; the covers are another
matter. Some parents gladly accept the need to replace
the outside covers at intervals and eagerly embrace
endoskeletal prostheses. Others prefer the ultimate
durability of the exoskeletal type. Function is similar
regardless of the external configuration. A few families
will accept an endoskeletal device without the covering
during the more destructive phases of childhood.
available feet are preferable starting at this age.
Almost all pediatric designs use nonarticulated feet;
the high-level or bilateral case is the possible exception.
The solid-ankle, cushion-heel (SACH) design is inexpensive
and reliable; dynamic-response alternatives have recently
become available. Initial results suggest enthusiastic
acceptance of the more responsive designs by both children
and parents, although the functional differences for
children are as yet undocumented.
7 to 12 Years
elementary school child goes through minor but continual
growth changes. Fit and function should be maintained
by regular follow-up, at least quarterly. As the preteen
years approach, both boys and girls develop interests
in new "outside" activities including sports, arts,
and social activities such as dancing. The youth's interests
begin to have an impact on the prosthetic design as
limitations of the previous artificial limb become apparent.
Each new fitting offers the opportunity to vary componentry
to address the increasing activities of this age group.
13 to 18 Years
the preteen and particularly the teen years, physiologic
and psychological changes are intensified- for amputee
and nonamputee alike. Cosmetic appearance naturally
becomes an increasing concern for both boys and girls.
This is also a time of transition for the prosthetist
inasmuch as he must recognize the increasing independence
of the maturing amputee and develop a good working relationship
that will last on into adulthood. During this period
any number of considerations will arise, from abrupt
changes in fashion (e.g., heel heights) to pregnancy,
and each must be handled with the seriousness they deserve.
ability to conform by being a nonconformist can become
a prosthetic factor too. Some will demand that the prosthesis
be inconspicuous and blend into the background, while
others will insist on a garish neon color lamination
as a statement of personal expression.The
need to provide some means of protection from the stresses
of competitive sports activities is common.
a general rule, the prosthetic componentry and suspension
will become increasingly sophisticated as the teen approaches
adulthood. By the time the youth is 18 years old, adult
componentry and fitting principles are fully applicable.
CONSIDERATIONS BY LEVEL OF AMPUTATION
has been discussed, the primary factor in selection
of prosthetic componentry is developmental readiness.
Beyond that, durability and function become significant
considerations. During the "sandbox years," simplicity
and repairability may be prime requirements; as adulthood
approaches, much more sophisticated prostheses are increasingly
for the partial-foot amputee varies according to the
degree of loss. Since children are lightweight and typically
have excellent vascularity, they often do very well
with partial-foot amputation. When only loss of the
toes is involved, a simple foam filler is usually all
that is required. Unlike the case with adults, it is
seldom necessary to modify the shoes themselves. This
is fortunate because shoe modifications would quickly
become expensive for the rapidly growing child.
to midfoot amputations often do well with a modified
University of California Biomechanics Laboratory (UCBL)-type
insert that incorporates a toe filler. Once the proximal
third of the foot is involved, suspension becomes a
problem, and the modified ankle-foot orthosis (AFO)
is one solution.
Another approach is to provide a flexible laminated
rubber "boot" for both function and better cosmetic
Syme Ankle Disarticulation
Syme and similar levels play an important role in pediatric
amputations since the growth plates are preserved (when
compared with a transtibial level) and the risk of bony
overgrowth is avoided. Furthermore, most children with
Syme or Boyd amputations can ambulate short distances
without any prosthesis. For the very young child there
is often insufficient discrepancy to provide a commercial
foot mechanism; the discrepancy usually increases as
the child matures due to more rapid growth on the uninvolved
side. Epiphysiodesis just prior to the cessation of
growth is always an option. The SACH foot has been the
only option until recently.
Dynamic-response feet have been well received by adults,
and some types are beginning to appear in pediatric
Transtibial (Below Knee)
components are selected according to the function desired,
as in adults. SACH remains most common,
but dynamic-response designs, particularly for the older
child, have also been well received. Many methods of
suspension are suitable for this population. Cuff suspension
alone may stress the ligaments if not reattached regularly
as the child grows. Although a loose cuff or fork strap
attached to a waist belt is more forgiving, such belts
are seldom necessary and encumber the children. Many
pediatric amputees do quite well with supracondylar
suspension, particularly those who need a little extra
mediolateral stability at the knee. Knee sleeves and
the silicone suction socket (3S) design both provide
suction suspension. Joints and corsets are rarely seen,
being reserved primarily for the child with marked ligamentous
damage to the knee.
Transfemoral (Above Knee)
same controversies that exist regarding adult sockets
apply to pediatric designs. Ischial containment and
quadrilateral contours have both worked well with this
age group. Many prosthetists elect to use an individualized
shape for growing children that is based on the cast
impression of their residual limb. The presence of significant
body fat or the use of bulky diapers dictates a unique
shape for the small child's socket. Knee criteria have
been previously discussed; a free knee is unnecessary
for the very young child.
key factor for the hip disarticulation fitting is to
plan ahead to accommodate circumferential growth of
the pelvis. The knee joint is usually omitted until
the child is near school age. The hip joint is provided
at the outset, however, to permit sitting down. A SACH
foot completes the prosthesis. Despite the simple componentry,
the pediatric hip disarticulate typically does very
well with a prosthesis. Presumably this is due to his
small stature (short lever arms) and high energy level.
Many progress to become excellent hands-free ambulators
even as adults. Most centers are experimenting with
thermoplastics and more flexible socket designs for
all levels of amputation. Results to date look very
encouraging, and further investigation is warranted.
Proximal Focal Femoral Deficiency
limb deficiency warrants individual discussion because
of the complex clinical picture it presents. Not only
is there a significant limb length discrepancy, but
hip joint involvement is also common. Hip abduction
and flexion contractures are common. The knee is often
unstable and may be difficult to palpate within the
short, fleshy thigh tissues.
All those factors complicate prosthetic management.
restoration is geared to minimize the excessive trunk
bending and internal rotation of the hip that typify
proximal femoral focal deficiency (PFFD) gait.
This is accomplished by meticulous casting of the affected
leg and pelvis while maintaining the proper rotation
and hanging angle. Careful molding is necessary to achieve
good ischial weight bearing rather than posterior-thigh
weight bearing. In cases where the foot remains, it
must be molded in a plantar-flexed position that allows
good cosmesis yet permits some weight bearing on the
sole of the foot. For those with telescoping hip joints,
maximum elongation during casting improves ischial weight
bearing during stance.
test sockets are invaluable in evaluating the above
factors. Remodification of the positive model and fitting
with a revised test socket is often required. Dynamic
alignment is individualized but must take into account
the child's age, physical findings, and any additional
abnormalities. For those with concomitant upper-limb
involvement, the socket brim may be utilized as a control
cable anchor point.
some cases, the clinic may elect to initially fit the
young child with shoe buildups and/or an AFO. Once the
child has grown somewhat, fitting with an extension
prosthesis or ablation of the foot and fitting with
a modified knee disarticulation prosthesis may be undertaken.
Rarely, Van Nes rotation-plasty may be performed and
the child is fitted with a modified transtibial prosthesis.
Bilateral PFFD is a special circumstance, and surgical
intervention is generally avoided. Definitive treatment
with orthotic devices or with extension prostheses may
be offered. As the child with bilateral PFFD grows and
the extension devices become longer, endurance and balance
are reduced. Many abandon external devices as they approach
adulthood and choose to ambulate unencumbered.
young person with an amputation or limb deficiency will
find that his life will be different in some ways from
the lives of his playmates. This does not necessarily
mean that he is limited; he will be as functional as
society and circumstances allow. Prosthetic restoration
may enhance or detract from the amputees independence,
depending upon the quality of fit and function provided.
Careful attention to detail, developmentally appropriate
complexity, and faithful follow-up are the cornerstones
of successful pediatric prosthetics.
- Aitken GT: Proximal Femoral Focal Deficiency-A
Congenital Anomaly. Washington, DC, National
Academy of Sciences, 1969.
- Beal LL: The impact of an anomalous child on those
concerned with his welfare. Orthop Prosthet Appliance
J 1962; 16:144-147.
- Brodsky R, Kay W: The use of the SACH foot with
children. Orthop Prosthet Appliance J 1961;
- Curry RN, Dorsch B: Developmental factors in the
case of the adolescent amputee. Orthot Prosthet
- Dorsch MS: Prosthetics considerations for the female.
Orthot Prosthet 1972; 26:3-5.
- Imler CD: Imler partial foot prosthesis IPFP-"The
Chicago Boot." Orthot Prosthet 1985; 39:53-56.
- Leimkuehler J: Syme's prosthesis-A brief review
and a new fabrication technique. Orthot Prosthet
- Ogg HL: Physical therapy for the preschool child
amputee. Orthop Prosthet Appliance J 1962;
- Pritham CH (ed): New concepts in A.K. sockets. Clin
Prosthet Orthot 1981; 9:4-30.
- Setoguchi Y: Some nonstandard prostheses for children.
Orthot Prosthet 1975; 29:11-18.
- Setoguchi Y: The Limb Deficient Child. Springfield,
Ill, Charles C Thomas, Publishers, 1982.
- Tablada C: A technique for fitting converted proximal
femoral focal deficiencies. Artif Limbs 1971;
Chapter 35B - Atlas
of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation