EQUIPPING THE LIMBLESS - Postgraduate Medical Journal · EYRE-BROOK: Equipping the Limbless...

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EQUIPPING THE LIMBLESSStumps and Artificial Limbs-Some Observations, including a

Report on Krukenberg Stumps and Cineplastic Work in Germany

By A. L. EYRE-BROOK, M.S., F.R.C.S.Bristol.

The- management of the limbless -from thevery day of amputation is of extreme import-ance; he must be influenced from the outsetto accept his disability as one that he can andwill overcome and the programme to this endmust be initiated forthwith.

For the double amputation, his future mustappear appalling as he contemplates his con-dition, the morning after his operation. Tothese, it is a help to bring such photographs asthose illustrated below (Fig. i), showing adouble leg amputation-A.K. and B.K. walk-ing without a stick, doing a hand stand,swimming and standing on the A.K. limbalone. These photographs make a strongimpression on any patient and give a clear aimto all who wish to become independent andwho have an average endowment of courageand energy. A knowledge of the accom-plishments of Group-Captain Bader, now anational figure, also does a great deal for any-one finding himself similarly handicapped.The limbless man on his own in a small

lhospital is, of course, at a disadvantage com-pared with those in a centre for the limbless,who have examples before them of fellowpatients in more advanced stages of rehabilita-tion. The provision of a warm swimming poolis invaluable as swimming is the form ofexercise par excellence for the limbless,whether of arm or leg; here, in the water, theygain more independence than they can everevince on land. This is particularly importantin the early stages of convalescence in doubleleg amputees.The limbless must always be maintained at

their greatest functional level. To remain inbed is harmful, psychologically and physically,once sound healing is obtained. Even a double

leg amputee can be up in a self propelled chairand can go to the physical medicine depart-ment for his exercises. These are much moreeasily performed in a department wheresuitable weights and pulleys at convenientheights are available and where class work canbe instituted, with the necessary competition,which should result. Three months mustnecessarily elapse between the amputation andthe provision of an artificial limb, and duringthis time the fullest shrinkage of the stump is-obtained and all muscles moving proximaljoints are kept as strong as possible. Theswimming pool, the self propelled chair andcrutches, used at the earliest opportunity,make these months pass with least interferencewith a normal life of human contacts andphysical exercise and are in marked contrastwith what befalls some patients, confined tobed in a ward and subjected to a demoralizingsympathy by those who have little knowledgeof the accomplishments of the limbless or thelimb maker. One word in passing on thelimb maker; this skilled craftsman is aspecialist and the limbless provided withlimbs by a general instrument maker aregetting less than full meqsure and can illafford it.

The stump is an exceedingly important newmember to the limbless, it is not to be com-pared with the remains of a tree, which bearsthe same name. It is, to the limbless, themember on which he relies to work hisartificial limb. It must, therefore, be fashionedin the light of expert knowledge and trainedwith this purpose in view. Details of fashion-ing stumps at suitable levels must not be dealtwith in this article. Let me only mention thatthe greatest tragedy in any stump is the un-

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treated haematoma; this should be preventedby drainage for 48 hours, when the loosestitch is tied, leaving no trace of this mostimportant step in sound stump surgery.The treatment of the stump consists of four

hourly stump bandaging, commenced once thestitches have been removed. This results inquick shrinkage so that the stump attains stabledimensions in the shortest period of time.Exercises must be given to all muscles con-trolling proximal joints, particularly to thosemainly employed in standing and walking, andthese exercises must be strenuous enough tocompare with the functional demands on thesemuscles during control of the artificial limb,and finally, no contractures must be allowedto develop and a full range of movements mustbe maintained. The B.K. stump on a pillowand the maintained sitting or supine positionsin bed are particularly liable to cause knee andhip contractures respectively. No pillow andthe daily exercises in the prone position are thelessons to be learnt for those cases which haveto be confined to bed.

1. Artificial LimbsMlaterial for artificial limbs

Duralum, steel and wood each has its rolein the construction of artificial limbs andplastics will play an increasing part in thefuture, although these latter are not expectedradically to change the construction ofprostheses. Although wood' was the first inthe field, it must not be considered as anobsolete material, it has attributes whichrecommend it above metal in certain roles andt is still very popular on the Continent.

Artificial LegsThe standard British artificial legs, as made

by Desoutter and Hangers, are fully dealtwith in standard works 1 and 2 and in themanufacturers' excellent brochures. It is thepurpose of this article to deal with develop-ments in other countries and to a less extent inour own, as the latter are better known.Commencing distally in the foot, there is

the oft condemned Lisfranc amputation whichhas so frequently ended in crippling varus andequinus deformities. I was impressed to seea ten year old Lisfranc amputation withoutdeformity and giving perfect function. The

secret was the maintenance of the os calcis inits normal position with its elevated forepartand this had been accomplished with a metalfootplate (Fig. 2), completed anteriorallv witha felt block to replace the missing forefoot ina normal shoe. ' Hendrix of Brussels is astrong protagonist of the Lisfranc amputationproperly cared for from the very outset-a tenyear end result must convince one of thepossibilities of this amputation. The tians-plantation of the Tibialis Anticus insertionlaterally is often very useful but Hendrixproves that this is not essential. In Belgium,U.S.A. and other countries, the orthopaedicsurgeon and mechanician have a greater ex-perience in making footplates, an essential forthe proper equipping of a Lisfranc amputation.The end bearing stump at the ankle level,

popular always in some schools in Canada andin Scotland, has regained much of its popu-larity in the United States. The controversystill rages but the amputations of this war,with their very low sepsis rate and more con-trolled after care, have resulted in a series ofAmerican stumps of the Syme's type whichcan be expected to stand the test of time verydifferently from those of the last war, of whichour Roehampton limb fitting surgeons speakso disparagingly. A disadvantage of theSyme's amputation, however, still remains inthe weight and unsightliness of the artificiallimbs so far conceived. Women, still withmuch reason, dislike the Syme's amputation.The lateral movement in the artificial foot

has been incorporated by many firms, includ-ing those in our country. A rubber bufferedcoupling situated below the ankle couplingallows of sufficient movement to adapt torough surfaces. The solid rubber foot yields alittle in all directions but is heavy and is onlyused on the Continent for agricultural workers,where its immunity to moisture is a greatadvantage. Some argue that the refinement oflateral foot movement only introduces a freshfactor which may go wrong, and that it is notworth the advantages gained, but this does notappear to be the opinion of the limbless fittedwith this improvement. The ladies of France,however, favour the most simple but shapelyfoot and ankle piece of the following design(Fig. 3). This shapely limb has no anklejoint nor lateral foot movement, only a rubber

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EYRE-BROOK: Equipping the Limbless

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Fig. i. What a Bilateral Amputee (A.K. and B.K., aged 45) can do.

Showing length of B.K. stump. Showing length of A.K. stump.Hand stand with artificial limbs. Standing on A.K. leg alone.Walking easily, hand in pocket and no stick, Swimming-excellent exercise for bilateral leg amputees.

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I II II II

e<neeion.tie)

Stemliece

Fig. 2. Hendrix's Prosthesis for a Lisfranc'sAmputation.

Fig. 4. Stabilax Knee (French).

Antero'-Thster;or Lateral. 11 I

Fig. 3. Shin and foot piece popular with Frenchwomen. (Only moveable parts are the yieldingof the Sorbo rubber heel inset and the solid felt

foot.)

R ol, actini-Knee Axlg'

Fig. 5. Osterly Gestange Knee (German),

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cushioned heel and a felt forefoot to allow ofthe essential metatarso-phalangeal movement.

KneesThe aim of all designers appears to be

stability in partial flexion, with a distractingaim following by some, to reproduce theanatomical movements, including the antero-posterior glide of a human knee. The latterresults in no advantages to the wearer of thelimb, although considerable ingenuity has beenexpended in some of the anatomical or func-tional knees seen on the Continent.The former aim is worthy of every effort.

The posteriorly displaced knee joint hinge, sothat the weight does not coine behind thishinge until 50 of flexion has been obtained, is,of course, almost universally employedthroughout the civilized world.Two interesting knees, worthy of trial, are

the Stabilax knee and the Osterly Gestangeknee, the former employing a double axis andanterior glide to maintain stability up to ajS° angle-of flexion, while the latter employs afriction surface knee, operated by a rod fromthe heel, this being pulled upon by the dorsi-flexing ankle. The Stabilax knee (Fig. 4) isvery popular in France but it was difficult todecide whether such good performances aswere seen were not largely due to the pro-ficiency of the wearers. The knee, however,did appear to have stability up to I ° of flexionalthough its action was ugly and did notsimulate that of a normal joint. A gain instability of the knee joint up to j 50 is, however,sufficient to be worthy of investigation andthese knees are being tried out in this country.The Osterly Gestange knee (Fig. 5) ap-

peared very sound in principle and a very goodperformance was seen in Munich. The kneewas, however, a little complicated and intro-duced further liabilities to breakdowns, whichdo so much to complicate the life of the limb-less. The brake action comes on as the ankledorsiflexes, which occurs in walking when theleg passes into a posterior position, and it is inthis position that the knee begins to flex. Therubber cushioned ball race of the knee axlewould appear to be a weak but essential pointin construction. The friction surface, em-ployed in the Hangers and Desoutter's knee in

this country, is used to vary the speed ofmovement of the shin piece in coming to thestraight position in the ' carry through'; thismovement brings the' leg into the forwardposition before stepping on to it; the amountof friction can be adjusted easily and is merelyused to slow up the movement so as to stimu-late the normal action. This brake action haslittle affect on stability in the early degrees ofknee flexion, but it greatly improves the gait.The German knee, referred to above,' is thebest load bearing knee so far seen and' cer-tainly needs investigation and trial, a knee thatcould bear weight in 30' of flexion would be agreat gain to above knee amputees.

Thigh SocketsNugent of New Zealand has been experi-

menting with a thigh socket, of which theoutlet varies greatly from the standard practicein this country. The standard thigh socketin this country has an ischial bearing surfacesloping inwards and forwards and an ovoidoutlet, while the Nugent socket has a quad-rilateral outlet (Fig.'6), an ischial seating whichis horizontal in both antero-posterior andlateral views, and a high anterior marginending medially in a. groove for the adductorlongus tendon. This latter is designed to keepthe stump back, thus holding the ischialtuberosity on the flat posterior shelf. Theperineal border is deeply cut away to allowcomfort without abducting the leg and thewhole outlet is designed on three precisemeasurements, taken from the stump, ratherthan using a master template of approximatelythe size of the stump, as in the standardpractice in England. These three measure-ments form the sides of a triangle with anglesat the great trochanter, the ischial tuberosityand the adductor longus tendon origin.'

Dr. Kelham at Roehampton has developeda somewhat similar socket, which is now ontrial. This socket embraces the above pointsand has a bevelling below the edge, comingout to an increased dimension at a somewhatlower level, wherO there is more musclevolume to accommodate. These sockets areon trial and may prove a considerable advancein accurate fitting. They are more like theContinental outlet and much more suitable forapplication of the suction socket principle.

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Suction Socket SuspensionA very interesting development was seen in

Germany in the form of the suction andvacuum thigh sockets. The principle of thesesockets is that the suspension of the artificiallimb depends upon negative pressure devel-oped in the socket below the thigh stump, thuspreventing the stump from pulling out. Thisprinciple was employed in this country afterthe last war without any outstanding success.Men can, however, be traced who have wornthis type of limb since the early twenties, theirgait is excellent and. their comfort muchgreater than those with a pelvic band orshoulder suspension. This fitting has, how-ever, never become a standard fitting in thiscountry and the number of such limbs suppliedhas been very few. With modifications inthigh socket design and in details of fitting,suction thigh sockets are in very general em-ployment in Germany with much success.The only difference between the vacuum andsuction socket is that the former employs anon return valve by means of which the stumpin weight bearing forces out any air which hasentered the socket while the limb was beingcarried forward. To release the vacuum, thevalve is unscrewed from its seating. Thesuction socket uses a spring valve which isoperated when expressing air, as'when firsttaking weight after sitting for some time, orwhen admitting air, in removing the leg. TheGerman thigh sockets were all of wood,quadrilateral in shape at the outlet and highfitting and all made to shaped plaster mouldsof the stump. A fleshy stump of good lengthis best, although suction sockets have beenfitted to stumps as short as 4 in., measured tothe perineum.The only stump covering is a lady's stocking

(Fig. 7), and, in applying the artificial leg, theloose end of the stocking is passed into thesocket and out through the valv'e seating, fromwhich the valve has been removed. Thestump is then eased into the socket by pullingon the stocking end. 7his important tech-nique leaves no folds of skin above the socketand the stump is well pulled down. Thestocking is partially pulled off in thismanoeuvre of pulling the stump into thesocket, and the end of the stocking is thenpushed into the empty lower part of the socket

and the valve screwed into its seating. Withfurther shrinkage of the stump the suctionbecomes less effective and a pelvic band of asimple type is worn by many. The suctionsocket principle does involve very accuratesocket fitting and adaptation to shrinkage atmore frequent'intervals. The fitting must bemost accurate in the upper 3 in. of the socketwhere movement is least in'the rocking of thestump in walking. The German cases and ourfew cases in this country appear to prefer woodfor these suction sockets; it is less hard andwarmer for the naked stump and can probablybe worked to a nearer perfect fitting. Skinsoreness and terminal oedema do not seem topresent any serious problem and the additionalsecurity of the fitting, the sense of the artificialleg being really part of the limb, must be atremendous advantage to the wearer.

Corset SuspensionCorset suspension is being developed in this

countrv by Dr. Craft of the Research Depart-ment at Roehampton. A number of B.K.,A.K. and tilting table limbs- have been fittedwith corset suspension, accurately moulded tothe individual patient, strengthened withwhale bone and fitted with quick release straps.The wearers, mostly women, appear delightedwith this improvement on the shoulder strapor pelvic band suspension. In the A.K. limb,the prominent extrinsic hip joint hinge is dis-pensed with, the limb being attached- to thecorset by only a posterior strap and theanterior knee pick up. 'I he wear of clothes isthus reduced and an objectionable prominenceis removed. An extension of the use of corsetsuspension, with a narrower type for men, isto be expected in this country.

Sword Belt SuspensionA narrow sword belt suspension (Fig. 8)

was in very general use in Germany and 'Willbe tried out in this country. It may provemore attractive than corset suspension to men,and appeared to be adequate in those suctionsocket cases which required some additionalsuspension. The illustration shows the metalloop which is attached to the outer side of thethigh socket and which follows the outlines ofthe great trochanter. To this loop is attacheda 3 in. leather band which passes round the

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Fig. 7 The Suction Thigh Socket.Note lady's thin stocking on End of stocking passed out Stump being pulled into Function with suction sus-

stump. through valve seating, socket, as stocking is par- pension alone.from which valve has been tially pulled off.unscrewed.

Oval Outlet toThigh Socket

Grea&t

Sou&re Outlet to

'ThbiS Socket

ShlelfFig. 6. Oval and square thigh sockets. iiorn.

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Fig. 9. t'he new vriting hand (British).

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Julne 1947 EYRE-BROOK: Equipping the Limbless 271

i 1^7hg '"eltl

CineplasticTunned$tuh dstaclM

rZ.WThnef

Insertion

Cineplastic Tunnels

,and Ex o sclesx

Fig. Io. Cineplastic tunnels in 5 usual sites.

NUU:L. Abece Abov6Lfbcv Oipsion.Fig. II. Sauerbruch's arm (or Huffner arm).

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i.n%5i?IFlap t m a'- 5de.Fig. I3A. Incisions for Krukenberg claw hand.

Rldial

Fig. 13B. Left Krukenberg claw hand.

4d

Olecranon

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opposite side of the pelvis between the greattrochanter and the iliac crest and is buckled infront.

Artificial ArmsAs in the case of artificial legs, the standard

practice in this country is well dealt with inthe books referred to at the beginning of thatsection. Artificial arms, as used in England,appear well in advance of any in use on theContinent and much research is proceeding toimprove the selection of instruments andgadgets with which the carrying or dress handcan be replaced. The usual arm has a de-tachable hand with a centrally operated pushrod, housed in the clip-on sprocket. The handhas a movable thumb and the various instru-ments which can replace the hand can similarlybe operated by the push rod, the* instrumentsand the hand being easily changed by pressingon a stud catch and pulling them off. Thecentrally operated push rod keeps all cablessafely housed within the apparatus. Theusual ' motors' employed are the forwardmovement of the shoulder on the sound side,pulling on a posterior harnessing, and theupward shrug of the shoulder on the am-putated side. Other motors are visualizedbut where the amputation is above the elbow,elbow movement has also to be powered andcontrolled. The cineplastic operation canprovide us with a number of motors whichprobably deserve an extended trial.One of the most useful products of the

Research Department at Roehampton is thewriting hand (Fig. 9) which is now availablefor general issue. The pen or pencil passesdown a channel between the index and middlefingers and the channel has rubber studs sothat adaptation is allowed for differences incircumference. The pen is firmly held by themobile thumb and writing is so easy andnatural that men who have adapted to lefthand writing for 20 years are returning towriting with an artificial writing hand. Somuch of writing occurs from the shoulder andelbow that right handed men who lose theirright arms are encouraged to write with theseartificial writing hands. The results are verysatisfactory.Rubber washing forearm sockets with simple

washing attachments have been constructed

for the double B.E. amputee, who can nowperform his own toilet where formerly he couldonly wash a limited anterior portion of his faceand body, using both his stumps. Anothergadget enabling a double forearm amputee touse toilet paper gives these men independencein a personal matter where it is very painful tobe otherwise. The Research Department atRoehampton has developed a considerableamount of new apparatus, including a tele-phone holder, and each new contribution adds^something to reduce the handicap of thelimbless.The split ring is probably the most useful

general purpose instrument but is far fromsatisfactory so long as it makes no pretence atconcealing the wearer's loss. The range ofinstruments which can be clipped into theforearm is now considerable but the moreuniversal the tool, the greater the advance, andthe more thp mechanical hand can supersedethese tools, the nearer we approach to per-fection. The ideal mechanical hand shouldopen and close actively, be capable of grippingarticles of very different sizes and the gripshould be maintained without effort by theoperation of an automatic catch. This in-volves much ingenuity in design and at everypoint one meets with the problem of weight;the more distallv the weight is found the moreserious are the disadvantages. Mlany areworking on these mechanical hands in Americaand in this countrv but so far no really satis-factory result has rewarded their labours.The appearance of the artificial hand has

recently been greatly improved by the intro-duction of a rubber glove simulating a naturalhand in colour and texture, even to the repro-duction of the subcutaneous veins. 'I'his is anAmerican invention and very few specimenshave so far been seen in this country but theimprovement in appearance is really out-standing.

2. Cineplhstic StumpsWe now come to some very interesting work

in Germany. The cineplastic operations con-sist of tunnelling a muscle belly with a skintube. By means of an ivory peg, held in ametal stirrup, the movement and power in thismuscle can be utilized to move an artificialhand or other joints of an artificial arm (Fig.

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io). The cineplastic operations were originallydevelopea in Germany by -Sauerbruch, butLebsche of Munich appears now to be thefinest exponent in that country. Muchcriticism has been raised against the cine-plastic stumps and many failures have occurredin the past, chiefly because these operationshave not been performed by surgeons ade-quately equipped with experience in plasticsurgery.

The present practice in Germany is a greatadvance on Sauerbruch's original design inthat skin tunnels through the muscles are' nolonger lined with skin graft but with normalskin, while the split skin graft is now used tocover the superficial defect, resulting from'theemployment of a flap (24 in.-3 in. wide) toline the tunnel, through the muscle. A largetunnel is very important (2 in.-3 in. in cir-cumference) so that hygiene may always besatisfactory and that the rods may operateloosely with a minimum of trauma. Lebschehas introduced a further advance in detachingthe chosen muscle from its tendon of insertionand carefully closing it over. The stump of themuscle thus presents no rough surfaces to formadhesions and, being detached from its tendonof insertion, is given a greater range of move-ment in accomplishing its new purpose. Sucha muscle, tunnelled in its lower third, may.have a range of tunnel movement of 2 in.-3in.The biceps can be so treated, leaving thebrachialis anticus to flex the elbow, andsimilarly the triceps, leaving gravity to extendthe elbow. Pectoralis major can also be em-ployed in a similar manner. These cine-plastic tunnels do more than provide a motorfor the hand and wrist movement, they alsoprovide effective. suspension of the limb, sothat a forearm amputation needs no aboveelbow corset. An extension of this purpose isthe provision of a skin tunnel in the sub-cutaneous tissue, simply to maintain the arti-ficial arm in place in a short B.E. amputation.By no other means can so short a B.E. stumpbe employed with normal control of elbowmovement. The artificial arm in use inGermany with these cineplastic stumps is theoriginal Sauerbruch arm illustrated here (Figs.ii and 12). The opening and closing of thehand will be understood from the diagram,both may be powered by muscles or the ex-

tension may be controlled by a spring. Thegrip cannot be very powerful, largely becausethe stiff fingers fail completely to adapt tocontour and give a very limited contact withan object, but the power of the grip willnaturally vary with'the muscle employed, thetravel of the cineplastic tunnel and efficientcontrol of intervening joints. The cases seenwhich were fitted with Sauerbruch arms andcineplastic tunnels were naturally not engagedin any hard manual work; however, one was afelt hat maker, another was an R;C. priest whowas able to take Mass unaided.. All 'werecompletely independent of help in personalmatters, dressing, eating and toilet, even thebilateral cases. Professor Lebsche demon-strated his complete programme for arm am-putations at different levels:-

I. Through wrist amputation-no cine-plastic tunnels but he used the pronation andsupination, through a bevel mechanism, towork the push and pull rod in the Sauerbruchhand.

2. Long forearm amputation-these menhad the choice between cineplastic tunnels inthe forearm flexor and extensor muscle belliesand a Krukenberg operation.

3. Medium forearm amputation-cine-plastic tunnels in forearm flexors and extensorsfor opening and closing hand. Oppositeshoulder harness for pronation a'nd supination.

4. Very short forearm amputations-sub-cutaneous holding tunnel on flexor surface ofstump kept the artificial arm in position andallowed of normal control of the elbow, bicepscineplastic tunnel for closing hand, spring foropening hand. Pronation and supination byopposite shoulder harness.

5. Above elbow amputation-biceps tunnelfor closing hand, and triceps tunnel for openinghand. Elbow flexion by opposite shoulder,elbow extension by gravity. Pronation andsupination by shrug of shoulder on amputatedside.

6. Short above elbow amputation-pec-toralis major tunnel for closing hand, spring*for opening hand, elbow flexion by oppositeshoulder harness, elbow extension by gravity,pronation and supination by shrug of shoulderon amputated side.

7. Bilateral amputation-as for two singleamputations but for a good length B.E. am-

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JEYRE-BROOK: IE'quipping the Limbless7

Fif.t. 15. The Krukenherg stump.

Full active separation.Full active closure. Gripping the handle bars.

Throwing a tennequoit.Tving his tie.

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'I'he lKrukenberg sturnp. Icarnine typing,LIsing hammri-iiers on wcdlgvs ini til early eeksof tr-ining.

Lifting a chair by direct upward pull. Removing wallet from hip pocket (the importanceof normal sensation).

Fig. I6.

CrossSection

Gmwes

SIfekv R(azoi -WId

Sfegy R<azor o-r Wease

Fig. 14. Wedges used in training the Krukenbergstump or claw hand,

ToV-- View

I WedcewitliPenciL.

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putation in a blind case, a Krukenberg'soperation was strongly advised.From the cases seen, and the film demonstra-

tion, it was evident that considerable dexteritywas possible with the - Sauerbruch arm,powered by these tunnelled muscles; thetunnels were undoubtedly robust whenfashioned correctly with normal skin, un-scarred openings and of a size sufficient easilyto allow the introduction of the little finger;there did, however, appear to be considerablyless power than in the artificial arms fitted inthis country.

Undoubtedly there are cases in this countryvery suitable for the Sauerbruch operation, asmodified.by Lebsche, and a great point to beremembered is that the stump is not mutilatedfor use with the standard limbs if the cine-plastic procedure does not meet with thesuccess anticipated. The cineplastic operationsare not difficult but a sound training in plasticsurgery is needed for their successful accom-plishment, as scarring must be reduced to aminimum and full allowance made for allcontractures.The Sauerbruch hand is not detachable

from the forearm and the Sauerbruch schoolfrown at the idea of replacing the hand bytools to increase efficiency. There does not,however, appear to be any reason why'thegeneral practice of fitting arms as used in thiscountry, cannot be extended by the employ-ment of additional ' motors' by cineplasticoperation in certain suitable cases.

3. The Krukenberg OperationThe Krukenberg operation is designed to

produce a claw 'hand' from the forearmstump by separating a 'radial from an ulnardigit, to each of which muscles are leftattached. These muscles will open and closethe cleft, as well as retaining pronation andsupination of the forearm.The greatest exponents of this operation in

Germany at the moment are the staff of theOskar Helene, Heim--a hospital in Berlinwhich appeared to be their equivalent ofQueen Mary's Hospital at Roehampton. Thisstaff has performed 500 Krukenberg operatiopson the amputees of the 1939-45 war. Whenone recalls that they recommend this operationonly for bilateral forearm amputees, and only

for those of a suitable length, one may justlyfeel appalled at the toll of amputations in-flicted on the German people during this war.The basic principles expounded by the'

staff of the Oskar Helene Heim are that theremaining stump provides the best prosthesesfor a forearm amputation, that the preservationof the sense of touch is all important, and that,where the forearm amputation is unilateral, thestump itself, without any operation, providesthe most useful ' helping hand.' The train-ing required for a Krukenberg stump takesfour to six months and it is found that as arule a unilateral forearm amputee will notapply himself adequately while he has a normalhand upon which to rely. The Krukenbergoperation is performed in two stages with aninterval of two weeks. The skin incisions andflaps are shown in the drawing (Figs. i3a andI3b), 'and the following notes cover theprocedure.

Flexor digitorium sublimus is split, the mediannerve identified and excised up to the antecubitalfossa, blunt dissection down to the interosseousmembrane, the membrane is cut up as high as 6-8cm. from the elbow, forceful splitting beyond thisto allow of 5 in. separation of the bone ends, thetourniquet is then released. Haemostasis is secured,the deep fascia is sutured to deep fascia along eachside of the cleft but a i in. separation remains be-tween the dorsal and ventral fascial edges. Notendon transplantation is performed. The extensordigitorium is the most important muscle in closingthe cleft and is split between the ring and middlefinger components (the power of this muscle inclosing the cleft was demonstrated by electricalstimulation).The radial digit is covered with the radial skin

flap and the proximal rotation flap completes thecommissure (the soft ventral skin stretched to allowgood rotation and can still be stitched back). Aflap is now raised over the lower ribs anterolaterallypedicle upwards and the defect is closed afteradequate undercutting. The forearm is now placedacross the suture line and the flap used to cover theskin defect on the ulnar digit, being sutured to therotation flap, the dorsal skin edge and along theend of the digit. Dressings are applied and the arnis fixed to the chest wall by plaster of Paris embrac-ing both.Two weeks later the pedicle of the chest flap is

severed and the closure is completed.Training is commenced as soon as healing is

complete and the wedges illustrated (Fig. I4)are used during training, although they arediscarded later.

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As regards the capabilities of the Kruken-berg stump in a bilateral amputee, these wereimpressively demonstrated by the youngtrainer and others at this hospital. Theirperformances included (Figs. i 5 and i6)

(a) Tying a tie.

(b) Writing.(c) Threading a needle with twine.(d) Buttoning a coat.(e) Cycling with confidence.(f) Playing vigorous hand ball and tennis

quoits.(g) Vigorous exercise wA,ith the punch ball.(h) Lifting 70 lb. by direct upward

pull with the straight elbow.

The men were trained to be completelyindependent as well as receiving vocationaltraining in heavy or light occupations. Thestumps undoubtedly stood up well to thestrain of hard use in most cases. In cases seenwith a Krukenberg stump on one side and aSauerbruch arm (cineplastic) on the other, thepatients appeared to prefer the former. Inthese cases, the cineplastic operation had beenperformed on one side because the forearmstump was too short for a Krukenberg opera-tion. It is noted that the Krukenberg opera-tion is bnly suitable for forearm stumps over acertain length, variously computed as from12 cm. to 17 cm., with an optimal length of22 cm. The Krukenberg and Sauerbruchoperations were thus employed in a singleplan of procedure, the bilateral case and theblind being the cases in which the Krukenbergoperation particularlv recommended itself.

The basic principle enunciated at the OskarHelene Heim for 'forearm amputation--'thatthe most useful prosthesis is the stump'was well illustrated by a short (4 in.) B.E.amputee employed as a blacksmith. His shortstump, which he uised to help in holding sledge-hammers, etc., was grooved and cornified in amost impressive manner. One could not helpbut be impressed wvith the importance of thepreservation of the touch sense in the blindand the general conclusion was that theKruklenberg' operation gives to the stump agreater usefulness than is accomplished by anyother procedure. This stump may be rather

unsightly but for function it appears unsur-passed both in power and in precision ofaction.

As in the case of the cineplastic operation,the Krukenberg stump can still be used in thestandard prosthesis used in this country so thatnothing need be lost in attempting whatappears in many cases to be a great gain. Forthe blind bilateral forearm amputation, theKrukenberg operation would appear to offergreat possibilities. Here' the preservation ofthe sense of touch is invaluable. The useof the Krukenberg operation in native races,where no artificial arm is to be expected,deserves consideration, but would there besufficient application in training, a factor ofmore importance even than the surgery, andwould there be any facilities for training ?The occasional case loses both facilities andexample and is, I fear, doomed to failure. Inthe Oskar Helene Heim, the surgery wasexcellent, the morale very high, the trainingfirst class, and each new case had the invaluableexample of those more advanced in theirtraining.

4. ConclusionLittle has been said about the standard

artificial limbs made in this country but thereare adequate sources of information availableto the reader. Advances are being made fromyear to year. This paper deals largely withobservations made in other countries duringthe last two years. It has touched on manyproblems of the limbless, some of themvirtually solved, others remaining in the ex-perimental stage while the solution of manyhas yet to be found. The work in Germanyshows that not only the artificial limb but alsothe amputation stumps themselves presentfurther possibilities. The Krukenberg stumpfor the bilateral blind amputee undoubtedlyprovides a great advance. The idea that theremaining forearm stump is the best form ofprosthesis, even for the sighted, deservescarefill attention. We know the importance oftouch in peripheral nerve lesions of the hand,has this been underestimated in the case of theforearm amputation ?

The cineplastic operation provides simplesuspension of the- artificial limb and a fresh

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June 1947 EYRE-BROOK: Equipping the Limbless 279

source of motors for the prosthesis. There isno question that these procedures work wellin the hands of the expert, technical difficultieshave been overcome and the limbless are pro-vided with a mechanical hand operated 'bythese motors. An improved type of hand forthe cineplastic stump would be a great helpas the Sauerbruch hand is a poor mechanicalhand. But is there any gain over the shoulderoperated artificial limbs used in this country,the power is greater in these latter but thesuspension not as simple ? Professor Lebscheemploys both cineplastic motors and shoulderaction, and the cineplastic operation must atleast be kept in mind as a means of providingfurther' motors in certain cases and as a help insuspension with very short stumps.The suction and vacuum sockets and the

quadrilateral outlet to the A.K. socket appear

to be definite advances. Further experience ofboth is needed before one can fairly judge theirvalue.- In Germany the suction sockets werevery popular in the hands of over 30 limbmakers who were visited, and ehave cases inthis country who have worn them for 20 yearswith great success.The art and science of equipping the limb-

less owes its antiquity to the fact that amputa-tion must be one of the oldest of operations,but it has, as yet, reathed no finality. Thesurgery, the limb fitting, the mechanics andthe engineering present further problems andthe ingenuity and the labours of many arebeing utilized in their solution.My thanks' are due to Professor Pomfret

"Kilner and to Dr. Craft of the ResearchDepartment at Roehampton for most of theexcellent photographs illustrating this article.

REFERENCES,. A MINISTRY of PENSIONS' publication (193), 'Artificial

limbs and their-relation to amputations.' is Majesty'sStationery Office.

2. LANGDALE-KELHAM and PERKINS (1942), 'Am-putations and Artificial Limbs,' Oxford University Press.



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