The Journal of Bone and Joint Surgery (American). 2006;88:1294-1300.
doi:10.2106/JBJS.E.00982
© 2006 The Journal of Bone and Joint Surgery, Inc.
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Prosthetic Management of Children with Unilateral Congenital Below-Elbow Deficiency

Jon R. Davids, MD1, Lisa V. Wagner, OTR/L1, Leslie C. Meyer, MD1 and Dawn W. Blackhurst, DrPH2

1 Motion Analysis Laboratory, Shriners Hospital for Children, 950 West Faris Road, Greenville, SC 29601. E-mail address for J.R. Davids: jdavids{at}shrinenet.org
2 Department of Biomedical Research, Greenville Hospital System, 701 Grove Road, Greenville, SC 29605

Investigation performed at the Shriners Hospital for Children, Greenville, South Carolina

The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: There is substantial controversy concerning the prosthetic management of children with unilateral congenital below-elbow deficiency. The optimal age at the time of the initial fitting, the value of intensive prosthetic training, and the preferred prosthetic design for these children have not been established.

Methods: The outcomes of prosthetic management for 260 children with unilateral congenital below-elbow deficiency, treated between 1954 and 2004, were analyzed with respect to ongoing clinic attendance and self-reported prosthetic use. A successful prosthetic outcome was defined as a child and parents who continued to attend the limb-deficiency clinic and claimed at the time of the most recent follow-up that the prosthesis had been worn for any period of time. An unsuccessful prosthetic outcome was defined as a child and parents who were lost to follow-up or who claimed at the time of the most recent follow-up that the child never wore the prosthesis. Survival analysis was performed.

Results: An unsuccessful prosthetic outcome was noted for 127 children (49%). Initial fitting prior to the age of three years was associated with improved prosthetic outcome (p < 0.001). With the numbers studied, there was no additional benefit noted for fitting before one year of age (p = 0.60). Improved prosthetic outcomes were noted in children who had received intensive training at the time of fitting with an active terminal device (p = 0.005). Provision of a variety of prosthetic designs over the growing years was also associated with improved prosthetic outcome (p < 0.001).

Conclusions: This study supports the initial prosthetic fitting for a child with unilateral congenital below-elbow deficiency prior to the age of three years, the provision of intensive training under the direction of an occupational therapist when an active terminal device is applied, and utilization of a variety of prosthetic designs over the child's years of growth. Further analysis of outcomes for the prosthetic management of these children will require more precise definitions of outcome in multiple domains and the development and validation of specific outcome instruments.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.


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