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
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.