INTERNATIONAL FORUM--
International Standadrds Organization Terminology: Application to Prosthetics and Orthotics
C. Michael Schuch, CPO, FISPO
Charles H. Pritham, CPO
ABSTRACT
In 1989 the International Standards Organization (ISO)
adopted terms intended for descriptive use in prosthetics,
orthotics and related allied health professions. Included are
ISO Standard 8548-1, Prosthetics and Orthotics - Limb Deficiencies, Part 1: Method of Describing Limb Deficiencies
Present at Birth, and Standard 8549-1, 2 & 3, Prosthetics
and Orthotics-Vocabulary, Part 1: General Terms for External Limb Prostheses and External Orthoses, Part 2:
Terms Relating to External Limb Prostheses and Wearers of
these Prostheses, and Part 3: Terms Relating to External
Orthoses.
In 1993, the American Academy of Orthotists and Prosthetists (AAOP) and the American Orthotic and Prosthetic
Association (AOPA) adopted and endorsed the ISO terminology. This terminology is also supported and endorsed
by the American Academy of Orthopaedic Surgeons
(AA OS) and the International Society for Prosthetics and
Orthotics (ISPO). This article reviews some of the ISO
terms.
Introduction
During the 1970s, with the advent and growth of ISPO, the
need for international descriptive communication amongst
physicians, surgeons, prosthetists, orthotists, engineers
and therapists increased dramatically. Understanding anatomical, orthopedic and rehabilitation terms, seemingly a
language of their own, is difficult enough within one's
native language. Translating terms from one language to
another was complicated by the fact that different systems
of nomenclature were used in different parts of the world.
In some cases different systems were used even within the
same country (1).
The first attempt to devise a unified system of nomenclature for congenital limb deficiencies was undertaken by
Frantz and O'Rahilly and was published in the Journal of
Bone and Joint Surgery in 1961 (2). Frantz and O'Rahilly
created a clear, concise and comprehensive system of nomenclature that was rapidly adopted by clinicians in the
United States. However, the system contained a number
of terms unacceptable to European orthopedic surgeons.
The primary problem was use of the word "hemimelia,"
which had multiple meanings in European translations (1).
Hemimelia literally means "half a limb," which may be
interpreted as "present," "absent" or "affected" in translations (1).
In 1966, in an effort to overcome some of the terminology problems, the Frantz and O'Rahilly scheme was revised, substituting the word "meromelia" for hemimelia to
describe partial-limb absences. However, many practitioners continued to use the original terminology.
Swanson proposed a third classification alternative in
1964 (3). To further confuse the terminology situation, the
German nomenclature for classification of limb deficiencies followed a different course.
It was against this background that a working group met
in Dundee, Scotland in June 1973 to develop a system of
terminology that might be acceptable internationally (1).
This group-which was formed under the auspices of ISPO
and had nine members representing five countries-was
charged with developing an accurate system of classification and nomenclature to facilitate scientific, descriptive
communication about amputation levels, congenital limb
deficiencies, and prosthetics and orthotics in general (4).
The terms created by this group have been modified slightly and adopted and endorsed by ISO.
ISO wanted the terms to be in scientific language that is
simple, precise and easily understood by all in the English-speaking world and easily translatable into other languages. In many cases, ISO terms incorporate vocabulary
that is familiar and already well accepted. In other cases,
ISO terms introduce new vocabulary in a departure from
previously accepted practice. This article reviews well-accepted, recently ISO-endorsed vocabulary. New terms,
primarily introduced to describe amputation levels and
congenital limb deficiencies, will be discussed and illustrated in detail.
Overview of Previously Accepted, ISO-Endorsed Terms
ISO 8549 Part I consists of general terms for external limb
prostheses and external orthoses and includes terms and
definitions for prostheses and orthoses, anatomical terms,
and personnel and procedures. Some examples from each
subsection are offered below (5):
2.1 Prostheses and Orthoses
2.1.1 prosthesis; prosthetic device: externally applied
device used to replace wholly, or in part, an absent
or deficient limb segment.
2.1.2 orthosis; orthotic device: externally applied
device used to modify the structural and functional characteristics of the neuromuscular and skeletal systems.
2.2 Anatomical Terms
2.2.1 lower limb: that part of the body comprising the
foot, the leg, the thigh, the pelvic girdle and the
intermediate joints.
2.2.2 hip joint: ball-and-socket joint between the proximal head of the femur and the acetabulum in the
Os coxae.
2.3 Personnel and Procedures2.3.1 orthotist: person who, having completed an approved course of education and training, is authorized by an appropriate national authority to
design, measure and fit orthoses.
2.3.6 prosthetic-orthotic assessment: review of the overall condition of the patient by those involved in the
treatment, and the recommendation by the prosthetist or orthotist of the components and clinical
fitting procedures best suited to the circumstances of that
patient.
ISO 8549 Part 3 consists of terms, abbreviations and
definitions relating to external orthoses. Examples include
(6):
2.1 foot orthosis (FO): orthosis that encompasses the
whole or part of the foot.
2.19 thoraco-lumbo-sacral orthosis (TLSO): orthosis
that encompasses the whole or a part of the thoracic, lumbar, and sacro-iliac regions of the trunk.
The important point to note concerning ISO 8549 Parts I
and 3 is that these are familiar terms, currently and previously used routinely within the allied health professions.
ISO adoption and endorsement does not constitute a
change from accepted practice.
New ISO Vocabulary
The vocabulary and terms adopted by ISO to describe
amputation levels and congenital limb deficiencies show
the greatest departure from previously accepted practice.
While attempting to describe similar clinical scenarios, the
previously accepted terms for amputation levels and congenital deficiencies were derived from very different origins and used unrelated terminology. Description of an
amputation/deficiency at mid-tibia would use the term below-knee amputation for an acquired amputation and terminal transverse partial hemimelia, lower limb for a congenital limb deficiency. Both vocabularies proved to be
difficult to translate from English to other languages, thus
the overwhelming need for revision.
ISO 8549-2.1 Level of Amputation of Limbs in Acquired
Amputees
This standard consists of terms relating to external limb
prostheses and wearers of these prostheses (terms and
definitions describe acquired amputation levels) (7). In a
departure from the previously accepted American practice
of using the terms above, below or through the joint involved, such as below-elbow or through-knee, the new
terminology uses three adjectives: trans, disarticulation
and partial.
The adjective trans is used when the amputation is across
the axis of a long bone, such as transfemoral or transhumeral. In the two cases where there are two contiguous
bones, tibia/fibula and radius/ulna, only the primary or
large bone is identified (e.g., transtibial, transradial).
When the amputation is between long bones, which anatomically is through the center of a joint, the adjective
disarticulation is used (e.g., knee disarticulation, ankle
disarticulation).
Partial describes amputations of the foot distal to the
ankle joint and amputations of the hand distal to the wrist
joint. The single exception is the use of the term forequarter amputation for amputation of the upper limb at the
scapulo-thoracic and the sternoclavicular joints.
Use of proper nouns for description, such as Syme or
Boyd, is discontinued in the new ISO vocabulary; a Syme is
referred to as an ankle disarticulation, and any amputation
distal to this level is referred to only as a partial-foot amputation. Refer to Figure 1
for a depiction of acquired amputation levels, the new ISO terms, and where applicable, the
previously accepted terms.
ISO 8548-1 Method of Describing Limb Deficiencies
Present at Birth
In this terminology, all congenital limb deficiencies fall
into one of two groups: transverse or longitudinal (1,4,8).
The transverse deficiencies resemble amputation-type
conditions and are characterized by normal development
until the point of the deficiency, beyond which the normal
anatomy does not exist. In the case of the long bones-the
arm, thigh, forearm and leg-the transverse deficiency is
described by naming the long bone and the general location with regard to the long bone, such as complete (total),
upper-third, middle-third, lower-third (e.g., transverse deficiency of the left thigh, lower third would be the term
applied to the long above-knee or transfemoral amputation-like limb that terminates in the distal third of the
femur) (see Figure 2
).
For transverse deficiencies that terminate in the carpal,
tarsal, metacarpal, metatarsal and phalangeal areas, only
the designations complete and partial are used (e.g., if one
row of carpals still remained, the terminology would be
transverse deficiency, carpals, partial) (see Figure 3
). For a
schematic depiction of transverse limb deficiencies, ISO
terminology, see Figure 4
.
The second category of congenital limb deficiencies,
designated as longitudinal deficiencies, includes all deficiencies that do not fall in the transverse category. These
deficiencies are characterized by absence of skeletal anatomy within the long axis of a limb and in some cases include
normal anatomy distal to the affected bone or bones. The
longitudinal deficiencies are named by the bones affected
in a proximodistal sequence, and terms indicate whether
each affected bone is totally or partially absent.
More specifically, for metacarpal bones and metatarsal
bones and their respective phalanges, the number of the
digit affected is stated by numbering these digits from the
radial and tibial sides, respectively, and numbering the
"thumb" and "great toe" as "1." Examples: Partial absence of the fibula would be a longitudinal deficiency of the
right fibula, partial (see Figure 5
). Upper-limb deficiency
of the radial side of the forearm would be a longitudinal
deficiency, right; radius, complete; carpals, partial; metacarpals 1, 2, complete; phalanges 1, 2, complete (see Figure 6
). For schematic depictions of longitudinal upper and
lower limb deficiencies, see Figure 7
and Figure 8
.
Worthy of comment are the longitudinal deficiencies of
the lower limb previously known as proximal femoral focal
deficiencies (PFFD). Classified A, B, C or D by Aitken
according to the degree of proximal femur and ilio-femoral
joint development, this group of deficiencies may continue
in clinical reference as Puffs (9). Indeed, other familiar
clinical terms such as amelia and phocomelia may persist as
well. However, it is incumbent upon us as professionals in
orthotics and prosthetics to support and use the ISO terminology in our publications, presentations and other professional endeavors.
Conclusion
In 1989 ISO adopted and endorsed a series of standards for
terminology relevant to orthotics and prosthetics. ISPO
and AAOS furthered the endorsement in 1992 by using
this terminology in their respective publications, Report of
ISPO Consensus Conference on Amputation Surgery (10)
and The Atlas of Limb Prosthetics-Surgical, Prosthetic
and Rehabilitation Principles (11).
In 1993 the boards of directors of AAOP and AOPA
independently passed motions to endorse and support the
ISO terminology. This terminology includes previously accepted terms as well as introduces new terms. Attempts
were made to select vocabulary that is easily understood in
English and that is successfully translatable into other languages.
Note:Figures 2-5 reproduced by photograph and figures 6-8 reproduced
by computer with permission of the American Orthotic and Prosthetic Association, see reference number 1.
C. Michael Schuch, CPO, FISPO, is assistant clinical professor and director of prosthetics and orthotics at Duke University Medical Center, Box 3885, MO4 Davison Building, Durham, NC 27710; (919) 684-6890; fax (919) 681-8496. Mr. Schuch is also the editor of the JPO.
Charles H. Pritham, CPO, is an insturctor and coordinator of education and research in prosthetics and orthotics at Duke University Medical Center; (919) 684-2474.
References:
- Kay HW et al. A proposed international terminology for the
classification of congenital limb deficiencies. In: Selected Readings: A Review of Prosthetics and Orthotics. Washington, D.C.:
American Orthotic and Prosthetic Association, 1980:24-39.
- Frantz CH, O'Rahilly R. Congenital skeletal limb deficiencies. JBJS 1961;43~A:H:8:1202-24
- Swanson AB. A classification for congenital malformation of
the hand. New Jersey Bulletin, Academy of Medicine
1964; 10: 166-9.
- Day HJB. The ISO/ISPO classification of congenital limb deficiency. In: Chapter 33 Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles. 2nd ed. St. Louis: Mosby
Year Book, 1992:743-8.
- International Organization for Standardization. ISO 8549-1:
Prosthetics and orthotics-vocabulary, Part 1: General terms for
external limb prostheses and external orthoses. Geneva: International Organization for Standardization, 1989:1-6.
- International Organization for Standardization. ISO 8549-3:
Prosthetics and orthotics-Vocabulary, Part 3: Terms relating to
external orthoses. Geneva: International Organization for Standardization, 1989:1-5.
- International Organization for Standardization. ISO 8549-2:
Prosthetics and orthotics-Vocabulary, Part 2: Terms relating to
external limb prostheses and wearers of these prostheses. Geneva: International Organization for Standardization, 1989:1-4.
- International Organization for Standardization. ISO 8548-1:
Prosthetics and orthotics-Limb deficiencies, Part 1: Method of
describing limb deficiencies present at birth. Geneva: International Organization for Standardization. 1989:1-6.
- Aitken GT. Proximal femoral focal deficiency: definition,
classification and management. In: Swinyard CW (ed.): Limb
Development and Deformity - Problems of Evaluation and Rehabilitation. Springfield, Ill.: Charles C. Thomas, 1969:1-22.
- Murdoch G, Jacobs NA, Wilson Jr. AB (eds.) Report of
ISPO Consensus Conference on Amputation Surgery. Copenhagen: International Society for Prosthetics and Orthotics: 1992.
- Bowker JH, Michael JW (eds.) Atlas of Limb Prosthetics-
Surgical, Prosthetic and Rehabilitation Principles. St. Louis:
American Academy of Orthopaedic Surgeons and C.V. Mosby
Co. :1992.
|
|
