O&P Flashcards
Difference between accommodative vs corrective orthosis?
Accommodative: for fixed deformities to redistribute forces
Corrective: modify CKC and loading.
What type of shoe opening do you want for use with orthoses
Blucher - has vamps that open wide for ease of application
NOT bal that has stitched down vamps.
Post vs wedge with orthotics?
Post – placed inside shoe for modification
Wedge – placed outside of shoe for modification (external modification)
Medial wedge (varus post)
limits or controls excessive eversion (pronation) and IR of tibia at heelstrike.
Lateral wedge (valgus post)
controls calcaneal and subtalar joints that are excessively inverted (supinated) and supinated at heelstrike
Heel lift
accommodates for leg length discrepancy
Inside shoe - up to 3/8 inch
Outside shoe - anything greater than 3/8 of inch.
Rocker bar
located proximal to metatarsal heads and improves weight shifting onto the met heads
Rocker bottom
located proximal to metatarsal heads and improves weight shifting onto the met heads
Subtalar neutral norm
~1-4 deg of inversion
Noted tibiofibular varum in subtalar neutral requires what compensation
medial foot elevation requiring excessive compensatory foot pronation during gait
Reasons for genu recurvatum
equinus deformity at the ankle
poor control of quad/hamstring
LLD (slight) – larger LLE will cause excessive knee flexion contralateral
Navicular Drop
Greater than 10 mm drop is considered abnormal. Places pt in excessive pronation
What rotational components superiorly can cause abnormal foot pronation
internal tibial torsion leads to increased medial rotation forces
Femoral anteversion leads to increased medial rotational forces
What rotation components superiorly can cause abnormal foot supination
Excessive external tibial rotation leading to increased lateral rotation forces
Excessive femoral retroversion leading to increased lat. rotation forces
Metatarsalgia
Pain at met heads from compression of plantar digital nerve
Solution: Shoe with….
Wide width (reduce pressure on transverse met. arch)
Long shoe with high toe box so that MTP’s are not cramped
Cushioned sole for shock absorption
Low heel to minimize pressure on met heads
If severe: transverse metatarsal bar (moves pressure from met heads to met shafts) Rocker sole (reduces motion of painful joints)
Sesamoiditis
Inflammation of sesamoid bones under 1st met heads
Solution: Shoe with…
Transverse metatarsal bar → (pressure from met heads to met shafts)
Rocker sole → (reduces motion at hallux joint)
Morton’s Syndrome
Pain between 1st & 2nd met heads; 2nd toe as long or longer than 1st toe
Solutions: Shoe with…
Long medial counter for rearfoot support/stability
Morton’s extension: flexible platform under 1st met & toe (1/8 to ¼”)
High & wide toe box to reduce compression on transverse arch
Long shoe to accommodate long 2nd toe
Thomas heel or medial sole wedge to support medial longitudinal arch
Mortons interdigital Neuroma
Pain at proximal phalanx or intersitital space b/w met heads (especially b/w 3rd & 4th)
Solutions: Shoe with…
Wide shoe to relieve transverse arch compression
Long enough to ↓ PF of MTP joints
Long medial counter to ↓pronation
Cushioned sole for ↑ shock absorption
Low heel to take pressure off of met heads
Metatarsal bar or rocker bar
Hallux Valgus (Bunions)
Pain at medial aspect of 1st MTP
Solution: Shoe with…
High/wide toe box
Thermold/soft upper
Long enough so toes are not cramped
Soft cushioned outsole
Low heel
Metatarsal Bar or Rocker sole
Hammertoes
Presentation: Weight bearing on met heads & distal phalanx
MTP: hyperextension
PIP: flexion
DIP: extension
Solutions: Shoe with…
High & wide toe box
Thermold/soft upper
Long enough to promote flexion of MTP’s & extension of PIP’s
Soft cushion outsole
Low heel
Metatarsal bar or Rocker sole
Claw toes
Presentation: Pressure on the tip of the distal phalanx
MTP: hyperextension or flexion
PIP: hyperflexion
DIP: hyperflexion
Solution: Shoe with…
High & wide toe box
Thermold/soft upper
Long enough to promote flexion of MTP joint & ext. PIP’s
Soft cushion outsole
Low heel
Metatarsal bar, rocker sole
Mallet toes
Presentation: Weight bearing on tip of distal phalanx
MTP: hyperextension
PIP: neutral
DIP: flexion (buckles)
Solution: Shoe with…
High & wide toe box
Thermold/soft upper
Long enough to promote flexion of MTP’s & extension of PIP’s
Soft cushion outsole
Low heel
Metatarsal bar, rocker sole
Pes planus
Observable pronation of midfoot results of foot to supinate during midstance
Solutions: Shoe with
o Fixed:
Broad shank (extra wide mid-foot)
Straight Last
Long Medial Counter
Medial Wedge sole to ↓ pressure on met heads & stabilize foot
o Flexible:
Long medial counter
Thomas heel with medial flare
Straight Last
Pes Equinus
Plantarflexion deformity
Solution: Shoe with…
o Fixed:
Posterior platform to support rearfoot from heel strike to midstance & mimics DF at toe-off
Equalize LLD (when equinus is unilateral)
o Flexible:
Low heel
Rocker bottom to provide DF assist and reduce loads on met heads
Pes Cavus
Excessive longitudinal arch with pressure on met heads and heel
Solutions: Shoe with…
Lateral flare for stability
Firm heel counter for rearfoot stability
Cushioned sole for shock absorption
Curved last to accommodate foot deformity
Metatarsal bar to reduce stress on met heads
Plantar Fasciitis
Pain on plantar surface of foot at heel
Solutions:
Long medial counter to limit heel valgus
High heel to limit tension on plantar fascia and Achilles tendon in WB
Posterior Heel Elevation
Night splint (5º of DF, in NWB)
Gel Cups
Haglund’s Deformity, Achilles Tendinitis, and Bursitis orthotic choices
Heel pain
Cause:
Haglund’s deformity: Osseous formation at insertion of Achilles tendon at calcaneus
Achilles tendinitis: Repetitive or intense strain on Achilles tendon
Heel Bursitis: Overuse or direct trauma to joint
Solutions for Haglund’s deformity, Achilles Tendinitis, and Bursitis:
Higher heel (slight) to reduce DF
Long medial counter to limit subtalar motion
Long shoe to reduce compression
Possible backless shoe for Haglund’s deformity
Posterior heel elevation to reduce tension on Achilles tendon
Foam filled heel cup
Pt with peripheral neuropathey with decreased Tib ant. (3-/5) and foot slap. Had dec. sensation and has occasional falls due to tripping. Hip and knee grossly 4/5. ROM is WNL for LE. Which orthotic is most appropriate?
Custom posterior leaf spring orthosis
- Custom posterior leaf spring orthosis: would be the most appropriate orthosis for this patient. This orthosis resists plantar flexion at heel strike and during swing phase, thus preventing foot slapping and toe dragging. A custom orthotic would be necessary since the patient has decreased sensation and is prone to skin breakdown.
- Prefabricated orthotic: would not be appropriate due to the patient’s diminished sensation. Sensory deficits typically require a custom-made orthotic to reduce the risk of skin breakdown.
Distal interphalangeal splint
- Rigid splint that is placed on either the volar or dorsal aspect of the finger and spans from the tip of the finger to the proximal portion of the middle phalanx.
- Used to immobilize the DIP joint to allow injured structures to heal or to rest a painful or inflamed joint.
- Conditions include: mallet finger, a distal Phalanx fracture, and DIP joint arthritis.
- When treating mallet finger, the DIP joint should be placed in neutral or slight hyperextension to allow for healing of the damaged extensor tendon.
Ulnar gutter splint
- Rigid splint that covers the ulnar side of the forearm and hand as well as the fourth and fifth digits.
- Used to immobilize the metacarpals and phalanges and is commonly used following a fracture to these structures.
- When splinting, the metacarpophalangeal (MCP) joints are placed in 60-90 degrees of flexion with the interphalangeal (IP) joints in full extension and the wrist in slight extension.
Radial gutter splint
- Rigid splint that covers the radial side of the forearm and hand as well as the second and third digits.
- Includes a thenar hole to allow for free movement of the thumb.
- This type of splint is used to immobilize the metacarpals and phalanges and is commonly used following a fracture of these structures.
- When splinting, the MCP joints are placed in 60-90 degrees of flexion with the IP joints in full extension and the wrist in slight extension.
Thumb spica splint
- Rigid splint that covers the radial side of the forearm and hand as well as the thumb.
- May cover the entire thumb or may stop at the proximal phalanx of the thumb and thus allow for IP joint motion.
- Used to immobilize the wrist and MCP joint of the thumb
- Commonly used for treating gamekeeper’s thumb, scaphoid fractures, first metacarpal fractures, de Quervain’s syndrome, and other thumb injuries.
- When splinting, the wrist should be in 20 degrees of extension with the MCP joint in slight flexion.
Volar/dorsal forearm splint
- Rigid splint that extends from the proximal forearm to the metacarpal heads, allowing for full elbow and MCP joint motion.
- Includes a thenar hole to allow for free movement of the thumb as well.
- Used to immobilize the wrist joint and is commonly used for treating fractures of the carpals, fractures of the distal radius or ulna or soft tissue conditions (e.g., sprain, tendonitis).
- Positioning of the splint will vary based on the condition being treated. This type of splint can also place the wrist and hand in a functional position to allow for improved grasping for patients with significant weakness of the forearm and hand. By placing the wrist in 20 degrees of extension, the finger flexors are shortened and have an improved mechanical advantage for grasping.
Sugar tong splint
- Rigid splint that covers the wrist and elbow joints and allows for greater immobilization than a volar or dorsal forearm splint.
- Limits supination and pronation in addition to any wrist motion.
- The splint starts on the dorsum of the hand, extends along the dorsal forearm to wrap around the elbow, and continues along the volar forearm to end at the palmar aspect of the hand.
- When splinting, the elbow should be in 90 degrees of flexion with the wrist and forearm in neutral.
- Commonly used for treating carpal fractures and distal radius or ulna fractures.
Long arm splint
- Rigid splint that covers the elbow joint (typically on the posterior side), spanning from the wrist to the distal humerus.
- Immobilize the elbow joint to allow for healing following injury or surgery.
- Prevent elbow flexion and extension movements as well as supination and pronation.
- This may be done following an elbow or proximal forearm fracture or to treat a soft tissue injury (e.g., tendonitis, tendon repair).
- When splinting, the elbow is typically placed in 90 degrees of flexion with the forearm in neutral.
Corset
- Constructed of fabric and may have metal uprights within the material to provide abdominal compression and support.
- Utilized to provide pressure and relieve pain associated with mid and low back pathologies.
Halo Vest Orthosis
- Invasive cervical thoracic orthosis that provides full restriction of all cervical motion.
- A metal ring with four posts that attach to a vest is placed on a patient and secured by inserting four pins through the ring into the skull.
- This orthosis is commonly used with cervical spinal cord injuries to prevent further damage or dislocation during the recovery period.
- A patient will wear a halo vest until the spine becomes stable.
Milwaukee Orthosis
- Designed to promote realignment of the spine due to scoliotic curvature.
- Custom made and extends from the pelvis to the upper chest.
- Corrective padding is applied to the areas of severity of the curve.
Taylor Brace
- Thoracolumbosacral orthosis
- Limits trunk flexion and extension through a three-point control design.
Thoracolumbosacral Orthosis (TLSO)
- A custom molded TLSO is utilized to prevent all trunk motions and is commonly utilized as a means of post-surgical stabilization.
- The rigid shell is fabricated from plastics in a bivalve style using straps/ Velcro to secure the orthosis.
Parapodium
- A parapodium is a standing frame designed to allow a patient to sit when necessary.
- It is a prefabricated frame and ambulation is achieved by shifting weight and rocking the base across the floor.
- It is primarily used by the pediatric population.
Craig Scott Knee ankle foot orthosis
KAFO designed specifically for people with paraplegia.
This allows a person to stand with a posterior lean of the trunk
What is the primary purpose of wearing a shoe with a medial sole flare?
resist eversion
A medial sole flare increases stability of the ankle by resisting eversion. A lateral sole flare would be used to resist inversion.
Relationship between DF/PF and knee flexion/knee extension (in regards typically to the orthosis)
DF associated with knee flexion
PF associated with knee extension
If someone has too much knee flexion – typically they have too much DF and if restricting DF this will help with the issue
Gait with paraplegia (orthoses/energy expenditure/which level)
Use of B KAFOs
Requires 6x energy expenditure than normal walking
Typically not used about T11 due to decreased trunk support/control
Hemiplegia and gait (speed/energy expenditure)
2x energy expenditure
1/2 the prior level of walking speed
A floor-reaction ankle-foot orthosis would be most appropriate for a patient that:
- demonstrates difficulty with knee flexion during gait
- presents with a spinal cord injury at the level L1
- demonstrates difficulty with knee extension during gait
- presents with stroke and demonstrates poor balance
demonstrates difficulty with knee extension during gait
A floor-reaction ankle-foot orthosis promotes knee extension and can help reduce knee buckling with ambulation.
A floor-reaction ankle-foot orthosis would be most appropriate for a patient that:
- demonstrates difficulty with knee flexion during gait
- presents with a spinal cord injury at the level L1
- demonstrates difficulty with knee extension during gait
- presents with stroke and demonstrates poor balance
demonstrates difficulty with knee extension during gait
A floor-reaction ankle-foot orthosis promotes knee extension and can help reduce knee buckling with ambulation.
Which of the following is the most appropriate for daytime use by a 14-year-old female with a mid-thoracic curve of 25 degrees?
- Boston thoracolumbosacral orthosis
- Philadelphia collar
- Jewett brace
- halo-vest
Boston thoracolumbosacral orthosis
The Boston thoracolumbosacral orthosis is used for daytime bracing and is most effective for curves below 35 degrees. A spinal orthosis is often warranted for scoliotic curves ranging from 25-40 degrees. Surgical intervention may be necessary for curves over 40 degrees.
Scoliosis intervention
Bracing most effective for curves < 35 deg.
A spinal orthosis is often warranted for scoliotic curves ranging from 25-40 degrees.
Surgical intervention may be necessary for curves over 40 degrees.
A solid ankle cushion heel is most likely to be prescribed to which patient requiring a prosthesis?
- an athlete who wishes to return to running and other sports
- a child
- a senior citizen who wishes to return to household and community ambulation
- a female who wishes to return to hiking mountainous terrain
A senior citizen who wishes to return to household and community ambulation
A solid ankle cushion heel (SACH) is appropriate for both genders and all ages and is most useful for ambulation over even surfaces for household distances.
A Pavlik harness would result in the hip being positioned in:
hip flexion and abduction
A Pavlik harness is the primary method of treating developmental dysplasia of the hip (DDH). DDH is a subluxed or dislocated hip in infancy as a result of abnormal congruency of the femoral head and acetabulum. The Pavlik harness maintains the infant’s hips in flexion and abduction to enhance acetabular development.
Which cervical orthosis effectively limits motion in all planes and allows for early mobility and rehabilitation after a vertebral fracture?
- Jewett orthosis
- Milwaukee brace
- Boston brace
- Minerva orthosis
Minerva orthosis
The Minerva orthosis positions the head and applies stabilizing forces under and around the chin and occiput to restrict flexion and extension, lateral motion and rotation of the head and cervical spine. The remaining options would not limit mobility in the cervical spine.
Which variable would be the most compelling to warrant use of a scoliosis brace?
-10 degree scoliotic curve
- rapid progression of an existing curve
- significant pain impacting functional activities
- subjective report of instability
rapid progression of an existing curve
Bracing is typically used in patients with 20-40 degree scoliotic curves. Rapid progression of an existing curve often warrants utilization of a scoliosis brace even if the magnitude of the curve does not reach the typical 20 degree threshold.
Serial splint
- corrective splint utilized to immobilizes a joint to increase ROM while correcting a deformity such as soft tissue contracture
Dynamic splint
- includes a spring or elastic component to exert force on a joint
- can help facilitate passive or assisted movement of a joint or to resist movement in the direction opposite the line of pull
- Not typically used with acute injuries
Functional splint
- support, protect, and stabilize a joint during specific activities (holding writing or eating utensil)
- Helps to improve efficiency and functional performance of a task.
Resting splint
- maintain a joint in a an appropriate position during an acute exacerbation of symptoms allowing the joint to rest while limiting the risk of contracture development.
K Level0
prosthesis will not enhance quality of life or mobility
K Level 1
- Transfers
- Ambulates level surfaces with fixed cadence
- Limited or unlimited household ambulation
K Level 2
- Traverses low level barriers such as curbs, stairs, or uneven surfaces
- Limited community ambulator
K Level 3
- Variable cadence ambulator
- Unlimited community ambulator
- Transverse most environmental barriers
- Prosthetic use beyond simple locomotion
K Level 4
- Exceeds basic ambulation skills
- Exhibits high impact, stress, or energy levels
- Typical of child, athlete, or active adult
Lateral bending gait deviation with prosthesis
- Prosthesis is too short
- Improperly shaped lateral wall
- High medial wall
- Prosthesis aligned in abduction
Abducted gait deviation with prosthesis
- Prosthesis is too long
- High medial wall
- Poorly shaped lateral wall
- Prosthesis aligned in abduction
- Inadequate suspension
- Excessive knee friction
Circumducted gait deviation with prosthesis
- Prosthesis is too long
- Excessive knee friction
- Socket too small
- Excessive plantar flexion
Excessive knee flexion in stance gait deviation with prosthesis
- Socket set forward in relation to foot
- Excessive dorsiflexion
- Stiff heel
- Prosthesis too long
Vaulting gait deviation with prosthesis
- Prosthesis too long
- Inadequate socket suspension
- Excessive alignment stability
- Excessive plantar flexion
Rotation of the forefoot at heel strike gait deviation with prosthesis
- Excessive toe-out built in
- Loose fitting socket
- Inadequate suspension
- Rigid SACH heel cushion
Forward trunk flexion gait deviation with prosthesis
- Socket too big
- Poor suspension
- Knee instability
Medial or lateral whip gait deviation with prosthesis
- Excessive rotation of the knee
- Tight socket fit
- Valgus in the prosthetic knee
- Improper alignment of toe break
Most common cause of LE amputation?
Peripheral vascular disease
Forequarter (scapulothoracic) amputation
UE amputation including surgical removal through the shld girdle
Shld disarticulation amputation
surgical removal of the UE through the shld.
Transhumeral amputation
surgical removal of the UE proximal to the elbow joint
Elbow disarticulation
surgical removal of the lower arm and hand through the elbow joint
Transradial amputation
surgical removal of the UE distal to the elbow joint
Wrist disarticulation amputation
surgical removal of the hand through the wrist joint
Partial hand amputation
surgical removal of the partial hand and digits at either the transcarpal, transmetacarpal or transphalangeal level
Digital amputation
surgical removal of the digits at either the MCP, PIP, or DIP level
Hemicorpectomy
surgical removal of the pelvis and both LE
Hemipelvectomy
surgical removal of the 1/2 of the pelvis and the LE
Hip disarticulation
surgical removal of the LE from the pelvis
Transfemoral amputation
(too short, long, optimal)
surgical removal of the LE above the knee joint
Too short:
- <50% preserved. Makes fitting a prosthesis a challenge and suspension
Too long:
- >66% preserved. Leads to mechanical advantage for prosthetic use.
- Reduced comesis since knee joint is distal to socket.
Optimal length: 50-66% of the femur length
Knee disarticulation
(also pros, cons)
surgical removal of the LE through the knee joint
Pros:
- less time and less blood (since less is going on) (less infection)
- femoral condyles can tolerate WB
- mechanical advantage for prosthesis since entire femur
- heals without much atrophy (less socket replacement/revision)
- preserve growth plate for children
Cons:
- length and shape makes prosthetic fitting difficult
- Where to place the knee unit - which affects energy cost and efficiency of prosthetic gait
Transtibial amputation (where, too much, too little, optimal)
- Surgical removal of the LE below the knee joint
- Too short:
1. mechanical advantage of the knee flexors exceed the extensors (difficult to advance prosthesis and difficult for stance phase control)
2. Surface area for WB decreases – leads to discomfort, skin irritation, limited use of transtibial prosthesis. - Too long:
1. Increased SA to distribute pressure and a longer lever arm to potentially enhance prosthetic control.
2. May not retain adequate soft tissue to envelope the tibia – causes sharp, anterior edge to cause pain, skin irritation, and breakdown. - Optimal - preserve 40-50% of the tibia (increases comfort of prosthesis, quality of gait, and most energy efficient)
Syme’s amputation
- Surgical removal of the foot at the ankle joint with removal of the malleoli.
- Complete disarticulation of the talocrural joint. (typically will keep the fat pad of the calcaneus)
- reduced the leg length
- good for short-distance ambulation without prosthesis
Transverse tarsal (Chopart’s) amputation
Amputation through the talonavicular and calacaneocuboid joints. The amputation preserves the PF, but sacrifices the DF often resulting in an equinus contracture.
- Mid-tarsal disarticulation. Disarticulation between the talus and anvicular and the calcaneus and cuboid.
Leaves only the talus and calcaneus!!
Tarsometatarsal (Lisfranc) amputation
Surgical removal of the metatarsals. The amputation perserves the DF and PF.
- between the tarsals and the metatarsals.
- keystone base of the 2nd metatarsal left in place to maintain transverse arch.
Keeps the tarsals, talus, and calcaneus!!
Transfemoral amputation common contractures (and where to strengthen)
Contractures:
- hip flexors
- hip abductors
- hip ER
Strengthen:
- Extensors
- Hip adductors (and abductors)
How to MMT a amputee?
- Test intact limb with typical MMT
- Test intact limb with more proximal hand placement (that will be used for amputated limb) as a point of reference
- Test the residual limb with proximal hand placement
Transtibial amputee primary contractures?
Significant risk of developing a hip and knee flexion contracture
Where is the body’s COM shifted to in standing after a LE amputation?
Loss of limb shifts COM slightly upward, backwards, and towards the remaining/intact limb
Amputee w/c considerations
- w/c is likely more energy efficient and quicker than hopping
- Wheels offset posterior is recommended to prevent posterior tipping.
- When reaching backwards or turning backwards has increased chance of tipping backwards (since no counter weight of the LEs)
- When reaching forward extreme pressure of intact limb/foot on chair foot plate can lead to anterior tipping.
Determination of K levels
Medicare Functional Classification Level…aka “K level”
- classifies pts based on functional ability
- Level is determined by current level of function, potential ability to function, and the pts particular needs.
Can be determined by:
– AMPRO (Amputee Mobility Predictor)
– thorough history and examination of the patient.
Who determines:
- MD, prosthetist, and PT
K levels functional abilities
0 - No ability/potential to ambualte or t/f safely with or without assist and prosthesis and won’t enhance QOL or mobility
1 - Ability or potential to use prosthesis for t/f or amb. on LEEVEL SURFACS with FIXED CADENCE
2 - Ability or potential for ambulation with ability to transverse low-level barriers (curbs, stairs, or uneven surfaces)
3 - Ability or potential for amb with VARIED CADENCE, transverse most barriers, and may have activities that require PROSTHETIC USE BEYOND SIMPLE LOCOMOTION
4 - Ability or potential for ambulation that EXCEEDS BASIC AMBULATION SKILLS (high impact, stress, or energy levels…athletes, weekend warriors)
K level 0
No prosthesis. Doesn’t enhance life
K level 1
Knee - single axis, constant friction mechanism
Foot - SACH, single axis
K level 2
Knee - Single axis, polycentric, constant friction
Ankle/foot - Flexible-keel feet and multi-axial ankle/feet
K level 3
Knee - Pneumatic, Hydraulic, microprocessor, variable friction controlled knee
Ankle/foot - flex foot, energy storing feet, multi-axial, or dynamic response feet
K level 4
Knee - Any appropriate
Ankle - Any appropriate
Suspension part of the prosthesis
How the prosthetic socket is attached to the residual limb.
Types:
- Vacuum
- Shuttle lock
- Suction
- Waist belt
- Harness
Socket definition within the prosthesis
- Interface between the residual limb and prosthesis.
- Want to total contact with pressure dispersal to the pressure tolerant
In general what type of tissue is the most pressure tolerant areas?
More muscular areas
Solid Ankle Cushion Heel (SACH)
- solid ankle joint. Keel made of wood/metal creates rigid interior to foot
- Cushion heel created wedge-shaped shock absorber at the posterior portion of the foot
- Rubber toe portion allows the toes to hyperextend during the terminal stance phase of gait and provides the energy storage to advance the limb forward.
Liner within the prosthesis
- Gel liners: cushioning and hosting a suspension mechanism such as a pin or lanyard.
- Mostly nonbreathable which can build up perspiration throughout the day. This can cause friction and irritation of the skin.
Insert portion of prosthesis
- flexible or soft that is placed in the socket.
Flexible
- made of plastic
- can improve comfort and fit
- relieves pressure through buildups and reliefs molded into insert
Soft
- generally foam
- provide cushioning on the residual limb during WB
Transtibial Pressure tolerant and pressure sensitive areas
Pressure tolerant:
- patellar tendon
- lateral fibular shaft
- medial and lateral tibial shaft
Pressure sensitive areas:
- fibular head
- lateral tibial flare
- tibial crest
- distal end of the fibula
- distal end of tibia
- patella
- anterior tibial tubercle
- peroneal nerve
- adductor tubercle.
Transfemoral Pressure tolerant and pressure sensitive areas
Pressure tolerant:
- Ischium
- Soft tissues of residual limb
Pressure sensitive:
- greater trochanter
- pubic tubercle
- pubic ramus
- pubic symphysis
- distal end of femur
- perineum
Initial wear schedule for new prosthesis
General Rules:
- start with 1 hour a day of total wear time (1/2 time with ambulation)
- inspection every 30 min or immediately after amb.
- If tolerating well – 1 hour added each day while respecting to 50% rule of rest:use.
- If continuing to tolerate time between inspection is expanded by 15-30 mins.
Vaulting gait deviation (prosthetic and amputee causes)
Prosthetic causes:
- prosthesis too long
- inadequate socket suspension
- excessive alignment stability
- Excessive PF
Amputee causes:
- Residual limb discomfort
- improper training
- fear of stubbing toe
- Short residual limb
- Painful hip/residual limb
Lateral bending gait deviation (prosthetic and amputee causes)
Prosthetic Causes:
- Prosthesis too short
- improperly shaped lateral wall
- high medial wall
- prosthesis aligned in abduction
Amputee Causes:
- Poor balance
- Abduction contraction
- Improper training
- Short residual limb
- Weak hip abductors on prosthetic side
- Hypersensitive and painful residual limb
Abducted gait deviation (prosthetic and amputee causes)
Prosthetic Causes:
- Prosthesis too long
- High medial wall
- Poorly shaped lateral wall
- Prosthesis positioned in abduction
- Inadequate suspension
- Excessive knee friction
Amputee Causes:
- Abduction contracture
- Improper training
- Adductor roll
- Weak hip flexors and adductors
- Pain over lateral residual limb
Circumducted gait deviation (prosthetic and amputee causes)
Prosthesis Causes:
- Prosthesis too long
- knee locked
- Excessive knee friction
- Socket too small
- Excessive PF
Amputee Causes:
- Abduction contracture
- Improper training
- Weak hip flexors
- Lacks confidence to flex the knee
- Painful anterior distal residual limb
- Inability to intiate prosthetic knee flexion
Excessive Knee Flexion During Stance gait deviation (prosthetic and amputee causes)….Early stance
Prosthetic Causes:
- Socket set forward in relation foot
- Excessive DF
- Stiff heel
- Prosthesis too long
Amputee Causes:
- Knee flexion contracture
- Hip flexion contracture
- Painful anteriorly in residual limb
- Decrease in quads strength
- Poor balance
Excessive knee flexion during stance gait deviation (prosthetic and amputee)….late stance
Prosthetic Causes:
- High heel
- Insufficient PF
- Insufficient DF stop
- Socket placed to anteriorly
Amputee:
- Flexion contracture
Too little knee flexion during early stance (prosthetic and amputee causes)
Prosthetic Causes:
- Soft heel cushion
- Posterior socket placement in relation to foot
Amputee Causes:
- Weak quads
- Extensor spasticity
Delayed knee flexion at late stance phase (prosthetic and amputee causes)
Prosthetic Causes:
- Low heel
- Excessive PF
- Socket placed posterior
Amputee Causes:
- Extensor spasticity
Rotation of forefoot at heel strike gait deviation (prosthetic and amputee causes)
Prosthetic Causes:
- Excessive toe-out built in
- loose fitting socket
- Inadequate suspension
- Rigid SACH heel cushion
Amputee Causes:
- Poor muscle control
- Improper training
- Weak medial rotators
- Short residual limb
Forward Trunk Flexion gait deviation (prosthetic and amputee causes)
Prosthetic Causes:
- Socket too big
- Poor suspension
- Knee instability
Amputee Causes:
- Hip flexion contracture
- Weak hip extensors
- Pain with ischial WB
- Inability to initiate prosthetic knee flexion
Medial or Lateral Whip gait deviation (prosthetic and amputee causes)
Prosthetic Causes:
- Excessive rotation of the knee
- Tight socket fit
- Valgus in the prosthetic knee
- Improper alignment of the toe break
Amputee Causes:
- Improper training
- Weak hip rotators
- Knee instability
Pistoning definition
- Translation of prosthetic limb from the residual limb
- From inadequate suspension and can result in distal residual limb skin issues.
Primary contracture for Syme Amputation?
Ankle PF (equinus deformity)
Myoelectric prosthesis
Device with EMG signals to control movements of the prosthesis with surface electrodes or implantable wires
Endoskeletal shank
- Rigid pylon covered with material designed to simulate the contour and color of the contralateral limb
- Highly adjustable, metal structure
Myodesis definition
- Anchoring of m. tissue or tendon to bone using sutures that are passed through small holes drilled in the bone.
- More stable than myoplastly
- Not performed with ischemic patients
Myoplasty definition
- Suturing of amputated muscle flaps together over the end of a bone following an amputation. (for distal muscle stabilizations)
- Not as common
- Used with patients with poor vascular health
Exoskeletal shank
- rigid external frame covered with a thin layer of tinted plastic to match the skin color distally.
- mimics shape, color, and size of anatomical limb
Pylon
- pipe-like structure that connects the socket of the prosthesis to the foot/ankle components.
- Assists with WB and shock absorption.
Stance Control (Safety)
Weight activated mechanism that maintains knee extension during WB even if the knee joint is not fully extended.
- If they knee is flexed greater than what the control mechanism is designed for, the mechanism will not engage.
Rotationplasty
- portion of the limb is removed while the remaining limb below is rotated and reattached.
- Often performed as a treatment for distal femoral osteosarcoma.
Where is the primary WB portion of the transtibial prostheses?
Patellar tendon
Excessive DF built into a prosthetic ankle may cause excessive…..
knee flexion during stance
Most common level of UE amputation
Transradial
The sutures are to be removed prior to using an elastic shrinker
Wrapping guidelines after amputation
Transtibial - two 4” bandadges; anchor above the knee
Transfemoral - 6” wrap; anchor around pelvis
- Wrap in diagonals
- Use tape to secure
