Finger or partial hand: Removal of one or more fingers or part of the hand
Wrist disarticulation: Removal of the hand at the wrist joint
Transradial (below elbow): Removal of the forearm below the elbow joint
Elbow disarticulation: Removal of the arm at the elbow joint
Transhumeral (above elbow): Removal of the arm above the elbow joint
Shoulder disarticulation: Removal of the arm at the shoulder joint
Lower extremity
Toe or partial foot: Removal of one or more toes or part of the foot
Ankle disarticulation: Removal of the foot at the ankle joint
Transtibial (below knee): Removal of the leg below the knee joint
Knee disarticulation: Removal of the leg at the knee joint
Transfemoral (above knee): Removal of the leg above the knee joint
Hip disarticulation: Removal of the leg at the hip joint
**Focus of NPTE is on lower extremity prosthesis
Components of prosthesis
Primary components
Sockets
custom -molded prosthetic that will have total contact with residual limb; goal is equal distribution of tissue load throughout the socket
Liners
Silicone barrier between residual limb and socket to decrease shear forces
Socks
Used to aid in changes size of residual limb
Terminal device
Interface between prosthetic limb and external environment
Upper limb: terminal device is hand or hook
Lower limb: terminal device is foot
Components of prosthesis specifically for transtibial amputation
Ankle-foot assembly
SACH foot (solid ankle cushioned heel):
A simple, durable, and lightweight foot with a solid ankle joint
Single-axis foot:
Features a hinged ankle joint that allows for up-and-down movement, enhancing knee stability.
Multi-axis foot:
Similar to a single-axis foot but also allows for side-to-side movement, making it better suited for uneven terrain
Microprocessor-controlled (MPC) feet:
These feet use sensors and a computer to adjust the ankle’s position and resistance based on the user’s movements and the environment
Shank
Endoskeleton prosthesis:
Structure: Features a tubular structure connecting the primary components like the socket, suspension system, foot, and knee unit
Appearance: Often covered with cosmetic foam
Advantages: Endoskeletal prostheses are adjustable and lighter than exoskeletal prostheses.
Disadvantages: Less durable than exoskeletal prostheses
Exoskeleton prosthesis:
Structure: Has a hard outer shell that provides structural strength and cosmetic shape
Materials: Traditionally constructed from wood or plastic
Durability: More durable than endoskeletal prostheses
Advantages: May be preferred by people who do physical labor or are in harsh environments
Disadvantages: Less customizable than endoskeletal prostheses.
Socket
Patellar tendon bearing (PTB) sockets:
Focus- PTB sockets, often used for below-knee amputations, focus weight-bearing stress on pressure-tolerant structures like the patellar tendon and medial tibia flare
Advantages:
Can be a good choice for patients with shorter or bony residual limbs
Easier to don/doff for amputees with poor hand dexterity, poor eyesight, or hemiparesis
Can be modified to accommodate changes in the residual limb after amputation
Disadvantages:
May not be ideal for patients with residual limb scar tissue or chronic skin breakdown
Total surface bearing (TSB) sockets:
Focus: TSB sockets, also used for below-knee amputations, distribute weight evenly across the entire limb surface, reducing pressure points
Advantages:
Often used with gel liners, which cushion the limb and protect the skin, making them great for amputees with scar tissue or sensitive skin
Offer better suspension than PTB designs, often using locking pins or suction systems
Disadvantages:
Can be more difficult to don/doff than PTB sockets
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Components of prosthesis specifically for transfemoral amputation
Knee unit
Single-axis knees:
Mechanism: A single pivot point, resembling a simple hinge.
Stability: Offer good stability during the stance (weight-bearing) phase but may require more effort for the swing (forward movement) phase
Suitable for individuals with lower activity levels, those who can voluntarily stabilize the knee
Types:
Manual Locking: The knee can be locked in extension for stability, and unlocked manually for sitting
Constant Friction: Provide a constant resistance to knee flexion during swing phase, aiding in stability
Polycentric (multiaxis) knees:
Mechanism: Multiple pivot points, allowing for a more natural and efficient gait, particularly during swing phase.
Stability: Shorten the prosthesis during swing, reducing the risk of tripping and improving stability.
Suitable for active individuals, those with longer residual limbs, or those who require a more natural gait.
Types:
Hydraulic/Pneumatic: Use fluid or air to control the swing phase, allowing for smoother and more natural movement
Microprocessor-Controlled: Use of sensors and electronics to adjust the resistance to knee flexion and extension based on the user’s gait and activity level.
Microprocessor knees:
Mechanism: Use of sensors and electronics to adjust the resistance to knee flexion and extension based on the user’s gait and activity level.
Benefits: Improve stability, reduce energy expenditure, and allow for a more natural and comfortable gait
Suitable for highly active individuals, those who require a high level of stability and control, or those who want to maximize their mobility.
Socket
Ischial containment (IC) sockets
These designs feature a narrow medial-lateral dimension with the ischium (part of the pelvic bone) encapsulated within the socket, rather than sitting on the brim
Sub-ischial sockets
These sockets have a lower proximal trim line than IC sockets, and are often used with vacuum-assisted suspension
Quadrilateral (quad) sockets
These were historically the most common type, but are less common now, although still used for some patients
Direct socket
* A novel method of fabricating a laminated interface directly onto the residual limb
Keys for transfemoral amputation and transtibial amputation
The posterior and medial walls are lower than the anterior and lateral walls of the socket
This allows room for the groin and sacrum.
Prosthetic gait deviations
Vaulting
Definition: An attempt to lengthen the stance phase on the intact limb by knee extension and ankle plantar flexion during mid-stance
Causes:
Limb too long
Poorly suspended prosthesis
Excessive plantarflexion
Circumduction
Definition: The prosthetic limb travels in a lateral arch during swing.
Causes:
Limb too long
Poorly suspended prosthesis
Excessive plantarflexion
Abducted gait pattern
Definition: The prosthetic limb is carried in an abducted position throughout the swing and stance phase
Causes:
Outset prosthetic foot
Prosthesis too long
Medially placed intact foot
Knee instability
Definition: Excessive knee flexion on prosthetic side in early stance
Causes:
Excessive foot dorsiflexion
Excessive socket flexion
Posterior translation of foot/pylon
Excessively hard heel cushion on prosthetic heel
Reduced toe clearance
Definition: Prosthetic toe drags or catches during swing phase
Causes:
Prosthetic limb too long
Inadequate suspension
Residual limb not getting into prosthetic socket all the way
Excessive plantarflexion of the prosthetic foot
Pelvic drop
Definition: The pelvis on the prosthetic side drops on initial contact as if “stepping into a hole”
Causes:
Prosthetic limb too short
Residual limb has shrunk relative to the socket
Excessively compliant heel cushion
Lateral trunk lean over prosthesis (trendelenburg)
Definition: Trunk bends laterally over the prosthesis (compensated Trendelenburg) during stance
Causes:
Inadequate adduction of the socket
Prosthesis too short
Outset foot
Medial wall too high causing pain
Gapping at lateral wall of socket
Medial/lateral whip
Definition: Abrupt medial or lateral movement of the prosthetic heel during swing
Causes:
Excessive external or internal rotation of socket
Socket too tight
Inadequate suspension
Excessive valgus of prosthetic knee
Increased knee flexion
Definition: Long prosthetic step (decreased stance time on prosthesis)
Causes:
Painful socket- residual limb painful
Prosthesis too long
Orthotics
Soft orthotics
Also called accommodative orthotics, these are made of flexible materials that mold to the shape of your foot. They can help with conditions like plantar fasciitis and diabetes-related foot ulcers
Rigid orthotics
Also called functional orthotics, these are made of firm materials like plastic or carbon fiber. They can help with foot deformities and repetitive stress injuries
Semi-rigid orthotics
These combine soft and rigid materials to provide both cushioning and stability.They are often used for flat feet.
Sports-specific orthotics
These are designed for athletes to improve alignment and reduce the risk of injury
Lower limb orthotics
Foot orthoses (FO)
Definition:
Foot orthoses are inserts placed inside shoes to support, align, or improve foot function. They help with conditions such as flat feet, plantar fasciitis, and overpronation
Components:
Shell: The main body of the orthotic, made from rigid, semi-rigid, or soft materials
Posting: Adjustments to correct alignment (e.g., medial wedge for overpronation)
Top Cover: Soft padding for comfort and shock absorption
Heel Cup: Helps control heel motion and provides stability
Arch Support: Maintains the natural arch to prevent excessive collapse
Types:
Rigid FO: Controls foot motion and alignment, typically made of plastic or carbon fiber.
Semi-Rigid FO: Provides balance between control and flexibility, often used in sports
Soft FO: Offers cushioning for diabetic patients or those with sensitive feet
Ankle-foot orthoses (AFO)
Definition:
Ankle-foot orthoses (AFOs) extend from the foot to just below the knee and are used for conditions affecting foot and ankle stability, such as drop foot, stroke, cerebral palsy, and peripheral neuropathy
Components:
Footplate: Extends under the foot to control foot movement
Ankle Joint: Can be fixed, hinged, or adjustable to allow varying degrees of movement
Straps: Secure the orthosis to the leg for stability
Calf Support: Provides additional control over ankle motion
Material: Typically made from thermoplastics, carbon fiber, or metal uprights for different levels of support
Types:
Solid AFO: Provides complete immobilization of the ankle joint
Hinged AFO: Allows controlled ankle motion while still providing support
Carbon Fiber AFO: Lightweight and energy-efficient for active users
Specific types of AFO
Other types:
Posterior leaf spring AFO: A flexible AFO that helps with foot clearance during walking by providing a spring-like effect
Carbon fiber AFO: A lightweight and strong AFO made of carbon fiber, offering good support and durability
Dynamic ankle foot orthosis (DAFO): Designed for individuals with neurological conditions, often shorter and with a neurological footplate design
Ground reaction force ankle foot orthosis (GRAFO): Designed to reduce instability at the knee joint as well as the foot and ankle
Hybrid AFO: A combination of different AFO types, offering a balance of support and flexibility
Knee-ankle-foot orthoses (KAFO)
Definition:
Knee-ankle-foot orthoses (KAFOs) extend from the foot to the thigh, providing support for patients with quadriceps weakness, spinal cord injuries, or post-stroke conditions.
Components:
Footplate: Provides support to the foot like an AFO
Ankle Joint: Can be rigid, hinged, or free-motion
Knee Joints: May include locking mechanisms (drop lock, bail lock) or free-motion for controlled knee flexion
Thigh Cuff: Provides proximal stability to the femur
Straps & Padding: Ensure proper fit and comfort
Materials: Metal (for strong support) or plastic (for lighter weight)
Types:
Locked KAFO: Prevents knee flexion for complete knee support.
Stance control KAFO: Allows free knee flexion during swing phase but locks during stance
Offset joint KAFO: Reduces knee buckling by shifting the mechanical knee joint posteriorly
Spinal orthoses
Lumbar-Sacral Orthoses (LSO)
Definition:
LSOs provide support and stability to the lumbar and sacral spine, commonly used for low back pain, post-surgical stabilization, herniated discs, and fractures
Components:
Rigid or Semi-Rigid Frame: Provides stability and restricts motion
Abdominal Panel: Offers compression to reduce lumbar lordosis
Straps or Velcro Closures: Ensure a snug fit.
Pelvic Section: Stabilizes the sacrum and lower lumbar spine
Types:
Rigid LSO
Restricts lumbar flexion and extension.
Commonly used post-surgery or for fractures.
Corset-style LSO
Provides mild to moderate support.
Often used for chronic back pain and muscle strain
Jewett brace
Hyperextension orthoses designed to limit spinal flexion
Used for anterior compression fractures
Thoracolumbar-Sacral Orthoses (TLSO)
Definition:
TLSOs provide support to the thoracic, lumbar, and sacral spine, commonly used for post-surgical recovery, scoliosis, and compression fractures
Components:
Rigid or Semi-Rigid Frame: Limits spinal movement
Anterior and Posterior Panels: Provide structural support
Straps for Compression: Adjusts tightness for stabilization
Shoulder Straps (for some models): Helps maintain posture
Types:
Rigid TLSO
Used for scoliosis and spinal fractures.
Limits motion in all planes.
**Hyperextension TLSO **
Limits spinal flexion but allows extension.
Common for compression fractures.
Soft TLSO
Provides mild support and posture correction.
Used for mild osteoporosis or muscle strain
Cervical Orthoses (CO)
Definition:
Cervical orthoses are designed to support and immobilize the cervical spine, commonly used for whiplash, post-surgical recovery, and cervical fractures
Components:
Collar or Shell: Provides cervical stabilization.
Anterior and Posterior Panels (for rigid braces): Limit flexion, extension, and rotation
Chin and Occipital Support: Maintains head position
Types:
Soft cervical collar
Provides minimal support and is used for mild strains or whiplash
Rigid cervical brace (e.g., Philadelphia Collar, Miami J, Aspen Collar)
Provides moderate to firm immobilization.
Common for post-operative care and cervical fractures
Halo vest orthosis
Provides maximum cervical immobilization
Used for unstable cervical fractures or post-surgical fusion
Sterno-occipital mandibular immobilizer
Limits flexion and extension, often used for C1-C3 fractures
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