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INTRODUCTIONINTRODUCTION Orthotics

An orthotic device (commonly just referred to as an orthotic) is an external device


applied on the body to limit motion, correct deformity, reduce axial loading, or
improve function in a certain segment of the body.
Design characteristics of an orthotic device are crucial to function. Most
important features include the following:

Weight of the orthosis


Adjustability
Functional use
Cosmesis
Cost
Durability
Material
Ability to fit various sizes of patients
Ease of putting on (donning) and taking off (doffing)
Access to tracheostomy site, peg tube, or other drains
Access to surgical sites for wound care
Aeration to avoid skin maceration from moisture

Indications for recommending orthotic devices include the following:

Pain relief
Mechanical unloading
Scoliosis management
Spinal immobilization after surgery
Spinal immobilization after traumatic injury
Compression fracture management
Kinesthetic reminder to avoid certain movements

Duration of orthotic use is determined by the individual situation.

In situations where spinal instability is not an issue, recommend use of an


orthosis until the patient can tolerate discomfort without the brace.
When used for stabilization after surgery or acute fractures, allow 6-12
weeks to permit ligaments and bones to heal.

Use of an orthotic device is associated with several drawbacks, including


the following:

Discomfort
Local pain
Osteopenia
Skin breakdown
Nerve compression
Ingrown facial hair for men
Muscle atrophy with prolonged use
Decreased pulmonary capacity
Increased energy expenditure with ambulation
Difficulty donning and doffing orthosis
Difficulty with transfers
Psychological and physical dependency
Increased segmental motion at ends of the orthosis
Unsightly appearance
Poor patient compliance

Success of the orthosis may lead to any of the following:

Decreased pain
Increased strength
Improved function
Increased proprioception
Improved posture
Correction of spinal curve deformity
Protection against spinal instability
Minimized complications
Healing of ligaments and bones

Maintenance of orthosis:
Orthosis should be simple and durable as possible.
Patient should be taught for:
Cleaning the leather.
Oiling the joints.
Wash the orthosis if possible.

Physicians must understand the biomechanics of the spine and each individual
orthosis. The cervical spine is the most mobile spinal segment with flexion
greater than extension. The occiput and C1 have significant flexion and
extension with limited side bending and rotation. The C1-C2 complex accounts
for 50% of rotation in the cervical spine. The C5-C6 region has the greatest
amount of flexion and extension. The C2-C4 region has the most side bending
and rotation.
When compared to the cervical and lumbar spine, the thoracic spine is the least
mobile. The thoracic spine has greater flexion than extension. Lateral bending
increases in a caudal direction, and axial rotation decreases in a caudal direction.
The lumbar spine has minimal axial rotation. The greatest movement in the
lumbar spine is flexion and extension. Immobilization of the spine increases
erector spinae muscle activity since normal rotation that occurs with ambulation
is limited by the orthosis.

Biomechanichal principles of orthotic design


The biomechanical principles of orthotic design assist in promoting
control, correction, stabilization, or dynamic movement.
All orthotic design are based on three relatively principles:
:These principles are

Pressure

equilibrium

The lever arm

The pressure principle:


the pressure should be equal to the total force per unit area.
Force
P = -----------------------Area of Application
It means that the greater the area of a pad or plastic shell of an
orthosis, the less force will be placed on the skin.
Therefore, any material that creates a force against the skin should
be of dimension to minimize the force on the tissue.

The equilibrium principle:


The sum of the forces and the bending moments created must be
equal to zero.
This means that three-point pressure or loading system occurs when
three forces are applied to a segment in such a way that a single
primary force is applied between two additional counter forces with
the sum of all three forces equalizing zero.
The primary force is of a magnitude and located at a point where
movement is either inhibited or facilitated, depending on the
functional design of the orthosis

The lever arm principle:


The farther the point of force from the joint the greater the moment
arm and the smaller the magnitude of force required to produce a
given torque at the joint.
This why most orthosis are designed with long metal bars or plastic
shells that are the length of adjacent segment.
The greater the length of the supporting orthotic structure, the
greater the moment or torque that can be placed on the joint or
unstable segment.
These three principles act dependently on each other
So when designing or evaluating an orthotic devise we should check
that:
1) There is adequate padding covering the greatest area possible for
comfort.
2) The total forces acting on the involved segment is equal to zero or
there is equal pressure throughout the orthosis and no areas of skin
irritation.
3) The length of the orthosis is suitable to provide an adequate force to
creat the desired effect and to avoid increased transmission of shear
forces against the anatomic tissues.

General othotic considerations:


The forces at the interface between the orthotic materials and the
skin.
The degrees of freedom of each joint.
The number of joint segments.
The neuromuscular control of a segment, including strength and
muscle tone.
The material selected for orthotic fabrication.
The activity level of the client.
The goal of orthotic fitting is to meet the functional requirements of
the client with minimal restriction.

Functional orthotic considerations:


1) Alignment:
2) Movement:
A) Assistance with joint motion.
B) Resistance with joint motion.
3) Weight bearing:
4) Protection
The biomechanical principles in orthotic design include balance of horizontal
forces, fluid compression, distraction, construction of a cage around the patient,
placement of an irritant to serve as a kinesthetic reminder, and skeletal fixation.
Construction of a cage around the patient, like a thoracolumbar brace, increases
intraabdominal pressure. Increased intraabdominal pressure converts the soft
abdomen into a semirigid cylinder, which helps to relieve part of the vertebral
load. In general, structural damage to posterior elements of the spine creates
more instability with flexion, whereas damage to anterior elements creates more
instability with extension.
Orthotic devices (orthoses) are generally named by the body regions that they
span. For example, a CO is a cervical orthosis, while a CTLSO is a
cervicothoracolumbosacral orthosis, spanning the entire length of the spine.
Many of these devices are also known by eponyms.

Types of orthosis

Types of
orthosis

Upper limb
orthosis

Spinal
orthosis

Lower limb
orthosis

Orthoses are named by the joints they encompass


LL orthoses
FO
KO
HO
Spinal orthoses
CO
TO
SO
SIO
UL orthoses
HdO
WO
EO
SO

Foot orthosis
Knee orthosis
Hip orthosis

Cervical orthosis
Thoracic orthosis
Sacral orthosis
Sacroiliac orthosis
Hand orthosis
Wrist orthosis
Elbow orthosis
Shoulder orthosis

AFO
KAFO
HKAFO
RGO

Ankle-foot orthosis
Knee-ankle foot orthosis
Hip-Knee-ankle foot orthosis
Reciprocal Gait orthosis

CTO
CTLSO

Cervical-Thoracic orthosis
Cervical-Thoracolumbosacral orthosis
Thoracolumbosacral orthosis

TLSO
LSO

Lumbosacral orthosis

WHO
EWHO
SEO
SEWHO

Wrist-Hand orthosis
Elbow-Wrist-Hand orthosis
Shoulder-Elbow orthosis
Shoulder-Elbow-Wrist-Hand orthosis

Cervical Orthotics
Several drawbacks to cervical orthotic (CO) use have been noted. The soft tissue
structures around the neck (eg, blood vessels, esophagus, trachea) limit
application of aggressive external force. The high level of mobility at all segments
of the cervical spine makes it difficult to restrict motion. Cervical orthoses offer no
control for the head or thorax; therefore, motion restriction is minimal. Cervical
orthoses serve as a kinesthetic reminder to limit neck movement.
Observe appropriate precautions associated with orthotic use. Keep in mind that
continued long-term use has been associated with decreased muscle function
and dependency.
The soft collar is a common orthotic device made of lightweight material,
polyurethane foam rubber, with a stockinette cover. It has Velcro closure strap for
easy donning and doffing. Patients find the collar comfortable to wear, but it is
soiled easily with long-term use.

Soft collar

Indications for use of the soft collar include the following benefits for the
patient:

Warmth
Psychological comfort
Support to the head during acute neck pain
Relief with minor muscle spasm associated with spondylolysis
Relief in cervical strains

The soft collar provides some limitations of motion for the patient,
including the following:

Limits full flexion and extension by 5-15%

Limits full lateral bending by 5-10%


Limits full rotation by 10-17%

The hard cervical collars are similar in shape to a soft collar but are made of
Plastizote, a rigid polyethylene material shaped like a ring with padding. Height
can be adjusted in certain designs to fit patients better. Velcro straps are used for
easy donning and doffing. The hard collar is more durable than a soft collar with
long-term use.
Malibu collar

Several problems can be alleviated with use of a hard collar. The


indications include the following:

Support to the head during acute neck pain


Relief of minor muscle spasm associated with spondylosis
Psychological comfort
Interim stability and protection during halo application

Motion restrictions for the hard collar include the following:

Limits full flexion and extension by 20-25%


Less effective in restricting rotation and lateral bending
Better than a soft collar in motion restriction

Head Cervical Orthotics


Head cervical orthotics (HCOs) include the occiput and chin to decrease range of
motion (ROM). Supported chin area is a common place for skin breakdown and
ingrown hair for men. The clavicle is another area for skin breakdown and
discomfort with HCOs. HCOs generally are used in stable spine conditions. Like
in the case of cervical orthotics, continued long-term use of HCOs has been
associated with decreased muscle function and dependency.
The Philadelphia collar is a semirigid HCO with a 2-piece system of Plastizote
foam. Plastic struts on the anterior and posterior sides are used for support. The
upper portion of the orthosis supports the lower jaw and occiput, while the lower
portion covers the upper thoracic region. The Philadelphia collar comes in
various sizes and is comfortable to wear, improving patient compliance. Velcro
straps are used for easy donning and doffing. The Philadelphia collar is difficult to
clean and becomes soiled very easily. An anterior hole for a tracheostomy is
available. A thoracic extension can be added to increase motion restriction and
treat C6-T2 injuries.
Philadelphia collar with a thoracic extension

Motion restrictions for the Philadelphia collar include the following:

Limits flexion and extension by 65-70%


Limits rotation by 60-65%
Limits lateral bending by 30-35%

The goal of the Philadelphia collar is to provide immobilization and is


indicated after the following:

Anterior cervical fusion


Halo removal
Dens type I cervical fracture of C2
Anterior diskectomy
Suspected cervical trauma in unconscious patients
Tear-drop fracture of the vertebral body (Note: Some tear-drop fractures
require anterior decompression and fusion.)
Cervical strai

The Miami J collar


is another cervical orthotic device in common use. The Miami J collar has a 2piece system made of polyethylene and a soft washable lining. The anterior
piece has a tracheostomy opening similar to that in the Philadelphia collar. Velcro
straps provide easy donning and doffing. The Miami J collar is a semi-rigid HCO.
A thoracic extension can be added to increase support and treat C6-T2 injuries.
The Miami J collar is available in various sizes and can be heated and molded to
a contoured fit.
Miami J collar

Motion restrictions with the Miami J collar include the following:

Limits flexion and extension by 55-75%


Limits rotation by 70%
Limits lateral bending by 60%

Indications for use of a Miami J collar are the same as the Philadelphia
collar.
The Malibu collar is similar to the Philadelphia collar as it is a semi-rigid orthosis
designed in a 2-piece system with an anterior opening for a tracheostomy. The
Malibu collar comes in only one size, but it is adjustable in multiple planes to
ensure proper fit. Anterior chin support height is also adjustable. Straps around
the chin, occiput, and lower cervical area provide for tightening. Padding around

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the chin can be trimmed to ensure proper fit. Thoracic extension can be added to
increase support and treat C6-T2 injuries.

Motion restrictions for the Malibu collar include the following:

Limits flexion and extension by 55-60%


Limits rotation by 60%
Limits lateral bending by 60%

Indications for use of a Malibu collar are similar to those for the Miami J and
Philadelphia collars.
The Aspen Collar has a 2-piece system made of polyethylene with soft foam
liner with an anterior opening for a tracheostomy. The Aspen collar is a semi-rigid
HCO with Velcro straps for easy donning and doffing.
Motion restrictions mirror those of the Miami J collar and include the
following:

Limits flexion and extension by 55-60%


Limits rotation by 60%
Limits lateral bending by 60%

Indications for use of the Aspen collar include the same as the HCOs discussed
above. The Jobst Vertebrace is made of high-density polyethylene with soft
polyethylene foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for
use in emergent transport situations, and it is similar to the Yale or Philadelphia
collar in restricting motion. The Jobst Vertebrace provides full contact along its
costal ends to the sternum and cradles the mandible for stability.
Motion restrictions for the Jobst Vertebrace are similar to those of the Yale
and Philadelphia collars, including the following:
The Jobst Vertebrace is made of high-density polyethylene with soft polyethylene
foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for use in
emergent transport situations, and it is similar to the Yale or Philadelphia collar in
restricting motion. The Jobst Vertebrace provides full contact along its costal
ends to the sternum and cradles the mandible for stability. Motion restrictions
for the Jobst Vertebrace are similar to those of the Yale and Philadelphia
collars, including the following:

Limits flexion and extension by 55-60%


Limits rotation by 60%
Limits lateral bending by 60%

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Indications for use of the Jobst Vertebrace are similar to those for the Miami J
and Philadelphia collars

Cervical Thoracic Orthotics


Cervical thoracic orthotics (CTOs) provide greater motion restriction in the middle
to lower cervical spine from the added pressure on the body. The upper cervical
spine has less motion restriction. CTOs are used in minimally unstable fractures.
The Sternal-Occipital-Mandibular-Immobilizer is a rigid three-poster CTO with
anterior chest plate that extends to the xiphoid process and has metal or plastic
bars that curve over the shoulder. Straps from the metal bars go over the
shoulder and cross to the opposite side of the anterior plate for fixation. A
removable chin piece attaches to the chest plate with an optional headpiece that
can be used when the chin piece is removed for eating. The two-poster CTOs
start from the chest plate and attach to the occipital component. The SOMI is
ideal for bedridden patients since it has no posterior rods.
Sternooccipital-mandibular immobilization brace

The SOMI is relatively comfortable to wear. Proper adjustment is crucial for


motion restriction; in fact, motion restriction may be minimal with incorrect
application. The SOMI is less effective compared to other braces in controlling
extension, but it is very effective in controlling flexion at the atlantoaxial and C2C3 segments. The SOMI is better than the cervicothoracic brace in controlling
flexion in the C1-C3 segments.
Indications for use of the SOMI include the following:

Immobilization in atlantoaxial instability because of rheumatoid arthritis


(Note: Ligamentous disruption in rheumatoid arthritis affects flexion more
than extension since extension is held in check by the intact dens.)

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Immobilization for neural arch fractures of C2 since flexion causes


instability

Motion restrictions with the SOMI include the following:

Limits cervical flexion and extension by 70%-75%


Limits lateral bending by 35%
Limits rotation by 60-65%

The Yale orthosis is a modified Philadelphia collar with thoracic extension made
of fiberglass extending anteriorly and posteriorly with mid-thoracic straps on the
sides connecting the 2 thoracic extensions. The thoracic component helps to
treat C6-T2 injuries. The occipital piece extends higher up on the skull posteriorly.
Increased contact surface area improves stability of the brace. Patients find the
Yale orthosis comfortable to wear. The Yale orthosis is easy to fabricate and
costs approximately
Various indications for use of the Yale orthosis include the following:

Immobilization to C1 fractures with intact transverse ligament


Immobilization after surgical fixation of Dens Type III fractures
Immobilization to Dens type I fractures
Immobilization to Hangman fractures (traumatic spondylolisthesis of C2)
Immobilization to Jefferson fractures (multiple fractures of C1 ring with
spreading due to axial loading)
Provide immobilization to postoperative fixation

Motion restrictions for the Yale orthosis include the following:

Limits flexion and extension by 85%


Limits rotation by 70% to 75%
Limits lateral bending by 60%

The four-poster brace is a rigid orthosis with anterior and posterior chest pads
connected by a leather strap. Molded occipital and mandibular support pieces
connect to the chest pads and have adjustable struts. Straps connect the
occipital and mandibular support pieces. The mandibular plate can interfere with
eating. This brace uses shoulder straps, but it has no underarm support. Open
design allows heat loss from the neck. The brace is as effective as the
cervicothoracic brace in controlling flexion in the mid-cervical area and is better
than the Philadelphia collar. The four-poster design limits lateral bending and
rotation better than the two-poster brace.

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Motion restrictions provided by the four-poster orthosis include the


following:

Limits flexion and extension by 80%


Limits lateral bending by 55%-80%
Limits rotation by 70%

The Guilford brace is a rigid CTO with a two-poster design with anterior chest
plate and shoulder straps that connect to the posterior plate. Chin plate and
occipital piece connect to the anterior and posterior struts. Underarm straps circle
the lower chest wall for stability. The brace has poor control of flexion, extension,
rotation, and lateral bending at C1-C2. Motion restrictions afforded by the
Guilford brace include limitation of flexion and extension from C3-T2.
Indications for use of the Guilford brace include the following:

Immobilization to minimally unstable fractures from C3-T2


Immobilization after postoperative internal fixation from C3-T2

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Halo device
The halo device is the most common device for treatment of unstable cervical
and upper thoracic fractures and dislocations as low as T3. The halo provides
maximum motion restriction of all cervical orthotics. The halo ring is made of
graphite or metal with pin fixation on the frontal and parietal-occipital areas of the
skull. Development of lightweight composite material led to design of radiolucent
rings compatible with magnetic resonance imaging (MRI). The halo ring attaches
to the vest anteriorly and posteriorly via 4 posters.
Halo device.

The halo vest has shoulder and underarm straps for tightening and usually is
made of rigid polyethylene and extends down to the umbilicus. Restriction in
cervical motion depends on the fit of the halo vest since improper fit can allow
31% of normal spine motion. The halo vest is the weak link in terms of motion
control. Compressive and distractive force can occur with variable fit of the vest.
Multidirectional shear forces can cause increased pinhole size with craterlike
enlargement. Pin loosening occurs twice as frequently with a heavier halo vest.
Generally, upper cervical spine injuries are treated best with a full-length vest to
the iliac crest.
Indications for use of a halo device are for immobilization in the following
cases:

Dens type I, II, and III fractures of C2 (Note: Dens type III fractures of C2
are treated more successfully with surgery.)
C1 fractures with rupture of the transverse ligament
Atlantoaxial instability from rheumatoid arthritis with ligamentous
disruption and erosion of the dens

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C2 neural arch fracture and disc disruption between C2 and C3. (Note:
Some patients may need surgery for stabilization.)
Bony single column cervical fractures
Following cervical arthrodesis
Following cervical tumor resection in an unstable spine
Following debridement and drainage of infection in an unstable spine
Following spinal cord injury (SCI)

Contraindications for use of the halo device include the following:

Concomitant skull fracture with cervical injury


Damaged or infected skin over pin insertion sites

The relative contraindications for use of the halo device include the
following:

Cervical instability with ligamentous disruption


Cervical instability with 2 or 3 column injury
Cervical instability with rotational injury involving facet joints

The application process for the halo device consists of several steps. Optimal
placement for the anterior pins is the anterolateral aspect of the skull 1 cm above
the orbital rim on the lateral part of orbit since this prevents penetration into the
orbit. Avoid placing pins in the temporalis muscle and through the
zygomaticotemporal nerve, which supplies sensation to the temporal area. Pins
inserted into the temporalis muscle affect mandibular motion and cause pain.
Placement away from the medial one third on the orbital rim preserves the
supraorbital and supratrochlear nerves and decreases risk of entering the frontal
sinus.
Insertion of posterior pins on the posterolateral aspect of the skull is less crucial.
Skin incisions are not necessary prior to pin placement. The halo ring should be
1 cm above the top of the ear. Place all pins perpendicular to the skull, and allow
1-2 cm clearance with the halo ring along the skull perimeter.
In adults, pin insertion requires a torque wrench set at 8 inches per pound since
this lowers incidence of pin infection and loosening. In children, set the torque
wrench between 2-5 inches per pound since the skull is too weak to sustain
heavier forces. Use multiple pin sites in children because of the weaker skull.
Determine the halo vest size by measuring chest circumference at the xiphoid
process. Elevate the patient at 30-40 for vest placement. Secure the posterior
portion to the halo first, then to the anterior part of the vest. Tighten the bolts on
the vest to a torque setting of 28 feet per pound. Tools for the vest sometimes are
taped to the anterior part of the vest in case of emergency.

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At 24-48 hours after placement, recheck all pins for loosening. Clean the pin sites
with saline or soap and water on a sterile swab. Take x-rays immediately after
halo placement and after any adjustment to check spinal alignment. Shaking of
the cervical spine because of forced movement against the orthosis or changes
in pin tightening can cause some segmental motion. Symptoms of dysphagia
may result from placement of the neck in too much extension. Repositioning of
the halo, if possible, can eliminate dysphagia.
Motion restrictions provided by the halo include the following:

Limits flexion and extension by 90-96%


Limits lateral bending by 92-96%
Limits rotation by 98-99%

Various complications associated with halo placement include the


following:

Neck pain or stiffness 80%


Pin loosening 60%
Pin site infection 22%
Scars 30%
Pain at pin sites 18%
Pressure sores 11%
Redislocation 10%
Restricted ventilation 8%
Dysphagia 2%
Nerve injury 2%
Dural puncture 1%
Neurological deterioration 1%
Avascular necrosis of the dens
Ring migration
Inadequate bony healing
Inadequate ligamentous healing

In use of the halo device, keep in mind the following important considerations:

The halo fixation device is used for 3 months to allow adequate time for
bone healing.
Use of an HCO after removal of the halo provides some support for the
head, as the neck muscles are weak and stiff.
Approximately 40-45% of patients with facet joint dislocations achieve
stability with the halo vest, whereas 70% of patients without facet joint
dislocations achieve stability.
Nearly 75% of patients without facet joint dislocation achieve good
anatomic results.
Surgical stabilization in cases of facet joint dislocation improves outcome.
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Patients with facet joint dislocation have higher likelihood of spinal cord
injury.
Thorough neurologic examination before and after reduction of facet joint
dislocation is important.

The best orthotic device to control various cervical regions is indicated as


follows:

All orthotics tend to control flexion better than extension.


The halo is the most effective in controlling flexion and extension at C1C3, followed by the four-poster brace, and then the cervicothoracic
orthotics.
The cervicothoracic orthotics are best at controlling flexion and extension
at C3-T1, while the SOMI brace is best at controlling flexion from C1-C5.
The SOMI is less effective in controlling extension compared to other
orthotics.
The halo is the best at controlling rotation and lateral bending from C1-C3.
The cervicothoracic brace is second best at controlling rotation and lateral
bending in the cervical spine.
The four-poster brace is slightly better at controlling lateral bending
compared to the cervicothoracic brace in the cervical spine.

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Thoracolumber orthotics
Thoracolumbar orthotics (TLOs) are used mainly to treat fractures from T10-L2
since their mobility is not restricted by the ribs, unlike fractures from T2-T9.
Immobilization from T10-L2 helps prevent further collapse.
The cruciform anterior spinal hyperextension (CASH) brace features anterior
sternal and pubic pads to produce force opposed by the posterior pad and strap
around the thoracolumbar region. Sternal and pelvic pads attach to the anterior
metal cross-shaped bar, which can be bent to reduce excess pressure on the
chest and pelvis. The brace is easy to don and doff, but it is difficult to adjust.
Compared to the Jewett brace, it provides greater breast and axillary pressure
relief. Two round upper chest pads can be used instead of the sternal pad to
decrease discomfort around the breast area. Average cost of a CASH brace is
approximately $460.
Indications for the CASH brace include the following:

Flexion immobilization to treat thoracic and lumbar vertebral body


fractures
Reduction of kyphosis in patients with osteoporosis

Motion restrictions provided by the CASH brace include the following:

Limits flexion and extension from T6-L1


Ineffective in limiting lateral bending and rotation of the upper lumbar
spine

Contraindications to use of the CASH brace include the following:

Three-column spine fractures involving anterior, middle, and posterior


spinal structures
Compression fractures due to osteoporosis

The Jewett hyperextension brace uses a 3-point pressure system with 1


posterior and 2 anterior pads. The anterior pads place pressure over the sternum
and pubic symphysis. The posterior pad places opposing pressure in the mid-

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thoracic region. The posterior pad keeps the spine in an extended position, and it
has a lightweight design that is more comfortable than the CASH brace. Pelvic
and sternal pads can be adjusted from the lateral axillary bar where they attach.
The pads can cause discomfort from pressure applied to small surface area. No
abdominal support is provided with this device. When the patient is seated, the
sternal pad should be half an inch inferior to the sternal notch, and the pubic pad
should be half an inch superior to the pubic symphysis. The Jewett brace is not a
custom-molded brace.
Jewett hyperextension brace

Indications for use of the Jewett brace include the following:

Symptomatic relief of compression fractures not due to osteoporosis


Immobilization after surgical stabilization of thoracolumbar fractures

Motion restrictions provided by the Jewett brace include the following:

Limits flexion and extension between T6-L1


Ineffective in limiting lateral bending and rotation of the upper lumbar
spine

Contraindications to use the Jewett brace include the following:

Three column spine fractures involving anterior, middle, and posterior


spinal structures
Compression fractures above T6 since segmental motion increases above
the sternal pad
Compression fractures due to osteoporosis

One important consideration in use of the Jewett brace is that it is more effective
than the CASH brace. The Korsain brace is a modification of the Jewett brace
with added abdominal support for increased rigidity. The cost of the Korsain
brace is similar to that of the Jewett brace.
Indications for the Korsain brace include the following:
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Symptomatic relief of compression fractures not due to osteoporosis


Immobilization after surgical stabilization of thoracolumbar fractures
Flexion immobilization to treat thoracic and lumbar vertebral body
fractures

Motion restrictions and contraindications of the Korsain brace are similar to the
Jewett brace.
The Knight-Taylor brace features a corset type front with lateral and posterior
uprights and shoulder straps to help reduce lateral bending, flexion, and
extension. Shoulder straps may cause discomfort in some patients. The brace
can be prefabricated and made with polyvinyl chloride or aluminum. The
posterior portion of the brace has added cross supports below the inferior angle
of the scapula and a pelvic band fitted at the sacrococcygeal junction. The
anterior corset is made of canvas and provides intracavitary pressure. The
anterior corset is laced to the lateral uprights. The brace is indicated to provide
flexion immobilization to treat thoracic and lumbar vertebral body fractures.
Cruciform anterior spinal hyperextension brace with round anterior chest
pads.

Motion restrictions of the Knight-Taylor brace include the following:

Poor rotation control


Limits flexion, extension, and lateral bending

Custom-molded plastic body jacket, or thoracolumbosacral orthosis (TLSO), is


fabricated from polypropylene or plastic and offers best control in all planes of
motion and increases intracavitary pressure. This orthosis has a lightweight
design and is easy to don and doff. The material is easy to clean and comfortable
to wear. This brace sometimes is referred to as the clamshell. The TLSO
provides efficient force transmission as pressure is distributed over wide surface
area, which is ideal for use in patients with neurologic injuries. The brace may
have a tendency to ride up on the patient in a supine position. Plastic retains

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heat, so an undershirt helps to absorb perspiration and protect the skin. Frequent
checks to ensure proper fit help prevent pressure ulcers.

Custom-molded plastic lumbosacral orthosis

Indications for the TLSO include the following:

Immobilization for compression fractures from osteoporosis


Immobilization after surgical stabilization for spinal fractures
Bracing for idiopathic scoliosis
Immobilization for unstable spinal disorders for T3 to L3

Motion restrictions for the TLSO include the following:

Limits sidebending
Limits flexion and extension
Limits rotation to some extent

Clinical information on the custom-molded TLSO suggests that it is more


effective in preventing idiopathic scoliosis curve progression than the Milwaukee
and Charleston braces. The mean curve progression with TLSO is less than 2
while the Charleston and Milwaukee braces have a curve progression greater
than 6. Fewer than 18% of patients treated with TLSO brace required surgery
for scoliosis compared to 23% for patients treated with a Milwaukee brace

Lumbosacral orthotics

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The chairback brace is a rigid short lumbosacral orthotic (LSO) with 2 posterior
uprights with thoracic and pelvic bands. The abdominal apron has straps in front
for adjustment to increase intracavitary pressure. The thoracic band is located 1
inch below the inferior angle of scapula. The thoracic band extends laterally to
the mid-axillary line, and the pelvic band extends laterally to the mid-trochanteric
line. Place the pelvic band as low as possible without interfering with sitting
comfort. Position the posterior uprights over the paraspinal muscles. Uprights
can be made from metal or plastic. The brace uses a 3-point pressure system
and can be custom molded to improve the fit for each individual patient.
Chairback brace from side view

Indications for use of the chairback brace include the following:

Unloading of the intervertebral discs and transmit pressure to soft tissue


areas
Relief for low back pain (LBP)
Immobilization after lumbar laminectomy
Kinesthetic reminder to patient following surgery

Motion restrictions of the chairback brace include the following:

Limits flexion and extension at the L1-L4 level


Limits rotation minimally
Limits lateral bending by 45% in the thoracolumbar spine

The chairback Ortho-Mold brace is similar to the chairback brace, but it has a
rigid plastic back piece custom molded to the patient. The plastic back can be
inserted into the canvas and elastic corset. The chairback Ortho-Mold brace
costs approximately $500-600.
Indications for use of the chairback Ortho-Mold brace and its motion restrictions
are the same as the chairback brace noted above..

23

The Williams brace is a short LSO with an anterior elastic apron to allow for
forward flexion. Lateral uprights attach to the thoracic band, and oblique bars are
used to connect the pelvic band to the lateral uprights. The abdominal apron is
laced to the lateral uprights. The brace limits extension and lateral trunk
movement but allows forward flexion. The brace is indicated to provide motion
restriction during extension to treat spondylolysis and spondylolisthesis. The
device is contraindicated in spinal compression fractures.

Motion restrictions of the Williams brace include the following:

Limits extension
Limits side bending at terminal ends only

The MacAusland brace is an LSO that limits only flexion and extension. This
brace has 2 posterior uprights but no lateral uprights. The 3 anteriorly directed
straps connect with the abdominal apron to provide increased support.
Indications for use of the MacAusland brace are similar to the chairback brace.
Motion restrictions include limitation of flexion and extension in the L1 to L4 level.
The Standard LSO corset has metal bars within the cloth material posteriorly that
can be removed and adjusted to fit the patient. The anterior abdominal apron has
pull-up laces from the back to tighten. The abdominal apron can come with
Velcro closure for easy donning and doffing. The Standard LSO corset has a
lightweight design and is comfortable to wear. The corset increases intracavitary
pressure. Anteriorly, the brace covers the area between the xiphoid process and
pubic symphysis. Posteriorly, the brace covers the area between the lower
scapula and gluteal fold.
Indications for the Standard LSO corset include the following:

Treatment of LBP
Immobilization after lumbar laminectomy

Motion restrictions of the Standard LSO corset include limitation of flexion


and extension.
The rigid LSO is a custom-made orthosis molded over the iliac crest for improved
fit. Plastic anterior and posterior shells overlap for a tight fit. Velcro closure in the
front is designed for easy donning and doffing. Multiple holes can be made for
aeration to help decrease moisture and limit skin maceration. The rigid LSO can

24

be trimmed easily to make adjustments for patient comfort and may be used in
the shower if needed.

Indications for use of the rigid LSO brace include the following:

Post-surgical lumbar immobilization


Treatment of lumbar compression fractures

Motion restrictions provided by the rigid LSO brace include the following:

Limits flexion and extension


Limits some rotation and side bending

Rigid LSO with hip spica uses a thigh piece on the symptomatic side and extends
to 5 cm above the patella. The hip is held in 20 of flexion to allow sitting and
walking. Some patients require a cane for ambulation after application.
Indications for the rigid LSO with hip spica use include the following:

Immobilization to treat lumbar instability from L3-S1


Immobilization after lumbosacral fusion with anchoring to the sacrum

Motion restrictions of the rigid LSO with hip spica include the following:

Limits flexion and extension


Limits some rotation and side bending

New brace designs for LSO have strapping systems designed to pull the brace
inward and up to improve hydrostatic affect to relieve pressure on the lumbar
spine. The better fit helps limit migration. Some low-profile designs take pressure
off the hip and rib area, which, in turn, improves patient compliance. Low-profile
braces allow easier fitting under clothes. These braces can treat areas from L3S1.
Some spinal braces come with an interchangeable back with an open center or
flat back design for postoperative patients. The same brace can be interchanged
with a back that has an indentation to fit the lordotic curvature of the lumbar spine
for pain management purposes. Braces with interchangeable parts allow a LSO
to be converted into a TLSO with a large back support and an attachment for a
sternal extension to prevent unwanted flexion. The sternal extension has straps
that attach to the LSO.

25

BRACING FOR SCOLIOSIS Bracing for scoliosis


The main goal of a brace in scoliosis is to prevent further deformity and prevent
or delay need for surgery. If surgery is needed, delaying the procedure as long as
possible helps optimize spinal height and avoid stunting of truncal growth.
Assessing the degree of skeletal maturity in a child with scoliosis is important
because with more advanced skeletal maturity, you expect less further skeletal
growth and thus less progression of the scoliosis. This has obvious implications
when forming a treatment plan.
Risser classification of ossification of the iliac epiphysis is used to evaluate
skeletal immaturity. Ossification of the iliac crest occurs from the anterior superior
iliac spine (ASIS) to the posterior superior iliac spine (PSIS). When ossification is
complete, fusion of the epiphysis occurs to the iliac crest. Risser staging is based
on using radiographs to determine what percent of the excursion (along the
length of the iliac epiphysis) has ossified. Risser score of 0-I with a curve of 2030 indicates nearly 70% chance of progression.
Risser stages are defined as follows:

Stage 0 = 0% excursion
Stage I = 25% excursion
Stage II = 50% excursion
Stage III = 75% excursion
Stage IV = 100% excursion and correlates with end of spinal growth
Stage V = fusion to ilium, indicating cessation of vertical height growth

The clinician must take into account several bits of clinical information about use
of braces in scoliosis including the following:

Patients with pre-brace curves of 20-29 require surgery in only 3% of


cases, whereas 28% of patients with pre-brace curves of 40-49 require
surgery.
26

Patients aged younger than 13 years with curves of 30-39 require surgery
25% of the time, whereas only 14% of patients older than 14 years with
curves 30-39 require surgery.
The most common time to lose control of idiopathic curves is at puberty.
Boys tend to show less curve progression than girls, and tend to have
later onset of curve progression between 15-18 years.
Younger patients show greater initial in-brace correction. Curve correction
with bracing greater than 50% is expected to have final net correction,
whereas curve correction less than 50% is expected to have limited
progression.
Generally, curves between T8-L2 have the best correction. Young patients
with large curves usually fail treatment with a brace.
Patients successfully completing treatment for idiopathic scoliosis using a
TLSO with initial curves measuring 20-45 can anticipate their scoliosis to
remain stable until adulthood. The correction of the curvature can be lost
over time, to its initial magnitude. Therefore, obtaining a spinal radiograph
in the third or fourth decade of life to check progression is reasonable.

The Milwaukee brace is a CTLSO originally designed by Blount and Schmidt to


help maintain postoperative correction in patients with scoliosis secondary to
polio. The brace is designed to stimulate corrective forces from the patient. When
the patient has been fitted properly with a brace, the trunk muscles are in
constant use; therefore, disuse atrophy does not occur. The brace has an open
design with constant force provided by the plastic pelvic mold. The pelvic portion
helps reduce lordosis, derotates the spine, and corrects frontal deformity.
Uprights have localized pads to apply transverse force, which is effective for
small curves. The main corrective force is the thoracic pad, which attaches to the
2 posterior uprights and 1 anterior upright. Discomfort from the thoracic pad
creates a righting response to an upright posture. The lumbar pads play a
passive role compared to the thoracic pads.
The uprights are perpendicular to the pelvic section, so any leg-length
discrepancy should be corrected to level the pelvis. The neck ring is another
corrective force and is designed to give longitudinal traction. Jaw deformity is a
potential complication of the neck ring. The throat mold, instead of a mandibular
mold, allows use of distractive force without jaw deformity.
During the child's growth, brace length can be adjusted. Pads also can be
changed to compensate for spinal growth. The brace needs to be changed if
pelvic size increases. Average cost of this brace is approximately $2100-2300.
Indications for use of the Milwaukee brace include the following:

Patients with Risser score of I-II and curves greater than 20-30 that
progress by 5 over 1 year need application of brace.

27

Curves between 30-40 need bracing, but not curves less than 20.
Curves of 20-30, with no year-over-year progression, require observation
every 4-6 months. The Milwaukee brace is used for curves with apex
above T7.

Duration of the Milwaukee brace use is determined by the following criteria:

Daily use ranges from 16-23 hours per day.


Treatment should continue until the patient is at Risser stage IV or V.
If curve is greater than 30, consider continued use for 1-2 years after
maturity since patients with curves of this magnitude are at risk for
progression.

Side effects of the Milwaukee brace include the following:

Jaw deformity
Pain
Skin breakdown
Unsightly appearance
Difficulty with mobility
Difficulty with transfers
Increased energy expenditure with ambulation

Failure to correct deformity can be caused by any of the following:

Poor patient compliance


Improper fit
Curves below T7

Keep in mind clinical information regarding use of the Milwaukee brace, including
the following:

Only 40% of patients with curves of

20-29 progressed with a Milwaukee brace, compared to 68% by natural


history without bracing.

28

When comparing the Milwaukee and Boston braces, note that curve
progression beyond 45 occurred in 31% of patients with the Boston brace
and in 62% with the Milwaukee brace.
X-rays to evaluate scoliosis in the Milwaukee brace are performed with the
patient in a standing position.
Successful outcomes with brace treatment show an in-brace curve
reduction greater than 50%.
The Milwaukee brace and a custom-made TLSO can be used to treat
Scheuermann kyphosis in children with pain, or pain with kyphosis greater
than 60.

The Boston brace is a prefabricated symmetric thoracolumbar-pelvic mold with


built-in lumbar flexion that can be worn under clothes. Lumbar flexion is achieved
through posterior flattening of the brace and extending of the mold distally to the
buttock. Braces with superstructures have a curve apex above T7. Curves with
an apex at or below T7 do not require superstructures to immobilize cervical
spine movement. This brace, unlike the Milwaukee brace, cannot be adjusted if
the patient grows in height. Both braces need to be changed if pelvic size
increases. Average cost of the Boston brace is approximately $2000.
Indications for use of the Boston brace include the following:

Curves 20-25 with 10 progression over 1 year


Curves 25-30 with 5 progression over 1 year
Skeletally immature patients with curves 30 or greater

Side effects associated with use of the Boston brace include the following:

Local discomfort
Hip flexion contracture
Trunk weakness
Increased abdominal pressure
Skin breakdown
Accentuation of hypokyphosis above brace in the thoracic spine

Certain preventive measures can reduce difficulties associated with use of


the Boston brace, including the following:

Regimen of hip stretches decreases contractures at the hip.


Exercise to promote active correction in the brace is suggested.

29

Presence of thoracic hypokyphosis is a relative contraindication for use of the


Boston brace.
Failure of the Boston brace to correct deformity can occur because of
several factors, including the following:

Curve above T7
Improper fit
Poor patient compliance

Duration of Boston brace use is determined by several factors, including


the following:

Daily use ranges from 16-23 hours per day.


Treatment should continue until the patient is at Risser stage IV or V.
If the curve is greater than 30, consider continued use for 1-2 years after
maturity since these curves are at risk for progression.
The Boston brace with and without superstructure is equally effective in
treating curves below T7.

Clinical information relevant to use of the Boston brace includes the


following:

The Boston brace is more effective than the Charleston brace in


preventing curve progression and avoiding surgery.
Nearly 43% of patients using the Boston brace progressed more than 5,
compared to 83% with the Charleston brace.
The use of a Charleston brace is only indicated with lumbar or small
thoracolumbar curves; avoid use in thoracic curves.
X-rays to evaluate scoliosis in the Boston brace are performed with the
patient in a standing position.
Successful outcomes with brace treatment show an in-brace curve
reduction greater than 50%.

The Charleston bending brace is a rigid custom-made orthosis designed to


correct scoliosis at nighttime to improve patient compliance. This brace holds the
patient in maximum side-bending correction. The Charleston bending brace costs
approximately $2000.
Indications for use of this particular brace include the following:
30

Curves 20-25 with 10 progression over 1 year


Curves 25-30 with 5 progression over 1 year
Skeletally immature patients with curves 30 or greater

Clinical information regarding use of the Charleston bending brace


includes the following:

The Charleston brace, compared to the Boston brace, is significantly less


effective in treating double major curves and single thoracic curves in
patients with Risser stage 0 to 1.
Over 50% of patients with a single thoracic curve treated with a
Charleston brace required surgery compared to 24% with the Boston
brace.
As a result, the Charleston brace is not recommended for use in thoracic
curves.
The Charleston brace is less effective at treating single thoracolumbar or
lumbar curves, but the figures are not statistically significant compared to
those for the Boston brace.
X-rays to evaluate scoliosis with the Charleston bending brace are
performed in a supine position since the patient wears it at night sleeping
supine.
Successful outcomes with brace treatment show an in-brace curve
reduction greater than 50%.

31

lower limb orthosis


A lower limb orthosis is an external device applied or attached to a lower body
segment to improve function by controlling motion, providing support through
stabilizing gait, reducing pain through transferring load to another area,
correcting flexible deformities, and preventing progression of fixed deformities.
Terminology
Orthosis (or orthotic device) is the medical term for what most people would refer
to as a brace or splint. Orthoses generally are named by the body regions that
they involve, as demonstrated by the following abbreviations:

AFO is an ankle-foot orthosis.


KAFO is a knee-ankle-foot orthosis.
HKAFO is a hip-knee-ankle-foot orthosis.
THKAFO is a trunk-hip-knee-ankle-foot orthosis.

Locomotion and gait


The total mass of the body can be considered concentrated at one point, called
the center of gravity. The center of mass is located in the midline, just anterior to
the second sacral vertebra while the individual is standing and walking. The
center of mass changes with the configuration and function of the body.
The line of gravity is a line passing through the center of gravity to the center of
the earth. This line (1) arises from the supporting surface between the ball and
heel of the foot, then (2) passes in front of the ankle and knee joints and slightly
behind the hip joint to the center of gravity, then (3) passes through the
32

lumbosacral junction and behind the lumbar vertebral bodies to intersect the
spine at the thoracolumbar junction, then (4) continues in front of the thoracic
vertebral bodies and through the cervicothoracic junction, and, lastly, (5) travels
behind the cervical vertebral bodies to the occipitocervical junction. When the
center of gravity does not fall through the area of support, it is unstable at that
moment.
Gait cycle is defined as the activity that occurs between the initial contact of one
extremity and the subsequent initial contact of the same extremity. During a
single gait cycle, each extremity passes through one stance phase and one
swing phase. Stance phase occupies over 60% of the gait cycle during walking at
average velocity. Stance phase includes initial contact, loading response,
midstance, terminal stance, and preswing. Swing phase includes initial swing,
mid swing, and terminal swing.

The average total displacement of the center of gravity in both the vertical and
lateral directions is less than 2 inches in normal gait. The increase in
displacement of the center of gravity increases the amount of energy for walking.
The purpose of using an orthosis is to enhance normal movement and to
decrease abnormal posture and tone. Lower extremity orthoses can be used to
correct abnormal gait patterns and to increase the efficiency of walking.

33

Lower extremity orthotics


An orthosis is classified as a static or dynamic device. A static orthosis is rigid
and is used to support the weakened or paralyzed body parts in a particular
position. A dynamic orthosis is used to facilitate body motion to allow optimal
function. In all orthotic devices, 3 points of pressure are needed for proper control
of a joint.
Principles
A lower limb orthosis should be used only for specific management of a selected
disorder. The orthotic joints should be aligned at the approximate anatomic joints.
Most orthoses use a 3-point system to ensure proper positioning of the lower
limb inside the orthosis.
The orthosis selected should be simple, lightweight, strong, durable, and
cosmetically acceptable. Considerations for orthotic prescription should include
the 3-point pressure control system, static or dynamic stabilization, flexible
material, and tissue tolerance to compression and shear force.

MATERIALS
An orthosis can be constructed from metal, plastic, leather, synthetic fabrics, or
any combination. Plastic materials, such as thermosetting and thermoplastics,
are the materials most commonly used in the orthotic industry.

Plastics
o Thermosetting materials can be molded into permanent shape after
heating. They do not return to their original consistency even after
being reheated. Thermoplastic materials soften when heated and
harden when cooled.
34

Low-temperature thermoplastics can be fabricated easily and


rapidly with hot water or hot air and scissors, but they are used
mainly in low stress activities.
o High-temperature (polypropylene) thermoplastics require higher
temperature (150C) to mold, but they are ideal for high stress
activities.
Leather, such as cattle hide, is used for shoe construction because it
conducts heat and absorbs water well.
Rubber
o Rubber has tough resiliency and shock-absorbing qualities.
o Rubber is used for padding in body jackets and limb orthoses.
Metal
o Metals, such as stainless steel and aluminum alloys, are
adjustable, but they are heavy and not cosmetically pleasing.
o Metals can be used for joint components, metal uprights, sprints,
and bearings.
o

35

SHOES AND FOOT ORTHOTICS


Shoes
Shoes are the important foundation of the lower limb orthosis. Shoes are used to
protect and warm the feet, transfer body weight while walking, and reduce
pressure or pain through redistributing weight. Shoes should be comfortable and
properly fitted. They should be at least 1 cm longer than the longest toe and
correspond to the shape of the feet.
The shoe can be divided into lower and upper parts. The lower parts consist of
the sole, shank, ball, toe spring, and heel. The upper parts include the quarter,
heel counter, vamp, toe box, tongue, and throat.

36

Parts of the shoe

Sole
o
o
o
o

Heel
o
o
o
o
o
o

Outer and inner soles are separated by compressible filler. Both of


them are made preferably of leather for breathability.
The ball is the widest part of the sole and corresponds to the area
of the metatarsal heads.
The shank area is from the anterior border of the heel to the ball. A
steel piece may be used to reinforce the shank area.
The toe spring is the space between the anterior sole and the floor.

Leather with rubber on the plantar surface commonly is used for the
heel.
A spring heel is one-eighth inch high.
An Oxford heel is three quarters to one inch high.
A military heel is one and one quarter inches high.
A Cuban heel is one and a half inches high.
The heel counter is the posterior portion of the upper part between
the quarters. This structure is used to reinforce the quarters and
support the calcaneus. The heel counter can increase the posterior
stability of the shoe.

Upper
o

The upper is the portion of the shoe above the sole.

37

o
o
o
o
o

The vamp is the anterior section.


The quarters are the posterior section.
The throat is the base of the tongue.
The tongue is a piece attached to the vamp.
The toe box is the reinforcement of the vamp to protect the shoe
from trauma.
Rocker shoe.

: Blucher style orthopedic shoe (top); diabetic shoe (bottom)

Shoe modifications
A properly fitted shoe should have adequate room for the foot to expand while
the patient is bearing weight. The shoe should be at least 1 cm longer than the
longest toe, and the widest part also should correspond to the widest part of the
foot. Shoes can be modified to reduce pressure on sensitive areas by
redistributing weight toward pain-free areas.
External shoe modifications

38

Heel modifications
o A cushioned heel: A wedge of compressible rubber is inserted into
the heel to absorb impact at heel strike. This cushion often is used
with a rigid ankle to reduce the knee flexion moment by allowing for
more rapid ankle plantar flexion.
o A heel flare: A medial flare is used to resist inversion, and a lateral
flare is used to resist eversion. Both flares are used to provide heel
stability.
o A heel wedge: A medial wedge is used to promote inversion, and a
lateral wedge is used to promote eversion. The heel counter should
be strong enough to prevent the hindfoot from sliding down the
incline created by the wedge.
o Extended heel: The Thomas heel projects anteriorly on the medial
side to provide support to the medial longitudinal arch. The reverse
Thomas heel projects anteriorly on the lateral side to provide
stability to the lateral longitudinal arch.
o Heel elevation: A shoe lift is used to compensate for fixed equinus
deformity or for any leg-length discrepancy of more than one
quarter of an inch.

Sole modifications
o

A rocker bar is a convex structure placed posterior to the metatarsal


head. The rocker bar is used to shift the rollover point from
metatarsal head to metatarsal shaft to avoid irritation of ulcers
along the metatarsal head in patients with diabetes mellitus (DM).

39

A metatarsal bar is a bar with a flat surface placed posterior to the


metatarsal head. The metatarsal bar is used to relieve the pressure
from the metatarsal heads.
o A sole wedge: A medial wedge is used to promote supination, and a
lateral wedge is used to provide pronation.
o A sole flare: A medial flare is used to resist inversion, and a lateral
flare is used to resist eversion. Both flares promote great stability.
o A steel bar: The steel bar is placed between the inner sole and
outer sole. This bar is used to reduce forefoot motion to reduce the
stress from phalanges and metatarsals.
Combination of sole and heel modifications: If heel elevation is more than
one half an inch, a sole elevation should be added to avoid equinus
posture.
o

Internal shoe modifications

Heel modifications
o Heel cushion relief: This soft pad with excavation is placed under
the painful point of the heel.
o Heel wedges: A medial heel wedge can rotate the hindfoot into
inversion. A lateral heel wedge can evert the hindfoot to avoid
pressure on the cuboid.
Sole modifications
o Metatarsal pad: This domed pad is designed to reduce the stress
from metatarsal heads by transferring the load to metatarsal shafts
in metatarsalgia.
o Inner sole excavation: A soft pad filled with compressible material is
placed under one or more metatarsal heads.
o Scaphoid pad: This type of pad extends from one half inch posterior
to the first metatarsal head to the anterior tubercle of the calcaneus.

40

The apex of the scaphoid pad is between the talonavicular joint and
the navicular tuberosity. The scaphoid pad is used for medial arch
support.
Toe crest: A crescent-shaped pad is placed behind the second
through fourth phalanges. The toe crest fills the void under the
proximal phalanges and reduces the stress.

Foot orthosis

The foot orthosis extends from the posterior border of the foot to a point
just posterior to the metatarsal heads. This device is used to
accommodate the abnormal foot to help restore more normalized lower
limb biomechanics.

41

UCBL (University of California at Berkeley Laboratory) insert: This insert is


made of rigid plastic fabricated over a cast of the foot held in maximal
manual correction. The UCBL encompasses the heel and midfoot, and it
has rigid medial, lateral, and posterior walls.
Heel cup: The heel cup is a rigid plastic insert that covers the plantar
surface of the heel and extends posteriorly, medially, and laterally up the
side of the heel. The heel cup is used to prevent lateral calcaneal shift in
the flexible flat foot.
Sesamoid insert: This addition to an orthosis is an insert amounting to
three quarters of an inch with an extension under the hallux to transfer
pressure off the short first metatarsal head and onto its shaft.

ANKLE-FOOT ORTHOTICS
An AFO is commonly prescribed for weakness or paralysis of ankle dorsiflexion,
plantar flexion, inversion, and eversion. AFOs are used to prevent or correct
deformities and reduce weight bearing. The position of the ankle indirectly affects
the stability of the knee with ankle plantar flexion providing a knee extension
42

force and ankle dorsiflexion providing a knee flexion force. An AFO has been
shown to reduce the energy cost of ambulation in a wide variety of conditions,
such as spastic diplegia due to cerebral palsy, lower motor neuron weakness of
poliomyelitis, and spastic hemiplegia in cerebral infarction.
Thermoplastic molded ankle-foot orthosis (posterior leaf spring, minimal
resistance, moderate resistance, maximal resistance/solid ankle-foot
orthosis).

Thermoplastic AFOs: These devices are plastic molded AFOs, consisting


of the following 3 parts: (1) a shoe insert, (2) a calf shell, and (3) a calf
strap attached proximally. The rigidity depends on the thickness and
composition of the plastic, as well as the trim line and shape.
Thermoplastic AFOs are contraindicated in cases of fluctuating edema
and insensation.
1. Posterior leaf spring (PLS): The PLS is the most common form of
AFO with a narrow calf shell and a narrow ankle trim line behind the
malleoli. The PLS is used for compensating for weak ankle
dorsiflexors by resisting ankle plantar flexion at heel strike and
during swing phase with no mediolateral control.
2. Spiral AFO: This AFO consists of a shoe insert, a spiral that starts
medially, passes around the leg posteriorly, then passes anteriorly
to terminate at the medial tibial flare where a calf band is attached.
The spiral AFO allows for rotation in the transverse plane while
controlling ankle dorsiflexion and plantar flexion, as well as
eversion and inversion.
3. Hemispiral AFO: This AFO consists of a shoe insert with a spiral
starting on the lateral side of the shoe insert, passing up the
posterior leg, and terminating at the medial tibial flare where the
calf band is attached. This design is used for achieving better
control of equinovarus than the spiral AFO can.
4. Solid AFO: The solid AFO has a wider calf shell with trim line
anterior to the malleoli. This AFO prevents ankle dorsiflexion and
plantar flexion, as well as varus and valgus deviation.

43

5. AFO with flange: This AFO has an extension (flange) that projects
from the calf shell medially for maximum valgus control and laterally
for maximum varus control.
6. Hinged AFO: The adjustable ankle hinges can be set to the desired
range of ankle dorsiflexion or plantar flexion.
7. Tone-reducing AFO (TRAFO): The broad footplate is used to
provide support around most of the foot, extending distally under
the toes and up over the foot medially and laterally to maintain the
subtalar joint in normal alignment. The TRAFO is indicated for
patients with spastic hemiplegia.
Metal and metal-plastic AFOs
This type of AFO consists of a shoe or foot attachment, ankle joint, 2 metal
uprights (medial and lateral), with a calf band (application of force) connected
proximally. The stirrup anchors the uprights to the shoes between the sole and
the heel. The caliper is a round tube placed in the heel of the shoe, which
connects to the uprights and also allows for easy detachability of the uprights. A
molded shoe insert is another alternative to fit the stirrup into the shoe, which
also allows maximum control of the foot and aligns the anatomic and mechanical
ankles.

Ankle joints: The mechanical ankle joints can control or assist ankle
dorsiflexion or plantar flexion by means of stops (pins) or assists (springs).
The mechanical ankle joint also controls mediolateral stability. Knee
extension moment is promoted by ankle plantar flexion, and knee flexion
moment is promoted by ankle dorsiflexion.
1. Free motion ankle joint: The stirrup has a completely circular top,
which allows free ankle motion and provides only mediolateral
stability.
2. Plantar flexion ankle joint stop: This ankle joint stop is produced by
a pin inserted in the posterior channel of the ankle joint or by
flattening the posterior lip of the stirrup's circular stop. The plantar
flexion stop has a posterior angulation at the top of the stirrup that
restricts plantar flexion but allows unlimited dorsiflexion and
promotes knee flexion moment. This design is used in patients with
weakness of dorsiflexion during swing phase and flexible pes
equinus.
3. Dorsiflexion ankle joint stop: The stirrup has a pin inserted in the
anterior channel of the ankle joint or by flattening the anterior lip of
the stirrup's circular stop. The dorsiflexion stop has an anterior
angulation at the top of the stirrup that restricts dorsiflexion but
allows unlimited plantar flexion and promotes a knee extension
moment in the meantime. This design is used in patients with
weakness of plantar flexion during late stance.

44

4. Limited motion ankle joint stop: This ankle joint stop has anterior
and posterior angulations at the top of the stirrup with restricted
dorsiflexion and plantar flexion ankle motion. The limited motion
ankle joint stop has a pin in the anterior and the posterior channel,
and it is used in ankle weakness affecting all muscle groups.
5. Dorsiflexion assist spring joint: This joint has a coil spring in the
posterior channel and helps to aid dorsiflexion during swing phase.
6. Varus or valgus correction straps (T-straps): A T-strap attached
medially and circling the ankle until buckling on the outside of the
lateral upright is used for valgus correction. A T-strap attached
laterally and buckling around the medial upright is used for varus
correction.

KNEE-ANKLE-FOOT ORTHOTICS AND KNEE


ORTHOTICS
KAFOs consist of an AFO with metal uprights, a mechanical knee joint, and 2
thigh bands. KAFO can be used in quadriceps paralysis or weakness to maintain
45

knee stability and control flexible genu valgum or varum. KAFO also is used to
limit the weight bearing of the thigh, leg, and foot with quadrilateral or ischial
containment brim. A KAFO is more difficult to don and doff than an AFO, so it is
not recommended for patients who have moderate-to-severe cognitive
dysfunction.

KAFO: This orthosis can be made of metal-leather and metal-plastic or


plastic and plastic-metal. The metal design includes double upright metal
KAFO (most common), single upright metal KAFO (lateral upright only),
and Scott-Craig metal KAFO. The plastic designs are indicated for closer
fit and maximum control of the foot, including supracondylar plastic KAFO,
supracondylar plastic-metal KAFO, and plastic shells with metal uprights
KAFO.
1. A double upright metal KAFO: This is an AFO with 2 metal uprights
extending proximally to the thigh to control knee motion and
alignment. This orthosis consists of a mechanical knee joint and 2
thigh bands between 2 uprights.
2. A Scott-Craig orthosis consists of a cushioned heel with a T-shaped
foot plate for mediolateral stability, ankle joint with anterior and
posterior adjustable stops, double uprights, a pretibial band, a
posterior thigh band, and knee joint with pawl locks and bail control.
Hyperextension of the hip allows the center of gravity falling behind
the hip joint and in front of the locked knee and ankle joint. With 10
of ankle dorsiflexion alignment, it allows a swing-to or swingthrough gait with crutches. This orthosis is used for standing and
ambulation in patients with paraplegia due to spinal cord injury
(SCI).
3. The supracondylar plastic orthosis uses immobilized ankle in slight
plantar flexion to produce a knee extension moment in stance to
help eliminate the need for a mechanical knee lock. This orthosis
also resists genu recurvatum and provides mediolateral knee
stability.
4. A plastic shell and metal upright orthosis consists of a posterior leaf
spring AFO with double metal uprights extending up to a plastic
shell in the thigh with an intervening knee joint.

Knee joints: The mechanical knee joint can be polycentric or single axis.
Polycentric is used for significant knee motion, and a single axis is more
common and is used for knee stabilization. Single axis knee joints include
the following:

46

1. Free motion knee joint: This joint has unrestricted knee flexion and
extension with a stop to prevent hyperextension. The free motion
knee joint is used for patients with recurvatum but good strength of
the quadriceps to control knee motion.
2. Offset knee joint: The hinge is located posterior to the knee joint
and ground reaction force; thus, it extends the knee and provides
great stability during early stance phase of the gait cycle. This joint
flexes the knee freely during swing phase and is contraindicated
with knee or hip flexion contracture and ankle plantar flexion stop.
3. Drop ring lock knee joint: The drop ring lock is the most commonly
used knee lock to control knee flexion. The rings drop to unlock
over the knee joint while the knee is in extension by gravity or
manual assistance. This type of joint is stable, but gait is stiff
without knee motion. A ball bearing on a spring can be added just
above the drop lock to keep it from slipping up as the patient
ambulates. Patients over 120 pounds usually feel more secure with
both medial and lateral drop locks.
4. Pawl lock with bail release knee joint: The semicircular bail attaches
to the knee joint posteriorly, and it can unlock both joints easily by
pulling up the bail or backing up to sit down in a chair. A major
drawback is the accidental unlocking while the patient is pulling his
or her pants up or bumping into a chair.
5. Adjustable knee lock joint (dial lock): The serrated adjustable knee
joint allows knee locking at different degrees of flexion. This type of
knee joint is used in patients with knee flexion contractures that are
improving gradually with stretching.
6. Ischial weight bearing: Most individuals in a KAFO sit partially on
the upper thigh band unless the cuff is brought up above the
ischium.
Knee cap and strap: The knee cap can be placed in front of the knee in
the orthosis to prevent flexion of the knee. A medial strap is used for genu
valgum and a lateral strap is used for genu varum. These buckles wrap
around the upright in the same way as ankle straps.

Knee orthoses
A knee orthosis (KO) only provides support or control of the knee but not of the
foot and ankle. The knee joint is centered over the medial femoral condyle. If the
patient does not have adequate gastrocnemius delineation so that there is a shelf

47

for the distal end of the orthosis to rest on, the brace may slide down the leg with
wear. In that case, the brace needs to extend to the sole of the foot.

Knee orthoses for patellofemoral disorder: These orthoses are used to


supply mediolateral knee stability and to control tracking of the patella
during knee flexion and extension. This type of orthosis includes an
infrapatellar strap KO and Palumbo KO.
Knee orthoses for knee control in the sagittal plane: These orthoses are
used to control genu recurvatum with minimal mediolateral stability. This
type of KO includes a Swedish knee cage and a 3-way knee stabilizer.
Knee orthoses for knee control in the frontal plane: These orthoses consist
of thigh and calf cuffs joined by sidebars with mechanical knee joints. The
knee joint usually is polycentric and closely mimics the anatomic joint
motion. This type of KO includes traditional metal-leather KO, Miami KO,
Canadian Arthritis and Rheumatism Society-University of British Columbia
KO, and supracondylar KO.
Knee orthoses for axial rotation control: These orthoses can provide
angular control of flexion-extension and mediolateral planes, in addition to
controlling axial rotation. This orthosis is used mostly in management of
sports injuries of the knee. This type of KO includes Lenox-Hill derotation
orthosis and Lerman multiligamentous knee control orthosis.

HIP-KNEE-ANKLE-FOOT ORTHOTICS
An HKAFO consists of a hip joint and pelvic band in addition to a KAFO. The
orthotic hip joint is positioned with the patient sitting upright at 90, while the
48

orthotic knee joint is centered over the medial femoral condyle. Pelvic bands
complicate dressing after toileting unless the orthosis is worn under all
clothing. Pelvic bands increase the energy demands for ambulation.

Pelvic bands
1. Bilateral pelvic band: This band is used more commonly with its
posterior metal ends located anterior to the lateral midline of the
pelvis and is interconnected by a flexible belt.
2. Unilateral pelvic band: This band rarely is used because most
conditions requiring a HKAFO have bilateral involvement.
3. Pelvic girdle: The pelvic girdle is made of molded thermoplastic
materials, providing a maximum degree of control in patients with
bilateral involvement.
4. Silesian belt: This belt has no metal or rigid band and offers mild
resistance to abduction and rotation of the hip. The Silesian belt
attaches to the lateral upright and encircles the pelvis.
Hip joints and locks: The hip joint can prevent abduction and adduction as
well as hip rotation.
1. Single axis hip joint with lock: This joint is the most common hip
joint with flexion and extension. The single axis hip joint with lock
may include an adjustable stop to control hyperextension.
2. Two-position lock hip joint: This hip joint can be locked at full
extension and 90 of flexion and is used for hip spasticity control in
a patient who has difficulty maintaining a seated position.
3. Double axis hip joint: This hip joint has a flexion-extension axis and
abduction-adduction axis to control these motions.

TRUNK-HIP-KNEE-ANKLE-FOOT ORTHOTICS

49

A THKAFO consists of a spinal orthosis in addition to a HKAFO for control of


trunk motion and spinal alignment. A THKAFO is indicated in patients with
paraplegia and is very difficult to don and doff.
1. Reciprocating gait orthosis (RGO): An RGO consists of bilateral KAFOs
with posteriorly offset locking knee joints, hip joints, and a custom-molded
pelvic girdle with a thoracic extension. The hip joints are coupled with
cables preventing bilateral hip flexion simultaneously. The hip extension
on one side coupling hip flexion on the other side through the cables
produces reciprocal walking gait pattern. The RGO combined with
functional electronic stimulation (FES) can be used for 2-point or 4-point
gait patterns in ambulatory paraplegic or tetraplegic (C8) patients. Using
the RGO with FES can double the patient's optimum gait speed, lower
blood pressure and heart rate, and increase oxygen uptake as compared
to ambulating with the RGO without FES.
2. Para walker: This device is a hip guidance orthosis, which consists of
bilateral KAFOs with a ball bearing hip joint and a body brace. Ambulation
is performed through trunk motion transmitted to the lower extremities with
hip flexion and extension via the brace. Hip flexion is restricted by a stop,
and hip extension may be free or limited by a stop. The para walker is
developed for patients with SCI. A study of 5 paraplegic patients found an
average reduction in oxygen consumption of 27%, with 33% faster
ambulatory rate compared to the RGO.
3. Parapodium: This device is developed for pediatric myelodysplastic
patients to allow them to stand without crutches for functional activities
with their upper limbs free. The parapodium consists of a shoe clamp,
aluminum uprights, a foam knee block, and back and chest panels. Hip
and knee may be locked for standing and unlocked for sitting. A torque
converter under the base allows side-to-side rocking to be translated into
forward propulsion.
4. Standing frame: This allows standing but does not permit hip and knee
flexion. The standing frame is used for children to learn standing balance
and achieve a swing-through gait.

SPECIAL PURPOSE LOWER LIMB ORTHOTICS

50

Weight-bearing orthoses: This orthosis is designed to eliminate weight bearing


through the lower extremities. Weight-bearing orthoses consist of patellartendonbearing orthosis (PTBO), ischial weight-bearing orthosis, and patten
bottom with uprights terminated in a floor pad or patten distal to the shoe.
1. Fracture orthoses: This orthosis stabilizes the fracture site and promotes
callus formation, while allowing weight bearing and joint movement after
initial subsiding pain and edema. The bony motion at the fracture site is
prevented through circumferential compression of the soft tissue. Fracture
orthoses include the tibial fracture orthosis and femoral fracture orthosis.
2. Angular and deformity orthoses: This orthosis is used in the pediatric
population. The Denis Brown splint is for clubfoot. A frame orthosis applies
corrective forces to proximal rotational deformities. A torsion shaft orthosis
is used in mild scissoring gait of spastic diplegia.
3. Congenital hip dislocation orthoses, such as Pavlik harness, Ilfeld splint,
and VonRosen splint are used to maintain the hip in flexion and abduction
position to hold the femoral head within the acetabulum.
4. The Scottish Rite, Toronto, and nonskeletal-bearing trilateral orthoses are
used in Legg-Calve-Perthes disease to maintain the hip in abduction and
keep the femoral head in the acetabulum.

: Rocker shoe.

51

: Blucher style orthopedic shoe (top); diabetic shoe (bottom)

Thermoplastic molded ankle-foot orthosis (posterior leaf spring, minimal


resistance, moderate resistance, maximal resistance/solid ankle-foot
orthosis).

Modular ankle-foot orthosis with double adjustable hinged joint ankle-foot


orthosis.

52

Flesh colored plastic Gelett joint with dorsiflexion assist ankle-foot


orthosis.

: Double upright metal ankle-foot orthosis.

Carbon plastic ankle-foot orthosis with footplate.

53

Double upright metal knee-ankle-foot orthosis.

: Plastic shell and metal uprights molded knee-ankle-foot orthosis with


drop lock joints.

Offset knee joint knee-ankle-foot orthosis.

54

Drop ring lock knee joint knee-ankle-foot orthosis.

55

Limb Prostheses
General Background:
External prosthetic appliances are devices used to replace the function of a
missing body part and are often referred to as prosthetic devices, or prostheses.
Lower limb prostheses are used to replace the function of a lower extremity. In
the elderly population, amputation (loss) of the lower extremity most often results
from complications of disease processes, such as diabetes, peripheral vascular
disease, thromboembolism and vasculitis. The second most common cause of
lower limb amputation is trauma to the limb, which is frequently seen in a
younger population. Amputation may also result from treatment for a malignancy
or various other medical conditions.
Several prosthetic devices are available to replace the function of lower limbs.
For amputees with above-knee limb loss, devices have traditionally consisted of
single-axis knees and/or hydraulic or pneumatic fluid-controlled therapy devices.
These devices provide optimum gait control at usual speed but require additional
compensation when walking slower or faster and also require increased
concentration and effort of the amputee. Although a device of this type does
produce a limp, the greatest stability is offered with the use of a manual locked
knee which locks the prosthesis straight for walking. The manual locked-knee
device has a release lever or cable that can be pulled to unlock the joint and
allows bending. Prosthetic devices consisting of an ankle and/or foot device are
also utilized for below-the-knee amputees.

Definition:
A limb prosthesis is an artificial replacement for any or all parts of the lower
extremity or upper extremity.
An artificial limb is a type of prosthesis that replaces a missing extremity, such
as arms and legs.

Purpose:
A prosthesis is used to provide an individual who has an amputated limb with the
opportunity to perform functional tasks, particularly ambulation (walking), which
may not be possible without the limb.
Amputation surgery most often is performed due to complications of peripheral
vascular disease or neuropathy; trauma is the second leading cause of
amputation. Industrial, vehicular, and war related accidents are the leading cause
of amputations, disease is the leading cause of amputations. [1] Cancer, infection
and circulatory disease are the leading diseases that may lead to amputation.
Amputations performed because of tumor or congenital limb deficiency are less

56

common. A congenital defect can create the need for an artificial limb when a
person is born with a missing or damaged limb.
The type of prosthesis (artificial limb) used is determined largely by the extent of
an amputation or loss and location of the missing extremity.

Recovery Stages:
The American Academy of Orthotists and Prosthetists (AAOP) formed the Clinical
Standards of Practice (CSOP) on Post-operative Management of the Lower
Extremity (2004). The committee defined stages of care extending from the
preoperative period to the late stage postoperative rehabilitation. Typically, the
postoperative recovery period (including activity recovery, reintegration,
prosthetic management and training) lasts from 1218 months. However, healing
of a residual limb is a continuous process and prosthetic readiness is an
individualized transition point. The following stages of care were defined:
Preoperative stage: This stage begins with the decision to amputate.
Acute hospital postoperative stage: This stage includes the time in the
hospital after amputation surgery, generally 514 days.
Immediate postacute hospital stage: This stage begins with the hospital
discharge and may extend up to eight weeks after surgery. Endpoints of
this stage are characterized by wound healing and readiness for a
prosthetic fitting.
Intermediate recovery stage: This stage begins with wound healing and
extends 46 months from the healing date and involves the use of a
preparatory prosthesis or first prosthesis. Often, the most rapid limb
volume changes occur during this period as a result of ambulation and
prosthetic use. This stage typically ends with stabilization of residual limb
size, as defined by consistency of prosthetic fit for several months.
Transition to stable stage: A period of relative limb stabilization after the
immediate recovery stage. This stage was historically marked as a
transition from the preparatory prosthesis to the definitive prosthesis,
although more recently it has been characterized by a change from a
rapidly changing limb to a slower maturation of the limb. While limb
volume changes are not as drastic in this stage, the limb may continue to
change for 1218 months after initial healing. Modular systems are
frequently encouraged during this stage.
Postoperative rehabilitation should begin as soon as possible. Fitting for the
prosthesis may begin once the suture line has completely healed, and swelling is
minimized, although in some rare cases (e.g., young patients with traumatic
amputations), a temporary prosthesis may be fitted in surgery. Immediate
57

postoperative prosthetic limb fitting has not gained wide acceptance due to
unacceptable rates of wound complications (Pinzur, 2003).
Residual limb shrinkage and swelling are often controlled in the postoperative
recovery phase with the use of various types of dressings. Ace wraps prevent
swelling and encourage shrinkage and may be used prior to complete healing of
the limb. A rigid dressing, such as a cast, may be used when temporary
prosthetic devices are recommended. Other methods to assist in shrinkage and
reduction of swelling include the use of compression stockings and stump
shrinkers (elastic stockings). The initial shrinkage and shaping of the limb takes
approximately six weeks to three months, depending on response and condition
(Sherman and Jones, 1995). Care of the residual limb is a lifelong process, and
changes in residual stump size may be the result of weight gain, weight loss or
swelling.
Prosthetic devices for children are often staged based on the childs
developmental readiness. The prosthesis must accommodate growth and other
physiological changes. According to AAOP (Cummings and Kapp, 1992),
methods that allow for growth and that may increase the lifespan of the
prosthesis include the following:
modification of socket liners
flexible sockets
removable sockets (slip or triple wall sockets)
adding or decreasing sock thickness
distal pads
the use of modular systems
growth oriented suspension systems and modifications
Furthermore, although the prosthetic treatment plan is highly individualized,
children require frequent follow-up for growth and typically require new devices
every 1218 months on average, although the actual lifespan of the device
depends on the childs rate of skeletal growth.

Types of Prosthetic Devices:


Prosthetic devices may be preparatory or permanent. A preparatory device (more
common for lower limb amputees) is a prosthesis made soon after an amputation
(approximately four weeks) as a temporary method of retraining a person to walk
and balance while shrinking the residual limb. Preparatory devices often use

58

transparent diagnostic test sockets and special fitting techniques to accurately fit
the prosthesis so problems can be eliminated before it is copied for the
permanent prosthesis. The average use of these devices may last for 36
months in some cases or until the residual limb has reached its final shape and
size. Stabilization of the residual limb is difficult to define; however, AAOP CSOP
(2004) suggests that a permanent prosthesis be recommended when a patient
has used a prosthetic device full time for a period of six months and when the
limb volume has stabilized to a point where the socket fit remains relatively
consistent for 23 weeks. Once fitted, the permanent prosthesis, also referred to
as a definitive prosthesis, is classified as a device that meets accepted clinical
standards for comfort, fit, function, appearance and durability. In some
circumstances, a patient may be fitted only for a permanent device, and fitting
should be delayed until the residual limb is fully mature (usually 34 months) or
until stabilization occurs in the patients weight and stump circumference
(Bodeau, 2002).
When an initial below-knee prosthesis (Health Care Financing Administration
[HCFA] Common Procedural Coding System [HCPCS] code L5500) or a
preparatory below-knee prosthesis (HCPCS codes L5510L5530, L5540) is
provided, prosthetic substitutions and/or additions of procedures and
components may be medically necessary in accordance with the functional level
assessment, except for HCPCS codes L5629, L5638, L5639, L5646, L5647,
L5704, L5785, L5962 and L5980; the latter are not considered medically
necessary. When a below-knee preparatory, prefabricated prosthesis (HCPCS
code L5535) is provided, prosthetic substitutions and/or additions of procedures
may be medically necessary in accordance with the functional level assessment,
except for HCPCS codes L5620, L5629, L5645, L5646, L5670, L5676, L5704
and L5962; the latter codes are not considered medically necessary.
When an above-knee initial prosthesis (HCPCS code L5505) or an above-knee
preparatory (HCPCS codes L5560L5580, L5590L5600) prosthesis is provided,
prosthetic substitution and/or additions of procedures and components may be
medically necessary in accordance with the functional level assessment, except
for HCPCS codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706,
L5964, L5980, L5710L5780 and L5790L5795; the latter codes are not
considered medically necessary. When an above-knee preparatory, prefabricated
prosthesis (HCPCS code L5585) is provided, prosthetic substitution and/or
additions of procedures and components may be medically necessary in
accordance with the functional level assessment, except for HCPCS codes
L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964 and L5966; the latter
codes are not considered medically necessary.

Functional Classifications
Prior to being fitted with a prosthetic device, the patient must demonstrate
specific functional levels. A functional level is defined as a measurement of the
capacity and potential of the patient to accomplish his/her expected post-

59

rehabilitation daily function. The Centers for Medicare and Medicaid Services
(CMS) have defined the following functional levels:
Level 0: Does not have the ability or potential to ambulate or transfer safely with
or without assistance and prosthesis does not enhance his/her quality of life or
mobility.
Level 1: Has the ability or potential to use prosthesis for transfers or ambulating
on level surfaces at fixed cadence; typical of the limited and unlimited household
ambulator.
Level 2: Has the ability or potential for ambulating with the ability to traverse
environmental barriers such as curbs, stairs or uneven surfaces; typical of the
limited community ambulator.
Level 3: Has the ability or potential for ambulating with variable cadence; typical
of the community ambulator who has the ability to traverse most environmental
barriers and may have

60

vocational, therapeutic, or exercise activity that demands prosthetic utilization


beyond simple locomotion.
Level 4: Has the ability or potential for prosthetic ambulating that exceeds basic
ambulating skills, exhibiting high impact, stress, or energy levels; typical of the
prosthetic demands of the child, active adult, or athlete.
Potential functional ability is based on reasonable expectations of the prosthetist
and the treating physician that are based on factors including but not limited to:
the patients past history (including prior prosthetic use, if applicable)
the patients current condition (including status of the residual limb and the
nature of other medical problems)
the patients desire to ambulate
A patient whose functional level is zero (0) is not a candidate for a prosthetic
device; the device is considered not medically necessary.
A basic (i.e., conventional) lower limb prosthetic device consists of the following:
a socket (connection between the residual limb and prosthesis)
a suspension mechanism (how the socket is attached to the prosthesis)
a knee joint (provides support during stance, smooth control during swing
phase and unrestricted motion for sitting and kneeling)
a pylon (a tube or shell that attaches the socket to the terminal device) that
is either exoskeleton or endoskeleton
a terminal device (foot)
Components and/or additions to the prosthesis may be medically necessary; the
determination of medical necessity is based on the patients functional ability and
expected functional potential as defined by the prosthetist and the ordering
physician. Additional documentation supporting medical necessity must
accompany claims submitted for prosthetic components and/or additions.
Customizing prosthetic devices with enhanced features is not medically
necessary if activities of daily living can be met with standard devices.
Accessories that are necessary for the effective use of the prosthetic device,
such as stump socks and harnesses, may be considered medically necessary
devices. Accessories that are not necessary for the effective use of the device
are considered not medically necessary.

61

The following items are typically included in the reimbursement for a


prosthetic device:
evaluation of the residual limb and gait
fitting of the prosthesis
cost of base component parts and labor contained in HCPCS base codes
repairs due to normal wear and tear during the 90 days following delivery
adjustments of the prosthesis or the prosthetic component made when fitting
the prosthesis or component and for 90 days from the date of delivery
when the adjustments are not necessitated by changes in the residual
limb or the patients functional ability

Description
There are several levels of lower limb amputation, including partial foot, ankle
disarticulation, transtibial (below the knee), knee disarticulation, transfemoral
(above the knee), and hip disarticulation. The most common are transtibial (midcalf) and transfemoral (mid-thigh). The basic components of these lower limb
prostheses are the foot-ankle assembly, shank, socket, and suspension syste
The basic components of a lower extremity prosthesis include:
the socket, a sock or gel liner, a suspension system, a knee joint (articulating
joint), the shank (a pylon), and a foot (terminal device)

62

(Fig. 1).

Figure 1: Lower extremity prosthesis components.

Foot-ankle assembly
The foot-ankle assembly is designed to provide a base of support during
standing and walking, in addition to providing shock absorption and push-off
during walking on even and uneven terrain. Four general categories of foot-ankle
assemblies are non-articulated, articulated, elastic keel, and dynamic-response.
One of the most widely prescribed foot is the solid-ankle-cushion-heel (SACH)
foot, due to its simplicity, low cost, and durability. It may be inappropriate,
however, for active community ambulators and sports participants. Articulated
63

assemblies allow motion at the level of the human ankle; this motion may occur
in one or more planes, depending on whether it is a single-axis or multi-axis foot.
These assemblies offer more mobility at the cost of less stability and increased
weight. The elastic keel foot is designed to mimic the human foot without the use
of mechanical joints; the dynamic-response foot is designed to meet the
demands of running and jumping in athletic us

Figure 3: Variety of Foot or Terminal Devices

Shank
The shank corresponds to the anatomical lower leg, and is used to connect the
socket to the ankle-foot assembly. In an endoskeletal shank, a central pylon,
which is a narrow vertical support, rests inside a foam cosmetic cover.
Endoskeletal systems allow for adjustment and realignment of prosthetic
components. In an exoskeletal shank, the strength of the shank is provided by a
hard outer shell that is either hollow or filled with lightweight material. Exoskeletal
systems are more durable than endoskeletal systems; however, they may be
heavier and have a fixed alignment, making adjustments difficult.

Suspension
Suspension devices should keep the prosthesis firmly in place during use and
allow comfortable sitting. Several types of suspension exist, both for the
transtibial and transfemoral amputation. Common transtibial suspensions include
sleeve, supracondylar, cuff, belt and strap, thigh-lacer, and suction styles.
Sleeves are made of neoprene, urethane, or latex and are used over the shank,
socket and thigh. Supracondylar and cuff suspensions are used to capture the
femoral condyles and hold the prosthesis on the residual limb. The belt and strap
method uses a waist belt with an anterior elastic strap to suspend the prosthesis,
while the thigh-lacer method uses a snug-fitting corset around the thigh. The
suction method consists of a silicone sleeve with a short pin at the end. The
sleeve fits over the residual limb and the pin locks into the socket. With a

64

transfemoral prosthesis, suction and several types of belt suspension also are
available.
Transfemoral amputations also provide the additional challenge of incorporating
a prosthetic knee unit. The knee unit must be able to bend and straighten
smoothly during ambulation, in addition to providing stability during weightbearing
on that limb. Knees are available as single-axis, polycentric, weight-activated,
manual-locking, hydraulic, and pneumatic units. Technology using
microprocessors in knee units is becoming a reality, although costs can be
prohibitive.

The socket
The socket enables the prosthesis to connect and fit to the stump (residual limb).
This is the most important prosthetic component. A good fit is critical. A socket
that is uncomfortable is a common reason why a prosthesis is rejected.
Contoured sockets fit closer to the remaining bones, muscles, and soft tissues
providing better support, and provide relief where it's needed for comfort. 8
Examples of contoured sockets include the Hanger ComfortFlex Socket
System, Quadrilateral Socket, CAT/CAM Socket, ML socket, Acrylic socket, Total
Contact Socket, Pump It Up system, the Otto Bock Air Cushion Socket system
and more. Liners are sometimes used inside the socket to obtain a better fit and
for comfort. A gel liner helps in pressure distribution, comfort, and skin
smoothing.

Operation

65

Use of an actual prosthesis usually follows a period of postoperative


management that includes addressing issues of pain, swelling, and proper
positioning. In addition, physical therapy for range of motion, strength, bed
mobility, transfers, and single limb ambulation often takes place during the initial
rehabilitation period. In some cases, an individual may be fitted with an
immediate post-operative prosthesis to allow for early double-limb ambulation.
Many individuals will be fitted with a temporary prosthesis when the wound has
healed. A temporary prosthesis allows for ambulation and continued shrinkage of
the residual limb until a definitive prosthesis is fit.
When evaluating a prosthesis before use, the prosthetist and physical therapist
should ensure that the inside of the socket is smooth and that all joints move
freely. The socket should fit securely on the residual limb, and the overall
prosthesis length should match the length of the intact leg. The patient must
learn how to properly put on the residual limb sock and the prosthesis itself. A
variety of techniques are used, depending on the type of socket and suspension
system.
Maintenance
The user should be aware of how to properly care for and maintain the
prosthesis, liner, and socks. Most plastic sockets and liners can be wiped with a
damp cloth and dried. Socks should be washed and changed daily. Due to the
wide variety of componentry and materials used in the fabrication of prostheses,
the prosthetist should be the source for instructions regarding proper care and
maintenance for each individual. In general, the patient should return to the
prosthetist for any repairs, adjustments or realignments.
Health care team roles
The patient's primary care physician, surgeon, neurologist, prosthetist, physical
and occupational therapists, nurses, and social worker are all important players
in the multidisciplinary health care team. Surveys of patients with amputations
have shown that the physical therapist, along with the physician and prosthetist,
plays one of the most valued roles in providing information and help both at the
time of amputation and following amputation. The entire team's input, along with
the patient's input, is vital in determining whether a prosthesis should be fit and
the specific prescription for the prosthesis. Input should be provided regarding
the patient's medical history, premorbid level of function, present level of function,
body build, range of motion, strength, motivation, and availability of familial and
social support.
The physical therapist usually plays a major role in training an individual to walk
with a prosthesis, and also is the health care professional who can evaluate
prosthetic function immediately and over time. The physical therapist is trained in

66

gait assessment and should watch for compensations and gait deviations that
may indicate a problem with the prosthesis.
Training
The main goal of prosthetic training usually is smooth, energy-efficient gait. This
includes the ability of the individual to accept weight on either leg, balance on
one foot, advance each leg forward and adjust to different types of terrain or
environmental conditions. Principles of motor learning often are used in training,
progressing from simple to complex tasks. Individuals begin with learning to keep
their bodies stable in a closed environment with no manipulation or variability. An
example may be practicing standing balance on one or both legs. Mobility,
environmental changes, and task variability are added slowly to further challenge
the individual as tasks are mastered. In the end, an example of a more complex
task practiced may be the ability walk in a crowded hallway while carrying an
object in one hand. In addition to ambulation training, the patient also should be
taught how to transfer to and from surfaces, assume a variety of positions such
as kneeling or squatting, and manage falls. Depending upon the individual's
previous and present level of function, use of a traditional cane, quad cane, or
crutches may be indicated. Patient motivation, comorbidity, level of amputation
and level of function are all factors in determining the outcome of rehabilitation.

Current Technology/Manufacturing
In recent years there have been significant advancements in artificial limbs. New
plastics and other materials, such as carbon fiber, have allowed artificial limbs to
be stronger and lighter, limiting the amount of extra energy necessary to operate
the limb. This is especially important for transfemoral amputees. Additional
materials have allowed artificial limbs to look much more realistic, which is
important to transradial and transhumeral amputees because they are more likely
to have the artificial limb exposed.[4]
In addition to new materials, the use of electronics has become very common in
artificial limbs. Myoelectric limbs, which control the limbs by converting muscle
movements to electrical signals, have become much more common than cable
operated limbs. Myoelectric limbs allow the amputees to more directly control the
artificial limb. Computers are also used extensively in the manufacturing of limbs.
Computer Aided Design and Computer Aided Manufacturing are often used to
assist in the design and manufacture of artificial limbs. [4]
Most modern artificial limbs are attached to the stump of the amputee by belts
and cuffs or by suction. The stump usually fits into a socket on the prosthetic.
The socket is custom made to create a better fit between the leg and the artificial
limb, which helps reduce wear on the stump. The custom socket is created by
taking a plaster cast of the stump and then making a mold from the plaster cast.

67

Newer methods include laser guided measuring which can be input directly to a
computer allowing for a more sophisticated design.
One of the biggest problems with the stump and socket attachment is that there
is a large amount of rubbing between the stump and socket. This can be painful
and can cause breakdown of tissue.

Artificial limbs are typically manufactured using the following steps:


1.
2.
3.
4.
5.
6.
7.
8.

Measurement of the stump


Measurement of the body to determine the size required for the
artificial limb
Creation of a model of the stump
Formation of thermoplastic sheet around the model of the stump
This is then used to test the fit of the prosthetic
Formation of permanent socket
Formation of plastic parts of the artificial limb Different methods
are used, including vacuum forming and injection molding
Creation of metal parts of the artificial limb using die casting
Assembly of entire limb.

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Types of Prosthesis
Prosthetic Shoes:
Prosthetic shoes (HCPCS code L3250) may be medically necessary if they are
an integral part of the prosthesis for a patient with a partial foot amputation.
These types of devices are used when all or most of the forefoot is missing and
are considered terminal prosthetic devices. The function of a prosthetic shoe is
different from that of an orthopedic shoe and supportive foot device, which are
used by individuals whose feet, although impaired, are essentially intact. Claims
for prosthetic shoes for other conditions are considered not medically necessary.

Foot Prostheses:
The basic lower-extremity foot prosthesis consists of the solid-ankle/cushionedheel (SACH) foot. Other prosthetic feet may be considered medically necessary,
based upon functional classification, ability and individual need. The SACH
simulates plantar flexion at heel strike by compressing an elastic heel wedge and
provides forefoot dorsiflexion by way of a flexible toe section. The device has no
moving parts and is frequently indicated for amputees defined as functional level
1, but may be used in level 2 or level 3 amputees. It may also be selected as a
preparatory prosthesis. A single-axis foot provides fore-aft movement about an
ankle axis limited and cushioned by plantar flexion and dorsiflexion bumpers. It is
often used in amputees of functional level 3 and is frequently preferred for abovethe-knee amputees because of the increase in knee stability during early stance
phase. Multiaxial devices provide inversion-eversion and some degree of
transverse rotation in addition to dorsiflexion and plantar flexion. These types of
devices are particularly suited for ambulating on uneven terrain and for bilateral
amputees. A flexible keel provides dynamic assist at toe-off, helping to propel the
leg into swing phase. The flexible keel is often used with a dynamic response

69

that allows the amputee to ambulate at variable cadence. The device deforms
during weight-bearing, storing energy and then releasing it during late stance
phase, allowing forward movement. The flexible keel is also known as a SAFE
(solid-ankle-flexible-endoskeletal) foot. Foot covers are included in the codes for
the prosthetic foot component.
Medical necessity for a prosthetic foot is based on the following functional levels:
An external-keel SACH foot (HCPCS code L5970) or single-axis ankle/foot
(HCPCS code L5974) may be medically necessary for a patient whose
functional level is 1 or above.
A flexible-keel foot (HCPCS code L5972) or multiaxial ankle/foot (HCPCS
code L5978) may be medically necessary for a patient whose functional
level is 2 or above.
A flex foot system (HCPCS code L5980), energy-storing foot (HCPCS code
L5976), multiaxial ankle/foot with dynamic response (HCPCS code
L5979), a flex-walk system or equal (HCPCS code L5981), or shank
system with vertical loading pylon (HCPCS L5987) may be medically
necessary for a patient whose functional level is 3 or above.

Knee Prostheses:
The basic lower-extremity prosthesis includes a single-axis, constant friction
knee. This device is a basic knee that acts as a door-and-hinge device, is freeswinging and does not allow stance control. It allows one-speed ambulation and
is often used in children. Other prosthetic knees may be medically necessary
based upon functional classification, ability and individual need. A hydraulic unit
that includes piston cylinders and contains either air (i.e., pneumatic) or fluid (i.e.,
hydraulic) may be added to the knee device to allow swing control as the
amputee speeds up or slows down. Swing control may allow the amputee to walk
at variable speeds. It is often used in more active amputees. The polycentric
knee, a device with multiple rotational axes, is sometimes referred to as the four
bar knee. It has four points of rotation connected by a linkage bar. The device is
asserted to be very stable in early stance and easy to flex in swing phase.

70

Medical necessity for a prosthetic knee device is based on the


following functional levels:
A high activity knee control frame (L5930) may be medically necessary for
patients whose functional level is 4.
Fluid, pneumatic or electronic knees (HCPCS codes L5610, L5613, L5614,
L5722L5780, L5822L5840, L5848, L5856, L5857, and L5858) may be
medically necessary for patients whose functional level is 3 or above.
Other knee systems (HCPCS codes L5611, L5616, L5710L5718, and
L5810L5818) may be medically necessary for patients whose functional
level is 1 or above.

Ankle Prostheses:
Axial rotation units (HCPCS codes L5982L5986) may be medically necessary
for patients whose functional level is 2 or above.

Sockets:
The socket is the part of the prosthesis that fits around the residual limb and fits
around the liner or socket insert. Test sockets are used prior to permanent
sockets to determine correct fitting. Test sockets (e.g.,
Page 6 of 18 Coverage Position Number: 0194

Socket replacements may be medically necessary if there is a functional or


physiological need, including but not limited to changes in the residual
limb, changes in functional need, irreparable damag

71

Transtibial Prosthesis:
A transtibial prosthesis is an artificial limb that replaces a leg missing below the
knee. Transtibial amputees are usually able to regain normal movement more
readily than someone with a transfemoral amputation, due in large part to
retaining the knee, which allows for easier movement.

Transfemoral Prosthesis
A transfemoral prosthesis is an artificial limb that replaces a leg missing above
the knee. Transfemoral amputees can have a very difficult time regaining normal
movement. In general, a transfemoral amputee must use approximately 80%
more energy to walk than a person with two whole legs. [5] This is due to the
complexities in movement associated with the knee.

Transradial Prosthesis
A transradial prosthesis is an artificial limb that replaces an arm missing below
the elbow. Two main types of prosthetics are available. Cable operated limbs
work by attaching a harness and cable around the opposite shoulder of the
damaged arm. The other form of prosthetics available are myoelectric arms.
These work by sensing, via electrodes, when the muscles in the upper arm
moves, causing an artificial hand to open or close.

Transhumeral Prosthesis
A transhumeral prosthesis is an artificial limb that replaces an arm missing above
the elbow. Transhumeral amputees experience some of the same problems as
transfemoral amputees, due to the similar complexities associated with the
movement of the elbow. This makes mimicking the correct motion with an
artificial limb very difficult.

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LOWER EXTREMITY PROSTHETICS


There are seven basic prosthetic options to consider for the person with a lower
extremity amputation:
Partial Foot Prosthetics
Complete Prosthetic Feet
Shock Absorbers and Rotators
Prosthetic Knees for Artificial Limbs
Prosthetic Interface Materials
Prosthetic Socket Design and Suspension
Cosmetic Covers

Partial Foot Prosthetics


Partial foot amputations are fit with prosthetic devices ranging from simple toefillers in shoes for toe amputations, to custom-molded silicone prosthetics that
incorporate contoured arch supports and carbon fiber keels. A comfortable fit,
control of weight-bearing forces and adaptation to the needs of each individual
are the most important features of this type of prosthesis. In some instances it
may be necessary to purchase slightly larger or extra-depth shoes to
.accommodate the arch support or prosthesis required
For persons with Diabetes, a comfortable and supportive pair of shoes with a soft
.sole and uppers is important to safeguard feet against any further injury

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Complete Prosthetic Feet


Prosthetic foot design and construction has progressed tremendously in the past
few decades and now commonly incorporates carbon fiber structures to reduce
weight and improve energy return. Some feet have terrain adapting and shock
absorbing features, while others are more suitable for special purposes such as
swimming. Most high-end feet can be tuned to suit each individual by adjusting
or exchanging internal elastomer bumpers or wedges, and are custom ordered
from the manufacturer to specifications for each client. Prosthetic feet are
selected by considering each individuals activity level and the type of terrain that
they will be traversing. We encourage our clients to become familiar with the
different types of prosthetic feet available, to assist in the selection of the most
.appropriate type for them
Prosthetic feet, like knees, hips, and other components incorporated into a
prosthesis, can be grouped according to a recognized functional level
:classification system
:Low Impact Level .1
.Daily activities involving limited and steady walking with the use of a walking aid
.Example: Ambulation at home, limited in community
:Moderate Impact Level .2
Daily activities involving normal walking, with the ability to demonstrate varied
.cadence
.Example: Community ambulation with confidence
:High Impact Level .3
.Daily activities involving fast walking, jogging and climbing stairs
.Example: Light manual labor, recreational sports
:Extreme Impact Level .4
.Daily activities involving rigorous walking, running and heavy lifting
.Example: Heavy manual labor including lifting, track and field sports
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SACH, Solid Ankle Cushioned Heel (Low Impact Level)


This foot has a wedge-shaped cushion in the heel that compresses with each
step and a simple internal supportive structure embedded in a foam cosmetic
shape. These feet can be quite light and are also suitable for prostheses
intended for use around water.

Sach Foot
Single Axis (Low Impact Level)
A hinged ankle joint is incorporated into the prosthetic foot. Rubber bumpers
.within the ankle structure absorb ankle motion induced by body weight

Dycor Foot
Multi Axis (Moderate Impact Level)
Rubber bumpers in the ankle mechanism permit a rocking motion of the foot from
heel to toe as well as from side to side. This can be useful for walking on uneven
terrain. Generally these feet do not have much stored energy return and they
.have a softer feeling underfoot than the SACH feet

Endolite Foot
75

Stored Energy (Moderate to High Impact Level)


These feet have an internal structure that acts like a spring. This spring will store
energy and return this energy to the amputee, propelling them forward, as the
toes of the prosthetic foot leave the ground. Some of the designs are virtually
maintenance-free, while others incorporating internal bushings and bumpers
require regular servicing to maintain optimal performance. Most of these feet
have terrain-adapting features that absorb irregularities in the ground and
improve performance on inclined surfaces. Some of the photos show the
prosthetic feet without their accompanying cosmetic covers.

Genesis II Foot

College Park Foot

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Luxon Foot
Talux Foot

Luxon DP Foot

Modular III Foot

Advanced Features Stored Energy (Moderate to High to Extreme Impact


Level)
These feet incorporate multiple features such as energy storage and return,
shock absorption and rotation, and terrain adaptation. Suitable for prolonged
walking, running and jumping they can be used both in daily ambulation and in
.sports

77

Ceterus Foot

Pathfinder Foot

Reflex VSP Foot


Shock Absorbers and Rotators
Rotators, with or without accompanying shock absorbers, are good additions to
most lower extremity prosthetic devices. While they do add weight to a
prosthesis, they reduce torsional stress on tissue. A rotation unit is definitely an
asset to playing golf, and some units can be tuned to suit the preferences of
.each individual

4R85 Torsion Adapter

Delta Twist Shock Absorber

Prosthetic Knees for Artificial Limbs


Like prosthetic feet, the type of prosthetic knee selected for each individual is
determined based on their intended activity level and the type of terrain that they
will be traversing. These knee units can be similarly grouped into categories
.associated with the four main Impact Levels
Children, Youth and Adults have access to many of the same classifications of
knee units, built to suit their weight range and activity levels. Contact us at

78

.Custom Prosthetic Services Ltd. to inquire about various prosthetic knee options
Single Axis Constant Friction Knees (Impact Level Low)
This is a basic knee where the friction is set for each patients walking speed.
The knee will feel stiff if the person is walking slower than the setting and not stiff
.enough if walking faster

Safety Knees (Impact Level Low)


This is a single axis knee as described above, but includes a locking mechanism
that will engage when the person places weight on the prosthesis, preventing the
knee from buckling. This lock is released when the toe of the prosthetic foot is in
.contact with the ground and weight is transferred off of the prosthesis

Manual Locking Knees (Impact Level Low)


A Manual Lock feature can be added to many knee designs and would usually be
used by very low impact level individuals, who need to ambulate with no
.possibility of the knee bending, unless the lock is manually released

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Bar Knees (Impact Level Low to Moderate unless it is combined with 4


pneumatic or hydraulic control for High)
This type of knee is designed to have more than one center of rotation
throughout the bending cycle and in this way mimics the human anatomical knee
joint. This design creates a stabile more easily controlled knee at the heel contact
moment of the gait cycle and has a smooth action from mid-stance until the toe
leaves the floor at the beginning of the swing phase portion of the gait cycle.
Each knee is designed or can be adjusted to increase or decrease the initial
centre of rotation and this influences knee safety. This type of knee also has less
length in swing phase to improve toe clearance and is particularly suited for
.persons with a long trans femoral or knee disarticulation amputation
These knees can have a constant friction brake and an adjustable knee
extension assist to adjust to the gait speed of each person, or they can include
either pneumatic or hydraulic swing phase control units. These features will
.determine performance levels of the knees

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to 7 Bar Knees (Impact Level Low to Moderate unless it is combined with 5


pneumatic or hydraulic control for High)
These knees are designed for additional safety and even smoother function than
the 4 Bar Knees. Again, these can include pneumatic or hydraulic swing phase
.controls for greater function

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Pneumatic Swing Control Knees (Impact Level High)


A pneumatic cylinder is installed in the knee that uses principles of fluid
mechanics to vary the resistance of the knee as the user changes their walking
speed. This allows the individual to walk at different cadences and have the
prosthetic knee keep pace to ensure the prosthesis is always in the correct
position for safety when placing weight onto the prosthesis at heel contact.
Pneumatic knee units are usually lighter in weight and less heavy duty than
.hydraulic knees

Hydraulic Swing Control Knees (Impact Level High)


A hydraulic fluid cylinder is installed in the knee that uses principles of fluid
mechanics to vary the resistance of the knee as the user changes their walking
speed. This allows the individual to walk at different cadences and have the
prosthetic knee keep pace to ensure the prosthesis is always in the correct
position for safety when placing weight onto the prosthesis at heel contact.
.Hydraulic knee units are usually heavier duty than pneumatic knees
Hydraulic Swing and Stance Control Knees (Functional Level III)
These Hydraulic knees can be set to different modes such as free swinging for
bicycle riding, or slow resistance for descending steps foot over foot. It is also
.and excellent safety feature for stumble recovery

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High Technology Knees (Impact Level Moderate to High to Extreme)


The Otto Bock 3C100 C-Leg System
The C-Leg Micro processor knee system provides optimal stability during the gait
cycle. Multiple sensors in the C-Leg records information more than 50 times per
second resulting in reproducing the closest possible natural gait for the amputee.
This new dimension provides stability and security whilst walking down stairs,
ramps and all uneven terrain.
We are pleased to discuss the benefits of this system with our clients.

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:Stance Flexion Feature


This feature allows the knee to bend slightly at heel contact without the knee
buckling on flexion. This feature acts as a shock absorber, the same as the
.human anatomical knee

Prosthetic Interface Materials


A prosthetic interface is that material located closest to the wearers skin,
whether it be the traditional fine nylon sheaths and stump socks or the newer
urethane, polymer gel and silicone liners with or without integral suspension pins.
At Custom Prosthetic Services Ltd. we strive to match each individual with the
most appropriate interface and prosthetic suspension system. Each type of
system requires routine cleaning to maintain good hygiene and healthy skin. We
also carry a number of skin care lotions and ointments to be used separately
from or together with the various types of gel liners. Considerable relief from
pressure and friction-related skin problems and effective management of
persistent scar tissue can be obtained through the use of a carefully shaped and
.supportive prosthetic socket coupled with the correct interface material
:Roll-On Gel Liners

84

85

Prosthetic Socket Design and Suspension


Custom Prosthetic Services Ltd. provides state-of-the-art prosthetic socket
design and components. Comfort begins with a properly designed socket. We
use careful hand-casting techniques and build prostheses that both support
weight bearing and relieve pressure regions. We use flexible inner socket liners
to allow the limb musculature to expand and contract throughout the gait cycle. In
our above-knee prosthetic designs this flexible liner is supported by a lightweight
rigid frame, which attaches to the prosthetic knee of choice. Many types of
prosthetic suspension systems, including suction fitting and locking pin
mechanisms are used. We use all of the advanced technology feet that will
.enhance the function of each prosthesis

86

Harmony VASS (Vacuum Assisted Socket System)


Total Environment Control and Suction Suspension System

87

The Harmony VASS system is a recent significant advance in the technology of


prosthetic suspension and volume control. Used correctly, the system offers
many benefits over conventional prostheses including: unrestricted vascular flow
(healthier for the tissues); control of swelling and edema; volume management;
and enhanced linkage of the prosthesis to the residual limb. An excellent choice
.for active individuals with below or above knee amputations
The VASS self-contained suction pump is linked to the interior of the prosthetic
socket and it maintains a low pressure environment therein, while a flexible
sealing sleeve prevents air entry at the socket brim. A urethane gel liner is worn
directly over the skin of the residual limb to absorb shear and impact forces. The
extra weight of this system is not a significant problem due to the feeling of being
'linked' solidly to the prosthesis. The VASS system can be retrofit to many
.existing prostheses or incorporated directly into the PATHFINDER foot

Cosmetic Covers
Custom Prosthetic Services Ltd. can provide very realistic looking cosmetic covers over below knee
.and above knee prostheses using custom colored latex and silicone skins. Inquire for more details

88

89

90

Upper Limb Prosthetics


Prosthesis and orthosis
A prosthesis is a device that is designed to replace, as much as possible, the
function or appearance of a missing limb or body part. An orthosis is a device
that is designed to support, supplement, or augment the function of an existing
limb or body part.
Characteristics of a successful prosthesis
Ideally, a prosthesis must be comfortable to wear, easy to put on and remove,
lightweight, durable, and cosmetically pleasing. Furthermore, a prosthesis must
function well mechanically and require only reasonable maintenance. Finally,
prosthetic use largely depends on the motivation of the individual, as none of the
above characteristics matter if the patient will not wear the prosthesis.
Considerations when choosing a prosthesis

Amputation level
Contour of the residual limb
Expected function of the prosthesis
Cognitive function of the patient
Vocation of the patient (eg, desk job vs manual labor)
Avocational interests of the patient (ie, hobbies)
Cosmetic importance of the prosthesis
Financial resources of the patient

Most common reasons for an upper extremity amputation


Reasons for amputation vary but can be correlated by age range. Correction of a
congenital deformity or tumor is commonly seen in individuals aged 0-15 years.
Trauma is the most common reason for amputation in patients aged 15-45 years,
with tumors being a distant second. Upper extremity amputations tend to be rare
in patients who are older than 60 years, but they may be required secondary to
tumor or medical disease.
Amputation levels

Transphalangeal amputation - Resection of the thumb or fingers at


distal interphalangeal (DIP), proximal interphalangeal (PIP), or
metacarpophalangeal (MCP) levels or at any level in between
Transmetacarpal amputation - Resection through the metacarpals
Transcarpal amputation - Resection through the carpal bones

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Transmetacarpal and transcarpal amputations are less


advised because, except for select circumstances, they
provide for decreased functional outcomes.
Wrist disarticulation - Transection between the carpals and
radius/ulna
Transradial amputation - Below-elbow amputation (May be
classified as long, medium, or short.)
Elbow disarticulation - Transection through the elbow joint
Transhumeral amputation - Above-elbow (Standard length is 5090% of humeral length.)
Shoulder disarticulation - Transection through the shoulder joint
Interscapulothoracic disarticulation (forequarter) - Amputation
removing the entire shoulder girdle (scapula and all or part of the
clavicle) (Some surgeons choose to leave part of the medial
clavicle.)
o

Definitions of relevant terminology

Residual limb - The preferred term for the remaining portion of the
amputated limb
Relief - A concavity within the socket that is designed for areas that
are sensitive to high pressure (bony prominences)
Buildup - A convexity that is designed for areas that are tolerant to
high pressure (such as a bulge)
Terminal device - The most distal part of a prosthesis that
substitutes for the hand; it may be a prosthetic hand, a hook, or
another device.
Myodesis - Direct suturing of residual muscle or tendon to
bone/periosteum
Myoplasty - Suturing of agonist-antagonist muscles pairs to each
other
Prehensile - Grasp

92

DIFFERENT TYPES OF PROSTHESES


The continuum of prostheses ranges from mostly passive or cosmetic types on
one end to primarily functional types on the other. The purpose of most
prostheses falls somewhere in the middle. Cosmetic prostheses can look
extremely natural, but they often are more difficult to keep clean, can be
expensive, and usually sacrifice some function for increased cosmetic
appearance.
Functional prostheses generally can be divided into the following 2 categories:

Body-powered prostheses - Cable controlled


Externally powered prostheses - Electrically powered .
o Myoelectric prostheses
o Switch-controlled prostheses

Body-powered prostheses
Body-powered prostheses (cables) usually are of moderate cost and weight.
They are the most durable prostheses and have higher sensory feedback.
However, a body-powered prosthesis is more often less cosmetically pleasing
than a myoelectrically controlled type is, and it requires more gross limb
movement.
Externally powered prostheses
Prostheses powered by electric motors may provide more proximal function and
greater grip strength, along with improved cosmesis, but they can be heavy and
expensive. Patient-controlled batteries and motors are used to operate these
prostheses. Currently available designs generally have less sensory feedback
and require more maintenance than do body-powered prostheses. Externally
powered prostheses require a control system. The two types of commonly
available control systems are myoelectric and switch control.
A myoelectrically controlled prosthesis uses muscle contractions as a signal to
activate the prosthesis. It functions by detecting electrical activity from select
residual limb muscles, with surface electrodes used to control electric motors.
Different types of myoelectric control systems exist.

The 2-site/2-function (dual-site) system has separate electrodes for


paired prosthetic activity, such as flexion/extension or
pronation/supination. This is more physiologic and easier to control.
When limited control sites (muscles) in a residual limb are available
to control all of the desired features of the prosthesis, a 1-site/2function (single-site) device may be used. This system uses 1
electrode to control both functions of a paired activity (for example,
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flexion and extension). The patient uses muscle contractions of


different strengths to differentiate between flexion and extension.
For instance, a strong contraction opens the device, and a weak
contraction closes it.
When multiple powered components on a single prosthesis must be
controlled, sequential or multistate controllers can be used, allowing
the same electrode pair to control several functions (eg, terminal
device, elbow activation). This type of controller requires the control
function of the electrodes to be switched from one function to the
other. This is accomplished by a brief co-contraction of the muscle
or by a switch used to cycle between control-mode functions.

Switch-controlled, externally powered prostheses utilize small switches, rather


than muscle signals, to operate the electric motors. Typically, these switches are
enclosed inside the socket or incorporated into the suspension harness of the
prosthesis. A switch can be activated by the movement of a remnant digit or part
of a bony prominence against the switch or by a pull on a suspension harness
(similar to a movement a patient might make when operating a body-powered
prosthesis). This can be a good option to provide control for external power when
myoelectric control sites are not available or when the patient cannot master
myoelectric control.
Many contemporary myoelectric control systems allow for the use of proportional
control so that the speed of the component or terminal device activation varies
with the intensity of the muscle contraction.

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Table 1. Various Upper Limb Prostheses1


Type

Pros

Cons

Cosmetic

Most lightweight
Best cosmesis
Less harnessing

High cost if custom-made


Least function
Low-cost glove stains easily

Body powered

Moderate cost
Moderately
lightweight
Most durable
Highest sensory
feedback
Variety of
prehensors
available for
various activities

Most body movement needed


to operate
Most harnessing
Least satisfactory appearance
Increased energy expenditure

Moderate or no
harnessing
Least body
movement needed
Battery
to operate
powered(myoelectric and/or
Moderate cosmesis
switch controlled)
More functionproximal areas
Stronger grasp in
some cases
Hybrid (cable to elbow or
TD* and battery powered)
If excursion to elbow and
battery-powered TD

If excursion to TD and
battery-powered elbow

Heaviest
Most expensive
Most maintenance
Limited sensory feedback
Extended therapy time for
training

All-cable excursion
to elbow or TD
All-cable excursion
to elbow
Battery-powered TD weights
Increased TD pinch forearm (harder to lift but
good for elbow disarticulation
All-cable excursion or long THA)
to TD
Low effort to
Lower pinch for TD and least
position TD
cosmetic
Low-maintenance
TD

*TD=terminal device
THA=transhumeral amputation

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TYPICAL COMPONENTS OF AN UPPER EXTREMITY, BODYPOWERED PROSTHESIS


A typical example of a transradial (below-elbow) prosthesis includes a voluntary
opening split hook; a friction wrist; a double-walled, plastic-laminate socket; a
flexible elbow hinge; a singlecontrol-cable system; a triceps cuff; and a figure-8
harness. A transhumeral (above-elbow) prosthesis is similar but includes an
internal-locking elbow with a turntable for the missing anatomic elbow, uses a
dualcontrol-cable system instead of a single-control cable, and does not require
a triceps cuff. All conventional body-powered, upper extremity prostheses have
the following components:

Socket
Suspension
Control-cable system
Terminal device
Components for any interposing joints as needed according to the
level of amputation

Socket
The socket of an upper extremity prosthesis typically has a dual-wall design
fabricated from lightweight plastic or graphite composite materials. In this design,
a rigid inner socket is fabricated to fit the patient's residual limb and the second,
outer wall is added, designed to be the same length and contour as the opposite,
sound limb. Comfort and function are directly tied to the fit of the inner socket. An
alternative approach parallels the rigid frame, flexible liner approach sometimes
used in lower extremity socket fabrication. The inner socket is fabricated from
flexible plastic materials to provide appropriate contact and fit. Surrounding the
flexible liner, a rigid frame is utilized for structural support and for attaching the
necessary cables and joints as
needed. The windows in the outer socket allow movement, permit relief over
bony prominences, and enhance comfort.
Suspension
The suspension system must hold the prosthesis securely to the residual limb, as
well as accommodate and distribute the forces associated with the weight of the
prosthesis and any superimposed lifting loads. Suspension systems can be
classified as follows:

Harnessed-based systems
Self-suspending sockets
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Suction sockets

Harnessed-based systems and their variants are the most commonly used
systems. For the figure-8 strap, a harness loops around the axilla on the sound
side. This anchors the harness and provides the counterforce for suspension and
control-cable forces. On the prosthetic side, the anterior (superior) strap carries
the major suspending forces to the prosthesis by attaching directly to the socket
in a transhumeral prosthesis or indirectly to a transradial socket through an
intermediate Y-strap and triceps cuff. The posterior (inferior) strap on the
prosthetic side attaches to the control cable. For heavier lifting or as an
alternative to the figure-8 harness, a shoulder saddle with a chest-strap
suspension can be used with a transradial prosthesis. A chest strap alone is
sometimes used to suspend a transhumeral prosthesis. The figure-9 harness is
an alternative for a patient with a long transradial amputation or a wrist
disarticulation, in order to provide the control harness provides minimal
suspension and requires a self-suspending socket, it is more comfortable than a
figure-8 harness. Self-suspending and suction sockets are capable of providing
adequate prosthetic suspension without the use of a harness. However, either
design can also be used with a harness suspension to provide for a more secure
suspension of the prosthesis.
Self-suspending sockets are largely limited to wrist or elbow disarticulations and
to transradial amputations. This socket design is most commonly utilized with an
externally powered, myoelectrically controlled transradial prosthesis. An example
of this type is the Munster socket. Proper fit of this socket precludes full elbow
extension.
Suction suspension is similar to lower extremity options. These sockets use an
external, elastic suspension sleeve; a one-way air valve; or roll-on gel
suspension liner with a pin-locking mechanism. Upper limb suction sockets
(unlike nonsuction sockets) require a total contact socket design and ideally a
residual limb with no skin invagination, scarring, and stable volume to avoid skin
problems, such as a choke syndrome. Suction socket designs are most
commonly used for the patient with a transhumeral amputation.
cable's necessary attachment point and counterforce. Although the figure-9

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Table 2. Suspension Options


Suspension

Harness

Selfsuspending

Suction

Indications

Figure-8

Transradial
Transhumeral
Light to
normal
activities

Advantages

Disadvantages

Simple,
durable,
adjustable

Axillary pressure
produces
discomfort

Greater lifting
ability, more
comfortable
than figure-8
harness

Reduced control
compared with
figure-8 harness,
difficult to adjust
in women
because straps
cross breasts

Shoulder
saddle and
chest strap

Transradial
Transhumeral
Heavy lifting

Muenster
Northwestern
Supracondyla
r

Wrist
disarticulation
Elbow
disarticulation
Short
transradial
Myoelectric
transradial

Ease of use

Limited lifting
capacity
compared with
harness
systems,
compromised
cosmesis,
reduced elbow
flexion

Suction
socket with
air valve

Transhumeral
with good soft
tissue cover

Secure
suspension,
elimination of
suspension
straps

Requires stable
residual volume,
harder to put
on than other
suspension
systems

Gel sleeve
with locking
pin

Transradial
Transhumeral
Compromised
limbs with
scarring or
impaired skin
integrity

Accommodate
limb volume
change with
socks,
reduced skin
shear

Greater cleaning
and hygiene
requirements,
can be
uncomfortable in
hot climates

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Control-cable mechanisms
Body-powered prosthetic limbs use cables to link movements of 1 part of the
body to the prosthesis in order to control a prosthetic function. This usually is a
movement of the humerus, shoulder, or chest, which is transferred via a Bowden
cable (a single cable passing through a single housing) to activate the terminal
device of the prosthesis. A control cable used to activate a single prosthetic
component or function is called a single-control cable, or Bowden cable system.
A dualcontrol-cable system uses the same cable to control 2 prosthetic
functions (such as flexion of the elbow and, when the elbow is locked, activation
of the terminal device). This latter control cable setup is accomplished with a
single cable passing through two separate cable Body movements that are
captured for prosthetic control

Glenohumeral forward flexion - A natural movement that provides


excellent power and reach and that can activate the terminal device
or flex an elbow joint; it is good for activities away from midline.
Biscapular abduction (chest expansion), mutual protraction - A
movement that can activate the terminal device; however, the
device must stay relatively stationary and the force generated is
weak. This movement is easy for the amputee to do. It is good for
fine motor activities that are performed near the midline or close to
the trunk of the body. Shoulder protraction can occur on just the
ipsilateral side for terminal-device control without biscapular
abduction (mutual protraction) for prosthetic control. Chest
expansion results in biscapular abduction without actual
protraction.
Glenohumeral depression/elevation, extension, abduction - Other
body movements that the amputee can utilize to control prosthetic
components/function; these movements are most frequently used
simultaneously, in a maneuver to lock or unlock an elbow for a
patient with a transhumeral amputation, via a separate, anterior
cable in a dual-cable system. This maneuver can be difficult to
master. The use of a waist belt or groin loop allows the amputee
to employ scapular elevation as an alternative motion, one that
operates a prosthetic function by utilizing a cable that has been run
through a pulley.

Nudge control Less cosmetic-appearing action; however, nudgecontrol devices and similhousings known as a fair lead cable system.are
types of systems are sometimes invaluable, offering cable-control options for
more complex cases where many control functions are needed.

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TERMINAL DEVICE
The major function of the hand that a prosthesis tries to replicate is grip
(prehension). The 5 different types of grips are as follows:

Precision grip (i.e., pincher grip) - The pad of the thumb and index
finger are in opposition to pick up or pinch a small object (e.g., a
small bead, pencil, grain of rice).
Tripod grip (i.e., palmar grip, 3-jaw chuck pinch) - The pad of the
thumb is against the pads of the index and middle finger.
Lateral grip (i.e., key pinch) - The pad of the thumb is in opposition
to the lateral aspect of the index finger to manipulate a small object
(such as turning a key in a lock).
Hook power grip - The distal interphalangeal joint and proximal
interphalangeal joint are flexed with the thumb extended (as
when carrying a briefcase by the handle).
Spherical grip - Tips of the fingers and thumb are flexed (when, for
example, screwing in a light bulb or opening a doorknob).

Terminal devices generally are broken down into 2 categories: passive and
active.
Passive terminal devices
Passive terminal devices fall into two classes, those designed primarily for
function and those to provide cosmesis. Examples of the functional passive
terminal devices include the child mitt frequently used on an infant's first
prosthesis to facilitate crawling or the ball handling terminal devices used by
older children and adults for ball sports. The main advantage of most passive
terminal devices is their cosmetic appearance. With newer advances in materials
and design, some passive hands are virtually indistinguishable from the native
hand. However, most of these cosmetic passive terminal devices usually are less
functional and more expensive than active terminal devices.
Active terminal devices
Active terminal devices usually are more functional than cosmetic; however, in
the near future, active devices that are equally cosmetic and functional may be
available. Active devices can be broken down into 2 main categories: hook (and
similarly specialized function) terminal devices and prosthetic hands. There are
designs of both of these terminal device groups available to operate with cable or
externally powered prostheses.
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Cable-operated terminal devices (hooks or hands) can be of a


voluntary opening design (most commonly used) or a voluntary
closing design. Voluntary opening mechanism - With a voluntary
opening mechanism, the terminal device is closed at rest. The
patient uses the control-cable motion to open the terminal device
against the resistive force of rubber bands (hook) or internal springs
or cables (hand). Relaxation of the proximal muscles allows the
terminal device to close around the desired object. The number of
rubber bands determines the amount of prehensile force that is
generated. One rubber band provides about 1 pound of pinch force
(typical nonamputee pinch force is 15-20 lb). Up to 10 rubber bands
can be used
Voluntary closing mechanism - With a voluntary closing
mechanism, the terminal device is open at rest. The patient uses
the control-cable motion to close the terminal device, grasping the
desired object. This type of mechanism usually is heavier and less
durable than a voluntary opening mechanism. It offers better control
of closing pressure (up to 20-25 lb) and is more physiologic, but
active effort may be needed to maintain closure for some terminal
devices to prevent dropping items. Because of the need to maintain
an active muscle contraction for terminal device closure, the
amputee can get some sensory feedback with this type of terminal
device.

A prosthetic hand usually is bulkier and heavier than a hook, but it is more
cosmetically pleasing. A prosthetic hand can be powered by a cable
or utilize external power. With a myoelectrically controlled device, it is possible for
the patient to initiate palmar tip grasp by contracting residual forearm flexors and
to release by contracting residual extensors.
Most hook-style terminal devices provide the equivalent of active lateral pinch
grip, while active hands provide a 3-point chuck action. Many different options
are available for terminal devices that address occupations, hobbies, and sports.
Many specialized terminal-device designs are available or are custom fabricated
by prosthetists to meet the unique functional requirements of individual
amputees. Most of the commercially available specialized terminal devices are
designed for various recreational and hobby activities. There are terminal
devices available for specific activities, such as golfing, bowling, swimming,
tennis, weight lifting, fishing, skiing, shooting pool, rock climbing, baseball,
hunting (bow and rifle), photography, and the playing of musical instruments
(guitars and drums).

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WRIST, ELBOW, SHOULDER, AND FOREQUARTER UNITS

Wrist units
The wrist unit provides orientation of the terminal device in space. It can be
positioned manually, by cable operation, or with external power (whether
myoelectrically or by switch). Once positioned, the wrist unit is held in place by a
friction lock or a mechanical lock. Several different unit designs are available,
including a quick-disconnect unit, a locking unit, and a flexion unit. Frictioncontrol wrist units are easy to position but can slip easily when carrying heavier
loads.
Quick-disconnect wrist unit
This style is configured to allow easy swapping of terminal devices that
have specialized functions.
Locking wrist unit
Wrist units with a locking capacity prevent rotation during grasping and lifting.
Wrist flexion unit
A wrist flexion unit can provide an amputee (especially a bilateral upper extremity
amputee) with improved function for midline activities, such as shaving,
manipulating buttons, or performing perineal care. A flexion wrist unit usually is
employed on only one side, most often the longer of the two residual limbs, but
ultimately it should be placed on the side that the amputee prefers. Multifunction
wrist units have become available.

Elbow units
Elbow units are chosen based on the level of the amputation and the amount of
residual function. It is helpful to remember that supination and pronation of the
forearm decrease as the site of amputation becomes more proximal.
Flexible elbow hinge

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Flexible elbow hinges are utilized for medium and long transradial amputations
and wrist disarticulations. When the patient has sufficient voluntary pronation and
supination, as well as elbow flexion and extension, flexible elbow hinges help
translate any residual active pronation and supination to the terminal device. A
triceps pad or cuff helps distribute suspension forces and is needed to anchor the
control cable.
Rigid elbow hinge
With short transradial amputations, a patient has no residual, active forearm
pronation and supination but does have adequate native elbow flexion. Rigid
elbow hinges provide additional stability. Hinges are available in single-axis or
polycentric versions. Rigid hinges are important in amputees with short
transradial limbs. In patients with very short transradial, residual limbs or limited
active elbow flexion, the use of step-up elbow hinges can improve prosthetic
function by increasing functional, active elbow motion. This system uses special
elbow joints together with a split-socket design permitting the prosthetic forearm
and attached terminal device to move 2 of motion for every 1 of actual residual
limb and elbow motion. Since movement of the limb and the prosthesis are not
directly connected, the proprioceptive feedback is compromised.
Internal elbow
The standard elbow component for a transhumeral prosthesis is an internal
locking elbow joint. This allows for 135 of flexion and can be locked into a
number of preset flexed positions. The standard internal elbow joint incorporates
a turntable that allows passive internal or external humeral rotation. Elbow
spring-lift assists are available and are used to counterbalance the weight of the
forearm, making elbow flexion easier.
The standard elbow unit requires a length of 8-10 cm to be adequately installed
in a transhumeral prosthesis. If the level of amputation is less than 8-10 cm
proximal to the distal end of the humerus, then an internal locking elbow unit
cannot provide symmetric elbow centers (prosthesis and sound upper
extremity). Even if an asymmetric elbow position (compared with the sound side)
is acceptable, functional problems will result with the prosthesis from this
alignment. Unless the forearm section of the prosthesis is lengthened to
accommodate the lengthened arm section, the amputee will not be able to reach
the midline or mouth, with the prosthesis compromising function. However,
lengthening the forearm to accommodate the added arm length will result in
difficulties when the patient tries to perform bimanual activities, and it usually will
not be cosmetically acceptable to the patient. For long transhumeral amputations
or elbow disarticulations, locking external elbowjointsmay be used, but they are
not cosmetic or as durable as internal elbow joints.

Shoulder and forequarter units


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When an amputation is required at the shoulder or forequarter level, function is


very difficult to restore. This is due to a combination of the weight of the
prosthetic components and the diminished overall function when combining
multiple prosthetic joints, as well as the increased energy expenditure necessary
to operate the prosthesis. For this reason, some individuals with a unilateral
amputation at this level choose a purely cosmetic prosthesis to improve body
image and the fit of their clothes or decide to go without a prosthesis.

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PROCESS/TIMELINE FOR AN AMPUTATION/PROSTHESIS


FITTING
Pre-amputation
Ideally, a patient who needs an upper extremity amputation should be seen by
the rehabilitation team prior to the surgery. This allows a chance to evaluate
postoperative needs and desires, to discuss prosthetic restoration, and to begin
any needed range-of-motion (ROM) exercises, strengthening, and training in
activities of daily living (ADLs). Peer support by another successful amputee at
the proposed level has a positive benefit for all amputees and may reduce
anxiety for the elective amputee patient. However, since most upper extremity
amputations are traumatic in nature, this is not always possible.
Surgical procedure
During the amputation surgery, several actions can be taken to maximize the
function of the residual limb. These actions include the following:

Bevel the bone end. This can help to minimize soft-tissue trauma
from sharp or irregular bone edges.
When severing a nerve, place gentle traction on it, sharply transect
it, and allow the nerve to retract into proximal soft tissue. A severed
nerve forms a neuroma (scar tissue) at the distal end. When the
neuroma forms in soft tissue, there is less likelihood of postsurgical
pain.
Perform a myoplasty (in which agonist-antagonist muscle pairs are
sutured to each other) or a myodesis (in which residual muscle is
stitched to bone) to secure the muscles of the residual limb. These
procedures stabilize the bone and soft tissues in the residual limb,
minimizing bone movement within the soft-tissue envelop of the
residual limb and therefore enhancing prosthetic
function. Maintaining muscle tension also facilitates the potential for
future myoelectric control, if desired.
During skin closure, position the wound edges to avoid bony
prominences at the distal end of the residual limb. This prevents
future pressure on the incision from the underlying bone when the
patient wears the prosthesis.
Ensure proper length so that specific prosthetic components may
be used that result in cosmesis and functional goals.

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Acute postsurgery
The major physical issues in this phase are adequate wound healing, pain
management, instruction in the performance of ADLs, mobility, ROM, and
strength. During this phase, a program to prepare the residual limb for the
prosthesis should be initiated. A skin desensitization program consists of the
following:

Gentle tapping on the distal portion of the residual limb to mature


the site
Massage to prevent excessive scar formation, with adherence of
the skin and soft tissues to underlying bone
Edema control with ace wraps, a rigid removable dressing, or a
residual limb (stump) shrinker
Application of pressure to the distal end of the residual limb to
prepare for anticipated contact on the residual limb following
prosthetic fitting

Psychology should be involved at this phase if possible (ie, elective procedure) or


immediately postoperatively. Adjustment and grief reaction are common for new
amputees. The patient may struggle with self-image and cosmetic
concerns early, as well as later, in the prosthetic restoration process. A simple
and organized psychological framework proposed by Van Dorsten delineates
the process well.3 The stages address survival, recovery and reintegration. The
amputee will have many questions and concerns during each stage. As
previously mentioned, peer support visits by another successful amputee can
provide a tremendous benefit for the new amputee. Initially, the team should
suggest and remind the patient of available peer support, but it is important to
allow the patient to indicate when he or she is ready for such a visit.
The frequency of psychological visits depends on many factors, such as
premorbid coping skills, family support, pain intensity, and medical-surgical
complications. The patient will need to be followed throughout the course of
immediate postamputation, prosthetic training, and functional reintegration back
into his or her societal routine.
Prosthesis fitting and testing
A temporary prosthesis can be fitted during surgery; in this way, when the patient
awakens, he or she can visualize a limb in place. This is called an immediate
postoperative prosthesis (IPOP). IPOPs are usually fitted in healthy young

106

patients with traumatic amputations. In such cases, rehabilitation physicians work


integrally with surgical specialists and prosthetists. Alternatively, in older patients
or in those with vascular disease, a prosthesis is not fitted until the suture line
has completely healed. The prosthesis must be individually fitted to the patient,
since 1 size does not fit all. Fitting an upper extremity amputee with a bodypowered preparatory prosthesis within 7-30 days after amputation is advisable.
This is referred to by Malone as the "golden period." 4 Prosthetic fitting during this
time correlates with a higher acceptance and success rate of prosthetic use.
Prostheses are either preparatory (nonpermanent) or definitive (permanent). The
advantage to using a preparatory prosthesis is that it is fitted while the residual
limb is still maturing. A preparatory prosthesis allows the patient to train with the
prosthesis several months earlier in the process. Use of a preparatory prosthesis
often results in a better fit for the final prosthesis, since the preparatory socket
can be used to mold the residual limb into the desired shape. During this period,
the patient test drives the prosthesis and learns what it can and cannot do.
Sometimes a preparatory prosthesis is not feasible because of financial
considerations. In this case, a patient can only be fitted for the definitive (final)
prosthesis. If a patient is being fitted for a final prosthesis without ever having
had a preparatory prosthesis, fitting for the socket should be delayed until the
residual limb is fully mature (a process that sometimes can take several months).

107

PHANTOM LIMB SENSATION AND PAIN


In addition to the usual postoperative pain, most individuals who have undergone
an amputation experience phantom sensation. Phantom sensation is the
perceived sense that the amputated limb, or at least a part of it, is still present.
Phantom sensation is not painful, and the patient usually just needs to be
reassured that this sensation is common and that he or she is not suffering from
mental instability. The phenomenon of telescoping can accompany phantom
sensation. Telescoping is the sensation that the amputated limb has shrunk (eg,
the toes are at the ankle, the foot is at the knee). Telescoping is normal and
usually fades without sequelae.
Phantom pain is the sensation of pain originating in the amputated part. Phantom
pain may or may not be dermatomal in nature. Individuals may describe a
burning, stinging, or cramping pain, or they may describe a feeling that the
missing body part is "positioned awkwardly or painfully." The pain usually
develops in the first month after amputation and is most likely to develop in
individuals who had a lot of pain before amputation. Phantom pain is constant
and is most intense right after the amputation. The pain becomes more
intermittent and resolves with time, although some patients can still experience
phantom pain years after the amputation. Patients who have undergone
amputation commonly report intermittent phantom pain symptoms, but they are
able to ignore them and require no medication for treatment. Phantom pain is
usually worse at night, after the extremity has been in a dependent position, and
can be worsened by anxiety and stress.
Unlike postsurgical pain, which responds well to opioids, such as Percocet or
Lortab, phantom pain is best treated with low doses of tricyclic antidepressants
(ie, nortriptyline or amitriptyline 10-25 mg PO qhs) that aim to improve sleep.
Phantom pain may respond well to medications such as carbamazepine
(Tegretol), amitriptyline (Elavil), pregabalin (Lyrica) and gabapentin (Neurontin;
titrate to at least 300 mg tid; serum gabapentin levels can be monitored),
which serve to stabilize the nerve's ability to depolarize and which decrease
dysesthetic symptoms.
Transcutaneous electrical nerve stimulation, topical anesthetics (ie, capsaicin
cream), and anxiolytics may be useful. Decreasing residual limb edema is
helpful, and the use of a prosthesis results in lower reports of phantom limb pain.
Theories exist as to why patients experience phantom limb pain and phantom
sensation. One theory is that the remaining nerves continue to generate impulses
spontaneously or as a result of irritation. A second theory is that the spinal cord

108

nerves begin excessive, spontaneous firing in the absence of expected sensory


input from the limb. A third theory is that altered signal transmission and
modulation occur within the somatosensory cortex. Other possible causes
include abnormal sympathetic function and psychologic factors.
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