Upon completion of this lecture student will be able to:
 Define basic terminology for orthotics and
prosthetics
 Categories the causes of amputation.
 Describe different stages of rehabilitation
 State criteria for good stump
 Identify the different level of extremity
amputation.
• Orthotics: is a specialty within the medical
field concerned with the design, manufacture
and application of orthoses.
• Orthosis (plural: orthoses): is "an externally
applied device used to modify the structural
and functional characteristics of the
neuromuscular and skeletal system".
• Orthotist: is the healthcare professionals that
specialize in the provision of orthoses.
Aim of using orthosis
An orthosis may be used to:
• Control, guide, limit and/or immobilize an extremity, joint or
body segment for a particular reason.
• To restrict movement in a given direction
• To assist movement generally
• To reduce weight bearing forces for a particular purpose
• To aid rehabilitation from fractures after the removal of a
cast
• To otherwise correct the shape and/or function of the body,
to provide easier movement capability or reduce pain
• Prosthetics: is a specialty within the medical
field concerned with the design, manufacture
and application of prosthesis.
• Prosthesis (plural: prostheses): is an
artificial device that replaces a missing body
part, which may be lost through trauma,
disease, or congenital conditions.
• Prosthetist: The person who manufacture
the prosthesis.
Amputation
• Amputation: AMBI means around, Putation means
trimming.
• Separation by cutting of terminal part of the body.
• It is the removal of a body extremity (part or
whole) by trauma, prolonged constriction,
or surgery. As a surgical measure, it is used to
control pain or a disease process in the affected
limb, such as malignancy or gangrene.
• Trauma:




RTA(Road Traffic accident)/ train accident.
Industrial accident.
Fracture complications.
Burns ‫ ــ‬thermal, electrical and chemical.
• Vascular:
 Thromboangiitis oblterians.
 Arteriosclerosis - senile and diabetic.
 Frost bite.
• Infections:




Leprosy
Actionomycosis.
Filariasis.
Gas ganganrene.
• Tumors- Malignant
 Bone – osteosarcoma.
 Soft tissue – fibrosarcoma.
• Congenital limb deficiency.
Rehabilitation of an Amputee
Rehabilitation:
• It is a process by which patient’s abilities are utilized to make
him independent physically, mentally, socially and
vocationally to make him lead a near normal life.
Stages of rehabilitation:
1.Pre- amputation counseling.
2.Amputation surgery.
3.Acute post amputation care.
4.Pre-prosthetic training.
5.Prosthetic fitting and training.
6.Reintegration into community.
7.Long-term follow up.
Rehabilitation team for amputee patient
Surgeon
Ergonomist
Physical
Therapist
Patient
Occupational
Therapist
Prosthetist
Psychologist
• The main aim of this stage is to prepare the patient physically, mentally for
amputation and post amputation period.
The stage includes:
A. Communication with patient and his family to explain about the need for
surgery and its outcomes.
B. Communication between rehabilitation team to discuss about the level of
amputation and prosthetic fitting.
C. Introductory session with patient regarding:
• Phantom limb pain.
• Prosthetic fitting.
• Mode of fitting and training.
• Time taken.
• Cost expenditure.
D. Demonstration by a trained volunteer and discussion between patient and
volunteer.
E. Pre- rehabilitation exercise program involving: other limbs – trunk muscles.
• Amputation is done when all other modalities are explored, evaluated
and rejected. The evidence suggests that the amputation is the best
solution to the patient’s plight.
Amputation is to achieve:
A. Most distal level with clinical condition.
B. Well healed stump.
C. Less functional loss.
D. Less energy with ambulation with prosthesis.
Amputation surgery includes:
A. Removal of a part or whole limb to exclude pathology.
B. Reconstruction to create a best possible stump.
Types of Amputation:
A. Guillotine amputation.
• Emergency amputation is done as life saving measure.
• It is the one in case where primary healing unlikely to occur.
• Amputation is done as low as possible to allow room for reamputation.
• The bone, muscles and skin are cut at the same level.
A. Definite (classical)amputation.
• One for which no further operative procedure is expected and
prosthesis can be fitted to the patient.
A. Revision amputation.
• Done in already amputated persons. E.g. guillotine
amputation, childhood amputation etc. aiming for better
stump
Stump
• It the residual part of the limb after amputation.
• Criteria for good stump:
1. Proper length.
2. Proper shape.
3. Skin free.
4. Healthy scar.
5. Good muscle strength.
6. Joint should has full ROM.
7. No neuroma.
8. No phantom sensation or pain.
Levels of Amputation
It depend up on:
•The pathology.
•Validity of tissues.
Levels of Lower Limb Amputation
Levels of Upper Limb Amputation
The stump is maintained postoperatively by:
A.Soft dressing.
B.Rigid dressing.
C.Crepe bandaging.
D.Controlled environment method.
E.Immediate Postoperative Prosthetic Fitting
(IPOPF).
Advantages :
• Allows inspection of wound.
• Allows near normal ROM.
Disadvantages:
• Does not prevent contractures.
• Does not prevent trauma.
• In form of plaster cast.
• It called as Immediate Postoperative Rigid Dressing
(IPORD)
Advantages :
• Pain is decreased.
• Wound heals quickly.
• Edema is prevented.
• Prevent contractures.
• Protect from trauma.
Disadvantages:
• Require careful application.
• Wound inspection cannot be done.
• Bandaging is done like ‘figure of 8’
• It need frequent rewrapping.
• This gives pressure from distal to proximal thus
reducing hematoma and edema.
• This done via using of machine that supplies
bacteria free environment to the wound a
with controlled humidity and temperature.
• This provides the perfect environment for
primary healing.
• It can be done especially for children and clean
traumatic ablation.
• The main aims are:
Control of pain.
Prevention of edema.
Prevention of infection.
Prevention of deformity/ stiffness.
Prevention of DVT.
Improving muscle power.
Control of pain
• Narcotics/ analgesics every 3 to 6 hours at least for 48
hours to maximum of 5 days.
• Then decrease the amount gradually.
• Catheter with infusion pump can be used in rate of 2 – 3
ml/ hour for 72 hours.
Prevention of edema
• Passive ROM exercises.
• Active ex’s will help in venous return and reduces edema.
• Crepe bandaging also help to reduce the edema.
• Tube gauze:
 Provides good skin tolerance.
 Provides pressure gradient from distal to proximal.
 The elastic nature gives more comfort to patient by
yielding to different size.
Tube gauze
Prevention of infection
• Proper wound care and with good antibiotic cover
can prevent infection.
Prevention of stiffness
• Passive ROM exercises.
• Active mobilization ex’s.
• Proper positioning.
• Early fitting to prosthesis.
Prevention of DVT
• Passive and active ex’s.
• Elastic stocking.
• Elasto crepe bandages.
Improve muscle power
• Chest physiotherapy.
• Ex’s to other limbs with intension to UL muscles
which used during crutch walking and wheel
chair mobility.
First Day
• Breathing ex’s.
• Proper positioning of the limb and stump.
Second Day
•
Sit up in bed.
• Breathing ex’s.
Third Day
• Drain removal.
• Stump ex’s.
Forth day
• Standing with or without support.
• Crutch walking.
Fifth to seventh day
• Suture removal.
• Stump bandaging.
This phase includes:
•
•
•
•
•
•
•
•
Active ROM ex’s.
Proper positioning of the stump.
Muscle strength.
Skin care.
Crutch training.
Wheel chair mobility.
Self care.
Patient and family education.
• Thus done through collaboration among physiotherapist,
occupational therapist, prosthetist.
This phase includes:
• Prosthetic fitting: including alignment check, pressure
point relief, color matching, etc.
• Donning and doffing training: for independence in care
activities.
• Skin care training: to avoid pressure ulcers, skin infections.
• Gait training: includes weight bearing, weight transfers,
stepping training, walking with or without assistive aids,
stair climbing, etc.
• Maintenance of prosthesis: Cleaning, maintaining and
replacement of prosthesis.
• This process should done gradually, and it may take
weeks or months.
• Organized trips for shopping, recreation or a part
time job should be done.
• Day hospital rehabilitation program: patient
participate in rehabilitation in hospital 6 hours/ day,
5 days/week. At evening and weekend the patient
return back to his home.
• Modified work and restricted work according to the
patient’s diablity.
• During the first year, follow up is advised every 3
months and thereafter as and whenever required